Hemorrhoidal Artery Ligation for the Treatment of Grade II-III Hemorrhoids: Is it Worth the Use of Doppler Guide in Long-Term Follow-Up?: A Single-Center Cohort Study.

Background: Hemorrhoidal artery ligation (HAL) may reduce postoperative pain and complications and shorten patients' recovery when compared to standard hemorrhoidectomy. It is unclear if the Doppler guide (DG) is useful in reducing recurrence risk. Objective: To compare two groups of patients (treated with DG-HAL or HAL) in terms of recurrence risk and patients' satisfaction grade. Methods: Between January 1, 2014 and January 31, 2021, 122 patients affected by grade II-III hemorrhoidal prolapse underwent DG-HAL or HAL at Chivasso Hospital, Italy. Mucopexy was routinely performed. After discharge, patients were subjected to 1-week, 1-, 3-, 6-, and 12-month clinical assessment. Thereafter, they were interviewed by telephone annually. Results: Seventy-six (62.3%) DG-HAL and 46 (37.7%) HAL procedures were performed. Median surgical time was 30 (15-45) minutes for DG-HAL versus 25 (15-40) minutes for HAL (P = 0.005). No intraoperative complications occurred. Postoperative bleeding needing surgery occurred in 2 (1.6%) patients in the DG-HAL group. During a median follow-up of 46 months (6-86), we registered 18 (23.7%) recurrences in the DG-HAL group and 13 (28.3%) in the HAL one (P = 0.574). No cases of incontinence or anal stenosis occurred. No significant difference was observed between the two groups in terms of patients' satisfaction. At multivariate analysis, age ≥ 65 years resulted a protective factor for recurrence (odds ratio 0.31; 95% confidence interval 0.09-0.98; P = 0.047). Conclusions: In our study, the use of DG did not reduce recurrence risk. Operative time was significantly increased in the DG-HAL group.

Outcomes of surgical treatment of diverticular abscesses after failure of antibiotic therapy.

Management of diverticular abscess (DA) is still controversial. Antibiotic therapy is indicated in abscesses ≤ 4 cm, while percutaneous drainage/surgery in abscesses > 4 cm. The study aims to assess the role of antibiotics and surgical treatments in patients affected by DA. We retrospectively analyzed 100 consecutive patients with DA between 2013 and 2020, with a minimum follow-up of 12 months. They were divided into two groups depending on abscess size ≤ or > 4 cm (group 1 and group 2, respectively). All patients were initially treated with intravenous antibiotics. Surgery was considered in patients with generalized peritonitis at admission or after the failure of antibiotic therapy. The primary endpoint was to compare recurrence rates for antibiotics and surgery. The secondary endpoint was to assess the failure rate of each antibiotic regimen resulting in surgery. In group 1, 31 (72.1%) patients were conservatively treated and 12 (27.9%) underwent surgery. In group 2, percentages were respectively 50.9% (29 patients) and 49.1% (28 patients). We observed 4 recurrences in group 1 and 6 in group 2. Recurrence required surgery in 3 patients/group. We administered amoxicillin-clavulanic acid to 74 patients, piperacillin-tazobactam to 14 patients and ciprofloxacin + metronidazole to 12 patients. All patients referred to surgery had been previously treated with amoxicillin-Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation clavulanic acid. No percutaneous drainage was performed in a hundred consecutive patients. Surgical treatment was associated with a lower risk of recurrence in patients with abscess > 4 cm, compared to antibiotics. Amoxicillin-clavulanic acid was associated with a higher therapeutic failure rate than piperacillin-tazobactam/ciprofloxacin + metronidazole.

Surgical rarities: case report of appendicular diverticulitis and literature review.

Appendicular diverticulosis is a rare condition observed in about 0.004-2% of all appendectomy specimens. Risk of perforation/bleeding is high and a relevant association with mucinous neoplasms is known. Appendectomy is indicated even in case of occasional finding. We present the case of a 22-year-old man who entered the Emergency Room for pain in right iliac fossa. Blood tests showed only a slight increase in C-reactive protein. Abdominal ultrasound (US) evidenced an appendix with thickened walls and a rounded fluid-filled hypoechoic lesion at its distal tip. Laparoscopic appendectomy confirmed the presence of mucocele. Postoperative course was uneventful and the patients discharged on postoperative day 3. Histological examination indicated diverticulitis/peridiverticulitis of the appendix and acute suppurative appendicitis. No perforation of the diverticula was detected. No neoplastic epithelium/mucous material was observed. In our case, preoperative US proved to be a useful alternative to computed tomography for the diagnosis.

Robot-assisted minimally invasive esophagectomy (RAMIE) with side-to-side semi-mechanical anastomosis: analysis of a learning curve.

Minimally invasive esophagectomy (MIE) reduces mortality and morbidity related to esophageal surgery, but a long learning curve is necessary due to the technical difficulties of thoracoscopy (35 to 119 patients required as reported in literature). Robot-assisted minimally invasive esophagectomy (RAMIE) with side-to-side semi-mechanical (SM) anastomosis may shorten completion of the learning curve. We present the results of the first 40 RAMIEs performed by a single surgeon with experience in esophageal and minimally invasive surgery. Patients included in this study underwent RAMIE between April 1, 2018 and April 30, 2021. According to the risk-adjusted cumulative sum analysis for postoperative complications, the first 19 patients were compared to the last 21. Pulmonary complications and atrial fibrillation occurred in 2.5% and 5% of cases, respectively. A single case of anastomotic leak in the early group was registered. Thirty-day mortality was 2.5%. R0 resection was obtained in all cases. No anastomotic strictures occurred during the follow-up (median of 20 months). A significant difference between the early group and the late one was observed for median operative time (425 vs 393 min, p = 0.001), estimated intraoperative blood loss (100 vs 50 ml, p = 0.003), Intensive Care Unit stay (days 2 vs 1, p = 0.004), hospital stay (days 13 vs 10, p = 0.007) and number of lymph nodes harvested (17 vs 21, p = 0.020). In conclusion, this study showed RAMIE to be safe and effective even in the early phase of its application. The learning curve resulted shorter than in MIE, with 19 patients needed to gain proficiency in our series.

Case report of mesenteric solitary fibrous tumour and review of the literature: 'once in a blue moon'.

Solitary fibrous tumour (SFT) is a rare mesenchymal tumour, usually originating from the serous surfaces, typically of the pleura and pericardium. However, it can also have localizations in soft tissues and visceral organs. We report the case of a 79-year-old woman affected by mesenteric SFT, localized in the sigmoid colon. We performed open excision of the abovementioned mass en-bloc with the sigmoid colon and left adnexal tissues. Pathological examination of surgical specimen revealed a diagnosis of SFT CD34+, high-risk of metastases. Mesenteric SFTs are even rarer forms of SFT and may be asymptomatic or cause intestinal occlusion. There is no consensus on the management of this tumour. Radical surgical excision is the only curative treatment, while adjuvant therapies are indicated in case of advanced disease. Due to the high metastatic risk of malignant forms, a long follow-up is mandatory in these cases.

Preaponeurotic endoscopic repair (REPA) of diastasis recti: a single surgeon's experience.

BACKGROUND: Diastasis recti is a pathology that affects not only the abdominal wall but also the stability of lumbopelvic muscles, consequently altering urinary and digestive functionality. Preaponeurotic endoscopic repair (REPA) is an endoscopic alternative to tummy tuck for the treatment of diastasis. In this study, the outcomes of REPA application by a single surgeon are presented. METHODS: A total of 172 patients underwent REPA for the treatment of diastasis recti between August 2017 and December 2019. One hundred twenty-four patients were followed for at least one year. Sixty-three patients responded to a survey on satisfaction and quality of life 12 months after surgery. RESULTS: Three (2.4%) recurrences occurred, of which two occurred in the same patient. The main postoperative complications observed were 12 (9.7%) seromas, 3 (2.4%) haematomas, a single wound infection, 3 (2.4%) cases of skin fold formation, and a case of trophic skin lesion that required negative pressure therapy. Quality of life after surgery, as reported by 63 patients who responded to the survey, was satisfactory. CONCLUSIONS: REPA is a safe and effective technique for diastasis recti treatment, representing a valid alternative to abdominoplasty. Since there is no need to access the peritoneal cavity and the mesh is onlay, there are no risks of bowel damage or adhesions between the intestine and prosthesis.

Endoscopic preaponeurotic access for complex ventral hernia repair with sublay mesh and bilateral anterior component separation: A case report.

INTRODUCTION: Minimally invasive techniques are now routine in complex abdominal wall defects repair. Although laparoscopy allows to reduce post-operative pain, promoting a more rapid recovery and shortening hospital stay, it is associated with risk of bowel injury and adhesions development, when intraperitoneal mesh is placed. We report the case of a patient affected by large recurrent incisional hernia, treated with a new hybrid endoscopic approach. PRESENTATION OF CASE: Patient treated with the novel approach is a 53-year-old male, BMI 27, smoker, with epigastric recurrence of incisional hernia and prosthetic fistula. An endoscopic preaponeurotic subcutaneous access was used. Repair with sublay mesh, bilateral anterior component separation and muscular reinsertions was conducted. Three months after surgery, no signs of recurrence were observed and complete functional recovery had been achieved. DISCUSSION: The new technique adopted benefits from all the advantages of minimally invasive surgery, allowing to avoid risks associated with laparoscopic access. Bilateral anterior component separation with muscular reinsertions is the key for tension-free suture. CONCLUSION: To our knowledge, this is the first time that a complex recurrent incisional hernia is repaired with the hybrid technique aforementioned. The approach used is certainly technically challenging, thus requiring a team skilled in the use of laparoscopy. Good outcomes reported are a further demonstration that minimally invasive surgery can be a valid alternative to traditional open techniques for large abdominal wall defects repair.

Patient selection criteria for an effective laparoscopic intraperitoneal ventral hernia repair in day surgery.

The laparoscopic treatment of abdominal wall defects is currently a valid alternative to the open technique, given the possibility to significantly reduce the length of hospital stay and, consequently, to allow its carrying out in a day surgery setting. The comparison between the two methods has also been the subject of a Cochrane meta-analysis performed by Sauerland et al. (Cochrane Database Syst Rev 3: CD007781, 2011), which pointed out how, in spite of many clinical trials indicating the superiority of laparoscopy in terms of invasiveness and postoperative pain control, the quality of evidence is low due to the excessive variability among the different series in terms of reported complications. Moreover, what should be the selection criteria of patients fit for laparoscopic treatment in day surgery is not yet defined. This retrospective study considered 94 patients with primary or recurrent incisional wall hernias treated with laparoscopic technique over a 7-year period of time, from 2011 to 2018. The aim was to define the selection criteria for an effective day surgery laparoscopic treatment, considering as outcome the rate of conversion to ordinary hospitalization (discharge > POD1). Discharge > POD 1 was necessary in 15 cases out of 94 (16%). Concerning this outcome, statistically significant risk factors were ASA score > I (p = 0.022), number of hernia orifices > 1 (p = 0.001), recurrent hernias (p = 0.002) and hernia diameter > 10 cm (p < 0.0001). These factors were confirmed by univariate binary logistic analysis. A stepwise model of multivariate analysis showed as determinants for adverse events ASA score > 1 (OR 5.2, 95% CI 1.1-25.6, p = 0.043) and hernias > 10 cm (OR 7.0, 95% CI 1.1-46.4, p = 0.045). This work highlighted some useful criteria for preoperative selection of patients fit for laparoscopic abdominal wall defects repair in a day surgery setting. In particular, criteria related to a favorable clinical outcome were ASA score < II and a hernia diameter < 10 cm.