Correction to: Outcomes after rectosigmoid resection for endometriosis: a systematic literature review.

The authors of the published version of this article missed to add the second affiliation of Mostafa Shalaby. The new affiliation is now added and presented correctly in this article. The remainder of the article remains unchanged.

Outcomes after rectosigmoid resection for endometriosis: a systematic literature review.

PURPOSE: "Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis. METHODS: We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed. RESULTS: Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days. CONCLUSIONS: Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.

Transanal Hemorrhoidal Dearterialization Versus Stapled Hemorrhoidopexy: Long-Term Follow-up of a Prospective Randomized Study.

AIM: This study aims to compare the early and late outcomes of transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) for the treatment of hemorrhoidal disease. METHODS: From January 2013 to December 2014, 100 patients-50 patients on each arm-were randomly allocated to THD or SH groups. The inclusion criteria were grade III and IV hemorrhoids diagnosed by clinical examination and proctoscopy. The primary outcome was to compare the recurrence rate with a minimum follow-up of 2 years, and the secondary outcome was to compare complications rate, time to return to work postsurgery, procedure length, and patient's satisfaction between the 2 techniques. RESULTS: The mean follow-up period was 33.7 ± 7.6. The recurrence rate was 4% in the SH group and 16% in the THD group ( P = .04). There was no difference in the intraoperative and postoperative complications rate; the pain score was significantly higher in the THD group. The mean operative time was significantly shorter in the SH group compared with the THD group. Patients in the THD group returned to work or routine activities significantly later compared with patients in the SH group. The overall satisfaction rate was also higher in the SH group. CONCLUSION: Both procedures are simple and easy to perform for the treatment of grade III and IV hemorrhoids. SH showed better results in terms of lower rate of recurrence, lower postoperative pain, quicker return to work, and higher patient satisfaction.

A pilot study assessing tolerance safety and feasibility of diagnostic transnasal esophagogastroduodenoscopy using an improved larger caliber endoscope and an adapted topical anesthesia.

BACKGROUND: Transnasal esophagogastroduodenoscopy (TN-EGDS) is well tolerated by patients and the examination is perceived comfortable without the need of a sedative drug. Conversely, mainly in Western literature, some authors report limitations in illumination, image quality, and working channel as affecting TN-EGDS diffusion. To overcome these disadvantages, a new transnasal endoscope (TNE) was tested but, due to its larger diameter, we have no evidence of its clinical safety and tolerability. A new adapted nasal anesthesia could be useful to improve TNE tolerance. In an independent, not sponsored, pilot prospective study we enrolled, in a busy clinical hospital setting, 30 adult patients receiving nasal atomized Lidocaine and Xylometazoline (XAL) to undergo a diagnostic TN-EGDS with TNE to evaluate its tolerance, safety, and feasibility. METHODS: Three physicians enrolled inpatients and outpatients with indication to diagnostic EGDS during a 6-month period. Main outcome measures were cardio-pulmonary monitoring data and patients' answers to an adapted questionnaire investigating pain, anxiety level, willingness to repeat the examination, operators' scores about endoscopy quality, examination conduction and anesthesia-related complications. RESULTS: The examination was completed by the transnasal route in 100 % of the enrolled patients, endoscopy satisfaction and feasibility were scored to nearly the highest levels by the three different physicians. A total of 29/30 patients (96.6 %) declared the willingness to repeat the same examination if needed. The mean patients' score for overall pain was 3.7 ± 1 SD (range 1-10 by Visual Analog Scale). Mean endoscopy duration was 11.1 ± 2.6 min (range 5.0-19.0). In a total of 17/30 TN-EGDS that lasted more than 11 min, higher heart frequency variations and worse tolerance scores were found (p < 0.05). CONCLUSION: Our pilot study demonstrates that TN-EGDS with TNE and NA is safe, well tolerated, and feasible. The best clinical tolerance is reached when TN-EGDS lasts <11 min.

Inflammatory fibroid polyp. A case report and review of the literature.

INTRODUCTION: The Inflammatory fibroid polyp (IFP) is a mesenchymal polypoid lesion of the gastrointestinal tract that follows a benign course. Incidence is extremely low: from 0,1% to 2 %. Histologically, it consists of a sub mucous proliferation of vascolarized fibromuscolar tissue with a high eosinophils inflammatory infiltration. IFP can arise everywhere in the gastrointestinal tract but is described more frequently in the gastric antrum (70%). CASE REPORT: We report a case of a 71-year-old woman presented to our department with a worsening history of lack's appetite, nausea and early satiety. We performed a review of the literature from 1949 to 2011. 196 cases of IFPs were found. CONCLUSION: Clinical symptoms are heterogeneous and endoscopy's examination revealed only presence of a sub-mucosal lesion, and their biopsies often gave not diagnostic localization. In the differential diagnosis, it's important to discern between eosinophilic gastroenteritis, gastrointestinal stromal tumor, inflammatory pseudotumor, hemangioendothelioma, and hemangiopericytoma. Eco-endoscopic appearance and biopsies associated may provide useful informations, that can steer to the diagnostic suspect of IFP. Despite this is a benign lesion, this one often needs a surgical excision on healthy margin. In literature is also described high local recurrence, specially when incomplete excision proceeded. KEYWORDS: Gastric sub-mucosal tumor, Inflammatory fibroid polyp, Stomach, Vanek's Tumor.

Percutaneous local ablation of unifocal subclinical breast cancer: clinical experience and preliminary results of cryotherapy.

OBJECTIVES: To assess the ablative effectiveness, the oncological and cosmetic efficacy of image-guided percutaneous cryoablation in the treatment of single breast nodules with subclinical dimensions after identification with ultrasonography (US), mammography, magnetic resonance (MRI) and characterization by vacuum assisted biopsy. MATERIALS: Fifteen women with a mean age of 73 ± 5 years (range 64-82 years) and lesion diameter of 8 ± 4 mm were undergoing cryotherapy technology with a single probe under US-guidance associated with intra-procedural lymph-node mapping and excision of the sentinel node. All the patients underwent surgical resection (lumpectomy) from 30 to 45 days after the percutaneous ablation. RESULTS: The iceball size generated by the cryoprobe during the procedure at minus 40°C was 16 × 41 mm. In 14 of the 15 patients was observed a complete necrosis of the cryo-ablated lesion both in post-procedural MRI follow-up and anatomo-pathological evaluation after surgical resection. In one case there was a residual disease in post-procedural MRI and postoperative histological examination, probably justified by an incorrect positioning of the probe. CONCLUSION: The percutaneous cryoablation as a "minimally invasive" technique can provide excellent oncological and cosmetic results on selected cases handled by experienced operators by using the tested devices.

Bowel perforations in a patient affected by Churg-Strauss syndrome under high-dose steroid treatment: will alternative drugs reduce risk of surgery?

Churg-Strauss syndrome is a relapsing-remitting vasculitis that frequently involves digestive system. Ischemic perforation of the large bowel is relatively rare and potentially life threatening. We report a case treated with high dose of steroids for a relapsing of Churg-Strauss vasculopathy that underwent emergency surgery for multiple large-bowel perforations. Massive use of steroids is common for controlling relapse of this disease, but this increases the risk of intestinal perforation. A prompt switching to alternative drugs when intestinal tract is involved should be considered in order to prevent surgery.

[Bodypackers syndrome. A case report and review of the literature]. / La sindrome "body packers". Caso clinico e revisione della letteratura.

INTRODUCTION: With the term Body packers we identify people who carry drugs hidden in their bodies especially on international flights. These event are constantly increasing all over the world. The accidental spontaneous opening of the drug packers is the major risk for patient's life, because the release cocaine inside the bowel can stir up the Body packers Syndrome. This eventuality is a medical surgical emergency that needs a wel timed diagnosis and a sudden treatment. CASE REPORT: We report a case of a 31 years old Caucasian woman, admitted from Rome International Airport to the nearest Emergency Unit and then moved to our Department because of suspected epilepsy hiding a diagnosis of Body packers Syndrome in acute phase. When the diagnosis was made, the woman was submitted to a colonoscopy and ciecotomy, and fifty-three packets were removed. In intensive care any complication occurred after surgery. CONCLUSION: The Body packing of drugs it's constantly a going problem. In Italy currently there aren't shared guide lines about the management of these patients. The international experience reports that in asymptomatic patients is enough a conservative treatment to help the spontaneous evacuation of packets but if the Body packers Syndrome is already present the best treatment is the surgical one. Quickness, accuracy and right use of radiology are the main factors to reach a correct diagnosis and to obtain a good result.

End-type stapled colostomy in emergency surgery.

INTRODUCTION: Colostomy is one of the most frequent procedures in emergency surgery. Several techniques have been described. The aim of this essay is to present our results using a circular stapler device when executing an end-type colostomy raising in emergency surgery. MATERIAL AND METHODS: During a period of 4 years, 47 patients underwent end-type colostomy raised under emergency circumstances using a circular stapler device. We gathered information on each patient, and performed 2 years follow-up. RESULTS: Forty-seven patients, 72.3% male and 27.7% female, were enrolled in this study. The most common indication was colorectal cancer (48.9%). We had an average rate of complications of 13.63% without a need to be operated on: parastomal hernia (6.81%), mild local cellulitis (4.54%), and retraction (2.27%). The medium diameter of colostomy at the time of surgery and after 1 month was equal to 3.4 cm and 3.1 cm respectively. Follow-up screenings showed that the diameter of colostomy held constant at 3 cm. DISCUSSION: End-type colostomy using a stapler device can be safely performed under emergency circumstances. It is not related to a higher rate of stomal stenosis in our series. This is the first essay that reports the diameter of colostomy with this technique. Early and late complications are similar to those that appear with the classical technique. Therefore, the end-type colostomy executed by means of a circular stapler device can be considered a safe and reliable technique.

Comparison of round smooth and shaped micro-textured implants in terms of quality of life and aesthetic outcomes in women undergoing breast reconstruction: a single-centre prospective study.

Breast cancer (BC) is the most frequent cancer among women, impacting 2.1 million women each year and having caused 627,000 deaths in 2018. In Italy, BC represents the first cancer diagnosis with 53,000 new cases in 2019 and the first cause of mortality for cancer among the female population. Breast implants represent the first reconstructive choice after mastectomy: in Italy, 411,000 prostheses have been implanted since 2010 and more than 95% of them are macro-texturized. The attempt to reduce complications such as capsular contracture, rotation and rupture of the prosthesis and the most recent BIA-ALCL association with macro-texturized implants have led to the development of new materials and the refinement of implants' coating techniques. We carried out a 1-year prospective single-centre study to evaluate patient-reported quality of life (QoL) and aesthetic outcomes after breast reconstructive surgery using two different prostheses: shaped micro-textured implants and round smooth implants. We treated 62 patients with radical or conservative mastectomy followed by reconstructive surgery performed with 44 shaped implants and 48 round implants. Quality of life evaluated through the Breast-Q®-questionnaire showed high scores of psycho-social well being in both groups, as well as pre- and post-operative aesthetic satisfaction and physical well being. Round smooth implants appear to be better in terms of softness, volume and less association with rippling, whereas shaped micro-textured implants prove to be better in the profile delineation. This study confirms the potentialities of both shaped micro-textured and round smooth implants in reconstructive surgery.

Acute complications following endoscopic intragastric balloon insertion for treatment of morbid obesity in elderly patients. A single center experience.

BACKGROUND: Obesity is a serious disease, with an increasing incidence also among subjects over 60 years old; surgical management has proven to be the most effective in the production of significant and durable weight loss. Intragastric balloon (IGB) treatment promotes a reduction of five to nine Body Mass Index (BMI) units in 6 months with an impressive improvement of obesity-associated comorbidities. METHODS: Two hundred and twenty-five patients, 106 men (47.1%) and 119 women (52.9%), were evaluated at our institution to be submitted to a IGB positioning. Of these, 12 patients (8 women and 4 men) were more than 60 years old. For all patients BMI, comorbidities, weight loss and complications were recorded. χ2 test was used to evaluate differences in complications rate between elderly and other patients. RESULTS: For the 12 elderly patients, we recorded a mean excess weight loss rate (EWL%) of 31.4. About complications, we recorded 2 severe esophagitis requiring IGB removal and 1 late gastric perforation. A higher complications rate was found in elderly population and the comparison with other patients revealed a significant difference (P<0.001). CONCLUSIONS: Our results underline that IGB treatment in elderly patients is safe and effective in terms of weight loss and improvement in comorbidities. IGB can cause complications which, sometimes, can be severe such as esophageal damage and gastric perforation. For the management of complications, we highly recommend a close follow-up in all patients and a deepened instrumental study in every suspect case.

Biological acellular pericardial mesh regulated tissue integration and remodeling in a rat model of breast prosthetic implantation.

The use of biological meshes has proven beneficial in surgical restriction and periprosthetic capsular contracture following breast prosthetic-reconstruction. Three different types (smooth, texturized, and polyurethane) of silicone round mini prostheses were implanted under rat skin with or without two different bovine acellular pericardial biological meshes (APMs, BioRipar, and Tutomesh). One hundred eighty-six female rats were divided into 12 groups, sacrificed after 3, 6, and 24 weeks and tissue samples investigated by histology and immunohistochemistry. Implantation of both APMs, with or without prostheses, reduced capsular α-SMA expression and CD3+ inflammatory cell infiltration, increasing capillary density and cell proliferation, with some differences. In particular, Tutomesh was associated with higher peri-APM CD3+ inflammation, prosthetic capsular dermal α-SMA expression and less CD31+ vessels and cell proliferation compared with BioRipar. None differences were observed in tissue integration and remodeling following the APM + prostheses implantation; the different prostheses did not influence tissue remodeling. The aim of our study was to investigate if/how the use of different APMs, with peculiar intrinsic characteristics, may influence tissue integration. The structure of APMs critically influenced tissue remodeling after implantation. Further studies are needed to develop new APMs able to optimize tissue integration and neoangiogenesis minimizing periprosthetic inflammation and fibrosis.

Results following laparoscopic sleeve gastrectomy in elderly obese patients: a single center experience with follow-up at three years.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) represents the most performed bariatric surgical procedure worldwide. Morbid Overweight in elderly patients is becoming a significant health problem even in Italy. As well as in younger age groups, bariatric surgery could be indicated even in this subset of patients. However the advantages and results of LSG in patients over 60 years old have received minimal attention. METHODS: The records of 375 patients underwent LSG between 2008 and 2016 were reviewed. In the entire series 18 patients were aged 60 years or older at the time of surgery. Since a 3 years follow-up was available for 12 patients out of the 18 aged over 60 we included in the study only these. General epidemiologic data, clinical findings, BMI and comorbidities surgical treatment and follow-up data were collected; postoperative measurements such as operative time, intraoperative complications, mortality rate, length of stay, incidence of early and late complications, Body mass Index (BMI), excess weight loss rate (EWL%) and comorbidities resolution were also recorded. RESULTS: LSG was successfully performed for all geriatric patients. Global complications rate was 16.6% At 3 years mean BMI was 34.4±3.8 with a mean EWL% 66.1±31.9. Postoperative resolution of obesity comorbidities was observed; Hypertension (71.4%), type 2 Diabetes Mellitus (T2DM) (50.0%), obstructive sleep apnea syndrome (OSAS) (66.6%) respectively. No intraoperative complications or mortality were recorded. CONCLUSIONS: LSG offered cure in geriatric patients affected by morbid obesity for weight loss and comorbidities resolution. Larger studies are necessary to analyze and minimize the incidence of postoperative complications associated to this surgical procedure in elderly patients.

Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review.

INTRODUCTION: Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions. EVIDENCE ACQUISITION: A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data. EVIDENCE SYNTHESIS: Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts. CONCLUSIONS: The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.

Anastomotic leakage following laparoscopic resection of low and mid rectal cancer.

PURPOSE: Anastomotic leakage is considered the commonest major complication after surgery for rectal cancer. MATERIALS AND METHODS: Patients who underwent laparoscopic LAR or ULAR for rectal cancer were recruited. The primary outcome was the incidence of the AL during 30 days postoperative. RESULTS: Fifty-nine consecutive patients were included in the study. Fifty-three patients underwent LAR with stapled colorectal anastomoses, while the remaining 6 patients underwent ULAR with hand-sewn coloanal anastomoses. The median duration of operation was 195 minutes (range; 120-315). The defunctioning ileostomy was created in 24 (7%) patients. Overall, there was no recorded mortality. Only 10 (17%) patients developed complications. There were only 4 patients who developed AL. Three patients had a subclinical AL as they had defunctioning ileostomy at the time of the initial procedure, the diagnosis was made by CT with rectal contrast. They were treated conservatively with transanal anastomotic drainage under endoscopic guidance. One patient had a clinically significant AL, demonstrated as a peritonitis. This patient required reoperation during which pelvic abscess was drained, resection of the previous anastomosis, and hartmann's colostomy was performed. CONCLUSION: Standardization of a definition, as well as, criteria for the diagnosis of AL, will help in comparison of the results and the surgical techniques in order to optimize the required care offered to rectal cancer patients. On expert hands, it is feasible to perform a laparoscopic sphincter-saving total mesorectal excision, additionally, it provides the advantages of a clear view of the deep pelvis and facilitates a precise sharp dissection. KEY WORDS: Anastomosis, Anastomotic Leakage, Rectal cancer, Total mesorectal excision.

Impact of Awake Breast Cancer Surgery on Postoperative Lymphocyte Responses.

BACKGROUND: Surgical stress and anesthesia affect the patient's immune system. Analysis of the lymphocyte response after breast-conserving surgery was conducted to investigate the differences between effects after general and local anesthesia. MATERIALS AND METHODS: Fifty-six patients with breast cancer were enrolled for BCS through local or general anesthesia. Total leukocytes, total lymphocytes, lymphocyte-subsets including CD3+, CD19+, CD4+, CD8+, CD16+CD56+ and CD4+/CD8+ ratio was examined at baseline and on postoperative days 1, 2 and 3. RESULTS: Baseline data showed no statistical difference between the two groups. Within-group ANOVA test showed significant differences for total leukocyte count (p<0.001), total lymphocyte count (p=0.009) and proportion of natural-killer cells (p=0.01) in the control group. Between-group analysis showed lower median values of total lymphocytes in the awake surgery group on postoperative days 1, 2 and 3 (p=0.001, p=0.02 and p=0.01, respectively) when compared to the control group. Patients who underwent surgery under general anesthesia had higher total lymphocyte counts on postoperative day 2 (p=0.04). CONCLUSION: In this randomized study, breast-conserving surgery plus local anesthesia had a lower impact on postoperative lymphocyte response when compared to the same procedure performed under general anesthesia.

Transanal Tube Drainage as a Conservative Treatment for Anastomotic Leakage Following a Rectal Resection.

PURPOSE: We evaluate the role of transanal tube drainage (TD) as a conservative treatment for patients with anastomotic leakage (AL). METHODS: Patients treated for AL who had undergone a low or an ultralow anterior resection with colorectal or coloanal anastomosis for the treatment of rectal cancer between January 2013 and January 2017 were enrolled in this study. The data were collected prospectively and analyzed retrospectively. The primary outcomes were the diagnosis and the management of AL. RESULTS: Two hundred thirteen consecutive patients, 122 males and 91 females, were included. The mean age was 66.91 ± 11.15 years, and the median body mass index was 24 kg/m2 (range, 20-35 kg/m2 ). The median tumor distance from the anal verge was 8 cm (range, 4-12 cm). Ninety-three patients (44%) received neoadjuvant therapy for nodal disease and/or locally advanced rectal cancer. Only 13 patients (6%) developed AL. Six patients developed subclinical AL as they had a defunctioning ileostomy at the time of the initial procedure. They were treated conservatively with TD under endoscopic guidance in the endoscopy unit and received intravenous antibiotics. Six weeks after discharge, these 6 patients underwent follow-up flexible sigmoidoscopy which showed a completely healed anastomotic defect with no residual stenosis. Seven patients developed a clinically significant AL and required reoperation with pelvic abscess drainage and Hartmann colostomy formation. CONCLUSION: These results suggest that TD for management of patients with AL is safe, cheap, and effective. Salvaging the anastomosis will help decrease the need for Hartmann colostomy formation. Proper patient selection is important.

Muzi's Tension Free Primary Closure of Pilonidal Sinus Disease: Updates on Long-Term Results on 514 Patients.

BACKGROUND: The aim of this study is to evaluate the long-term results of Muzi's tension free primary closure technique for pilonidal sinus disease (PSD), in terms of patients' discomfort and recurrence rate. METHODS: This study is a retrospective analysis of prospectively collected data. Five hundred fourteen patients were treated. Postoperative pain (assessed by a visual analog scale, VAS), complications, time needed to return to full-day activities, and recurrence rate were recorded. At 12, 22, and 54 months postoperative, patients' satisfaction was evaluated by a questionnaire scoring from 0 (not satisfied) to 12 (greatly satisfied). RESULTS: The median operative time was 30 min. The overall postoperative complication rate was 2.52%. Median VAS score was 1. The mean of resumption to normal activity was 8.1 days. At median follow-up of 49 months, recurrence rate was 0.4% (two patients). At 12 months' follow-up, the mean satisfaction score was 10.3 ± 1.7. At 22 and 54 months' follow-up, the score was confirmed. CONCLUSIONS: Muzi's tension free primary closure technique has proved to be an effective treatment, showing in the long-term follow-up low recurrence rate and high degree of patient satisfaction. Therefore, we strongly recommend this technique for the treatment of PSD.