Laparoscopic resection of multiple aneurysms of the gastroepiploic arterial arcade.

BACKGROUND: Gastroepiploic arterial aneurysms (GEAA) represent a very rare disorder [1, 2]. The risk of GEAA rupture is high, and it is associated with a high mortality rate [3]. GEAAs are usually identified following rupture or are incidentally diagnosed. In emergency, an open surgical approach to treat GEAAs has been most frequently reported [4]. Alternatively, if the patient is hemodynamically stable, an angiography and embolization can be attempted. Herein we report the case of a patient presenting with two fissurated GEAAs that were successfully excised laparoscopically after failure of the endovascular approach. MATERIALS AND METHODS: A 83-year-old lady was admitted for acute epigastric pain. Upon admission, her general status was stable. The abdomen was soft and slightly painful at deep palpation in epigastrium, with no sign of peritonism. In her past medical history, she had a transient ischemic attack and atrial fibrillation episodes for which a pacemaker had been placed. Her blood examinations showed a slight anemia (hemoglobin 10.5 g/dl). An abdominal ultrasonography identified two solid, circular, nodules next to the gastric anterior wall that, in a following angio-TC, were diagnosed as two aneurysms of the gastro-epiploic arterial arcade (GEA), one measuring 17 mm × 13 mm, the other 39 mm × 33 mm. Both showed X-ray signs of impending rupture and intraluminal "thrombization". The patient underwent selective angiography, during which, after an attempt of common hepatic artery catheterism, a dissection and, consequently, an occlusion of the hepatic artery and the celiac trunk unfortunately occurred. Therefore, after a catetherism of the superior mesenteric artery, only a partial and incomplete embolization procedure was possible. As a matter, at the end of the angiographic procedure, reperfusion of the GEA coming from the splenic and hepatic artery was recognized. After 24 h, repeated abdominal CT scan with contrast showed the persistence of the aneurysms with no dimensional changes and the presence of a small active extravasation of contrast from the lateral aneurysm. RESULTS: Laparoscopic surgical exploration was then warranted. Two voluminous GEA arcade aneurysms, very close to greater curvature of the stomach, were identified. After a cautious visceral dissection, the right and left gastroepiploic arteries were clipped and sectioned. Due to the presence of strength adhesions between the aneurysms and the greater curvature of the stomach, we decided to perform double aneurismectomy "en bloc" with the excision of the adjacent greater gastric curve by using an articulated laparoscopic stapler (Endo GIA™ 60 mm Articulating Medium/Thick Reload with Tri-Staple™ Technology, MEDTRONIC, Minneapolis, US). No intraoperative complications were reported. The patient was discharged in fifth post-operative day. CONCLUSIONS: In case of failure of a non-surgical management of ruptured GEA aneurysms, the laparoscopic resection is a safe and effective procedure.

Laparoscopic repair of perforated peptic ulcer: single-center results.

BACKGROUND: Perforated peptic ulcer (PPU), the most common indication for emergency gastric surgery, is associated with high morbidity and mortality rates. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of laparoscopic repair (LR) of PPU outweigh the disadvantages. METHODS: From January 2002 to December 2012, 111 patients underwent surgery for perforated ulcer. A "laparoscopy-first" policy was attempted and then applied for 56 patients. The exclusion criteria for LR ruled out patients who had shock at admission, severe cardiorespiratory comorbidities, or a history of supramesocolic surgery. The aim of this study was a retrospective analysis of the 56 patients treated laparoscopically. RESULTS: The patient distribution was 30 men and 26 women, who had a mean age of 59 years (range 19-95 years). The mean ulcer size was 10 mm, and the Mannheim peritonitis index (MPI) was 21. LR was performed for 39 (69.6%) of the 56 patients and included peritoneal lavage, suturing of the perforation, and omental patching. Conversion to laparotomy was necessary in 17 cases (30.4%). The "conversion group" showed significant differences in ulcer size (larger ulcers: 1.9 vs. 0.7 mm; p < 0.01), ulcer-site topography (higher incidence of posterior ulcers: 5 vs. 0; p < 0.01), and MPI score (higher score: 24 vs. 20; p < 0.05). The LR group had a mean operating time of 86 min (range 50-125 min), an in-hospital morbidity rate of 7.6 %, a mortality rate of 2.5%, and a mean hospital stay of 6.7 days (range 5-12 days). None of these patients required reintervention. CONCLUSIONS: The results showed that LR for PPU is feasible with acceptable mortality and morbidity rates. Skill in laparoscopic abdominal emergencies is required. Perforations 1.5 cm or larger, posterior duodenal ulcers, and an MPI higher than 25 should be considered the main risk factors for conversion.

Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines.

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Laparoscopic transcystic exploration for single-stage management of common duct stones and acute cholecystitis.

BACKGROUND: Common bile duct (CBD) stones are found in 10% of patients who undergo elective laparoscopic surgery for gallstone disease and in 10-20% of patients who present with acute cholecystitis (AC). For the latter, the role of laparoscopic transcystic exploration of the common duct (LTCE) as part of a single-stage procedure is still unknown. METHODS: This study, based on a "laparoscopy first" policy, included 201 subjects with cholecystocholedocholithiasis: 104 underwent a scheduled laparoscopic surgery (group A), and 97 where admitted for AC and had urgent laparoscopy (group B). Group B patients were significantly older (68.4 vs. 62.1 years; P = 0.0045), had a higher proportion of women (56% vs. 41%; P = 0.0345), and included more patients in the ASA III-IV class (39% vs. 21%; P = 0.0006). LTCE was performed by using basket-wired catheters. CBD clearance, operating time, conversion rate, morbidity and mortality, postoperative hospital stay, readmission, and residual CBD stones were the main outcome measures. RESULTS: Clearance of CBD was obtained in 84% of patients of group A and in 80% of patients of group B (P = not significant). Time spent in the operating room was longer for group B (175 vs. 141 min; P = 0.0003). There were no significant differences for postoperative hospital stay (group A 4.9 vs. group B 5.2 days), readmission rate (3.7% vs. 3.7%), and residual CBD stones (2.8% vs. 3.1%). Need to convert and morbidity occurred more frequently in group B (11.7% vs. 4.6% and 28.7% vs. 16.8%, respectively), but differences were not significant. In group A, one patient died from MOFS. CONCLUSIONS: LTCE has proved to be a simple technique with a high yield of CBD clearance in the acute setting. Courses are comparable to those observed for the same procedure in elective surgery despite the fact that patients with AC are more at risk for drawbacks.

Intestinal Ischemia: Unusual but Fearsome Complication of COVID-19 Infection.

The pathophysiology of gastrointestinal damage in coronavirus disease (COVID-19) is probably multifactorial. It is not clear whether the etiology of intestinal ischemia may be directly related to viral replication or may result from hyper-coagulability following SARS-CoV-2 infection.To confirm a pathogenic role of COVID-19, we retrospectively investigated the presence of SARS-CoV-2 virus in the ischemic bowel of five COVID-19 patients undergoing emergency surgery for intestinal ischemia in the period of March 2020-May 2021. Immunohistochemical positivity with weak intensity was observed in four out of five cases, but only one case was strongly positive both at immunohistochemistry and at molecular analysis. The histological alterations in the intestinal tissue samples showed similarity with the well-known alterations described in typical targetorgans of the virus (e.g., the lung). This observation suggests a similar mechanism of action of the virus. Further larger studies are, thus, required to confirm this preliminary finding. Clinicians should carefully monitor all COVID-19 patients for the possible presence of a SARS-CoV-2 intestinal infection, a potential cause of ischemia and bowel perforation.

Uncommon cause of acute abdomen: volvulus of gallbladder with necrosis. Case report and review of literature.

Gallbladder volvulus is a rare condition which can mimic an acute cholecystitis. This condition is characterized from a rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. Preoperative diagnosis is difficult. This is an acute surgical emergency that must be treated with immediate detorsion and cholecystectomy. We report a case of acute gallbladder torsion in an elderly man and review the clinical aspects of the disease in the context of the available literature.

[Outcome of laparotomy for severe secondary peritonitis]. / La laparostomia nelle peritoniti secondarie severe.

BACKGROUND: Temporary abdominal closure with planned re-operations is a treatment method for several critical abdominal conditions. Aim of the study was to evaluate the effectiveness of laparostomy and the risk factors for survival in patients presenting with severe secondary peritonitis (SSP). METHODS: 52 patients (mean age 66.5) with a SSP were analyzed. The peritonitis developed spontaneously (n=34) or complicated a recent surgical operation (n=18). 18 patients were operated on for a bowel cancer and 6 of them had a metastatic disease. Skin closure (n=21), bogota bag (n=16) and vacuum-pack (n=15) were the methods employed to achieve temporary abdominal closure for planned re-operations. The severity of the disease was calculated by using APACHE II and Mannheim Peritonitis Index (MPI) scoring systems. Survival was the main outcome measure. RESULTS: Mortality was 38% (n=20). Age, sex, pathogenesis of the peritonitis, type of temporary abdominal closure, number of re-operations and occurrence of entero-atmospheric fistula did not differ significantly between survivors and nonsurvivors. APACHE II (19.6 vs. 14.3; p=. 0015) and MPI (35.5 vs. 27.8; p=. 001) scores were significantly greater in the non-survivors group. The occurrence of perforated left colon/rectum was also significantly greater among non-survivors. By multivariate analysis only MPI resulted to be a significant independent risk factor for survival (p < 0.05). CONCLUSIONS: SSP is a life-threatening condition. Laparostomy may have a role in controlling the source of abdominal infection but even with this outmost invasive surgical measure, mortality still remains high. For these patients, MPI may have a role as outcome predictor.

Indocyanine Green (ICG) for the assessment of splenic perfusion during laparoscopic splenic artery aneurysmectomy. A case report.

CASE REPORT: We describe the case of a 54-year-old man with a 20mm splenic aneurysm, who underwent laparoscopic aneurysmectomy, without splenic removal. The residual splenic blood supply was assessed by using indocyanine green i.v. administration. CLINICAL FINDINGS: The patient presented at ED with abdominal pain, syncopal episode, and tachycardia. A CT scan with contrast showed hemoperitoneum with a 20mm splenic aneurysm, which was located at the bifurcation of the splenic and left gastroepiploic artery. Treatment and Outcome Laparoscopic surgery was then warranted. Abdominal exploration revealed a serohemorrhagic collection without active source of bleeding. After opening the gastro-colic ligament and obtaining vascular control of the splenic artery, the aneurysm was clipped and resected. No macroscopic modifications occurred to the spleen. This finding was confirmed by intravenous administration of indocyanine green. The operating time was 265 minutes. During the postoperative course, a grade A pancreatic fistula occurred. The patient was discharged on postoperative day seventh. CLINICAL RELEVANCE: The management of true splenic artery aneurysms should be patient-tailored, considering the location of the aneurysm, operative risks and the patient's age, life expectancy and clinical status. The use of ICG in splenic surgery helps delineate the splenic parenchyma and evaluate residual splenic vascularization. KEY WORDS: Indocyanine Green, Laparoscopy, Mini-invasive Surgery, Splenic Artery Aneurysm.

A delayed conversion may increase the risk of major complications in acute cholecystitis approached laparoscopically. A retrospective comparative cohort study.

AIM: Aim of this study was to evaluate whether timing of laparoscopy lasting longer than two hours before converting to open surgery can worsen the postoperative course during laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). MATERIALS AND METHODS: Medical records of 1,161 patients who underwent urgent laparoscopic cholecystectomy for AC during the period 2001-2017 were retrospectively analyzed. A conversion to open surgery was performed in 70 (6%) patients. Among these, two groups of patients were identified: group 1 (n=51; 73%) included patients who underwent laparotomy within 2 hours from the beginning of the operation, and group 2 (n=19; 27%) included patients who underwent conversion to open surgery after more than 2 hours of laparoscopy. Patients were analyzed for demographic data and comorbidities. Major outcome measures were mortality, morbidity and length of stay. A p value < 0.05 was considered significant. RESULTS: Reasons for conversion to open surgery included severe inflammation (46%), visceral adhesions (27%), inability to manage common bile duct stones (17%), intolerance to pneumoperitoneum (7%) and the presence of a cholecystoduodenal fistula (1%). By comparing these groups, no significant differences were noted regarding overall morbidity (29% vs 42%, p=0.31), mortality (2% vs 5%, p=0.46) and mean postoperative length of stay (8.7 vs 8.2 days, p=0.75). Major postoperative complications (grade III-V according to Clavien and Dindo classification) were significantly more frequent in group 2 (p=0.03). CONCLUSIONS: When approaching AC laparoscopically, the decision to convert to open surgery within two hours may prevent the occurrence of major postoperative complications. Early conversion does not seem to affect the mortality and length of hospital stay. KEY WORDS: Acute Cholecystitis, Conversion, Laparoscopy.

Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy.

Introduction: Over the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS. Methods: All the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011-2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study. Results: There were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m2 (SD ± 3.33). Thirteen cases (38%) were Wasvary's modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann's procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender (p = 0.010) and MPI (p = 0.034) correlated with a high percentage of Hartmann's procedures. Conclusion: DCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.

Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA).

INTRODUCTION: No definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question. MATERIAL AND METHODS: A prospective analysis of adult patients enrolled in the IROA. RESULTS: Among 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogotà-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence. CONCLUSION: Entero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment.

Gastrointestinal stromal tumour of the duodenum in childhood: a rare case report.

BACKGROUND: Gastrointestinal stromal tumours (GISTs) are uncommon primary mesenchymal tumours of the gastrointestinal tract mostly observed in the adults. Duodenal GISTs are relatively rare in adults and it should be regarded as exceptional in childhood. In young patients duodenal GISTs may be a source of potentially lethal haemorrhage and this adds diagnostic and therapeutic dilemmas to the concern about the long-term outcome. CASE PRESENTATION: A 14-year-old boy was referred to our hospital with severe anaemia due to recurrent episodes of upper gastrointestinal haemorrhage. Endoscopy, small bowel series, scintigraphy and video capsule endoscopy previously done elsewhere were negative. Shortly after the admission, the patient underwent emergency surgery for severe recurrence of the bleeding. At surgery, a 4 cm solid mass arising from the wall of the fourth portion of the duodenum was identified. The invasion and the erosion of the duodenal mucosa was confirmed by intra-operative pushed duodenoscopy. The mass was resected by a full-thickness duodenal wall excision with adequate grossly free margins. Immunohistochemical analysis of the specimen revealed to be positive for CD117 (c-KIT protein) consistent with a diagnosis of GIST. The number of mitoses was < 5/50 HPF. Mutational analysis for c-KIT/PDGFRA tyrosine kinase receptor genes resulted in a wildtype pattern. The patient had an uneventful course and he has remained disease-free during two years of follow-up. CONCLUSION: Duodenal GISTs in children are very rare and may present with massive bleeding. Cure can be achieved by complete surgical resection, but even in the low-aggressive tumours the long-term outcome may be unpredictable.

Oncologic colon cancer resection in emergency: are we doing enough?

BACKGROUND: The primary challenge of surgery for colon cancer (CC) presenting as an emergency is the control of the complication but a proper oncologic technique should not be missed when bowel resection is feasible. Currently, recommended oncologic criteria include en-bloc resection of invaded organs and structures, an adequate extent of the bowel resection and of the free margins and an adequate number of lymph nodes yielded. METHODS: Chart-review of 499 CC patients undergone colectomy. One hundred and twenty-one (group A) presented as emergencies (obstruction n=85, perforation n=30, hemorrhage n=6) and were analyzed for tumor stage, need for enlarged resection, distal free margin, lymph node yield, mortality and morbidity. Results were compared with those observed in the 378 patients operated electively (group B). RESULTS: Group A patients had a more advanced cancer stage (stage III/IV 62.8% vs. 48.7%, p<.01), but the need for enlarged resection was not significantly different in the two groups. Also the length of free distal margin was similar (means, group A: 97 mm; group B: 84 mm, p=ns). The number of excised nodes was greater in emergency (means, group A: 26.2 nodes; group B: 20.8 nodes, p<.01). Compared with group B, emergency procedures resulted in higher morbidity (22.3% vs. 13.4%, p<.05) and mortality (8.2% vs. .8%, p<.0001). CONCLUSIONS: Recommended oncologic resection techniques may be applicable to surgery for complicated tumors of the colon and radical resection may be warranted by emergency colectomy. The worse long-term prognosis for patients with colonic cancer presenting acutely may be related to the stage of the disease rather than to the failure of surgery.

Acute appendicitis complicating De Garengeot's hernia treated with combined laparoscopic-open technique: a case series and literature review.

An acute appendicitis in the context of a De Garengeot's hernia is a very rare event and represents a hard challenge for surgeons. As only few cases have been reported in literature, there is no consensus about its optimal surgical strategy of treatment. Here we present two consecutive cases of female patients presenting an uncommon acute appendicitis in a femoral hernia treated with a combined laparoscopic/open technique. KEY WORDS: Acute appendicitis, De Garengeot's hernia, Laparoscopy.

Less is more: an outcome assessment of patients operated for gallstone ileus without fistula treatment.

BACKGROUND: The treatment of gallstone ileus (GI) consists of surgical removal of the impacted bilestone with or without cholecystectomy and repair of the biliodigestive fistula. The objective of this study was to assess whether sparing patients a definitive biliary procedure adversely influenced the outcome. MATERIALS AND METHODS: Patients with a diagnosis of GI were reviewed. Two groups were identified: patients who underwent a definitive biliary procedure with relieving the intestinal obstruction (group 1/G1) and those who did not have a definitive biliary procedure (group 2/G2). In G2, patients were evaluated on long-term follow-up for the risk of recurrent GI disease, cholecystitis, cholangitis and gallbladder cancer. RESULTS: Among 1075 patients admitted for small bowel obstruction, 20 (1.9%) were diagnosed with gallstone ileus. 3 (15%) of these belong to G1, 17 (85%) to G2. The overall postoperative morbidity rate was 35% (7/20) with one complication exceeding grade II in each group. No deaths were reported. Mean follow-up was 50 months. During follow-up, one of G2 patients had recurrent disease. No biliary tract infections or gallbladder cancer were identified. CONCLUSION: Enterolithotomy without fistula closure is confirmed to be safe and effective for the management of gallstone ileus both on a short- and long-term basis.

Early cholecystectomy for non-severe acute gallstone pancreatitis: easier said than done.

BACKGROUND: Laparoscopic cholecystectomy (LC) carried out within 3 days after an attack of non-severe acute gallstone pancreatitis (NSAGP) is recommended to reduce hospital stay and overall costs. Aim of the study was to evaluate factors that may delay a timely surgical management of NSAGP and the consequences of this deviation. METHODS: We reviewed the charts of patients admitted for NSAGP and managed by LC during the last 14 years. A total number of 316 patients entered the study, 98 of whom underwent early LC. A comparison of pre-operative and outcome data from the group of patients undergone early LC and those who received a delayed LC (>3 days since the admission) was made. RESULTS: Only 31% of patients presenting with NSAGP were managed by early LC. Respect to these, patients who received a delayed LC were significantly older and had a greater occurrence of clinical signs suggesting common bile duct stones (CBDS). Stabilization of co-morbidities and need to investigate preoperatively the common duct were the main factors associated to the surgical delay. By comparing patients undergone early LC and those who received delayed LC, differences regarding conversion to open surgery (2% vs. 1.3%), need to explore the common bile duct (18.3% vs. 25.6%), CBDS clearance rates (94.4% vs. 94.6%), morbidity (8.1% vs. 8.7%), and postoperative hospital stay (3.9 vs. 3.2 days) were however statistically not significant. CONCLUSIONS: Several reasons could delay the 3-day recommendation for surgery in NSAGP. These include the need to achieve before surgery the control of age-related co morbidities, and the workup to investigate for common duct stones. A fast track program aiming to early surgery would be advisable for patients presenting with NSAGP. Compared to delayed LC, early LC appears to shorten overall hospitalization but it does not seem to have any clinical impact on the course.

IROA: International Register of Open Abdomen, preliminary results.

BACKGROUND: No definitive data about open abdomen (OA) epidemiology and outcomes exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) promoted the International Register of Open Abdomen (IROA). METHODS: A prospective observational cohort study including patients with an OA treatment. Data were recorded on a web platform (Clinical Registers®) through a dedicated website: www.clinicalregisters.org. RESULTS: Four hundred two patients enrolled. Adult patients: 369 patients; Mean age: 57.39±18.37; 56% male; Mean BMI: 36±5.6. OA indication: Peritonitis (48.7%), Trauma (20.5%), Vascular Emergencies/Hemorrhage (9.4%), Ischemia (9.1%), Pancreatitis (4.2%),Post-operative abdominal-compartment-syndrome (3.9%), Others (4.2%). The most adopted Temporary-abdominal-closure systems were the commercial negative pressure ones (44.2%). During OA 38% of patients had complications; among them 10.5% had fistula. Definitive closure: 82.8%; Mortality during treatment: 17.2%. Mean duration of OA: 5.39(±4.83) days; Mean number of dressing changes: 0.88(±0.88). After-closure complications: (49.5%) and Mortality: (9%). No significant associations among TACT, indications, mortality, complications and fistula. A linear correlationexists between days of OA and complications (Pearson linear correlation = 0.326 p<0.0001) and with the fistula development (Pearson = 0.146 p= 0.016). Pediatric patients: 33 patients. Mean age: 5.91±(3.68) years; 60% male. Mortality: 3.4%; Complications: 44.8%; Fistula: 3.4%. Mean duration of OA: 3.22(±3.09) days. CONCLUSION: Temporary abdominal closure is reliable and safe. The different techniques account for different results according to the different indications. In peritonitis commercial negative pressure temporary closure seems to improve results. In trauma skin-closure and Bogotà-bag seem to improve results. TRIAL REGISTRATION: ClinicalTrials.gov NCT02382770.

Erratum to: IROA: International Register of Open Abdomen, preliminary results.

[This corrects the article DOI: 10.1186/s13017-017-0123-8.].

[Simultaneous laparoscopic treatment for common bile duct stones associated with acute cholecystitis. Results of a prospective study]. / Trattamento laparoscopico simultaneo per coledocolitiasi associata a colecistite acuta. Risultati di uno studio prospettico.

Laparoscopy for the management of acute cholecystitis has gained wide acceptance. Although it is well known that acute cholecystitis may be complicated by common bile duct stones in up to 15% of cases, to date there are no published studies addressing the management of common bile duct stones detected during laparoscopy for acute cholecystitis. We postulated that, when found, common bile duct stones associated with acute cholecystitis could be effectively and safety managed during the same laparoscopic procedure. We report on a five-year prospective study (2001-2005) involving 313 unselected patients who presented with a clinical diagnosis of acute cholecystitis (confirmed by specimen examination) and without any contraindication to laparoscopy. At surgery, transcystic cholangiograms were obtained in 289 (92%); the other 24 were excluded from the study. With an established diagnosis of common bile duct stones, attempts were made to clear the common bile duct by transcystic basket retrieval, ERCP or choledochotomy. Prevalence of common bile duct stones in acute cholecystitis, success of laparoscopic common duct clearance, conversion rate, operative time, morbidity, and postoperative hospital stay were the main outcome measures. Common bile duct stones were found in 63 pts (21.7%) presenting with acute cholecystitis. At laparoscopy, 12 patients (19%) required conversion to open surgery, 3 of these being due to failure to achieve common bile duct clearance. Common bile duct stones were cleared entirely laparoscopically in 51 patients (81%) by means of transcystic stone retrieval (38 pts, 75%), ERCP (12 pts, 23%) or choledocotomy (1 pt, 2%). At intention to treat analysis, patients undergoing cholecystectomy plus common bile duct clearance compared to those undergoing cholecystectomy alone, spent significantly more time in the operating theatre (mean 192 min vs 118 min, p < 0.001), needed open conversion more frequently (19% vs 6.1%, p = 0.0045), and had a higher overall morbidity rate (17.4% vs 4.4%, p = 0.015). The simultaneous procedure also adversely affected the postoperative hospital stay (mean 4.8 vs 3.4 days, p = 0.0164). Mortality was nil in both groups. The prevalence of common bile duct stones in patients presenting with acute cholecystitis should not be neglected. When common bile duct stones are found, clearance may be obtained laparoscopically in a substantial number of cases without any need for open surgery. The simultaneous laparoscopic approach for acute cholecystitis and common bile duct stones remains, however, a highly skilled and technically demanding procedure. Although a moderate incidence of drawbacks is observed, the results should be interpreted from the point of view of an all-in-one procedure that allows the patients to be cured without needing any further sequential interventions.

Giant epidermoid cyst of the spleen with carbohydrate and cancer antigen production managed laparoscopically.

True cysts of the spleen are rare; in a few cases, high serum levels of carbohydrate and cancer antigen have been reported. In such instances, cyst resection or splenectomy is indicated to rule out malignant lesions and to remove the cancer antigen producing epithelium. We report the case of a young woman with a symptomatic giant epidermoid cyst of the spleen. Due to the secreting epithelium lining the cyst, serum levels of CA 19-9 and CA 125 were elevated. Laparoscopic splenectomy achieved symptoms relief and and long-term normalization of serum tumor markers.