Prospective observational study of abdominal wall reconstruction with THT technique in primary midline defects with diastasis recti: clinical and functional outcomes in 110 consecutive patients.

INTRODUCTION: Surgical treatment of diastasis recti is still a matter of debate. Open approaches such as abdominoplasty, which offer the possibility to combine reparation of the diastasis with abdominal cosmetic surgery, are challenged by the emerging less-invasive laparoscopic or robotic techniques that offer shorter recovery for patients. However, evidence in favour of one of the two approaches concerning both short- and long-term complications and functional results is still lacking. In this paper, we analysed clinical and functional results of a new endo-laparoscopic technique for midline reconstruction (THT technique) in patients with primary abdominal wall defects associated with diastasis recti. METHODS: Prospective observational study on 110 consecutive patients was submitted to endo-laparoscopic reconstruction of the abdominal wall with linear staplers. Morbidity and relapse rates with clinical and radiological follow-up were recorded at 1, 6, 12, and 24 months after the operation. Data regarding the impact of surgery on patients' quality of life (EuraHSQol) on chronic low back pain (Oswestry Disability Index, ODI) and urinary stress incontinence (Incontinence Severity Index, ISI) were gathered. RESULTS: After a mean follow-up of 14 months, the morbidity rate was 9.1% and no recurrences were recorded. 6-month follow-up ultrasound showed a rectus muscles mean distance of 6.7 mm; EuraHSQol, ODI, and ISI scores significantly improved in 93%, 77%, and 63% of the cases, respectively. CONCLUSIONS: The THT technique proved to be a feasible, safe, and effective alternative for corrective surgery of primary midline hernias associated with diastasis recti. Short- and mid-term results are encouraging but need to be confirmed by further studies with longer follow-up. The achieved midline reconstruction offers a significant improvement of patients' perceived quality of life through reduction of abdominal wall pain, bulging, low back pain, and urinary stress incontinence.

Predictive value of the sentinel lymph node procedure in the staging of non-metastatic colorectal cancer.

PURPOSE: Despite the recent growing interest of the scientific community, there is still no consensus on the actual applicability and effectiveness of sentinel lymph node (SL) procedure in colon cancers. This study aims to quantify feasibility, detection rate, negative predictive value, and accuracy of the SL identified with fluorescent dye in early colon cancers (ECC). METHODS: This study conducted a consecutive sampling of 95 patients with non-metastatic colorectal cancer who have been treated with laparoscopic colon resection and complete mesocolic excision after a 25-mg indocyanine green peritumoral laparoscopic injection and SL identification with a near-infrared camera. The SL was later isolated and sent to ultra-staging. RESULTS: Ninety-five patients with an average age of 71 (range 37-90) and a mean BMI of 25 (range 18-39) have been recruited. On the patient sample (92 Pts), an average of 1.49 SL (range 1-5) and a mean time of 4 min were identified. The detection rate was 96.8% and the negative predictive value and accuracy rates were 96.2% and 93.4%, respectively. CONCLUSIONS: Mapping the SL with fluorescent dye can play an important role in the treatment of colon cancers, particularly those at early stages, and can lead to ultra-conservative surgery.

Early diagnosis of anastomotic leakage after colorectal surgery by the Dutch leakage score, serum procalcitonin and serum C-reactive protein: study protocol of a prospective multicentre observational study by the Italian ColoRectal Anastomotic Leakage (iC.

BACKGROUND: Anastomotic leakage (AL) is a dreaded major complication after colorectal surgery. There is no uniform definition of anastomotic dehiscence and leak. Over the years many risk factors have been identified (distance of anastomosis from anal verge, gender, BMI, ASA score) but none of these allows an early diagnosis of AL. The DUtch LeaKage (DULK) score, C reactive protein (CRP) and procalcitonin (PCT) have been identified as early predictors for anastomotic leakage starting from postoperative day (POD) 2-3. The study was designed to prospectively evaluate AL rates after colorectal resections, in order to give a definite answer to the need for clear risk factors, and testing the diagnostic yeld of DULK score and of laboratory markers. Methods and analysis. A prospective enrollment for all patients undergoing elective colorectal surgery with anastomosis carried out from September 2017 to September 2018 in 19 Italian surgical centers. OUTCOME MEASURES: preoperative risk factors of anastomotic leakage; operative parameters; leukocyte count, serum CRP, serum PCT and DULK score assessment on POD 2 and 3. Primary endpoint is AL; secondary endpoints are minor and major complications according to Clavien-Dindo classification; morbidity and mortality rates; readmission and reoperation rates, length of postoperative hospital stay (Retrospectively registered at ClinicalTrials.gov Identifier: NCT03560180, on June 18, 2018). Ethics. The ethics committee of the "Comitato Etico Regionale delle Marche - C.E.R.M." reviewed and approved this study protocol on September 7, 2017 (protocol no. 2017-0244-AS). All the participating centers submitted the protocol and obtained authorization from the local Institutional Review Board.

Laparoscopic adhesiolysis: consensus conference guidelines.

AIM: Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post-surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice. METHODS: A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts. RESULTS: Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion-preventing agents, the need for high-technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection. CONCLUSION: Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.

Europe-wide reduction in primary productivity caused by the heat and drought in 2003.

Future climate warming is expected to enhance plant growth in temperate ecosystems and to increase carbon sequestration. But although severe regional heatwaves may become more frequent in a changing climate, their impact on terrestrial carbon cycling is unclear. Here we report measurements of ecosystem carbon dioxide fluxes, remotely sensed radiation absorbed by plants, and country-level crop yields taken during the European heatwave in 2003. We use a terrestrial biosphere simulation model to assess continental-scale changes in primary productivity during 2003, and their consequences for the net carbon balance. We estimate a 30 per cent reduction in gross primary productivity over Europe, which resulted in a strong anomalous net source of carbon dioxide (0.5 Pg C yr(-1)) to the atmosphere and reversed the effect of four years of net ecosystem carbon sequestration. Our results suggest that productivity reduction in eastern and western Europe can be explained by rainfall deficit and extreme summer heat, respectively. We also find that ecosystem respiration decreased together with gross primary productivity, rather than accelerating with the temperature rise. Model results, corroborated by historical records of crop yields, suggest that such a reduction in Europe's primary productivity is unprecedented during the last century. An increase in future drought events could turn temperate ecosystems into carbon sources, contributing to positive carbon-climate feedbacks already anticipated in the tropics and at high latitudes.

CT scan structured report for the study of abdominal wall defects: a fast, easy and practical tool at the service of both surgeons and radiologist.

PURPOSE: The advantages offered by structured reporting have already been highlighted in the literature. However, there is still no evidence on the validity of this reporting method for the study of abdominal wall defects. This study aims to show the experience of the Trentino Hernia Team (THT) multidisciplinary group in the development and use of a structured CT scan report for the study of abdominal wall defects. METHODS: A regional multidisciplinary team (THT group) used a Delphi method to identify and select the most important CT scan parameters needed to describe and stage abdominal wall defects for correct preoperative planning. Based on the selected parameters, a CT scan structured report was worked out and collectively accepted. The first 20 structured reports obtained were individually tested for compilation speed and homogeneity of the data reported by five distinct radiologists. The reports were then evaluated by five different surgeons to test the simplicity of interpretation. RESULTS: We produced a model of a structured report for the study of the abdominal wall defects and tested it in our hospital network on the first 20 reports. The average completion time was 18 min (range 12-25). There was no heterogeneity among the reported data. The reports were analysed by five distinct surgeons to evaluate completeness and simplicity of interpretation. Each surgeon used a Likert scale from 0 to 5 to evaluate each report, producing average scores of 4.8 and 4.1 for completeness and comprehensibility respectively, with a mean combined total score of 8.9 out of 10. CONCLUSIONS: Our structured report represents a fundamental tool capable of providing the surgeon with all the measurements of the parameters necessary for correct preoperative planning. At the same time, it is of crucial help for the radiologists representing an easy and fast way to report all the needed parameters using the same standards.

Fluxes of oxidised and reduced nitrogen above a mixed coniferous forest exposed to various nitrogen emission sources.

Concentrations of nitrogen gases (NH(3), NO(2), NO, HONO and HNO(3)) and particles (pNH(4) and pNO(3)) were measured over a mixed coniferous forest impacted by high nitrogen loads. Nitrogen dioxide (NO(2)) represented the main nitrogen form, followed by nitric oxide (NO) and ammonia (NH(3)). A combination of gradient method (NH(3) and NO(x)) and resistance modelling techniques (HNO(3), HONO, pNH(4) and pNO(3)) was used to calculate dry deposition of nitrogen compounds. Net flux of NH(3) amounted to -64 ng N m(-2) s(-1) over the measuring period. Net fluxes of NO(x) were upward (8.5 ng N m(-2) s(-1)) with highest emission in the morning. Fluxes of other gases or aerosols substantially contributed to dry deposition. Total nitrogen deposition was estimated at -48 kg N ha(-1) yr(-1) and consisted for almost 80% of NH(x). Comparison of throughfall nitrogen with total deposition suggested substantial uptake of reduced N (+/-15 kg N ha(-1) yr(-1)) within the canopy.

Crohn's disease and Takayasu's arteritis: is this association difficult to find out?

Takayasu's arteritis is rarely reported associated with Crohn's disease in the English world literature. A case of Takayasu's arteritis type V in a young female affected by Crohn's disease is presented and the pathophysiology mechanism, and the clinical and diagnostic aspects are underlined. Surgical strategy is discussed.

Carriage of CARD15 variants and smoking as risk factors for resective surgery in patients with Crohn's ileal disease.

BACKGROUND: It is controversial whether CARD15 variants are truly associated with a more severe form of Crohn's disease. The relative role of CARD15 genotype and smoking in Crohn's disease progression is also debated. AIM: To investigate the association between CARD15 variants and history of resective surgery in patients with Crohn's ileal disease, taking into account smoking as a possible confounding factor. METHODS: We originally assessed CARD15 genotype in 239 north Italian Crohn's disease patients (mean follow-up: 10.1 +/- 8.1 years). We then focused on 193 patients with proven ileal involvement, 70 of whom (36.3%) carried CARD15-mutated alleles (G908R, R702W, L1007fs). RESULTS: Carriage of CARD15 variants was positively associated with family history and ileal-only disease and negatively associated with uncomplicated behaviour at maximal follow-up (P < 0.05). Ileal resection was the only variable independently associated with CARD15 variants at multivariate analysis (OR 3.8; 95% CI 1.6-9.2; P = 0.003). Kaplan-Meier analysis showed that ileal resection was favoured both by CARD15 variant-carriage (P = 0.01) and by smoking (P = 0.05), but smoking did not affect progression to surgery in variant carriers (P = 0.31). Thirteen of 14 (93%) patients being resection-free at 15-year follow-up, had CARD15 wild-type genotype (P = 0.01), whereas only seven (50%) had never smoked (P = 1.0). CONCLUSIONS: In summary, CARD15 variant-associated Crohn's ileitis is virtually committed to stricturing and/or penetrating disease and, eventually, to resective surgery. Smoking accelerates progression to surgery in patients with wild-type CARD15 genotype, but it seems to exert no additional effect in CARD15-variant carriers.

Soil respiration in a mixed temperate forest and its contribution to total ecosystem respiration.

Soil respiration (SR) was measured with an infrared gas analyzer in nine plots representative of the heterogeneous vegetation in a mixed coniferous-deciduous forest in the Belgian Campine region. Selected plots included the two most representative overstory species (Pinus sylvestris L. and Quercus robur L.) in combination with the most representative understory species of the forest. A model that includes temperature and water as the main controlling variables was fitted to the data. We found large spatial variability in SR among plots, with typically lower fluxes under the coniferous overstory than under the deciduous overstory (means of 4.8 +/- 0.4 and 8.8 +/- 0.5 Mg C ha(-1) year(-1), respectively). Total annual soil carbon (C) emissions were estimated by weighting fluxes from different types of vegetation according to their relative contribution to the footprint area of the eddy covariance flux measurement. The relative contribution of the two main tree species to the footprint-weighted total SR varied among seasons with the more abundant coniferous overstory contributing the most to total SR during most of the year. Nonetheless, during summer, the contribution of deciduous plots to total SR was disproportionally high because of the more pronounced seasonality of belowground metabolic activity. Net ecosystem carbon dioxide exchange was measured by eddy covariance, and we estimated total ecosystem respiration (TER) with footprint-constrained nighttime fluxes. Mean total annual SR and TER were 6.1 +/- 0.11 and 9.1 +/- 1.15 Mg C ha(-1) year(-1), respectively. The 95% confidence interval of the ratio of annual SR:TER ranged from 0.58 to 0.76, with a mean of 0.67. The contribution of SR to TER tended to vary seasonally, with minimum contributions during summer (less than 50% of TER) and maximum contributions during winter (about 94% of TER).

Vector competence of rural and urban strains of Aedes (Stegomyia) albopictus (Diptera: Culicidae) from São Paulo State, Brazil for IC, ID, and IF subtypes of Venezuelan equine encephalitis virus.

Aedes albopictus (Skuse) is an Asiatic mosquito species that has spread and colonized all continents except Antarctica. It has major public health importance because it is a potential vector of several pathogens. The objectives of our study were to analyze the vector competence of urban and rural strains of Ae. albopictus from São Paulo State (Brazil) for Venezuelan equine encephalitis virus (VEE) subtypes IC, ID, and IF, and to evaluate the effect of infection with subtype IC of VEE on mosquito longevity. Both mosquito strains were susceptible to subtypes IC and ID, but the infection rate for subtype IF was low. Infection and transmission rates of Ae. albopictus for subtype IC were similar to those reported for Ochlerotatus taeniorhynchus (Wiedemann). The high infection, dissemination, and transmission rates for subtype ID reported for Oc. fulvus (Wiedemann) and Culex (Melanoconion) spp. are comparable with those found in this study. We found significant differences in the susceptibility to subtype IC between rural and urban populations of São Paulo. Significant survival rate differences were observed between uninfected and infected mosquitoes, but there were no differences in survival between rural and urban mosquito strains.

Synchronous isolated splenic metastasis from colon carcinoma.

We report the first case known to us of a synchronous isolated splenic metastasis from colon carcinoma in a 52-year-old woman operated on splenectomy, left colectomy, and ileal resection. The patient died of diffuse carcinomatosis 1 year after the operation. Splenectomy for isolated splenic metastasis from colon carcinoma is justified, and serum tumor markers are useful to detect metastases early during the follow-up, as in our report.

Interactive effects of temperature and precipitation on soil respiration in a temperate maritime pine forest.

Soil respiration (SR) was monitored periodically throughout 2001 in a Scots pine (Pinus sylvestris L.) stand located in the Belgian Campine region. As expected for a temperate maritime forest, temperature was the dominant control over SR during most of the year. However, during late spring and summer, when soil water content (SWC) was limiting, SR was insensitive to temperature (Q(10) = 1.24). We observed that during prolonged rain-free periods, when SWC was less than 15% (v/v), SR decreased dramatically (up to 50%) and SWC took over control of SR. During such drought periods, however, rain events sometimes stimulated SR and restored temperature control over SR, even though SWC in the mineral soil was low. We hypothesize that restoration of temperature control occurred only when rain events adequately rewetted the uppermost soil layers, where most of the respiratory activity occurred. To quantify the rewetting capacity of rain events, an index (I(w)) was designed that incorporated rainfall intensity, time elapsed since the last rain event, and atmospheric vapor pressure deficit (a proxy for evaporative water losses). To simulate SR fluxes, a model was developed that included the effects of soil temperature and, under drought and non-rewetting conditions (I(w) and SWC < threshold), an SWC response function. The model explained 95% of the temporal variability in SR observed during summer, whereas the temperature function alone explained only 73% of this variability. Our results revealed that, in addition to temperature and SWC, rain plays a role in determining the total amount of carbon released from soils, even in a maritime climate.

Above- and belowground biomass and net primary production in a 73-year-old Scots pine forest.

We estimated above- and belowground biomass and net primary production (NPP) of a 73-year-old Scots pine (Pinus sylvestris L.) forest stand in the Belgian Campine region. Total biomass for the stand was 176 Mg ha(-1), of which 74.4% was found in stems. The root system contained 12.6% of total biomass, most of it in coarse roots (> 5 mm). Fine roots (< 5 mm) comprised only about 1.7% of total biomass, and more than 50% of fine root biomass was retrieved in the litter layer and the upper 15 cm of the mineral soil. The ratio of belowground biomass to aboveground biomass was 0.14, which is lower than that of other Scots pine forests and other coniferous forests. Between 1995 and 2001, mean annual NPP was 11.2 Mg ha(-1) year(-1), of which 68.7% was allocated to aboveground compartments. Stems, needles and cones made relatively high contributions to total NPP compared with branches. However, branch NPP was possibly underestimated because litterfall of big branches was neglected. The proportion of total NPP in belowground components was 31.3%. Coarse root NPP (2% of total) was low compared with its biomass. Fine root NPP was 3.3 Mg ha(-1) year(-1), representing about 29.5% of total NPP; however, the estimate of fine root NPP is much more uncertain than NPP of aboveground compartments. The ratio NPP/GPP (gross primary production) was 0.32, which was low compared with other coniferous forests.

Conservative approach in the treatment of the biliary tract's iatrogenic lesions.

Iatrogenic lesions of the biliary tract have always represented a problem of real actuality in the abdominal surgery. The incidence of post-cholecystectomy complications is from 0.1% to 0.25% and it's increased to 0.3-0.6% for laparoscopic surgery. Potential predisposing factors to iatrogenic biliary lesions are anatomic anomalies, acute and chronic phlogosis and technical mistakes. Anatomic anomalies are present in 6-25% of all cases according to different statistics; an incomplete knowledge of the biliary tract can predispose to a mistake legating or dissecting a wrong branch. This paper present a caseload of 27 patients admitted to our Service of Digestive Endoscopy owing to post laparoscopic cholecystectomy complications. Patients have been recruited in a period from two days to six months to the intervention. Detected complicances have been divided in "major", which comprehended biliary lesions (7 cases) and biliary stenosis (8 cases), and in "minor" which included biliary leakages (12 cases). CPRE, PTC, Ultrasound, CT and cholangio-MR were used to diagnose the biliary damage. Conservative approach has been resolutive in all patients with minor biliary lesions and in three cases of major lesions; in seven cases of biliary stenosis endoscopic-radiologic combined treatment has been successfully performed, in the other patients surgical operation was obliged choice. Comparing our results with literature we can affirm that conservative treatment represents the first choice in case of minor lesions (100% of successes), whereas in case of major biliary lesions it constitutes a valid alternative to the reparative surgery; when surgical option results impossible to defer, it can help the surgeon identifying the damage and draining the biliary tract.

Sentinel node role in breast cancer surgery.

Radical surgery of breast cancer includes lymphadenectomy of axilla as well as the dissection of the neoplastic tissue. However recently many works have raised doubts on the opportunity of performing routinary axillary dissection, which elevates morbidity risk, in absence of axillary metastases. However, unfortunately, information on axillary lymph node pathology, is not available with any other technique excluding complete dissection and istopathological examination. Sentinel node technique is a new methodology that consents evaluation of lymph node status in the operating theatre. It allows the surgeon to judge on the opportunity of carrying out the lymphadenectomy or not.

Central venous catheter disruption and embolization: percutaneous retrieval. A case report.

Disruption followed by intravasal embolization is a rare (0.5%) however possible complication secondary to the insertion of a central venous catheter. The carriers of these implantable systems are patients who, for their cure and at times even for their survival, require the chronic intravenous infusion of drugs and solutions. Therefore materials that can allow long-term insertion with a minimum of complications are the most suitable. There are several causes of disruption and embolization of cannulae. The most common are represented by the pinch-off syndrome and catheter disconnection from reservoir. The literature on the subject is illustrated and a personal case treated with intravascular retrieval is reported.

[Surgical treatment of Crohn's disease. Indication and management in 20 patients]. / Trattamento chirurgico del morbo di Chron. Indicazioni e tattica chirurgica in 20 pazienti.

MATERIALS AND METHODS: Sixty-seven patients with Crohn's disease underwent surgery in our department in the period 1989-1996. In this paper we evaluated only the first 20 patients. Ten were female and 10 male. There was single localization in 13 patients and multiple in 7. Surgery was limited to the macroscopically involved intestinal segment. Reconstruction of the intestinal tract has been carried out with a double layer polyglycolic acid end-to-end manual anastomosis. RESULTS: We had no operative deaths and early morbidity. In the follow-up we observed 2 anastomotic recurrences respectively three and five years after the operation; none of them required surgical treatment. One patient of 20 had a colocutaneous fistula four months after operation because of the relapse of the disease at preanastomotic level. CONCLUSIONS: The results obtained in our limited experience allow us to affirm that, when elective surgery is possible, the most reliable surgical behaviour is a limited resection of the diseased segment. Quality of life improved after surgery in all patients.

Comparing Landslide Maps: A Case Study in the Upper Tiber River Basin, Central Italy.

/ The preparation of landslide maps is an important step in any landslide hazard assessment. Landslides maps are prepared around the world, but little effort is made to assess their reliability, outline their main characteristics, and pinpoint their limitations. In order to redress this imbalance, the results of a long-term research project in the Upper Tiber River basin in central Italy are used to compare reconnaissance and detailed landslide inventory maps, statistical and geomorphologically based density maps, and landslide hazard maps obtained by multivariate statistical modeling. An attempt is made to discuss advantages and limitations of the available maps, outlining possible applications for decision-makers, land developers, and environmental and civil defence agencies. The Tiber experiment has confirmed that landslides can be cost-effectively mapped by interpreting aerial photographs coupled with field surveys and that errors and uncertainties associated with the inventory can be quantified. The experiment has shown that GIS makes it easy to prepare landslide density maps and facilitates the production of statistically based landslide hazard models. The former supply an overview of the distribution of landslides that is easily comprehended but do not provide insight on the causes of instability. The latter, giving insight into the causes of instability, are diagnostically powerful, but are difficult to prepare and exploit.

Adjuvant treatment of early stage ovarian carcinoma.

Surgery is considered the mainstay of diagnosis and treatment in early ovarian carcinoma. Only accurate staging laparotomy can detect subclinical metastases remote from the ovary, thus allowing the identification of the truly early tumors. However the complete macroscopic removal of neoplastic disease is not synonymous with cure. Many postoperative treatments have been carried out in order to improve the prognosis of patients with stage I-II ovarian carcinoma. The present paper reviews the main clinical trials on the employment of external radiotherapy, intraperitoneal radioisotope instillation and systemic chemotherapy in the management of early ovarian carcinoma. The patients appear to benefit from adjuvant treatment, with the exception of those with stage I Ai-I Bi well differentiated tumor, even if there is no agreement in literature about the superiority of a particular therapeutic approach. However the high response rates obtained in patients with advanced ovarian carcinoma with DDP containing combination chemotherapy have suggested to clinicians the use of such treatment also in early stage tumors. In our experience none of the 11 stage I ovarian cancer patients, who received 6 courses of DDP-based combination chemotherapy, have developed recurrent disease after a median follow-up of 54 months (with a range from 24 to 72 months).