Elective sigmoid colectomy for diverticular disease. Laparoscopic vs open surgery: a systematic review.

AIM: A meta-analysis of nonrandomized studies and one randomized trial was conducted to compare laparoscopic surgery with open surgery in the elective treatment of patients with diverticular disease. METHOD: Published randomized and controlled clinical trials that directly compared elective open (OSR) with laparoscopic surgical resection (LSR) in patients with diverticular disease were identified using the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. End-points included 30-day mortality and morbidity and were compared by determining the relative risk ratio, odds ratio, and the absolute effects. RESULTS: Eleven nonrandomized studies of 1430 patients were identified and included in the meta-analysis. There was only one randomized study, which included 104 patients. The meta-analysis suggested that elective LSR was a safe and appropriate option for patients with diverticular disease and was associated with lower overall morbidity (P = 0.01) and minor complication rate (P = 0.008). CONCLUSION: The results of the nonrandomized study generally agreed with those of the randomized study, except for the incidence of minor complications, which was higher in both the LSR and OSR groups of the randomized study. In this study, the high overall morbidity of 42.3% reported in the LSR group is a cause for concern.

Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis.

AIM: The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer. METHOD: The following electronic databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. RESULTS: Five nonrandomized studies including a total of 5012 patients were identified. Meta-analysis suggested that rectal washout significantly reduced the local recurrence rate (P < 0.0001; OR 0.57; 95% CI 0.43-0.74). It was also significantly lower after washout in patients having radical resection only (P = 0.0004; OR 0.54; 95% CI 0.39-0.76), patients treated by a curative resection (P < 0.0001; OR 0.55; 95% CI 0.42-0.72) and those undergoing preoperative radiotherapy (P = 0.04; OR 0.62; 95% CI 0.39-0.98). CONCLUSION: Taking into account the limitations of the design of the included studies the meta-analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.

Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome.

AIM: The study aimed to compare robotic rectal resection with laparoscopic rectal resection for cancer. Robotic surgery has been used successfully in many branches of surgery but there is little evidence in the literature on its use in rectal cancer. METHODS: We performed a systematic review of the available literature in order to evaluate the feasibility, safety and effectiveness of robotic versus laparoscopic surgery for rectal cancer. We compared robotic and laparoscopic surgery with respect to twelve end-points including operative and recovery outcomes, early postoperative mortality and morbidity, and oncological parameters. A subgroup analysis of patients undergoing full-robotic or robot-assisted rectal resection and robotic total mesorectal excision was carried out. All aspects of Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) statement were followed to conduct this systematic review. Comprehensive electronic search strategies were developed using the following electronic databases: PubMed, EMBASE, OVID, Medline, Cochrane Database of Systematic Reviews, EBM reviews and CINAHL. Randomized and nonrandomized clinical trials comparing robotic and laparoscopic resection for rectal cancer were included. No language or publication status restrictions were imposed. A data-extraction sheet was developed based on the data extraction template of the Cochrane Group. The statistical analysis was performed using the odd ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. RESULTS: Eight non randomized studies were identified that included 854 patients in total, 344 (40.2%) in the robotic group and 510 (59.7%) in the laparoscopic group. Meta-analysis suggested that the conversion rate to open surgery in the robotic group was significantly lower than that with laparoscopic surgery (OR = 0.26, 95% CI: 0.12-0.57, P = 0.0007). There were no significant differences in operation time, length of hospital stay, time to resume regular diet, postoperative morbidity and mortality, and the oncological accuracy of resection. CONCLUSION: Robotic surgery for rectal cancer has a lower conversion rate and a similar operative time compared with laparoscopic surgery, with no difference in recovery, oncological and postoperative outcomes.

Laparoscopic vs open resection for rectal cancer: a meta-analysis of randomized clinical trials.

AIM: Laparoscopic and open rectal resection for cancer were compared by analysing a total of 26 end points which included intraoperative and postoperative recovery, short-term morbidity and mortality, late morbidity and long-term oncological outcomes. METHOD: We searched for published randomized clinical trials, presenting a comparison between laparoscopic and open rectal resection for cancer using the following electronic databases: PubMed, OVID, Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. RESULTS: Nine randomized clinical trials (RCTs) were included in the meta-analysis incorporating a total of 1544 patients, having laparoscopic (N = 841) and open rectal resection (N = 703) for cancer. Laparoscopic surgery for rectal cancer was associated with a statistically significant reduction in intraoperative blood loss and in the number of blood transfusions, earlier resuming solid diet, return of bowel function and a shorter duration of hospital stay. We also found a significant advantage for laparoscopy in the reduction of post-operative abdominal bleeding, late intestinal adhesion obstruction and late morbidity. No differences were found in terms of intra-operative and late oncological outcomes. CONCLUSION: The meta-analysis indicates that laparoscopy benefits patients with shorter hospital stay, earlier return of bowel function, reduced blood loss and number of blood transfusions and lower rates of abdominal postoperative bleeding, late intestinal adhesion obstruction and other late morbidities.

Upper gastrointestinal massive bleeding successfully treated intra-operatively with a collagen and thrombin-based high-viscosity gel for haemostasis. Case report.

A 57-year-old male patient was admitted in our Department for a non-variceal upper gastrointestinal massive bleeding. In accordance with the clinical guidelines, the patient underwent an early endoscopy (within 24 hours from admission), which showed the source of bleeding in the second portion of the duodenum. An endoscopic haemostatic injection with dilute adrenalin (epinephrine, 1:10.000) was then performed. After 8 hours, severe recidive bleeding occurred with reduced haemoglobin levels, which led us to an emergency surgical treatment. A gastric resection was performed, followed by the application of high-viscous gel (Floseal) into the source of bleeding within the duodenal lumen. This technique allowed to obtain a definitive haemostasis without long-term complications. Our experience suggests that the intra-operative application of Floseal can be an effective alternative to traditional haemostatic techniques in the emergency surgical treatment of upper gastrointestinal bleeding. This also provides additional time to perform other haemostatic techniques techniques avoiding the precarious haemodynamic conditions of a patient in emergency.

[The sentinel lymph node mapping in colon cancer]. / Il linfonodo sentinella nei tumori del colon.

BACKGROUND: malignant tumors of the colon can metastases along the lymphatic system in a sequential way, which means that there will be a first node to be involved and then from this disease will pass to another node and so gradually. The sentinel lymph node is the first lymph node or group of nodes reached by metastasizing cancer cells from a tumor. OBJECTIVES: the present work aims to determine the predictive value of the sentinel lymph node procedure in the staging of non-metastatic colon cancer. PATIENTS AND METHODS: in this prospective study joined up only 26 patients with adenocarcinoma of the colon T2-T3, without systemic metastases, and with these criteria for inclusion: a) minimum age: 18 years old; b) staging by total colonoscopy, chest X-ray and CT scan; c) patients classified as ASA 1-3; d) informed consent. Within 20 minutes from the colic resection, the bowel was cut completely along the antimesenteric margin and is performed submucosal injection of vital dye within 5 mm from the lesion at the level of the four cardinal points; then the lymph nodes are placed in formalin and sent to the pathologist. The lymph nodes were subjected to histological examination with haematoxylin-eosin and with the immunohistochemistry technique. RESULTS: from January to December 2008 only 26 patients joined up in this prospective study. From the study were excluded the 4 patients with T4 and M1 tumour. Also 7 patients with stenotic lesions were excluded. Patients considered eligible for our study were only 14. The histopathological examination of haematoxylin-eosin revealed: a) in 4 cases were detected mesocolic lymph node metastases; b) in 10 cases were not detected mesocolic lymph node metastases. In cases there were no metastases, the mesocolic sentinel lymph nodes lymph nodes were examined with immunohistochemical technique; in 2 cases were revealed the presence of micrometastases. In one case was identified aberrant lymphatic drainage patterns (skip metastasis); the sentinel lymph node (negative examination wit eaematoxylin-eosin) was studied with immunohistochemical technique that has not revealed the presence of micrometastases. CONCLUSIONS: the examination of the sentinel node is feasible with the ex vivo method. Using the immunohistochemical technique we detect micrometastasis in 20% of the cases, not revealed with the classical haematoxylin-eosin examination. The study of sentinel lymph node with multilevel microsections and immunohistochemical techniques allow a better histopathological staging.

[The abdominal compartment syndrome and the importance of decompressive re-laparotomy]. / La sindrome compartimentale addominale ed il ruolo della re-laparotomia decompressiva.

BACKGROUND: the Abdominal Compartment Syndrome (ACS) is an increasingly recognized complication of both medical and surgical patients. The World Society of the Abdominal Compartmental Syndrome defined Intra Abdominal Hypertension (IAH) as a mean Intra Abdominal Pressure (IAP) ≥ 12 mm Hg and the ACS as IAP ≥ 20 mmHg (with or without an abdominal perfusion pressure < 60 mm Hg) that is associated with dysfunction or failure of one or more organ systems that was not previously present. The IAH contributes to organ failure in patients with abdominal trauma and sepsis and leads to the development of ACS. OBJECTIVES: This study aims to investigate the clinical significance of IAH, the prevalence of ACS and the importance to the effects to the abdominal decompressive re-laparotomy. Patients and methods. The study included 10 patients, 4 men and 6 women with an average age of 68 years (range, 38-86) operated and and treated with xifo-pubic laparotomy between January 2007 and December 2008. According to gold-standard methods, we measured the IAP by indirect measurement using the transvescical route via Foley bladder catheter. RESULTS: among 10 patients with laparotomy, 8 patients (80%) developed IAH < 20 mm Hg but they have not reported significant organ dysfunction , while 2 patients (20%) developed an IAH > 20 mm Hg associated whit organ dysfunction. For this reason, the last 2 patients were undergoing to the decompressive re-laparotomy with temporary closure. CONCLUSION: in according to our experience and the results of the literature, we believe essential monitoring abdominal pressure in patients with abdominal laparotomy. The abdominal decompressive re-laparotomy is a useful procedure to reduce symptoms and improve the health of the patient.

[Presacral myelolipoma: a case report]. / Mielolipoma presacrale: case report.

BACKGROUND: Presacral tumors are more frequently benign, and only occasionally malignant, showing a slow growth and an incidence of 1:40.000. They are asymptomatic in the 26-50% of the cases. When symptoms occur, these are related to the dimensions of the tumor, to its location and to the presence of infection. CASE REPORT: We report the case of a 69-year old woman with a lower abdominal pain associated with paresthesia and ipostenia of the right inferior limb. Digital rectal examination showed a fixed, mild tender and hard tumor of the posterior rectal wall. CT, MR and CT-guided biopsy sequently performed revealed a solid, dishomogeneous mass, located in the presacral region, with a connective likely origin, without pelvic lymphoadenopathy. The operation allowed to esteem a mass which was tenaciously adherent to the sacrum. We performed a total excision. Final histological diagnosis was myelolipoma. CONCLUSIONS: The Authors' opinion is that the en-bloc resection of these tumors with an anterior surgical approach allows a histological diagnosis of the nature, representing the best treatment for potentially malignant lesions, which are frequently radio and chemo-resistant.

Colovesical fistulae in the sigmoid diverticulitis.

In most cases Colovesical fistulae are complications of diverticular disease and representing the most common kind of colodigestive fistula; less common are colovaginal, colocutaneous, coloenteric and colouterine fistula. In this article we review the literature concerning colovesical fistulae in colorectal surgery for sigmoid diverticulitis and report on two cases that required a surgical treatment, one elective and the other in emergency. In both cases we performed a sigmoid resection with a primary anastomosis and small vesical window-ectomy placing a Foley catheter for about 10 days.

[Abdominal compartimental syndrome as a complica-tion of Fournier's gangrene]. / Sindrome compartimentale addominale da gangrena di Fournier. Case report.

Analyzing a complex case and referring to the literature, the authors describe abdominal compartmental syndrome as a complication of Fournier's gangrene, stressing out the importance of an early diagnosis to perform prompt and effective treatment. The characteristic of this case is not represented only by the Fournier's gangrene rarity, but also by the appearance of an abdominal compartmental syndrome due to the gangrene extension from the scrotum to the abdominal wall and cavity through the spermatic funiculus. The treatment of the abdominal compartmental syndrome was the surgical toilette of the necrotic regions (scrotum, abdominal wall and cavity) together with an orchiectomy.

Acute appendicitis: a descending trend?

AIM: The diagnosis-related group (DRG) system is a prospective hospital payment system used to categorize hospital patients expected to require similar hospital services. In Italy, hospital productivity is calculated from DRG-based data coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which is a classification system for coding of diagnoses and operations for indexing medical records by diagnosis and operations. The aim of our survey was to determine the national incidence of appendectomies based on the coded summary of selected data in hospital discharge reports (HDR). METHODS: The Italian Ministry of Health online database was searched for data collected between 2001 and 2003. The search engine allows analysis by different regions but not by individual hospital. The national incidence of appendectomy was calculated using data collected from the ICD-9-CM and from the HDR. In a deeper analysis, regional data and data from individual hospitals were compared. RESULTS: The analysis revealed the incidence of appendectomy, rates of simple acute appendicitis vs complicated appendicitis, common laparotomic appendectomy vs laparoscopic appendectomy, as well as mean duration of hospitalization. CONCLUSION: The incidence of acute appendicitis has considerably decreased, whereas the rates of complicated appendicitis have increased because of longer diagnostic and therapeutic delay, inappropriate antibiotic therapy and upclassifying of diagnosis and procedures in the HDR (ICD-9-CM) in order to obtain a ''wider impact'' on DRG.

An unusual case of rectal carcinoid removed by transanal endoscopic microsurgery.

The name ''carcinoid'' was invented by Oberndorfer in 1907, when the nature of those histological entities was little understood. Usually, they were found in various locations in the gastrointestinal (GI) apparatus (67%), most of them in the small intestine (25%), appendix (12%), and rectum (14%).The techniques used for their removal are various. The authors present here a case of rectal carcinoid removed using the transanal endoscopic microsurgery technique, and referred to the diagnosis and treatment of this uncommon tumor. A 37-year-old male was admitted to the Santa Maria Hospital of Terni (Italy) with a chief complaint of intermittent pain in the lower right quadrant, that began three years ago. Complete blood count (CBC) and laboratory data as tumor markers and urinary 5-hydroxyindoleacetic acid (5-HIAA) showed no abnormalities, while urinary vanilmandelic acid level was elevate (18 mg/24 h). The patient was submitted to a colonoscopy with magnifying endoscopy and biopsy. The histological finding demonstrated a nodule characterized by cellular proliferation, with few microscopical abnormalities, arranged in small cords with a glandular pattern, separated by dense connective tissue. Histochemically the tumor cells were cytocheratins +/-, chromogranin positive, synaptophysine positive, CD56 positive and Growth Index MIB1-Ki67 which was almost zero. The patient also underwent an endoscopic ultrasonography and an Octreoscan. He was operated using a transanal endoscopic microsurgery technique. The use of Transanal Endoscopic Microsurgery (TEM) as a safe and feasible technique for exciding rectal tumors can be easily understood, for the excellent view and precise dissection. The use of new surgical devices as Harmonic Scalpel has improved the precision of this kind of approach, increasing the appropriateness of this approach compared to other kind of resection. A full diagnostic course and an immunohistochemistry are mandatory for precise diagnosis of rectal carcinoid. Careful attention must be paid to these tumors because of their unexpected behaviour.

[Laparoscopic cholecystectomy for acute cholecystitis]. / La colecistectomia laparoscopica nel trattamento della colecistite acuta.

BACKGROUND: The aim of this study is to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to determine the optimal timing. PATIENTS AND METHODS: The study was performed in two groups of 70 consecutive patients (similar in age and ASA classification), retrospectively reviewed, who had been diagnosed with acute cholecystitis and were underwent early or delayed laparoscopic cholecystectomy. In early group surgery took place within 48 hours of admission in hospital. The interval for delayed laparoscopic cholecystectomy was 8-12 weeks after medical treatment. RESULTS: In delayed group 21,4% of patients required urgent surgery after failure of conservative treatment. The most important significant difference is the total hospital stay: the early group had a significant shorter hospital stay (7 days) vs delayed group (13 days). Other differences were the conversion rate (8,6% in early group vs 12,7% in delayed group) and median the operation time (84 min. in early group vs 106 min. in delayed group). Post-operative complications developed in 6,3% in early group vs 2,6% in delayed group. CONCLUSION: The optimal treatment of acute cholecystitis is urgent laparoscopic cholecystectomy but in our experience early laparoscopic cholecystectomy increased postoperative morbidity in hospital decreased conversion rate, median operation time and hospital stay.

[Laparoscopic adhesiolysis in acute small bowel obstruction]. / Trattamento laparoscopico delle occlusioni del tenue.

At the beginning of the laparoscopic surgery, intestinal obstruction was considered an absolute contraindication for this approach, because of the high risk of injuring the bowel. Today laparoscopic surgery for small bowel obstruction is still under evaluation. Adhesions are the most common cause of obstruction; although an important proportion of these patients can be nonoperatively treated, some of these require immediate operation. The aim of this review was to evaluate the reliability and immediate results of laparoscopic management of small bowel obstruction by postoperative adhesions. Laparoscopic management of acute small bowel obstruction is feasible, but it is often difficult and may be hazardous. The patients with acute obstruction may be undergo laparoscopy after a careful selection. Morbidity is low if the operation is performed by skilled. The immediate benefit is rapid intestinal motility and shorter hospital stay. The long-term effect is the prevention of small bowel obstruction recurrences by new postoperative adhesions.

[Laparoscopic appendectomy]. / L'appendicectomia laparoscopica.

Most laparoscopic procedures are performed on an elective basis. However, as general surgeons have gained more experience with laparoscopy, they are employing this procedure also for the evaluation and treatment of acute abdominal conditions such acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer and abdominal trauma, acute pancreatitis and intestinal obstruction. Although its advantages are still under debate, the laparoscopic approach has already been adopted by many centers in the emergency setting.

[Chilaiditi's syndrome: a rare cause of abdominal pain in the differential diagnosis of the abdominal perforation. Case report]. / Sindrome di Chilaiditi: una causa rara di dolore addominale nella diagnosi differenziale della sindrome perforativa addominale. Case report.

A case of a 92-years-old patient with abdominal pain and constipation is presented. He reported a recent traumatic fracture of the upper limb. Traditional diagnostic work-up for patient with abdominal pain was started up. He was submitted to abdominal film that demonstrated air underneath the diaphragm suggestive for perforation. This hallmark is opposed to clinical condition of patient, so differential diagnosis for rare Chilaiditi's syndrome was considered, because this syndrome is frequent in old patient. Diagnostic work-up was completed with upper abdominal CT that excluded intestinal perforation and confirmed the diagnosis of Chilaiditi's syndrome showing hepatodiaphragmatic interposition of the dilated colon. Therefore it was decided in favour of medical therapy. In the our case, in spite of negative clinical examination, the uncertain radiological hallmark obliged us to exclude diagnosis of abdominal perforative syndrome that needs emergency operation. Although the Chilaiditi's syndrome is rare, it must be considerated in differential diagnosis of perforative abdominal syndrome, when there are doubts about the subdiaphragmatic air in abdominal film.

Therapeutic strategies in the surgical management of pancreatic neoplasms in the elderly.

The clinical records of all consecutive patients aged 65 and older undergoing surgical treatment for pancreatic neoplasms between January 1980 and January 1992 were reviewed in order to establish a clinical trial based on the morbidity and mortality rates related to the different surgical procedures. In early diagnosed neoplasms, in patients in good general condition, even in the geriatric age a radical surgical procedure is preferred. In other cases, a palliative surgical procedure has to be performed if possible, namely a bilio-digestive anastomosis, associated if necessary with a gastro-enteric anastomosis.

The anastomotic aneurysms.

The authors describe their experience of anastomotic aneurysm diagnosis and treatment. They are classed into two groups: slowly growing anastomotic aneurysms, which are the most common; and rapidly growing anastomotic aneurysms, which are more infrequent. A follow-up is proposed in order to detect this involvement early, in election. Urgent diagnostic timing is also proposed. Moreover an analysis is made of criteria to follow in their therapy and indications to surgical treatment. In the period from January 1988 to October 1992 we observed 413 patients and 876 anastomosis or arterial sutures in election, discovering 27 anastomotic aneurysms whereas in 6 cases we had patients who were affected with rapidly growing anastomotic aneurysms. These were urgently operated, whereas of the 27 patients with slowly growing anastomotic aneurysms, 22 were operated and in 5 cases we preferred to check them by a close follow-up.

[Rare neoplastic and common pathologies of the thyroid]. / A proposito di patologie rare neoplastiche e non della ghiandola tiroide.

Observation of three cases of rare thyroid pathology (medullary carcinoma, thyroid lymphoma, De Quervain's subacute thyroiditis) triggers a discussion of the need to take due account of such rare pathologies in preoperative differential diagnosis in order to avoid giving the wrong treatment. The fact that extemporary histological examination is no help in such situations is also discussed.