Anatomical and Functional Features of the Internal Rectal Prolapse With Outlet Obstruction Determined With 3D Endorectal Ultrasonography and High-Resolution Anorectal Manometry: An Observational Case-Control Study.

OBJECTIVES: To investigate correlation between rectal wall thickness (RWT) and anorectal pressures, in obstructed defecation syndrome (ODS) patients caused by internal rectal prolapse. METHODS: ODS patients and healthy volunteers (HVs) underwent 3D endorectal ultrasound (3D-EUS) and high-resolution anorectal manometry (HRAM); RWT, total rectal wall volume (TRWV), pushing endorectal pressure (PEP), recto-anal gradient were determined RESULTS: We enrolled 35 ODS patients and 25 HVs. Patients showed markedly decreased TRWV, PEP, and recto-anal gradient. Linear correlation was found between markedly reduced TRWV and markedly hypotonic PEP. CONCLUSIONS: HRAM and 3D-EUS could be performed in ODS assessment, to better understand rectal function.

Is Percutaneous Transhepatic Biliary Drainage Better than Endoscopic Drainage in the Management of Jaundiced Patients Awaiting Pancreaticoduodenectomy? A Systematic Review and Meta-analysis.

PURPOSE: To compare postoperative complications in patients who underwent pancreatoduodenectomy after either endoscopic or percutaneous biliary drain (BD). MATERIAL AND METHODS: Data from studies comparing the rate of postoperative complications in patients who underwent endoscopic BD or percutaneous BD before pancreatoduodenectomy were extracted independently by 2 investigators. The primary outcome compared in the meta-analysis was the risk of postoperative complications. Secondary outcomes were the risks of procedure-related complications, postoperative mortality, postoperative pancreatic fistula, severe complications, and wound infection. For dichotomous variables, the odds ratio (OR) with 95% confidence interval (CI) was calculated. RESULTS: Thirteen studies, including 2334 patients (501 in the percutaneous BD group and 1833 in the endoscopic group), met the inclusion criteria. Postoperative and procedure-related complication rates were significantly lower in the percutaneous BD group (OR = .7, 95% CI = .52-.94, P = .02 and OR = .44, 95% CI = .23-.84, P = .01, respectively). No significant differences were observed when severe postoperative complications, postoperative mortality, postoperative pancreatic fistula, and wound infection rates were compared. CONCLUSIONS: In patients awaiting pancreatoduodenectomy, preoperative percutaneous BD is associated with fewer procedure-related or postoperative complications than endoscopic drain.

Laparoscopic Management of Hepatocellular Carcinoma: A Critical Reappraisal.

Following the introduction of the first laparoscopic liver resection, after ∼25 years, a critical reappraisal seems to be warranted. Liver resection represents the first choice for curing early hepatocellular carcinoma (HCC) allowing a curative chance also in selected patients with intermediate stage tumors. The criteria for liver resectability by laparoscopy remains the same for open surgery, which is oncological criteria (absence of extrahepatic tumor location; completely resectable R0 resection), anatomic (resectability of involved segment with its own blood surely and biliary drainage; absence of vascular invasion of portal or hepatic veins) and technical (possibility to leave in place a residual volume ≥40%). Anatomic resections being more challenging than wedged resections, were initially performed mainly for lesions located in the left liver (segments 2, 3, and 4) and segments 5 and 6 of the right liver (anterior and lateral hepatic segments). Left lateral segmentectomy seemed most suited for laparoscopic resection because of the thinness of the liver, the possibility of resection without hilar dissection, ease of stapling the left hepatic vein and portal pedicles of segment II and III by mechanical stapling. Conversely, right hepatectomy seemed most difficult and technically challenging to perform. The analysis of literature confirms that minor liver resections for HCC can be safely conducted also in cirrhotic patients and that laparoscopy, when feasible, should be the approach of first choice. As mentioned, there have been several studies that compared the long-term outcomes of laparoscopic hepatectomy (LH) versus open hepatectomy for HCC, even in cirrhotic patients, showing that laparoscopy does not seem to have any impact on the risk of postoperative HCC recurrence. However, further studies seem to be required, especially for long-term oncological results and for major hepatectomy, before LH become a common alternative to open liver surgery. The practice of performing LH (major) is challenging, due to the significant complexity of these interventions.

Quality of life and scar evolution after negative pressure or conventional therapy for wound dehiscence following post-bariatric abdominoplasty.

No studies have examined scars and quality of life after different treatments of wound dehiscence in patients undergoing post-bariatric abdominoplasty. Scars and quality of life of patients with postoperative wound dehiscence managed with negative pressure wound therapy (group A) and conventional wound therapy (group B) were reviewed 6 months after wound healing. Of 38 patients undergoing treatment for wound dehiscence after 203 abdominoplasty, 35 (group A = 14 versus group B = 21) entered the study. Wound healing in group A was significantly faster than group B (P = 0·001). Patients (P = 0·0001) and observers (P = 0·0001) reported better overall opinions on a scar assessment scale for group A. Better overall quality of life and general health satisfaction were observed in group A (P < 0·05). A significant correlation was observed between the World Health Organization Quality of Life scores and Patient and Observer Scar Assessment Scale scores (r=-0·68, P < 0·0001) in all 35 patients. Negative pressure wound therapy is feasible and effective in patients with wound dehiscence following post-bariatric abdominoplasty. An adequate post-treatment outcome is achieved compared with conventional wound therapy in light of a strong association found between worse patient scar self-assessment and poor overall quality of life, regardless of the received treatment.

Long-term functional follow-up after anterior rectal resection for cancer.

PURPOSE: This is a retrospective analysis including all of the patients that have undergone anterior resection for rectal cancer from January 1998 to December 2005 in two tertiary referral centers. The study aims to evaluate the long term functional results after low anterior resection and to identify the risk factors of postoperative bowel disorders. METHOD: Data were collected from the clinical records, and then the low anterior resection syndrome score which is a specific questionnaire to investigate the symptoms after surgery was submitted to the selected patients. Exclusion criteria were intra-abdominal rectal cancer, partial mesorectal excision, permanent stoma, recurrent local disease, and patients who declined the questionnaire. RESULTS: A total of 93 patients were included in the analysis with a median age at the diagnosis of 66 years. The median follow-up was 13.7 years, and low anterior resection syndrome was reported in 44 patients (47.5 %), with major manifestations in 19 patients (20.5 %), and minor symptoms in 25 patients (27 %). Age more than 70 years, tumor distance from the external anal verge, neoadjuvant treatment, and interval time of closing stoma are independent prognostic factors of functional disorders after surgery. CONCLUSIONS: Because of its great impact on the quality of life of these patients, it is necessary to early identify the syndrome trying to reduce its manifestations. Moreover, the symptoms seem to remain stable 1 year after surgery; hence, it is important to have an exhaustive, preoperative counseling and an integrated post-operative functional and rehabilitational follow-up in association with the oncologic pathway.

Remission of type 2 diabetes in patients undergoing biliointestinal bypass for morbid obesity: a new surgical treatment.

BACKGROUND: Nutrient interaction with the mid-gut may play a role in improving type 2 diabetes mellitus (T2D) after bariatric surgery. However, Roux-en-Y gastric bypass, biliopancreatic diversion, and sleeve gastrectomy include diversion of food from the duodenum and/or partial gastrectomy. Biliointestinal bypass (BIBP) was introduced to eliminate the major side effects of jejunoileal bypass. It does not involve any change to the anatomy of the stomach or the duodenum. A prospective evaluation of the role of BIBP in glycemic control has not been reported. OBJECTIVES: Longitudinal evaluation of T2D after BIBP. SETTING: University hospitals in Europe and Canada. METHOD: The effects of BIBP on metabolism and glycemia in 28 consecutive patients with T2D were evaluated over 2 years. RESULTS: Decreases (P<.001) in fasting glycemia, insulinemia, and homeostasis model assessment were observed 3 months after surgery, were improved after 1 year, and remained stable after 2 years. Glycosylated hemoglobin levels decreased at 3, 12, and 24 months after surgery (from 9.2±2.1 to 6.3±1.1 (P<.0001), 4.9±1.7 (P<.0001), and 4.8±1.1 (P<.0001), after 3, 12, and 24 months, respectively). Medical therapy was discontinued in 83% (20 of 24) of the patients; for the remaining 17% (4 of 24), therapy was reduced to oral hypoglycemic agents. CONCLUSION: BIBP had a favorable risk-benefit relationship and positive metabolic effects in the short term. How BIBP achieves optimal glycemic control and whether it improves ß-cell function and/or insulin sensitivity require further study.

Double loop reconstruction following pancreaticoduodenectomy for malignant tumor: Short-term outcome.

BACKGROUND: To evaluate the use of a double loop reconstruction following pylorus preserving proximal pancreaticoduodenectomy (PPPPD). METHODS: Morbidity and mortality were evaluated in 55 patients undergoing PPPPD for malignant tumors, followed by a double loop reconstruction. RESULTS: The mean intra-operative blood loss was 908mL±531. In-hospital mortality was 5.4% (3/55 pts). The mean length of hospital stay was 17±5 days (range 12-45 days). Postoperative complications occurred in 25 patients (46.2%). Five patients developed an anastomotic leak, one biliary and four pancreatic (4/55; 7%). Delayed gastric emptying occurred in 8 patients (14.5%). Reoperation was required in two patients for hemorrhage. CONCLUSIONS: A double loop alimentary reconstruction following PPPPD led to a low incidence of DGE and pancreatic fistula. Although mortality rate was higher than that reported by referral centres, this technique has been performed in a not specialized unit attaining acceptable results.

A Gelatin-Thrombin Matrix Topical Hemostatic Agent (Floseal) in Combination With Harmonic Scalpel Is Effective in Patients Undergoing Total Thyroidectomy: A Prospective, Multicenter, Single-Blind, Randomized Controlled Trial.

BACKGROUND: Hemostasis during thyroidectomy is essential; however, the safest, most efficient, and most cost-effective way to achieve this is unclear. This randomized, multicenter, single-blind, prospective study evaluated the efficacy and safety of using different hemostatic approaches in patients undergoing total thyroidectomy. METHODS: Patients aged ≥18 to 70 years were randomized to Floseal + a harmonic scalpel (HS), Floseal alone, HS alone, or standard total thyroidectomy. Primary endpoint was 24-hour drain output. Secondary endpoints included surgery duration and complications. RESULTS: Two hundred and six patients were randomized to Floseal + HS (n = 52), Floseal alone (n = 54), HS alone (n = 50), and standard total thyroidectomy (n = 50). The 24-hour drain output was lower in the Floseal + HS group compared with standard thyroidectomy. Floseal + HS also had a shorter surgery time (P < .0001) versus the other 3 treatments. CONCLUSION: Floseal + HS can be effective at reducing postsurgical drain output and provides a complementary hemostatic approach in patients undergoing total thyroidectomy.

Sleeve gastrectomy improves obstructive sleep apnea syndrome (OSAS): 5 year longitudinal study.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is prevalent among morbidly obese patients. Evaluation of the specific effects of sleeve gastrectomy (SG) on upper airway function has not been reported. Given the possibility that some patients will not respond despite weight loss, no studies have investigated whether other mechanisms may be responsible for persistent OSAS after bariatric surgery. OBJECTIVES: To evaluate by subjective and objective assessment the impact of SG on upper respiratory physiology in the long-term. SETTING: University Hospital, Division of Bariatric and ENT Surgery, in Italy. METHODS: Thirty-six consecutive patients with OSAS who underwent laparoscopic SG were prospectively enrolled. The effect of SG on respiratory function and OSAS was followed for 5 years. RESULTS: All patients completed the 5-year follow-up. A significant (P<.001) improvement in modified Epworth Sleepiness Scale questionnaire (ESS) was obtained in 91.6% (33/36) of patients. The Apnea/Hypopnea index (AHI) improved in 80.6% (29/36) of patients after surgery (from 32.8 ± 1.7 to 5.8 ± 1.2 (P<.001), 4.9 ± 1.7). The remaining 19.4% (7/36) of patients with a positive ESS and/or AHI all had an associated respiratory resistance due to nasal obstructive diseases. CONCLUSION: SG improved OSAS overall, but patients who did not improve or only partially improved despite weight loss were found to have an associated nasal responsible pathology. How these patients will respond to nasal surgery and whether a 2-step procedure should be recommended for OSAS patients requires further study.

Esophageal papilloma: Flexible endoscopic ablation by radiofrequency.

Squamous papilloma of the esophagus is a rare benign lesion of the esophagus. Radiofrequency ablation is an established endoscopic technique for the eradication of Barrett esophagus. No cases of endoscopic ablation of esophageal papilloma by radiofrequency ablation (RFA) have been reported. We report a case of esophageal papilloma successfully treated with a single session of radiofrequency ablation. Endoscopic ablation of the lesion was achieved by radiofrequency using a new catheter inserted through the working channel of endoscope. The esophageal ablated tissue was removed by a specifically designed cup. Complete ablation was confirmed at 3 mo by endoscopy with biopsies. This case supports feasibility and safety of as a new potential indication for Barrx(TM) RFA in patients with esophageal papilloma.

D-shape asymmetric excision of sacrococcygeal pilonidal sinus with primary closure, suction drain, and subcuticular skin closure: an analysis of risks factors for long-term recurrence.

BACKGROUND: Few studies have reported long-term recurrence rates after asymmetric excision with primary closure in the treatment of sacrococcygeal pilonidal disease. METHODS: A retrospective analysis of a prospectively maintained database of 550 surgical excisions performed for sacrococcygeal pilonidal disease between 1988 and 2005 was performed. RESULTS: A total of 550 patients with a diagnosis of pilonidal sinus underwent surgical excision over a period of 17 years. Thirty-eight out of the 550 patients (3.5%) were lost at follow-up. At a mean follow up of 11.2 ± 5.3 years, median 11 years (range = 3-22), the recurrence rate was 8.9%. Actuarial 1-, 5-, 10-, and 20-year disease-free survival rates were 98%, 94%, 92%, and 83%, respectively, with a median overall disease-free survival of 10 years (95% confidence interval [CI] = 3-15). When patients were stratified according to several variables known to influence recurrence, an age of less or ≥22 years (odds ratio [OR] = 1.5, 95% CI = 0.3-7.5, P = .001), a family history of sinus (OR = 5.9, 95% CI = 2.7-12, P = .0001), and intraoperative methylene blue use (OR = 6.3, 95% CI = 1.2-31, P = .024) were indicated as independent predictors of disease-free survival rates. CONCLUSIONS: D-shape asymmetric excision and scar lateralization, with primary multilayer subcuticular closure, suction drain insertion, and skin closure in patients with sacrococcygeal pilonidal disease is a safe and adequate surgical treatment offering an effective healing rate as well as low recurrence. Several features are likely to predict a better or a worse long-term recurrence rate in patients undergoing surgery for sinus pilonidalis.

The patterns of reflux can affect regression of non-dysplastic and low-grade dysplastic Barrett's esophagus after medical and surgical treatment: a prospective case-control study.

BACKGROUND: To date, therapeutic guidelines and pattern of reflux for patients with no-dysplasia (ND) or low-grade dysplasia (LGD) Barrett's esophagus (BE) remain unclear. We aimed to analyze pattern of reflux and regression of ND- or LGD-BE after medical and surgical treatment. METHODS: We studied a cohort of ND- and LGD-BE patients who underwent laparoscopic total fundoplication and a cohort of ND- and LGD-BE patients managed medically. Patients were matched for age, sex, and disease duration. After 1 year of follow-up at least, all patients underwent upper endoscopy with esophageal biopsies to evaluate any histological changes, as well as manometry and impedance-pH-metry to re-assess reflux patterns. RESULTS: Thirty-seven patients (20 LGD, 17 ND) undergoing laparoscopic fundoplication were enrolled and compared with 25 patients (13 LGD, 12 ND) managed with proton pump inhibitors (PPI). Laparoscopic fundoplication resulted in a better control of both acidic and weakly acidic reflux (P < 0.001) and was associated with a higher probability of reversion for LGD (P < 0.01). Esophageal motility did not differ between surgically and medically treated patients. CONCLUSIONS: In patients with ND- or LGD-BE, laparoscopic fundoplication seems to warrant a better control of all kinds of refluxate and it is associated with a higher likelihood of reversion of both LGD- and ND-BE, compared with PPI therapy.

Costs of laparoscopic and open liver and pancreatic resection: a systematic review.

AIM: To study costs of laparoscopic and open liver and pancreatic resections, all the compiled data from available observational studies were systematically reviewed. METHODS: A systematic review of the literature was performed using the Medline, Embase, PubMed, and Cochrane databases to identify all studies published up to 2013 that compared laparoscopic and open liver [laparoscopic hepatic resection (LLR) vs open liver resection (OLR)] and pancreatic [laparoscopic pancreatic resection (LPR) vs open pancreatic resection] resection. The last search was conducted on October 30, 2013. RESULTS: Four studies reported that LLR was associated with lower ward stay cost than OLR (2972 USD vs 5291 USD). The costs related to equipment (3345 USD vs 2207 USD) and theatre (14538 vs 11406) were reported higher for LLR. The total cost was lower in patients managed by LLR (19269 USD) compared to OLR (23419 USD). Four studies reported that LPR was associated with lower ward stay cost than OLR (6755 vs 9826 USD). The costs related to equipment (2496 USD vs 1630 USD) and theatre (5563 vs 4444) were reported higher for LPR. The total cost was lower in the LPR (8825 USD) compared to OLR (13380 USD). CONCLUSION: This systematic review support the economic advantage of laparoscopic over open approach to liver and pancreatic resection.

Recent trends in endoscopic management of achalasia.

Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter (LES) and usually with an elevated LES pressure, leading to an altered passage of bolus through the esophago-gastric junction. A definitive cure for achalasia is currently unavailable. Palliative treatment options provide only food and liquid bolus intake and relief of symptoms. Endoscopic therapy for achalasia aims to disrupt or weaken the lower esophageal sphincter. Intra-sphincteric injection of botulinum toxin is reserved for elderly or severely ill patients. Pneumatic dilation provides superior results than botulinum toxin injection and a similar medium-term efficacy almost comparable to that attained after surgery. Per oral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and further objective and long-term follow up. This article will review different endoscopic treatments in achalasia, and summarize the short-term and long-term outcomes.

Outcome of medical and surgical therapy of GERD: predictive role of quality of life scores and instrumental evaluation.

INTRODUCTION: Aim of this study is to determine whether quality of life (QoL) assessment in association with instrumental evaluation can help to identify factors predictive of outcome both in surgically and medically treated GERD patients. METHODS: Between January 2005 and June 2010, 301 patients affected with GERD were included in the study. QoL was evaluated by means of GERD-HRQL and SF-36 questionnaires administered before treatment, at 6 months, at 1 year follow-up and at the end of the study. The multivariate analysis was used to detect if variables such as sex, age, heartburn, acid regurgitation, dysphagia, presence of esophagitis, percentage of total time at pH < 4, symptom index score (SI), the SF-36 and HRQL scores before treatment, at 6 months and 1 year could affect the QoL questionnaires scores at the end of the study. RESULTS: One hundred forty-seven patients were included in the surgical group and 154 in the medical group. No differences with regard to gender, age, mean SF-36 and HRQL scores before treatment were documented. At the end of the study, quality of life was significantly improved for SF-36 and HRQL scores, either for surgical or medical group. The multivariate analysis showed no factors individually affected the SF-36 and the HRQL scores, but symptom index score (SI) and QoL questionnaires scores at 6 months and 1 year follow-up. CONCLUSIONS: The combined use of pHmetry with evaluation of SI and QoL questionnaires can predict the outcome of GERD patients managed either by medical or surgical therapy.

Total thyroidectomy with harmonic scalpel combined to gelatin-thrombin matrix hemostatic agent: is it safe and effective? A single-center prospective study.

INTRODUCTION: Hemostasis during thyroidectomy is essential; however, the safest, most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with combination of harmonic scalpel (HS) and Floseal. METHODS: Patients undergone TT were divided into two groups: HS + Floseal and traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates. RESULTS: Between September 2012 and January 2014, 165 patients were enrolled (100 to HS + Floseal, 65 to standard hemostasis); 80.5% female; mean age 42.3 years. The 24-h drain output was lower in the HS + Floseal group compared with standard TT. HS + Floseal also had a shorter mean surgery time (p < 0.0001) vs standard TT. No differences in post-surgical complications and in hypocalcemiarates between groups. CONCLUSION: combination of Floseal plus the HS is effective and safe for TT and it provides a complementary hemostatic approach.