From keyhole to sandwich: change in laparoscopic repair of parastomal hernias at a single centre.

BACKGROUND: Nearly 50% of patients with an ostomy will develop a parastomal hernia (PSH). Its repair remains a surgical challenge. Both laparoscopic "modified Sugarbaker" (SB) and Keyhole (KH) repair are currently in use, frequently with unsatisfactory results.''Sandwich Repair'' (SR) may be an alternative to reduce recurrence rates. We present the change of our technique from KH to SR. METHODS: We collected data from all consecutive laparoscopic PSH repairs at our institution from 2004 until now (from 2004 to 2013 treated with KH, from 2014 with SR) and compared the results of the two groups. Primary endpoint was recurrence rate at 1 year. Secondary outcomes were operative time, PO length of hospital stay (LOS), and short and long-term complications. RESULTS: 13 patients underwent SR. Main changes in surgical technique concerned primary defect closure, no stay sutures, use of glue for first mesh fixation, and partial lateral covering of the underlying mesh with a peritoneal flap. Early postoperative course after SR was uneventful and no recurrence at 1 year was recorded. In the KH group (19 patients), short-term complications occurred in two cases (10%), with one parietal hematoma and one case of intensive pain; we had four recurrences at 1 year (21%). LOS was shorter in the SR group (mean 4 days vs 6, p = 0.004). The KH group had 2 (10%) occurrences of chronic seroma and one bowel perforation (5%), while the SR group had one (8%) occurrence of chronic pain. Median follow-up was 26 months (range 13-78) for the SR group and 47 months (12-105) for the KH group. CONCLUSION: SR is safe and effective in expert hands and provides promising preliminary results.

Two-meshes approach in posterior component separation with transversus abdominis release: the IMPACT study (Italian Multicentric Posterior-separation Abdominal Complex hernia Transversus-release).

BACKGROUND: Surgical management of large ventral hernias (VH) has remained a challenge. Various techniques like anterior component separation and posterior component separation (PCS) with transversus abdominis release (TAR) have been employed. Despite the initial success, the long-term efficacy of TAR is not yet comprehensively studied. Authors aimed to investigate the early-, medium-, and long-term outcomes and health-related quality of life (QoL) in patients treated with PCS and TAR. METHODS: This multicenter retrospective study analyzed data of 308 patients who underwent open PCS with TAR for primary or recurrent complex abdominal hernias between 2015 and 2020. The primary endpoint was the rate of hernia recurrence (HR) and mesh bulging (MB) at 3, 6, 12, 24, and 36 months. Secondary outcomes included surgical site events and QoL, assessed using EuraHS-QoL score. RESULTS: The average follow-up was 38.3 ± 12.7 months. The overall HR rate was 3.5% and the MB rate was 4.7%. Most of the recurrences were detected by clinical and ultrasound examination. QoL metrics showed improvement post-surgery. CONCLUSIONS: This study supports the long-term efficacy of PCS with TAR in the treatment of large and complex VH, with a low recurrence rate and an improvement in QoL. Further research is needed for a more in-depth understanding of these outcomes and the factors affecting them.

Using parametric model order reduction for inverse analysis of large nonlinear cardiac simulations.

Predictive high-fidelity finite element simulations of human cardiac mechanics commonly require a large number of structural degrees of freedom. Additionally, these models are often coupled with lumped-parameter models of hemodynamics. High computational demands, however, slow down model calibration and therefore limit the use of cardiac simulations in clinical practice. As cardiac models rely on several patient-specific parameters, just one solution corresponding to one specific parameter set does not at all meet clinical demands. Moreover, while solving the nonlinear problem, 90% of the computation time is spent solving linear systems of equations. We propose to reduce the structural dimension of a monolithically coupled structure-Windkessel system by projection onto a lower-dimensional subspace. We obtain a good approximation of the displacement field as well as of key scalar cardiac outputs even with very few reduced degrees of freedom, while achieving considerable speedups. For subspace generation, we use proper orthogonal decomposition of displacement snapshots. Following a brief comparison of subspace interpolation methods, we demonstrate how projection-based model order reduction can be easily integrated into a gradient-based optimization. We demonstrate the performance of our method in a real-world multivariate inverse analysis scenario. Using the presented projection-based model order reduction approach can significantly speed up model personalization and could be used for many-query tasks in a clinical setting.

Preliminary results of laparoscopic colorectal resections: does surgeon's age influences outcomes?

INTRODUCTION: Several randomized controlled trials demonstrated that laparoscopic colon resection is a safe and effective technique for colon and rectum diseases. In fact mini-invasive procedure required an adequate learning curve to safely perform it. Many studies confirm there is a comparatively long learning curve in laparoscopic surgery, with demonstrable decrease in conversion and complication rates with increasing experience. AIMS OF THE STUDY: In this study we want to demonstrate feasibility of laparoscopic colon resection performed by a junior surgeon, referring to short-term outcomes as primary end point. RESULTS: A total of 163 patients underwent colorectal resections of whom 88 were enrolled in the laparoscopic (LCR) and 75 in the open group, respectively. The mean operative time was 183.4 min in the LCR group and 151.2 min in the open group. The mean number of lymph nodes collected was 21.3 in the LCR group and 22.1 in the open group. 10.5% who underwent LCR developed postoperative complications compared with 16% of open group; this difference was statistically significant. Postoperative death occurred in one patient for each group. CONCLUSIONS: Our study demonstrate that results obtained by an under 35-year-old surgeon, fully trained in laparoscopic surgery but with limited overall experience in colorectal resections, can be at least as good as the ones obtained in open surgery. This seems to be true both in term of intra-postoperative complications as well as for oncological results.

Frailty in major oncologic surgery of upper gastrointestinal tract: How to improve postoperative outcomes.

INTRODUCTION: Certain surgical interventions, especially those involving upper GI tract remain challenging, due to high morbidity and mortality rates. The study of frailty in the surgical population has allowed the identification of those patients with a higher risk of poor postoperative outcomes. There remains a lack of evidence regarding the possibility of improving these results through a preoperative holistic management of the patients. The aim of this study is to evaluate whether preoperative treatment, in carefully selected patients, can improve the outcome following surgery. PATIENTS AND METHODS: Between March 2015 and February 2016 patients affected by malignant tumors of the upper GI tract were enrolled at our Institution for major oncologic surgery. Amongst them, frail patients (Group 1) were identified using a validated scoring system and underwent a multidisciplinary preoperative management plan, composed of nutritional intervention, physical/respiratory enhancement and optimization of ongoing therapy. Short-term postoperative outcomes were then compared with a control group (Group 2) of patients with comparable frailty features and surgical indications, who had undergone surgery in the period from March 2013 to February 2014. RESULTS: 30-days and 3-months mortality, overall and severe complication rates were found to be significantly lower (p < 0.05) in Group 1 (41 patients) when compared with Group 2 (35 patents). No significant differences were recorded for the following outcomes: length of stay, referral to post-discharge institutionalisation and hospital re-admission. DISCUSSION: This study confirms advantages provided by preoperative treatment in frail patients, suggesting a new pathway for the improvement of postoperative outcomes.

Delayed development and rupture of an aortic aneurysm after closed abdominal trauma.

A case is reported of a patient who, following the surgical repair of a lesion of the superior mesenteric artery secondary to a closed abdominal trauma, slowly developed an aneurysm of the abdominal aorta which subsequently ruptured. Surgical management of the aneurysm by aortic graft implantation proved successful.

[Isolated thrombosis of the left brachiocephalic venous trunk]. / Trombosi isolata del tronco venoso brachio-cefalico sinistro.

Only Flower (1976) has reported an isolated obstruction of the left brachiocephalic venous trunk following the observation of a unilateral distension of the left superior jugular vein secondary to compression of the homolateral innominate vein during a type I dissecting aneurysm of the aorta. The rarity of the finding is the reason for the report of two cases of isolated thrombosis of the venous trunk in question observed almost simultaneously some 19 months earlier. In both cases it was possible to identify the aetiopathogenic causes as congenital or acquired constriction of the "aortosternal strait" associated with thrombophilic alteration to the blood coagulation system.

[Doppler ultrasonography in the diagnosis of diseases of the supra-aortic trunks]. / L'ultrasonografia doppler nella diagnostica delle affezioni dei tronchi sovraaortici.

Systematic examination of the upper aortic arch vessels by direct Doppler ultrasonography of the common and internal arteries is proposed, together with calculation of the flow rate, pressure-perfusion index, carotid ratio, and carotid distensibility index on a systematic basis. Obligatory compression movements to evaluate the several supplementary pathways in the case of disease are also recommended to complete the examination.

[Doppler ultrasonic arteriography with colorimetric morpho-function analysis of frequency (Echoflow). Preliminary trials]. / L'arteriografia ultrasonica ad effetto Doppler con analisi colorimetrica morfo-funzionale delle frequenze (Echoflow). Esperienza preliminare.

Doppler arteriography with chromatic frequency analysis is a new and very sound diagnostic method in cases of vascular disease. It can be carried out with apparatus such as the Echoflow (reg'd), a natural development of the Doppler technique ultrasonography. Vessels are shown in red, yellow, or blue, depending on the rate of their intraluminal flow. Surface arteries lying 5-6 cm below the skin and not hidden by bone can be studied. Preliminary results on 23 supra-aortic trunks, 21 lower extremity arterial systems, and 5 upper limb systems are described. The use of the instrument in other situations in also recommended.

[Management of a clinical pathology laboratory using a record system on personal computer data base]. / Gestione del laboratorio di patologia clinica, mediante sistema relazionale in data base su personal computer.

Data collection and processing via a Report System Data Base (dBASE III) is a new method recently implemented on Personal or Microcomputer. The major advantage compared to other systems lies in the possibility of working simultaneously with several open files that interact amongst themselves practically in real time. Procedures and programmes can also be created without the need to convert them to machine language. Management of the Clinical Pathology Laboratory via dBASE III is described. The Data Base Record files were specially created. Data on the necessary alteration in mass storage dimensions are supplied on the basis of the number of tests to be carried out. Preliminary information on the possibility of translating currently used statistical equations through the keyboard are also given. The package produced is absolutely interactive and does not require special training. It may therefore be used easily both by the laboratory doctor and personnel responsible for input and reference.

[Screening and vaccination against hepatitis B among health personnel. Short-term results]. / Screening e vaccinazione anti epatite B in operatori sanitari. Risultati a a breve termine.

In the framework of the campaign for anti-HBV vaccination conducted by the Regione Piemonte, the Mauriziano Hospital in Valenza and the Unità Sanitaria Locale 71, screened and then vaccinated a group of 199 medical workers at risk of HBV. It was found that the infection was asymptomatic in the vaccinated subjects (16%) and the chronic HBsAg carriers (1.5%), that the risk of infection increases with age (p less than 0.01) and length of service (p less than 0.05) and that there is a connection with the mean figures produced by other studies conducted on hospital staff. Vaccination gave satisfactory results, with protective antibody responses in 87% of the cases, of whom about half presented levels over 1000 mIU/ml and no significant side effects.

[Automation of ambulatory Doppler color echocardiography using a relational data base in a personal computer]. / Automatizzazione dell'Ambulatorio di ecocardiografia Doppler-color mediante sistema relazionale in database su personal computer.

Office automation in echocardiography is necessary linked to the need of speeding up the reporting which is generally done, to date, in a subsequent phase and it is time consuming With the present work we suggest a software made with the dBASE III Plus applied package, on a PS/2 IBM computer which makes it possible to quickly calculate the bodily surface and at the same time having instantaneous presentation of the normality ranges of the cardiac structures, of the myocardiac kinesis and the Doppler-color appraisal of valvular flows. The speed of reporting is greatly increased and all the data taken make up a database standardized for future statistical elaborations, besides providing an electronic file of echocardiographical reports.

[Massive intestinal hemorrhage caused by leiomyoma of the jejunum. Report of a case]. / Emorragia intestinale massiva da leiomioma del digiuno. Descrizione di un caso.

Small-bowel leiomyoma is a rare tumour. The authors report a case complicated by severe bleeding. Esophagus-gastro-duodenal endoscopy was not decisive enough, while TC was the most reliable instrumental investigation. Because of dimensions basic than 10 cm, the presence of a pseudocapsule end the absence of cariokinetic figures, the histopathologic test supports the hypothesis that it was a benign disease. One year follow-up, negative for relapse, confirm that the lesion is benign.

[Reconstruction of the breast: critical evaluation of surgical technics]. / La ricostruzione della mammella: valutazione critica delle tecniche chirurgiche.

After reviewing the reasons for the increasingly widespread practice of breast reconstruction, the authors describe at some length the most reliable surgical techniques available and, on the basis of the results obtained, suggest an even broader range of indications for this type of surgical therapy.

[Papillomas and papillomatosis of the breast: clinical, diagnostic and therapeutic implications]. / I papillomi e la papillomatosi mammaria: implicazioni cliniche, diagnostiche e terapeutiche.

The authors describe the different clinical and histologic features of solitary papilloma, multiple papillary lesions and diffused papillomatosis, and point out the different surgical approach in the three forms described.

[Phyllode tumor of the breast: clinico-surgical implications]. / Il tumore filloide della mammella: implicazioni clinico-chirurgiche.

The authors illustrate the peculiar features of breast "phylloid cystosarcoma", and analyse its features of benignity and eventual sarcomatous transformation; moreover, they, point out the different types of surgical treatment.

[Femoro-femoral crossover bypass in monolateral obstructions of the iliac artery]. / Il bypass femoro-femorale cross over nelle ostruzioni monolaterali dell'arteria iliaca.

The Authors report the result of their ten-years experience with femoro-femoral crossover bypass in 26 patients affected with unilateral occlusion of the iliac artery. This bypass is an easy and quick procedure, useful in both short and long term. The patency rate after 58 months is 84.6%. Thus, its use indicated in a high number of patients, not only for a limb salvage treatment of a disabling claudication. The indications for this bypass can be extended to low surgical risk subjects, and it does not have to be considered only for the high-risk patients, instead of major surgery procedure on the aorto-iliac axis. The minimal necessary conditions of the limbs for performing the femoro-femoral crossover bypass are a pressure gradient of 35 mmHg and the angiographical demonstration of the unilateral occlusion. If the contralateral axis appears patent, but there are also multiple atherosclerotic sites, we consider other bypasses as therapeutical choices: aorto-bifemoral, ilio-femoral and the femoro-femoral cross-over itself; in the latter case we previously perform a transluminal angioplasty or an endarterectomy of the donor iliac artery. In these situations is essential to evaluate of the benefit/risk rate for every single patient.

[Carotid surgery and its monitoring in our experience]. / La chirurgia carotidea e il suo monitoraggio nella nostra esperienza.

Carotid endarterectomy (CEA) is the elective surgical procedure to prevent stroke due to stenosis of the carotid bifurcation. During a period of 17 years the Authors performed 215 operations on the carotid arteries of 168 patients. The average age was 64.6 and the male/female ratio was 3/1. Patients were symptomatic in 75.8% of cases and asymptomatic in the remaining 24.2%. Preoperative investigations consisted of echo-Duplex scanning, arteriography, cerebral CT or MRI. Indications for surgery were: stenosis wider than 70% in 173 cases, ulcerated or "high-risk" stenosis in symptomatic patients in 37 cases, and carotid malformation in 5 cases. The intraoperative use of shunt (12% of the operations) was selective, depending from the results of our monitoring system: stump pressure and transcranial Doppler (TCD) of the middle cerebral artery (MCA) ipsilateral to the procedure. The global major stroke/mortality rate was 3.3% (7/215), the minor morbidity was 8.8% (19/215). Mortality rate was 0.5% (1/215). The major stroke/mortality rate for symptomatic patients was 4.2% and for asymptomatic patients was 0%. The average follow up was 58 months (range 1-192) for 200/215 patients, with 15/215 patients (7%) lost. The postoperative incidence of stroke after 4 years was 8.5% (17/200), with an annual mortality rate of 1.6% (min. after 2 months, max. 118, average 55 months). CEA is a safe procedure to prevent cerebral infarctions, but it still carries an operative risk. A better monitoring would allow to understand the mechanisms of clamp-induced ischaemia and prevent it, therefore decreasing the operative risks and extending the surgical indications to a higher ratio of asymptomatic subjects. TCD is becoming essential for our goal: it is useful in deciding to insert an intraoperative shunt, check the carotid flow, recognize embolic events, and also during the initial phase of carotid preparation.