Clinical outcomes and quality of life associated with the use of a biosynthetic mesh for complex ventral hernia repair: analysis of the "Italian Hernia Club" registry.

With the development of newer meshes and approaches to hernia repair, it is currently difficult to evaluate their performances while considering the patients' perspective. The aim of the study was to assess the clinical outcomes and quality of life consequences of abdominal hernia repairs performed in Italy using Phasix and Phasix ST meshes through the analysis of real-world data to support the choice of new generation biosynthetic meshes. An observational, prospective, multicentre study was conducted in 10 Italian clinical centres from May 2015 to February 2018 and in 15 Italian clinical centres from March 2018 to May 2019. The evaluation focused on patients with VHWG grade II-III who underwent primary ventral hernia repair or incisional hernia intervention with a follow-up of at least 18 months. Primary endpoints included complications' rates, and secondary outcomes focused on patient quality of life as measured by the EuroQol questionnaire. Seventy-five patients were analysed. The main complications were: 1.3% infected mesh removal, 4.0% superficial infection requiring procedural intervention, 0% deep/organ infection, 8.0% recurrence, 5.3% reintervention, and 6.7% drained seroma. The mean quality of life utility values ranged from 0.768 (baseline) to 0.967 (36 months). To date, Phasix meshes have proven to be suitable prostheses in preventing recurrence, with promising outcomes in terms of early and late complications and in improving patient quality of life.

[Aorto-oesophageal fistula due to an aortic endovascular prosthesis: case report and state of the art]. / Fistola aorto-esofagea da protesi aortica endovascolare: caso clinico e stato del'arte.

Aorto-oesophageal fistula is a rare and often fatal condition due to pathologies of the aorta and oesophagus. Recently, a new aetiology for aorto-oesophageal fistulas has been detected, namely, decubitus of an aortic endovascular prosthesis positioned in the presence of aneurysms. The symptoms are those of Chiari's triad: (1) chest pain and/or dysphagia (2) haematemesis (3) massive haematemesis. If the patient is haemodynamically stable the gold standard diagnostic examination is a CT scan with contrast medium. Aorto-oesophageal fistulas are characterised by a rapidly worsening acute clinical presentation and high postoperative morbidity and mortality. The treatment of aorto-oesophageal fistula is divided into three progressive steps: (1) control of bleeding; (2) prevention of mediastinitis; (3) oesophageal repair. We report a case of a 59-year-old male patient with an aorto-oesophageal fistula due to the decubitus of an endovascular aortic prosthesis previously positioned for a traumatic aneurysm of the descending aorta. We controlled the bleeding in emergency with a Sengstaken-Blakemore tube. Since the cardiovascular surgeons excluded any intervention, we executed a bipolar oesophageal exclusion in our department of general surgery and subsequently positioned a self-expanding oesophageal prosthesis by a retrograde route. The patient survived for 7 months, the cause of death being septic shock.

Budget Impact Analysis of a Biosynthetic Mesh for Incisional Hernia Repair.

PURPOSE: With the development of newer prostheses for hernia repair, it is nowadays difficult to understand the total cost of managing patients treated with these advanced medical devices, especially in the complex abdomen, in which various complications may occur. The aim of this study was to determine the economic implications of these prostheses in order to inform decision making in the management of incisional hernia repair. METHODS: A budget impact analysis model was developed to evaluate the economic consequences related to the management of patients undergoing complex (Centers for Disease Control and Prevention wound class II-III or Ventral Hernia Working Group grade 2/3) incisional hernia repair through biosynthetic, synthetic, or biological meshes, from the hospital perspective in Italy. The model was populated with complication rates mainly retrieved from the literature to compare the current scenario with 60%, 10%, and 30% rates of synthetic, biosynthetic, and biological mesh utilization, respectively, with future hypothetical scenarios that consider increasing rates of biosynthetic mesh utilization with respect to the other types of mesh in the next 5 years. Hospital costs of the different events were estimated based on health care resource consumption derived from an electronic survey addressed to key opinion leaders in the field. FINDINGS: The analysis compared the current scenario with future hypothetical scenarios that consider increasing utilization rates of biosynthetic meshes of 25%, 38%, and 44% in the next 1, 3, and 5 years, as estimated by clinicians. Considering 40,000 incisional hernia repairs per year, an increasing use of the biosynthetic meshes may result in a decrease in the total hospital budget of about €153 million in the next 5 years, with a savings per patient of about €770. IMPLICATIONS: The findings of this study support the use of biosynthetic meshes for complex abdominal wall repairs in Italy, showing a potential decrease in the hospital budget in Italy after the diffusion of the new biosynthetic prostheses. Further studies and data from clinical practice would provide additional information to increase the understanding of the economic sustainability of these advanced devices.

[Treatment of neoplastic stenosis of the left colon: presurgical expandable metal stent vs emergency surgery. Comparison of results and survival rates]. / Trattamento delle stenosi neoplastiche del colon sinistro: endoprotesi autoespadibili prechirurgia vs chirurgia d'urgenza. Confronto di risultati e tassi di sopravvivenza.

In recent years there has been a substantial increase in the use of self-expandable metal stent endoprostheses for preoperative "bridge to surgery" treatment of obstructive colorectal cancer. Stent insertion for malignant tumours is still controversial because of the increased risk of metastasis and regional advance of the cancer. We compared the short-term results and long-term survival times with preoperative stent insertion vs emergency surgery without stents. From January 2004 to December 2005, 16 patients (9 stent+surgery vs 7 emergency surgery) were admitted to our emergency department with obstructive colon cancer. There was no significant difference in general condition (age and comorbidity) or in cancer classification between the two groups. The percentage of resections with primary anastomosis was significantly higher in the stent group and the percentage of stoma creation significantly lower in the stent group. There was no significant difference in prognosis between the two groups. Because preoperative expandable metal stent insertion for obstructive colorectal cancer had better postoperative results and no disadvantages in terms of long-term prognosis, the Authors recommend this procedure for the preoperative treatment of obstructive colorectal cancer.

[Early stoma closure in colorectal resections after endoscopic monitoring of the anastomosis. Clinical results]. / Chiusura precoce di stomia dopp dopresezione del retto previo controllo anastomotico endoscopico. Risultati clinici.

The need for a protection of a colo-colonic or colorectal anastomosis (by a colostomy or ileostomy) does not always encounter a general consensus except in selected clinical settings such as a low or ultra-low colorectal anastomosis or a colo-colonic or colorectal anastomosis after resection for acute disease. Commonly, a protective stoma is closed within 3-6 months after x-ray or endoscopic monitoring of the anastomosis. We believe in the importance of an open debate on the timing of bowel reconstruction and on the ways of monitoring the anastomosis. The aim of our study was to confirm the feasibility of early closure of stomas without specific increased risks, and especially to demonstrate the usefulness of early endoscopic monitoring of the anastomosis. We present 26 consecutive patients who underwent a left colonic resection or a colorectal resection with a stoma constructed for protection. In these patients the early restoration of bowel continuity was achieved between postoperative days 8 and 15 after endoscopic monitoring. There have been no specific complications related to the endoscopic manoeuvre. The morbidity rate after early bowel continuity restoration was 4.1%, which is lower than the rates encountered in the literature (6-8.6%). We consider as innovative the concept of early endoscopic monitoring, which is commonly not indicated in the presence of a recent anastomosis. We believe that in selected conditions the risk of perforation due to this manoeuvre can be eliminated.

[Direct electric conduction glove for laparoscopic surgical instruments. Preliminary results of a prototype]. / Conduzione elettrica diretta guanto-strumento chirurgico laparoscopico. Risultati preliminari di un prototiopo.

The authors present their prototype of a system for electrical conduction in direct contact with laparoscopic tools, devised, designed and produced by them at the Politecnico di Torino Department of Mechanical Engineering. The system consists of a two-sided plate, one side being a non-conducting adhesive surface to stick to the surgical glove and the other a thin, flexible conductor shell. The authors used the instrument with surgical tools with metal handles during 4 laparoscopic procedures. Nowadays the method commonly used to electrify laparoscopic tools is by using a wire plugged to a fixed conducting point on the instrument. The prototype described here was devised and produced to avoid some of the awkwardness encountered during the numerous manoeuvres required to connect and disconnect the wire at the time of surgical intervention. This device permits the direct transfer (by contact) of electrical energy from the wire to surgical tools. The advantage is greater rapidity in changing surgical tools, with the possibility of immediately obtaining an electrified instrument in the surgeon's hand.

[Cholecystobiliary fistula: laparoscopic treatment with an endostapler]. / Fistola colecisto-biliare: trattamento laparoscopico con stapler.

The Authors report a case of cholecystobiliary fistula due to cholelithiasis and bile duct lithiasis, treated laparoscopically with an endostapler. In view of the rarity of this condition, we believe it may be useful to discuss the diagnostic work-up in the light of the diagnostic and therapeutic measures currently available. We also review the literature with a view to defining the existing classifications of cholecystobiliary fistulas. We conclude by stressing the importance the endoscopic placement of nasobiliary catheters preoperatively to facilitate laparoscopic treatment.

[Thread-passer for laparoscopic use. Preliminary results with a prototype]. / Passafilo a uso laparoscopico: risultati preliminari di un prototipo.

The Authors present their prototype of a thread-passer for laparoscopic use, devised, designed and produced by them. The prototype was made at the Politecnico di Torino, Department of Mechanical Engineering. This tool consists of a rod measuring 12 mm in diameter, with a curved dove-tailed slotted end to lodge and pass the surgical thread. A 5-mm diameter operative canal passes through the instrument to permit the passage of a dissector to grasp the thread. The Authors used the instrument during three cholecystectomies and three appendectomies. The aim is to pass the thread around an anatomical structure without any loose ends, using only one port to favour surgical manoeuvres and avoiding the use of much more expensive devices.