Comparative study of laparoscopic ventral mesh rectopexy versus perineal stapler resection for external full-thickness rectal prolapse in elderly patients: enhanced outcomes and reduced recurrence rates-a retrospective cohort study.

BACKGROUND: In elderly patients with external full-thickness rectal prolapse (EFTRP), the exact differences in postoperative recurrence and functional outcomes between laparoscopic ventral mesh rectopexy (LVMR) and perineal stapler resection (PSR) have not yet been investigated. METHODS: We conducted a retrospective multicenter study on 330 elderly patients divided into LVMR group (n = 250) and PSR (n = 80) from April 2012 to April 2019. Patients were evaluated before and after surgery by Wexner incontinence scale, Altomare constipation scale, and patient satisfaction questionnaire. The primary outcomes were incidence and risk factors for EFTRP recurrence. Secondary outcomes were postoperative incontinence, constipation, and patient satisfaction. RESULTS: LVMR was associated with fewer postoperative complications (p < 0.001), lower prolapse recurrence (p < 0.001), lower Wexner incontinence score (p = 0.03), and lower Altomare's score (p = 0.047). Furthermore, LVMR demonstrated a significantly higher surgery-recurrence interval (p < 0.001), incontinence improvement (p = 0.019), and patient satisfaction (p < 0.001) than PSR. Three and 13 patients developed new symptoms in LVMR and PSR, respectively. The predictors for prolapse recurrence were LVMR (associated with 93% risk reduction of recurrence, OR 0.067, 95% CI 0.03-0.347, p = 0.001), symptom duration (prolonged duration was associated with an increased risk of recurrence, OR 1.131, 95% CI 1.036-1.236, p = 0.006), and length of prolapse (increased length was associated with a high recurrence risk (OR = 1.407, 95% CI = 1.197-1.655, p < 0.001). CONCLUSIONS: LVMR is safe for EFTRP treatment in elderly patients with low recurrence, and improved postoperative functional outcomes. TRIAL REGISTRATION: Clinical Trial.gov (NCT05915936), retrospectively registered on June 14, 2023.

Nationwide analysis of open groin hernia repairs in Italy from 2015 to 2020.

INTRODUCTION: Inguinal hernia repair is one of the most commonly performed operations in general surgery. A total of 130.000 inguinal hernia repairs are performed yearly in Italy, and approximately 20 million inguinal hernias are treated worldwide annually. This report represents the trend analysis in inguinal hernia repair in Italy from a nationwide dataset for the 6-year period from 2015 to 2020. MATERIALS AND METHODS: Based on regional hospital discharge records, all the inguinal hernia repairs performed in public and private hospitals in Italy between 2015 and 2020 were reviewed based on diagnosis and procedure codes. For the aim of this study, data from the AgeNas (The National Agency for Regional Health Services) data source were analyzed. RESULTS: Elective inguinal hernia repairs outnumbered urgent operations over the 6-year study period, ranging from 122,737 operations in 2015 to 65,780 in 2020 as absolute numbers, and from 87.96 to 83.3% of total procedures in 2019 and 2020 respectively, with an annual change ranging from - 66.58%, between 2020 and 2019, to - 2.49%, between 2019 and 2018 (mean = - 18.74%; CI =- 46.7%-9.22%; p < 0.0001). CONCLUSIONS: This large-scale review of groin hernia data from a nationwide Italian dataset provides a unique opportunity to obtain a snapshot of open groin hernia repair activity. More specifically, there is a trend to perform more elective than urgent procedures and there is a steady decrease in the amount of open hernia repairs in favor to laparoscopy.

Factors influencing delayed discharge after day-surgery laparoscopic cholecystectomy: the DeDiLaCo study protocol.

OBJECTIVE: Laparoscopic cholecystectomy (LC) is the gold standard for most benign gallbladder diseases. Early discharge (<24 hours) has the same outcomes as longer (>24 hours) hospital stay. Nevertheless, the rate of delayed discharge >24 hours range from 4.6% to 37%. The primary endpoint of this Italian nationwide study is to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge >24 hours and identify potential limiting factors of early discharge. Results from these analyses will be used to select patients who can be safely discharged on the same day after surgery. Secondary endpoints will be to evaluate the patient's quality of life (QoL), assess the direct health costs associated with late discharge, and quantify the patient's involvement in the treatment process. PATIENTS AND METHODS: This prospective, observational study was conducted following a resident-led model and the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. All patients were treated according to the local hospital protocol and received routine care as standard therapy. RESULTS: We expected to obtain the enrollment of at least 500 patients based on an assumed difference in discharge delay between the reference and the recruitable population of 6% and the identification of factors related to discharge failure within 24 h. Early discharge after LC leads to advantages both in terms of clinical outcomes and quality of life of the patient, and it is highly effective in terms of health costs and shortening the waiting list. However, clinical reality differs from the results of randomized studies by a complex series of non-objectionable real-world data influencing treatment plans. Therefore, we expected to identify independent predictors and factors of failure of early discharge. CONCLUSIONS: Clinical reality often differs from randomized trial results. In Italy, the vast majority of delayed discharges after LC may not be related to surgery and can be prevented both with logistical reorganization and with a readjustment of the trust reimbursement policies.

Self-management-competency as a new target in Hidradenitis suppurativa care.

Background: Hidradenitis suppurativa affects approximately 1% of the population.Objective: Highlighting the relevance of self-management-competency as a new therapeutic target.Method: 258 patients from the 'Epidemiology and Care in Acne inversa (EpiCAi)' project were included in the study. Disease burden was measured by patient-rated questionnaires in terms of disease activity, pain, quality of life, depression and insomnia and correlated with the domains of the health education impact questionnaire (heiQ) measuring self-management-competency.Results: 66 male (25.6%) and 192 female (74.4%) patients, with a mean age of 40.3 ± 10.24 years were included. Mean scores of pain on the numeric rating scale (NRS), Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS) were 5.11 ± 2.68, 11.35 ± 7.79 and 13.71 ± 7.57, respectively. The Insomnia severity index (ISI) showed a mean of 9.58 ± 5.76. The HADS has the highest increased total risk across all heiQ domains. With respect to the heiQ domains, the highest exposure can be attributed to improving constructive attitudes and approaches as well as decreasing emotional distress.Conclusion: There is a clear association of self-management-competency with overall disease burden, which underlines the need for psychoeducational support. This study provides ideas to develop new possible strategies of care.

Exploring the link between poor oral hygiene and mesh infection after hernia repair: a systematic review and proposed best practices.

BACKGROUND: There is a reasonable body of evidence around oral/dental health and implant infection in orthopaedic and cardiovascular surgery. Another large area of surgical practice associated with a permanent implant is mesh hernia repair. This study aimed to review the evidence around oral/dental health and mesh infection. METHODS: The research protocol was registered in PROSPERO (CRD42022334530). A systematic review of the literature was undertaken according to the PRISMA 2020 statement. The initial search identified 582 publications. A further four papers were identified from references. After a review by title and abstract, 40 papers were read in full text. Fourteen publications were included in the final review, and a total of 47,486 patients were included. RESULTS: There is no published evidence investigating the state of oral hygiene/health and the risk of mesh infection or other infections in hernia surgery. Improvement in oral hygiene/health can reduce surgical site infection and implant infection in colorectal, gastric, liver, orthopaedic and cardiovascular surgery. Poor oral hygiene/health is associated with a large increase in oral bacteria and bacteraemia in everyday activities such as when chewing or brushing teeth. Antibiotic prophylaxis does not appear to be necessary before invasive dental care in patients with an implant. CONCLUSION: Good oral hygiene and oral health is a strong public health message. The effect of poor oral hygiene on mesh infection and other complications of mesh hernia repair is unknown. While research is clearly needed in this area, extrapolating from evidence in other areas of surgery where implants are used, good oral hygiene/health should be encouraged amongst hernia patients both prior to and after their surgery.

Laparoscopic approach in emergency for the treatment of acute incarcerated groin hernia: a systematic review and meta-analysis.

PURPOSE: Minimally invasive approach for acute incarcerated groin hernia repair is still debated. To clarify this debate, a literature review was performed. METHODS: Search was performed in PubMed, Embase, Scopus, Web of Science, and Cochrane databases, founding 28,183 articles. RESULTS: Fifteen articles, and 433 patients were included (16 bilateral hernia, range 3-8). Three hundred and eighty-eight (75.3%) and 103 patients (22.9%) underwent transabdominal preperitoneal and totally extraperitoneal repair, respectively, and in 5 patients, the defect was buttressed with broad ligament (1.1%) (not specified in 3 patients). Herniated structures were resected in 48 cases (range 1-9). Intraoperative complications and conversion occurred in 4 (range 0-1) and 10 (range 0-3) patients, respectively. Mean operative time and hospital stay ranged between 50 and 147 min, and 2 and 7 days, respectively. Postoperative complications ranged between 1 and 19. Five studies compared laparoscopic and open approaches (163 and 235 patients). Herniated structures were resected in 19 (11.7%) and 42 cases (17.9%) for laparoscopic and open approach, respectively (p = 0.1191). Intraoperative complications and conversion occurred in one (0.6%) and 5 (2.1%) patients (p = 0.4077), and in two (1.2%) and 19 (8.1%) patients (p = 0.0023), in case of laparoscopic or open approach, respectively. Mean operative time and hospital stay were 94.4 ± 40.2 and 102.8 ± 43.7 min, and 4.8 ± 2.2 and 11 ± 3.1 days, in laparoscopic or open approach, respectively. Sixteen (9.8%) and 57 (24.3%) postoperative complications occurred. CONCLUSION: Laparoscopy seems to be a safe and feasible approach for the treatment of acute incarcerated groin hernia. Further studies are required for definitive conclusions.

[Hidradenitis suppurativa /acne inversa-surgical options, reconstruction and combinations with drug therapies-an update]. / Hidradenitis suppurativa/Acne inversa ­ operative Optionen, Rekonstruktionen und Kombinationen mit medikamentösen Therapien ­ Ein Update.

Hidradenitis suppurativa/acne inversa (HS/AI) is a chronic inflammatory skin disease whose treatment includes both conservative and surgical treatment options. In Hurley stages II and III, surgical resection of irreversibly destroyed tissue should be the objective. For this purpose several resection techniques exist, which differ primarily with regard to their invasiveness and tendency to recur. To date, there is no generally accepted consensus on the use of different resection and reconstruction techniques or the inclusion of drug therapies in the overall therapeutic concept.

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study.

BACKGROUND: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. METHODS: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. RESULTS: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. CONCLUSION: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2.

ANTECEDENTES: Las estrategias quirúrgicas están siendo adaptadas en presencia de la pandemia de la COVID-19. Las recomendaciones del tratamiento de la apendicitis aguda se han basado en la opinión de expertos, pero hay muy poca evidencia disponible. Este estudio abordó este aspecto a través de una visión de los enfoques mundiales de la cirugía de la apendicitis. MÉTODOS: La Asociación de Cirujanos Italianos en Europa (ACIE) diseñó una encuesta electrónica en línea para evaluar la actitud actual de los cirujanos a nivel mundial con respecto al manejo de pacientes con apendicitis aguda durante la pandemia. Las preguntas se dividieron en información basal, organización del hospital y cribaje, equipo de protección personal, manejo y abordaje quirúrgico, así como las características de presentación del paciente antes y durante de la pandemia. Se utilizó una prueba de ji al cuadrado para las comparaciones. RESULTADOS: De 744 respuestas, se habían completado 709 (66 países) cuestionarios, los datos de los cuales se incluyeron en el estudio. La mayoría de los hospitales estaban tratando a pacientes con y sin COVID. Hubo variabilidad en las indicaciones de cribaje de la COVID-19 y en la modalidad utilizada, siendo la tomografía computarizada (CT) torácica y el análisis molecular (PCR) (18,1%) las pruebas utilizadas con más frecuencia. El tratamiento conservador de la apendicitis complicada y no complicada se utilizó en un 6,6% y un 2,4% antes de la pandemia frente a un 23,7% y un 5,3% durante la pandemia (P < 0.0001). Un tercio de los encuestados cambió la cirugía laparoscópica a cirugía abierta debido a las recomendaciones de los grupos de expertos (pero carente de evidencia científica) durante la fase inicial de la pandemia. No hubo acuerdo en cómo filtrar el humo generado por la laparoscopia. Hubo una reducción general del número de pacientes ingresados con apendicitis y un tercio consideró que los pacientes atendidos presentaban una apendicitis más grave que las comúnmente observadas. CONCLUSIÓN: La pandemia ha demostrado que ha sido posible el tratamiento conservador de la apendicitis leve. El hecho de que algunos cirujanos cambiaran a una apendicectomía abierta podría ser el reflejo de las pautas deficientes que se propusieron en la fase inicial del SARS-CoV2.

Adhesive Small Bowel Obstruction and the six w's: Who, How, Why, When, What, and Where to diagnose and operate?

BACKGROUND AND AIMS: Approximately 75% of patients admitted with small bowel obstruction have intra-abdominal adhesions as their cause (adhesive small bowel obstruction). Up to 70% of adhesive small bowel obstruction cases, in the absence of strangulation and bowel ischemia, can be successfully treated with conservative management. However, emerging evidence shows that surgery performed early during the first episode of adhesive small bowel obstruction is highly effective. The objective of this narrative review is to summarize the current evidence on adhesive small bowel obstruction management strategies. MATERIALS AND METHODS: A review of the literature published over the last 20 years was performed to assess Who, hoW, Why, When, What, and Where diagnose and operate on patients with adhesive small bowel obstruction. RESULTS: Adequate patient selection through physical examination and computed tomography is the key factor of the entire management strategy, as failure to detect patients with strangulated adhesive small bowel obstruction and bowel ischemia is associated with significant morbidity and mortality. The indication for surgical exploration is usually defined as a failure to pass contrast into the ascending colon within 8-24 h. However, operative management with early adhesiolysis, defined as operative intervention on either the calendar day of admission or the calendar day after admission, has recently shown to be associated with an overall long-term survival benefit compared to conservative management. Regarding the surgical technique, laparoscopy should be used only in selected patients with an anticipated single obstructing band, and there should be a low threshold for conversion to an open procedure in cases of high risk of bowel injuries. CONCLUSION: Although most adhesive small bowel obstruction patients without suspicion of bowel strangulation or gangrene are currently managed nonoperatively, the long-term outcomes following this approach need to be analyzed in a more exhaustive way, as surgery performed early during the first episode of adhesive small bowel obstruction has shown to be highly effective, with a lower rate of recurrence.

Should enhanced recovery after surgery (ERAS) pathways be preferred over standard practice for patients undergoing abdominal wall reconstruction? A systematic review and meta-analysis.

PURPOSE: Although many studies assessing enhanced recovery after surgery (ERAS) pathways in abdominal wall reconstruction (AWR) have recently demonstrated lower rates of postoperative morbidity and a decrease in postoperative length of stay compared to standard practice, the utility of ERAS in AWR remains largely unknown. METHODS: A systematic literature search for randomized and non-randomized studies comparing ERAS (ERAS +) pathways and standard protocols (Control) as an adopted practice for patients undergoing AWR was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and EMBASE databases. A predefined search strategy was implemented. The included studies were reviewed for primary outcomes: overall postoperative morbidity, abdominal wall morbidity, surgical site infection (SSI), and length of hospital stay; and for secondary outcome: operative time, estimated blood loss, time to discontinuation of narcotics, time to urinary catheter removal, time to return to bowel function, time to return to regular diet, and readmission rate. Standardized mean difference (SMD) was calculated for continuous variables and Odds Ratio for dichotomous variables. RESULTS: Five non-randomized studies were included for qualitative and quantitative synthesis. 840 patients were allocated to either ERAS + (382) or Control (458). ERAS + and Control groups showed equivalent results with regard to the incidence of postoperative morbidity (OR 0.73, 95% CI 0.32-1.63; I2= 76%), SSI (OR 1.17, 95% CI 0.43-3.22; I2= 54%), time to return to bowel function (SMD - 2.57, 95% CI - 5.32 to 0.17; I2= 99%), time to discontinuation of narcotics (SMD - 0.61, 95% CI - 1.81 to 0.59; I2= 97%), time to urinary catheter removal (SMD - 2.77, 95% CI - 6.05 to 0.51; I2= 99%), time to return to regular diet (SMD - 0.77, 95% CI - 2.29 to 0.74; I2= 98%), and readmission rate (OR 0.82, 95% CI 0.52-1.27; I2= 49%). Length of hospital stay was significantly shorter in the ERAS + compared to the Control group (SMD - 0.93, 95% CI - 1.84 to - 0.02; I2= 97%). CONCLUSIONS: The introduction of an ERAS pathway into the clinical practice for patients undergoing AWR may cause a decreased length of hospitalization. These results should be interpreted with caution, due to the low level of evidence and the high heterogeneity.

Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization - systematic review and recommendations from the HS ALLIANCE working group.

Hidradenitis suppurativa (HS)/acne inversa is a debilitating chronic disease that remains poorly understood and difficult to manage. Clinical practice is variable, and there is a need for international, evidence-based and easily applicable consensus on HS management. We report here the findings of a systematic literature review, which were subsequently used as a basis for the development of international consensus recommendations for the management of patients with HS. A systematic literature review was performed for each of nine clinical questions in HS (defined by an expert steering committee), covering comorbidity assessment, therapy (medical, surgical and combinations) and response to treatment. Included articles underwent data extraction and were graded according to the Oxford Centre for Evidence-based Medicine criteria. Evidence-based recommendations were then drafted, refined and voted upon, using a modified Delphi process. Overall, 5310 articles were screened, 171 articles were analysed, and 65 were used to derive recommendations. These articles included six randomized controlled trials plus cohort studies and case series. The highest level of evidence concerned dosing recommendations for topical clindamycin in mild disease (with systemic tetracyclines for more frequent/widespread lesions) and biologic therapy (especially adalimumab) as second-line agents (following conventional therapy failure). Good-quality evidence was available for the hidradenitis suppurativa clinical response (HiSCR) as a dichotomous outcome measure in inflammatory areas under treatment. Lower-level evidence supported recommendations for topical triclosan and oral zinc in mild-to-moderate HS, systemic clindamycin and rifampicin in moderate HS and intravenous ertapenem in selected patients with more severe disease. Intralesional or systemic steroids may also be considered. Local surgical excision is suggested for mild-to-moderate HS, with wide excision for more extensive disease. Despite a paucity of good-quality data on management decisions in HS, this systematic review has enabled the development of robust and easily applicable clinical recommendations for international physicians based on graded evidence.