Surgical management of ostomy complications: a MISSTO-WSES mapping review.

BACKGROUND: The creation of an ileostomy or colostomy is a common surgical event, both in elective and in emergency context. The main aim of stoma creation is to prevent postoperative complications, such as the anastomotic leak. However, stoma-related complications can also occur and their morbidity is not negligible, with a rate from 20 to 70%. Most stomal complications are managed conservatively, but, when this approach is not resolutive, surgical treatment becomes necessary. The aim of this mapping review is to get a comprehensive overview on the incidence, the risk factors, and the management of the main early and late ostomy complications: stoma necrosis, mucocutaneous separation, stoma retraction, stoma prolapse, parastomal hernia, stoma stenosis, and stoma bleeding. MATERIAL AND METHODS: A complete literature research in principal databases (PUBMED, EMBASE, SCOPUS and COCHRANE) was performed by Multidisciplinary Italian Study group for STOmas (MISSTO) for each topic, with no language restriction and limited to the years 2011-2021. An international expert panel, from MISSTO and World Society of Emergency Surgery (WSES), subsequently reviewed the different issues, endorsed the project, and approved the final manuscript. CONCLUSION: Stoma-related complications are common and require a step-up management, from conservative stoma care to surgical stoma revision. A study of literature evidence in clinical practice for stoma creation and an improved management of stoma-related complications could significantly increase the quality of life of patients with ostomy. Solid evidence from the literature about the correct management is lacking, and an international consensus is needed to draw up new guidelines on this subject.

Surgical management of urinary diversion and stomas in adults: multidisciplinary Italian panel guidelines.

INTRODUCTION: Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about this topic. Therefore, clear, and comprehensive clinical guidelines based on evidence-based data and best practice are needed. The aim of this article was to elaborate guidelines for practice management of urinary stomas in adults. EVIDENCE ACQUISITION: Experts guided review of the literature was performed in PubMed, National Guideline Clearing-house and other databases (updated March 31, 2018). The research included guidelines, systematic reviews, meta-analysis, randomized clinical trials, cohort studies and case reports. Five main topics were identified: "stoma preparation," "stoma creation," "stoma complications," "stoma care" and "stoma reversal." The systematic review was performed for each topic and studies were evaluated according to the GRADE system, AGREE II tool. Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low level of scientific evidence statements a consensus conference composed by expert members of the major Italian scientific societies in the field of stoma management and care was performed. EVIDENCE SYNTHESIS: After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines with definitive recommendations was elaborated and prepared for publication. This manuscript is focused on statements about surgical management of urinary stomas. These guidelines include recommendations for adult patients only, articles published in English or Italian and with complete text available. CONCLUSIONS: These guidelines represent the first Italian guidelines about urinary stoma multidisciplinary management with the aim to assist urologists and stoma specialized nurses during the urinary stoma management and care.

Italian Guidelines for the Nursing Management of Enteral and Urinary Stomas in Adults: An Executive Summary.

PURPOSE: This article is an executive summary of Italian guidelines for nursing management of enteral and urinary ostomies in adults. METHODS: Scoping review and generation of evidence and consensus-based clinical guidelines. SEARCH STRATEGY: The Multidisciplinary Italian Study group for STOmas (MISSTO) was founded in 2018. This group created guidelines for management of enteral and urinary ostomies in adults based on a scoping review of the literature. The research included previous guidelines, systematic reviews, meta-analyses, randomized clinical trials, cohort studies, and case reports. Five main topics were identified: "stoma preparation," "stoma creation," "stoma complications," "stoma care," and "stoma reversal" (for enteral stomas)." All the studies were evaluated according to the GRADE system and AGREE II tool. Recommendations were elaborated in the form of statements, with an established grade of recommendation for each statement. For low levels of scientific evidence statements, a consensus conference composed of expert members of the major Italian scientific societies in the field of stoma management and care discussed, corrected, validated, or eliminated the statements. A final version of the guidelines with definitive recommendations was elaborated and prepared for publication. FINDINGS/CONCLUSIONS: This document represents the first Italian guidelines on enteral and urinary stoma management to assist nurses caring for persons with an enteral or urinary ostomy.

Laparoscopic Management of Internal Hernia After Roux-en-Y Gastric Bypass.

INTRODUCTION: Internal hernia (IH) represents the most common cause of small-bowel obstruction after laparoscopic RYGBP. The anatomic changes resulting from RYGBP, the use of laparoscopy, and the postoperative weight loss all account for the high incidence of IH after this procedure. As the symptoms may be very vague, the interpretation of the clinical picture may result difficult. Moreover, laparoscopic treatment of IH could be very challenging for surgeons not familiar with the modified intestinal anatomy of the RYGBP. METHODS: The video shows the management of an IH at the Petersen's defect. A 51-year-old female was assessed for recurrent abdominal pain 3 years after a RYGBP. A CT scan showed the mesenteric swirl sign, so a diagnostic laparoscopy was performed. The video first shows the identification of the herniated bowel through the mesenteric defect. Then, complete reduction of the IH and the closure of the Petersen's defect are shown. RESULTS: The total operative time was 35 min. The postoperative stay was uneventful and the patient was discharged in postoperative day one. CONCLUSION: In case of clinical suspicion of IH, even in case of normal laboratory and radiological findings, a surgical exploration is indicated.

Laparoscopic Conversion of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass for Chronic Bile Reflux.

BACKGROUND: One anastomosis gastric bypass (OAGB) demonstrated similar results to traditional Roux-en-Y procedures. A possible concern is how to manage a chronic bile reflux when medical therapy results ineffective. Revision of the gastro-jejunal anastomosis, obtaining a Roux-en-Y reconstruction, has already been proposed, but technical details have not been elucidated yet. This video shows how to revise a 200-cm OAGB to treat chronic bile reflux, by converting the procedure to Roux-en-Y, having a short gastric pouch and a long efferent limb. METHODS: A 51-year-old patient complained of recurrent heartburns 2 months after OAGB. A gastroscopy witnessed the presence of a 6-cm long gastric pouch with pouchitis and bile reflux in esophagus. Specific medications were ineffective. He underwent a revisional laparoscopic procedure. The efferent limb was measured and consisted of 650 cm. The afferent limb was then divided next to the previous gastro-jejunal anastomosis and a jejuno-jejunal anastomosis was performed distally at 70 cm on the alimentary limb. RESULTS: Total operative time was 50 min. The postoperative stay was uneventful and the patient was discharged in postoperative day four. At 6 months follow-up he is still free of medications without symptoms. CONCLUSIONS: The ideal scenario for the presented technique is the finding of a long efferent limb, in order to fashion a Roux-en-Y limb without the risk of postoperative malabsorption. To reach this goal, we suggest the measurement of the whole small bowel intra-operatively, in order to assess the length of the common channel left in place.

Psychopathological similarities and differences between obese patients seeking surgical and non-surgical overweight treatments.

PURPOSE: To compare the psychopathological characteristics of obese patients seeking bariatric surgery with those seeking a medical approach. METHODS: A total of 394 consecutive outpatients seeking bariatric surgery were compared with 683 outpatients seeking a medical treatment. All patients were referred to the same institution. RESULTS: Obesity surgery patients reported higher body mass index (BMI), objective/subjective binging and more severe general psychopathology, while obesity medical patients showed more eating and body shape concerns. Depression was associated with higher BMI among obesity surgery clinic patients, whereas eating-specific psychopathology was associated with higher BMI and objective binge-eating frequency among obesity medical clinic patients. CONCLUSIONS: Patients seeking bariatric surgery showed different psychopathological features compared with those seeking a non-surgical approach. This suggests the importance for clinicians to consider that patients could seek bariatric surgery on the basis of the severity of the psychological distress associated with their morbid obesity, rather than criteria only based on clinical indication.

Age as a predictive factor of testosterone improvement in male patients after bariatric surgery: preliminary results of a monocentric prospective study.

BACKGROUND: Male obesity can be associated with symptomatic alterations in sex hormones resulting in hypogonadism and impaired fertility. Surgical-induced weight loss can improve the sex hormone profile in men. The aim of the present study is to evaluate the levels of sex hormones in obese males before and after 6 months from bariatric surgery. Possible mechanisms and clinical implications are also discussed. METHODS: We evaluated levels of serum total testosterone (TT), sex hormone-binding globulin (SHBG), calculated free testosterone (cFT), follicular-stimulating hormone (FSH), luteinizing hormone (LH), and total estradiol (E2) in 20 male patients at the baseline and 6 months after bariatric surgery. RESULTS: Median [interquartile range] age at the time of surgery was 40.5 [27.2-46.7] years with a median [interquartile range] BMI of 43.6 [40.9-48.7] kg/m(2). The median baseline levels of TT, SHBG, cFT, LH, and FSH were reduced; levels of E2 were elevated. At 6 months from surgery, the median BMI dropped to 34.8 [31.7-40.5] kg/m(2), TT, SHBG, cFT, LH, and FSH increased, while levels of E2 decreased. The improvement in the sex hormone profile was more evident in younger patients, with a statistically significant difference in cFT following surgery and in the raise of TT and cFT between the groups of patients below and above 35 years. At multivariate analysis, the age was the best predictive factor of the postoperative variations of TT. CONCLUSIONS: These preliminary results confirm the general improvement in sex hormone profile in obese men after bariatric surgery and introduce the age as a possible contributing factor to this improvement.

A multicentric Western analysis of prognostic factors in advanced, node-negative gastric cancer patients.

BACKGROUND: The presence of lymph node metastasis is one of the most important prognostic factors in patients with gastric carcinoma. Node-negative patients have a better outcome, nevertheless a subgroup of them experience disease recurrence. AIM: To analyze the clinicopathological characteristics of lymph node-negative advanced gastric carcinoma patients submitted to gastrectomy and D2 lymphadenectomy with a retrieved number of nodes greater than 15, after an actual follow-up of almost 5 years, and to evaluate outcome indicators. STUDY DESIGN: The records of 301 patients who underwent curative gastrectomy for gastric carcinoma and were adequately staged as N0 between 1992 and 2002 were retrospectively analyzed from the prospectively collected database of 7 centers participating to the Italian Research Group for Gastric Cancer. RESULTS: Disease-specific and disease-free survival after 3, 5, and 10 years were 90.4%, 86.1%, 75.9%, and 72.1%, 57.3%, 57.3%, respectively. Mortality was 1.7%. The factors associated with a better disease-free survival at univariate analysis were age <60, T2 tumors, distal location, intestinal histotype, and number of retrieved nodes >25; depth of infiltration and histotype were the only 2 independent predictors of 5-year recurrence-free survival at multivariate analysis. CONCLUSION: These parameters must be considered to stratify node-negative gastric cancer patients for an adjuvant treatment and follow-up scheduling. Survival was similar to that previously reported by Eastern Centers. Lymphadenectomy is suggested to be effective, and retrieval of more than 25 nodes may be warranted.