Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis

BACKGROUND

The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023.

MATERIALS AND METHODS

The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google.

RESULTS

We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%).

CONCLUSIONS

The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.

Study of the Milkability of the Mediterranean Italian Buffalo and the Tunisian Maghrebi Camel According to Parity and Lactation Stage

While considered as hard milkers, both buffaloes and camels are milked with equipment destined for dairy cows based on external morphological similarities with this species. This work aimed to study similarities and differences in milkability traits between Mediterranean buffaloes and Maghrebi she-camels and to evaluate the effect of parity and lactation stage. A total of 422 milk flow curves recorded with an electronic milkmeter (Lactocorder®) for both species were accessed. Milking characteristics including milk yield per milking, peak milk flow, average milk flow, duration of the main milking phase, duration of total milking, duration of various phases of milk flow, lag time and time to milk ejection, stripping yield, overmilking time and incidence of bimodal milk flow curves were evaluated for both species. Results showed that the values of milk yield per milking, duration of the main milking phase and duration of total milking were higher in buffaloes (3.98 ± 0.10 kg; 4.07 ± 0.11 min; 9.89 ± 0.21 min, respectively) compared to camels (3.51 ± 0.08 kg; 3.05 ± 0.09 min; 3.76 ± 0.09 min, respectively). However, camels had significantly higher peak and average milk flow (2.45 ± 0.07 kg/min and 1.16 ± 0.03 kg/min, respectively). Camels took significantly less time for milk ejection to occur. Only 15.49% of recorded curves were bimodal in buffaloes while 34.93% of bimodal curves were recorded for camels. Overmilking was significantly higher in buffaloes (3.64 ± 0.21 min vs. 0.29 ± 0.02 min). Parity and lactation stage had a significant effect on most studied milking traits suggesting the need for some particular practices with primiparous animals and animals at different levels of lactation for both species.

Teat morphology across five buffalo breeds: a multi-country collaborative study

The buffalo (Bubalus bubalis) is a species of worldwide importance, raised to produce milk, meat, and hides, and often used as a working animal in rural contexts with low access to hi-tech solutions. In the present study, 100 lactating buffaloes (50 primiparous and 50 pluriparous) of five popular breeds were recruited to characterize and compare teat morphology. In particular, the focus was put on the Nili Ravi, Mediterranean, Egyptian, Bulgarian Murrah, and Azeri buffaloes raised in Pakistan, Italy, Egypt, Bulgaria, and Iran, respectively. In all countries, a longitudinal cross-section ultrasound was obtained before the milking to measure teat parameters at individual level: overall, teat canal length (TCL) averaged 24.13 mm, teat diameter (TD) 30.46 mm, cisternal diameter (CD) 17.80 mm, and teat wall (TW) 7.12 mm. The most variable trait across breeds was TCL which was positively correlated with CD and TD and negatively with TW, regardless of the teat position (front/rear or left/right). A strong negative correlation was found between TW and CD (- 0.43). The analysis of variance revealed that the fixed effect of breed significantly affected all the traits except TD. In fact, Bulgarian Murrah, Azeri, and Egyptian buffaloes presented the greatest estimate of TCL, whereas NR the smallest (14.70 mm). The TW was maximum in Nili Ravi, Egyptian, and Mediterranean buffaloes, with estimates equal to 8.19, 7.59, and 8.74 mm, respectively. Nili Ravi also showed the greatest TL (82.39 mm). In terms of CD, the lowest least square mean was that of Mediterranean buffaloes (12.14 mm). Primiparous and pluriparous buffaloes differed in terms of TD, TW, and TL, with older animals presenting the highest least square mean. In terms of position, instead, significant differences were observed for TD, CD, and TL when comparing front and rear teats, as left and right teats did not differ. Teat anatomy includes a set of heritable morphological features and is therefore breed-dependent. Differences presented in this study could be attributed to the divergent breeding objective and selective pressure across the five breeds; e.g., in some cases such as Mediterranean buffalo, selection for decades was oriented to improve milk production and milkability and achieve optimal conformation for mechanical milking. A better understanding of the mammary gland anatomical descriptors can be informative of the history of a breed and could provide useful insights to guide possible selection.

Amiata donkey body conformation, udder characteristics, and their relationship with milk yield and quality

To date, no selective actions have been taken to improve milk traits in dairy donkeys, and the characteristics of the udder are not well defined in relation to the productive characteristics. This study aimed at increasing knowledge on Amiata dairy donkey body conformation, udder traits, and their relationship with milk yield and quality. Morphological, udder, and teat measurements and milk evaluations of 45 pluriparous jennies were carried out. The average wither height of the jennies was 126 cm and the chest girth was 148 cm; a large standard deviation of some body measurements was found. Forty-nine percent of the animals showed a moderately developed udder, while most of the jennies had symmetrical half-udders (96%) and the intermammary cleft was clearly visible in 53% of subjects. Correlation analysis indicated that bigger animals tend to have bigger udders, higher teat diameter, and greater distance between teat tips. A positive correlation between the teat length and the milk fat was found ( p < 0.01), which suggests that jennies with longer teats have a better ability to release milk fat. The results of this paper may be useful to define the characteristics of the milking device and address selective choices of the animals.

A retrospective study on dioxins and dioxin-like polychlorinated biphenyls in milk and dairy products from the Latium region (Italy) over a 7-year study period (2011-2017)

This study reports the data of polychlorinated dibenzo-p-dioxins (PCDDs), -furans (PCDFs), and polychlorinated biphenyls dioxin-like (dl PCBs) measured in a total of 260 samples of the dairy supply chain collected over a period of 7 years (2011-2017) in the Latium region (Italy). Levels and average profiles of congeners were reported for each group of the analyzed dairy matrices, and any differences between different sampling strategies were considered (around likely pollutant sources or casual sampling). Of the samples, 95.4% resulted compliant with the regulated levels; only samples belonging to the "sheep bulk milk" matrix were found to be above either the action levels or the maximum levels (tot. 12 samples). Raw milk of the sheep species showed the highest averages (PCDD/F 0.248 and dl PCB 0.966 WHO TEQ pg/g of fat) compared to the milk of other species. The buffalo milk showed a content of dl PCB significantly lower (dl PCB: 0.371 WHO TEQ pg/g of fat) than the sheep milk (p<0.05). Dioxins were found to be superior to furans in almost all dairy products, except in the noncompliant samples where furans were higher. The OCDD was found to be the most abundant congener in almost all dairy products. This study provides a first list of reference values for background contamination of the dairy supply chain in the Latium region. These pre-existing values will be useful in all cases of environmental pollution to identify critical situations.

Influence of milking units and working vacuum level on the mechanical milking of goats

The objectives of this study were to evaluate and compare the effect of working vacuum levels (35 and 44 kPa) and liners dimensions (mouthpiece lip diameter and overall length, 20–185 and 22–170 mm) on the main milking characteristics of goats. The results highlight that both the working vacuum level and the liner dimension have influenced the milk flow curve parameters. The maximum variations were found for peak flow rate, which increased significantly with liner dimensions of 20–185 mm at a working vacuum level of 44 kPa as well as average milk flow rate and for plateau phase duration. The incorrect adoption of operative parameters and unsuitable milking machine components, might affect the performance of the mechanical milking and negatively affecting animal productions and welfare.

Effects of the Physiological Status and Diet on Blood Metabolic Parameters in Amiata Dairy Donkeys

Simple Summary

This study investigated the physiological responses of donkeys feeding two different diets during maintenance, pregnancy and lactation. To investigate how the metabolic state influences dairy production, we also assessed the relationships between the blood metabolic profile and milk quality. We found that pregnancy and the first months of lactation led to lower feed intake and increases in blood non-esterified fatty acids (NEFAs), which was linked to the difficulty that the jennies have in meeting the higher energy needs. The intake of the concentrate in the diet was associated with the increase in blood glucose, both during maintenance and lactation. Higher NEFA were related to lower de novo synthesized milk fatty acids, whereas higher plasma B-HBA were related to higher somatic cell count. This paper contributes to the knowledge of physiological responses of jennies during milk production phases and provides information for donkey milk producers.

Abstract

Body weight changes and blood metabolic parameters in jennies feeding two different diets and in three physiological statuses were investigated (maintenance vs. pregnancy; maintenance vs. lactation). The relationships between blood metabolic profile and milk quality were also evaluated. Fourteen jennies were allocated to two groups (1: pregnant/lactating; 2: non-pregnant, non–lactating). Pregnant jennies and maintenance jennies (during the first 10-week measurement period) fed a diet consisted of ad libitum grass hay (diet 1); lactating jennies and maintenance jennies (during the last 10-week measurement period) fed ad libitum grass hay plus 2 kg/head/day of concentrate (diet 2). Blood sampling was performed on the jennies of both groups; individual milk samples were also collected during the first 70 days in milk. Higher blood NEFA (p < 0.05) were found in pregnant compared to maintenance jennies (diet 1) (68 vs. 37 μmol/L). Lactating jennies showed higher (p < 0.01) average blood NEFA (268 vs. 26 μmol/L) and glucose (66 vs. 55 mg/dL) compared to the maintenance (diet 2). Blood glucose was positively correlated to milk fat (p < 0.05), while negative significant correlations between de novo milk fatty acids and NEFAs were observed. Positive correlations between plasma B-HBA and somatic cell count (p < 0.01) were also found.

The Management of Acute Colonic Diverticulitis in the COVID-19 Era: A Scoping Review

Background and Objective: During the COVID-19 pandemic, health systems worldwide made major changes to their organization, delaying diagnosis and treatment across a broad spectrum of pathologies. Concerning surgery, there was an evident reduction in all elective and emergency activities, particularly for benign pathologies such as acute diverticulitis, for which we have identified a reduction in emergency room presentation with mild forms and an increase with more severe forms. The aim of our review was to discover new data on emergency presentation for patients with acute diverticulitis during the Covid-19 pandemic and their current management, and to define a better methodology for surgical decision-making. Method: We conducted a scoping review on 25 trials, analyzing five points: reduced hospital access for patients with diverticulitis, the preferred treatment for non-complicated diverticulitis, the role of CT scanning in primary evaluation and percutaneous drainage as a treatment, and changes in surgical decision-making and preferred treatment strategies for complicated diverticulitis. Results: We found a decrease in emergency access for patients with diverticular disease, with an increased incidence of complicated diverticulitis. The preferred treatment was conservative for non-complicated forms and in patients with COVID-related pneumonia, percutaneous drainage for abscess, or with surgery delayed or reserved for diffuse peritonitis or sepsis. Conclusion: During the COVID-19 pandemic we observed an increased number of complicated forms of diverticulitis, while the total number decreased, possibly due to delay in hospital or ambulatory presentation because of the fear of contracting COVID-19. We observed a greater tendency to treat these more severe forms by conservative means or drainage. When surgery was necessary, there was a preference for an open approach or a delayed operation.

A rare case of polypoid primary anorectal melanoma with subsequent giant stomach metastasis: a gastrointestinal involvement of both primary and metastatic mucosal melanoma

Introduction: Melanoma can involve the gastrointestinal apparatus as both primary and metastatic lesions. Primary anorectal mucosal melanoma (ARMM) and metastatic gastric melanoma are rare entities and usually resulted in a poor prognosis. Case: We presented a case of a 61-year-old man who after the complete excision of an ARMM developed a gastric metastasis after almost three years form the complete tumour excision. Upon esophagogastroduodenoscopy, a giant ulcered mass resulted in melanoma metastasis. The patient underwent a near-total gastrectomy. After five months of follow-up, the patient is disease-free. Conclusion: The incidence of ARMMs is increasing, highlighting the necessity of new prevention and treatment strategies in order to achieve a better prognosis for these patients. There are no known risk factor for ARMMs but surgery, together with the combination of anti-CTLA-4 and anti-PD-1 antibodies, are promising therapeutic options. Early and aggressive treatments are required, together with a strict multidisciplinary approach.

Ilioinguinal Nerve Neurectomy is better than Preservation in Lichtenstein Hernia Repair: A Systematic Literature Review and Meta-analysis

OBJECTIVE

This study aimed to evaluate the incidence of chronic groin pain (primary outcome) and alterations of sensitivity (secondary outcome) after Lichtenstein inguinal hernia repair, comparing neurectomy with ilioinguinal nerve preservation surgery. The exact cause of chronic groin postoperative pain after mesh inguinal hernia repair is usually unclear. Section of the ilioinguinal nerve (neurectomy) may reduce postoperative chronic pain.

METHODS

We followed PRISMA guidelines to identify randomized studies reporting comparative outcomes of neurectomy versus ilioinguinal nerve preservation surgery during Lichtenstein hernia repairs. Studies were identified by searching in PubMed, Scopus, and Web of Science from April 2020. The protocol for this systematic review and meta-analysis was submitted and accepted from PROSPERO: CRD420201610.

RESULTS

In this systematic review and meta-analysis, 16 RCTs were included and 1550 patients were evaluated: 756 patients underwent neurectomy (neurectomy group) vs 794 patients underwent ilioinguinal nerve preservation surgery (nerve preservation group). All included studies analyzed Lichtenstein hernia repair. The majority of the new studies and data comes from a relatively narrow geographic region; other bias of this meta-analysis is the suitability of pooling data for many of these studies. A statistically significant percentage of patients with prosthetic inguinal hernia repair had reduced groin pain at 6 months after surgery at 8.94% (38/425) in the neurectomy group versus 25.11% (113/450) in the nerve preservation group [relative risk (RR) 0.39, 95% confidence interval (CI) 0.28-0.54; Z = 5.60 (P < 0.00001)]. Neurectomy did not significantly increase the groin paresthesia 6 months after surgery at 8.5% (30/353) in the neurectomy group versus 4.5% (17/373) in the nerve preservation group [RR 1.62, 95% CI 0.94-2.80; Z = 1.74 (P = 0.08)]. At 12 months after surgery, there is no advantage of neurectomy over chronic groin pain; no significant differences were found in the 12-month postoperative groin pain rate at 9% (9/100) in the neurectomy group versus 17.85% (20/112) in the inguinal nerve preservation group [RR 0.50, 95% CI 0.24-1.05; Z = 1.83 (P = 0.07)]. One study (115 patients) reported data about paresthesia at 12 months after surgery (7.27%, 4/55 in neurectomy group vs. 5%, 3/60 in nerve preservation group) and results were not significantly different between the two groups [RR 1.45, 95% CI 0.34, 6.21;Z = 0.51 (P = 0.61)]. The subgroup analysis of the studies that identified the IIN showed a significant reduction of the 6th month evaluation of pain in both groups and confirmed the same trend in favor of neurectomy reported in the previous overall analysis: statistically significant reduction of pain 6 months after surgery at 3.79% (6/158) in the neurectomy group versus 14.6% (26/178) in the nerve preservation group [RR 0.28, 95% CI 0.13-0.63; Z = 3.10 (P = 0.002)].

CONCLUSION

Ilioinguinal nerve identification in Lichtenstein inguinal hernia repair is the fundamental step to reduce or avoid postoperative pain. Prophylactic ilioinguinal nerve neurectomy seems to offer some advantages concerning pain in the first 6th month postoperative period, although it might be possible that the small number of cases contributed to the insignificancy regarding paresthesia and hypoesthesia. Nowadays, prudent surgeons should discuss with patients and their families the uncertain benefits and the potential risks of neurectomy before performing the hernioplasty.

The Effect of Pre-milking Stimulation on Teat Morphological Parameters and Milk Traits in the Italian Water Buffalo

Water buffaloes (Bubalus bubalis) are very sensitive to environmental stimulus before and during milking, and this explains why disrupted milk ejections due to blood oxytocin level instability are frequent in this species. According to the literature, the manual stimulation (MS) of teats before milking promotes oxytocin release and allows milk ejection to start within 2-3 min. However, the pre-milking stimulation of teats is not always part of the milking routine in Italian buffalo farms; moreover, buffaloes with unstable milk let-down are sometimes treated with exogenous oxytocin (OX). Different types of pre-milking stimulation can impact differently on the mammary gland epithelium and structures and, therefore, on milk yield. In this study, we observed the changes in teat morphological traits before and after the application of three types of stimuli, i.e., no manual stimulation (NS), MS, and OX, in buffaloes reared in an Italian dairy farm. In particular, measurements were available for 23 and 21 buffaloes for front and rear teats, respectively. Subsequently, the effect of the pre-milking stimulation type was estimated on teat morphological characteristics and on milk traits recorded after the application of stimuli. The results showed that the teat canal length was shorter (P < 0.05) after stimulation in the case of MS and OX compared to NS. Cistern diameter was overall greater for MS and lower for OX. On the contrary, teat wall thickness was greater and lower for OX and MS, respectively. Milk yield and quality (fat, protein, and somatic cell score) were similar across the three types of pre-milking stimulation. In perspective, the impact of these types of pre-milking stimulation should be evaluated on a large scale, and the focus might be put on mammary gland epithelium integrity, mastitis incidence, and other udder health indicators in milk, e.g., electrical conductivity, differential somatic cell count, lactose content, and sodium and chloride concentration.

Dermatome Mapping Test in the analysis of anatomo-clinical correlations after inguinal hernia repair

Background

Nerve identification is recommended in inguinal hernia repair to reduce or avoid postoperative pain. The aim of this prospective observational study was to identify nerve prevalence and find a correlation between neuroanatomy and chronic neuropathic postoperative inguinal pain (CPIP) after 6 months.

Material

A total of 115 patients, who underwent inguinal hernia mesh repair (Lichtenstein tension-free mesh repair) between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%). Furthermore, these patients were undergoing Dermatome Mapping Test in preoperatively and postoperatively 6 months evaluation.

Results

Identification rates of the iliohypogastric (IH), ilioinguinal (II) and genitofemoral (GF) nerves were 72.2%, 82.6% and 48.7% respectively. In the analysis of nerve prevalence according to BMI, the IH was statistically significant higher in patients with BMI < 25 than BMI ≥ 25 P (< 0.05). After inguinal hernia mesh repair, 8 patients (6.9%) had chronic postoperative neuropathic inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome. The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542).

Conclusion

The anatomy of inguinal nerve is very heterogeneous and for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms. Dermatome Mapping Test in an easy and safe method for preoperative and postoperative 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified.

On the Effect of the Temperature-Humidity Index on Buffalo Bulk Milk Composition and Coagulation Traits

Little is known about the effects of high levels of environmental temperature and humidity on milk yield and quality in buffaloes since this species is known to be more heat tolerant than cattle. However, the distribution of sweat glands and the dark skin color can negatively affect heat tolerance. Moreover, due to increased global temperatures, concerns regarding heat stress and thermoregulation in dairy animals, including buffaloes, have been extended to the northern hemisphere. In this study, the effects of both the temperature-humidity index (THI) and the maximum daily temperature-humidity index (MTHI) were estimated on bulk milk traits, namely fat, protein, lactose, urea content, pH levels, somatic cell score, coagulation properties, and bacteria count. The dataset consisted of repeated data from 99 Mediterranean water buffalo farms, and mixed models were used for the analyses. Supporting the negative correlations observed, bulk milk fat, protein, and lactose content were significantly lower when THI and MTHI were higher. Similarly, milk pH was lower when THI and MTHI were high; however, high levels of THI or MTHI seemed to not be markedly associated with the milk's coagulation ability. According to both analysis of variance and correlations, the somatic cell score was not significantly affected by the THI and MTHI. This is the first study based on a large dataset that evaluates the impact of high temperature and humidity in Italian buffalo milk and that provides correlations with traits of interest for the dairy industry, i.e., milk acidity and coagulation ability. In general, findings show that the effects of elevated THI and heat stress on bulk milk quality in buffalo is less evident than in cattle. These preliminary results intend to open debate on the issue of heat stress in dairy buffaloes that are reared in temperate regions. Further studies should focus on individual milk and performance and should investigate the relationship between high THI and buffalo fertility, behavior, and welfare.

Farms at risk from environmental pollution: a proposal for a risk ranking procedure

OBJECTIVES

to produce a methodology for the risk ranking of farms located around proven or potential sources of contamination to prioritize the monitoring procedures in food production.

DESIGN

environmental factors that can favour the risk of contamination of products of animal origin (POAO) around a pollutant source were identified. A scale of standardized scores was produced for each risk factor (RF) in order to obtain a risk-based classification. Subsequently, an algorithm was developed to obtain a relative risk assessment (RRA).

SETTING AND PARTICIPANTS

in order to validate the proposed methodology, data of 80 livestock farms in a polluted area, enrolled in a previous study, were subjected to the RRA. Results of RRA were compared with contamination data.

MAIN OUTCOME MEASURES

seven RFs were included in a mathematical formula used to classify each farm.

RESULTS

a scoring system was produced for each RFs and an algorithm was developed to obtain RRA which is an estimate of the farm probability of having POAO contamination in comparison to other farms located in the same area potentially affected by chemical pollution based exclusively on site-specific environmental characteristics. In the case study used for validation, a significant relationship between RRA and contamination data was found.

CONCLUSIONS

the proposed methodology is a useful tool to support the authorities responsible for the food safety in carrying out the monitoring of POAO in areas subject to environmental risks. It helps to rationalize resources and make controls more effective.

Study of Milkability and Its Relation With Milk Yield and Somatic Cell in Mediterranean Italian Water Buffalo

Milkability is defined as the ability of an animal to give a regular, complete, and rapid milk secretion by the mammary gland in response to a proper milking technique. The aim of the present study was to investigate the relationship of milkability pattern with milk yield and somatic cell score in buffaloes. Milk yield and milkability can be observed through the milk flow profiles recorded by an electronic milkmeter (Lactocorder). A total of 2,288 milk flow curves of Mediterranean Italian buffaloes were used for one-way analysis of variance, and eight milk emission patterns were studied. The most represented milk flow curve was type 3 (27.32%), followed by type 6 (17.79%) characterized by a very long plateau phase. The less represented curve was type 1 (4.41%) characterized by long lag time and low peak flow rate. According to analysis of variance, milk yield ranged from 2.21 to 5.22 kg per milking for types 1 and 6, respectively, whereas the peak flow rate was minimum (0.50 kg/min) and maximum (1.73 kg/min) for types 1 and 4, respectively. The total milking time was on average 11.29 ± 3.68 min; lag time and milk emission time averaged 2.19 ± 2.34 min and 4.30 ± 2.33 min, respectively. The 12.5% (n = 286) of total curves were classified as bimodal and 60 of these were found in type 4. Based on literature, type 4 curves are representative of very short teat canals and very high milk flow. Average somatic cell score was 3.63 ± 1.67 units, with maximum least-squares mean found for type 1 and minimum for type 6. Buffaloes showing curves of type 5 and 6 were characterized by the greatest milk yield at milking, lowest somatic cell score, and lowest milking time. Results of the present study evidenced that such traits could be used in the dairy buffaloes as indicators to improve udder health and milkability.

Accuracy and feasibility of SentiMag technique for localization of non-palpable breast lesions

BACKGROUND

Non-palpable breast lesions are more frequent now than in the past due to the attention toward the mammary pathology and the screening diffusion; the marking of such lesions is very important for a successful surgery. The SentiMag System uses a magnetic marker that is inoculated transdermal in the breast through an 18-gauge needle.

METHODS

Between April 1^st and June 30^th, 2018, 16 patients with non-palpable breast lesions were selected and subjected to surgery using the SentiMag System in our Unit. They were women with a mean age of 52 years (range 30-84 years). Seven of 16 (43.7%) had a borderline preoperative histological or cytological diagnosis (C3/B3), and nine (56.3%) a diagnosis of carcinoma (C5/B5). Six (37.5%) were marked on ultrasound guidance and 10 (62.5%) on a mammography stereotaxic guide.

RESULTS

The time for the marker positioning ranged from 2 to 10 minutes. The radiological control of the surgical specimen always showed the presence of both the lesion and the marker, both centered within the specimen and intact. The pathology revealed seven benign lesions, one in-situ, and eight infiltrating carcinomas.

CONCLUSIONS

The SentiMag represents a fast and safe preoperative marking system of non-palpable breast lesions, cutting the radio exposure for personnel and patients. The marker is not displaced over time and it is rapid to place and easy to locate intraoperatively, allowing a clear dissection plane around the lesion. Thus, this reduces the amount of gland removed, improving the aesthetic result mostly in small breasts.

Effects of animal versus vegetal rennet on milk coagulation traits in Mediterranean buffalo bulk milk

Given consumer interest in Mozzarella di latte di Bufala and other cheeses, and the growing interest of the cheese industry in offering products adequate for lactovegetarian consumers, this study aimed to compare clotting capacity of vegetal and animal rennet in buffalo milk. Milk coagulation properties of 1,261 buffalo bulk milk samples collected during milk quality testing were assessed by lactodynamography using commercial animal (75% chymosin and 25% bovine pepsin) and vegetal (Cynara cardunculus) rennets. Chemical composition of milk samples was predicted by MilkoScan (Foss Analytics, Hillerød, Denmark) calibrated with specific buffalo standards. Rennet effect (animal versus vegetal) was statistically analyzed with a paired t-test. Fat, protein, and lactose contents of milk samples were 7.94%, 4.52%, and 4.80%, respectively. A similar variability of milk coagulation properties was observed with both rennets, with the exception of greater variability of curd firmness at 30 min after the addition of vegetal rennet compared with animal rennet (73 and 26%, respectively). On average, when using plant rennet, milk started to coagulate and reached the 20-mm coagulum 12 ± 0.22 min and 1.9 ± 0.20 min, respectively, later than with animal rennet. Thirty minutes after rennet addition, curds were almost twice as firm in animal as in vegetal rennet (difference of 23.92 ± 0.66 mm). However, curd firmness at 60 min was only 1.21 ± 0.39 mm thicker with vegetal than with animal rennet. Moreover, when using animal rennet, 99.52% of samples started coagulating within the first 30 min of analysis, whereas only 70.42% did so when using vegetal rennet. We conclude that vegetal rennet has the capacity to coagulate buffalo milk, achieving a similar curd firmness to that of animal rennet at 60 min. Further studies are needed to evaluate the sensory characteristics and consumer acceptability of Mozzarella di latte di Bufala processed with vegetal rennet.

Reduction of postoperative lymphorrhoea in patients undergoing radical lymphadenectomy for stage III melanoma: prospective study using collagen-fibrin patches

BACKGROUND

Radical lymph nodes dissection (RLND) is the standard procedure for regional control of disease in patients with metastatic melanoma (stage III). Because of its aggressiveness, lymphorrhoea is a constant problem in postoperative.

METHODS

In this prospective nonrandomized study with a retrospective analysis of data, patients undergoing surgical treatment of axillary or iliac-inguinal RLND received standard treatment plus a collagen-fibrin sealant patch (TachoSil) (N.=50) or standard treatment alone (N.=50). The first endpoint was the comparison between the treated population and the control group, in terms of persistence of drainage and average daily volume of lymphorrhoea. The second aim was to relate patients' BMI, volume of lymphorrhoea and time of drainage in the two groups.

RESULTS

In the comparison between the two groups receiving or not the treatment with collagen-fibrin patch, we found an average difference both in the volume of daily lymphorrhoea (42.91±6.61 cc) and in the persistence of drainage (9.292±1.644 days) with P value <0.0001. Besides, the collagen-fibrin patch was actually effective in reducing lymphorrhoea and time of drainage, regardless of patients' BMI.

CONCLUSIONS

The results of this study confirm and support the starting thesis: TachoSil is an effective tissue sealant able to reduce lymphorrhoea and drainage removal times following a radical lymphadenectomy, independently from the BMI.

Retained sponges in abdomen: an analysis of the judgments of the Italian Supreme Court

The administration of justice in Italy includes first, second and third instance. The first and second instances are represented by the Court of First Instance and the Court of Appeal: these are judgment of Romamerit. The court of last appeal for both the civil and the criminal jurisdiction is the Court of Cassation, the Italian Supreme Court. It is a court of legitimacy that should provide for a consistent and uniform interpretation of the law and that only on points of law, not on factual evidence. The Court of Cassation can confirm the sentence of second instance, can dismiss it without referral, can deciding and closing the trial definitively, or dismiss it referring the case to the judge of merit that must decide according to the principles set out in the legitimacy. The aim of this study is to analyze the Supreme Cassation Court's judgments on the legal proceedings about retained sponges in abdomen.

Surgical treatment of gastrointestinal stromal tumors of the duodenum: a literature review

Background

Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4-5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment.

Methods

An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST.

Results

Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections).

Conclusions

dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1-2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided.

Short communication: Phenotypic characterization of total antioxidant activity of buffalo, goat, and sheep milk

Free radicals are reactive and unstable waste molecules produced by cells, responsible of damages and alteration on DNA, proteins, and fat. The daily intake of antioxidant compounds, acting against free radicals and their detrimental effects, is essential for human health. Milk contains several compounds with antioxidant activity, and the sum of their reducing potential blocking free radicals development is defined as total antioxidant activity (TAA). This novel trait has been described in literature both in individual and bulk cow milk, but there are no reports from other dairy species. Therefore, the present study aimed to investigate phenotypic variation of TAA in individual samples of buffalo (n = 105), goat (n = 112), and sheep (n = 198) milk. Total antioxidant activity was measured through a reference spectrophotometric method, and expressed as millimoles per liter of Trolox equivalents (TE). The greatest TAA was observed in sheep milk, averaging 7.78 mmol/L of TE and showing also the broadest phenotypic variation expressed as coefficient of variation (13.98%). Significantly lower TAA values were observed for buffalo (7.35 mmol/L of TE) and goat (6.80 mmol/L of TE) milk, with coefficients of variation of 8.18 and 8.47%, respectively. Total antioxidant activity exhibited weak correlations with milk yield and chemical composition. Phenotypic values of TAA presented in this study will be used to assess the ability of mid-infrared spectroscopy to predict this new trait and thus to collect data at the population level.

From Invention to Innovation: Risk Analysis to Integrate One Health Technology in the Dairy Farm

Current Hazard Analysis Critical Control Points (HACCP) approaches mainly fit for food industry, while their application in primary food production is still rudimentary. The European food safety framework calls for science-based support to the primary producers’ mandate for legal, scientific, and ethical responsibility in food supply. The multidisciplinary and interdisciplinary project ALERT pivots on the development of the technological invention (BEST platform) and application of its measurable (bio)markers—as well as scientific advances in risk analysis—at strategic points of the milk chain for time and cost-effective early identification of unwanted and/or unexpected events of both microbiological and toxicological nature. Health-oriented innovation is complex and subject to multiple variables. Through field activities in a dairy farm in central Italy, we explored individual components of the dairy farm system to overcome concrete challenges for the application of translational science in real life and (veterinary) public health. Based on an HACCP-like approach in animal production, the farm characterization focused on points of particular attention (POPAs) and critical control points to draw a farm management decision tree under the One Health view (environment, animal health, food safety). The analysis was based on the integrated use of checklists (environment; agricultural and zootechnical practices; animal health and welfare) and laboratory analyses of well water, feed and silage, individual fecal samples, and bulk milk. The understanding of complex systems is a condition to accomplish true innovation through new technologies. BEST is a detection and monitoring system in support of production security, quality and safety: a grid of its (bio)markers can find direct application in critical points for early identification of potential hazards or anomalies. The HACCP-like self-monitoring in primary production is feasible, as well as the biomonitoring of live food producing animals as sentinel population for One Health.

Measurements of β and α hexachlorocyclohexane in Juglans regia and Prunus spinosa trees in a contaminated area, central Italy

Vegetables play an important role in the human diet, and the transfer of toxic contaminants from the soil to plants has been little studied for most tree species and their edible portions. In an area affected by hexachlorocyclohexane (HCH) contamination, in the Sacco River Valley (central Italy), measurements of β- and α-HCH isomers were made on different parts of two tree species: Juglans regia and Prunus spinosa. Concentrations were analysed in roots, branches, leaves, fruits, and seeds. A spatial evaluation of the results highlighted an inverse association of contamination with distance from the river, which is the main route of transport in the environment. Results in J. regia showed decreasing values in this order: branches > leaves > husks > nutmeat. Results in P. spinosa showed decreasing values in the following order: branches > leaves > fruits. In J. regia, nutmeat values were all below limit of detection (LOD, 0.0005 mg/kg), except in one case in which a very low concentration of β-HCH was found (0.006 mg/Kg), compliant with maximum residue limits (MRLs). The ability of J. regia to store large quantities of β-HCH in wooden and leafy parts but not in edible kernels makes this plant a potential and precious tool in remediation and economical reconversion of polluted areas. It is also valuable for food and wood manufacturing.

Surgery for colorectal cancer in elderly: a comparative analysis of risk factor in elective and urgency surgery

INTRODUCTION

Colon cancer therapy is primarily surgical. Advanced age does not represent a contraindication to surgery. We analyse the results of surgery in ultra 75 patients undergoing surgery for colorectal cancer by examining the correlation between the comorbidity and any post-operative complications.

MATERIALS AND METHODS

We surgically treated 66 patients for colorectal cancer, aged over 75. The examined subjects were compromised for various reasons. We have evaluated the different influences of risk factors in elective and urgency operation.

DISCUSSION

Several studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery. The assessment of general conditions in elderly patients, as demonstrated by the literature, is a fundamental moment in the management of colorectal cancer.

CONCLUSIONS

The surgical choice should be made case by case (custom-made), not based on age only.

Postoperative mortality and morbidity in older patients undergoing emergency right hemicolectomy for colon cancer

INTRODUCTION

Even with the advances in surgical technique and perioperative care, morbidity and mortality after colorectal cancer surgery remain considerable, and patients (pt) who present as an emergency have an even higher mortality and morbidity rate.

METHODS

A total of 35 pt with caecum or ascending colon cancer between January 2007 and June 2015, three departments in Italy and in Poland, were included in the study. The intention of surgery in all cases was curative resection with ileo-colic anastomosis. Comparative statistical analysis was performed.

RESULTS

Acute bowel obstruction was the major complication of CRC that led to an emergency hemicolectomy. Postoperative mortality and morbidity rates were in total 12.5 and 28.1%, respectively. All the deaths happened in Poland. Of the pt, 42.8% had morbidity in Poland and 16.6% in Italy. Out of the pt, 25% presenting with perforation: 25% died, 25% had wound dehiscence, 12.5% had pulmonary oedema, and 12.5% had an intra-abdominal abscess. The mean age of the pt with complications in Poland and in Italy was 79.3 and 72.0 years, respectively.

CONCLUSION

We observed that particularly lethal combination is older age, perforation with peritonitis and advanced stage of the cancer.

A LC-MS-MS method to detect recombinant bovine somatotropin misuse in buffalos

Recombinant bovine somatotropin (rbST) is a peptide hormone used to increase milk yield in cows and buffalos. In Europe, its use has been banned. However, rbST is sometimes illegally included in zootechnical practices for profit purposes, undermining the fair trade and the law prescriptions. For this reason, efficient and reliable analytical techniques are required to contrast rbST misuse. A few LC-MS-MS methods have been developed to detect, in cow serum, methyonil-rbST, one of the two main rbST forms available on the market. The other form, which is widespread, is identical to the most abundant variant of bovine somatotropin (bST) and differs from the buffalo somatotropin for one amino acid in the N-terminus. For this reason, it is technically possible to distinguish both rbST forms in serum of buffalos. In this work, we describe a novel LC-MS-MS-based method, capable to quantify, with a high sensitivity and selectivity, the methyonil-rbST and the other bST-identical recombinant form in buffalo serum, previously purified using a solid-phase extraction procedure. The method was internally validated and used to analyse 152 serum samples, collected from eight buffalos administered with rbST for a period of 3 months, according to conventional protocols. The obtained results confirmed the suitability of the method in the detection of illegal hormonal treatments. Graphical abstract ᅟ.

Robotic versus Laparoscopic Approach in Colonic Resections for Cancer and Benign Diseases: Systematic Review and Meta-Analysis

Objectives

The aim of this systematic review and meta-analysis is to compare robotic colectomy (RC) with laparoscopic colectomy (LC) in terms of intraoperative and postoperative outcomes.

Materials and Methods

A systematic literature search was performed to retrieve comparative studies of robotic and laparoscopic colectomy. The databases searched were PubMed, Embase and the Cochrane Central Register of Controlled Trials from January 2000 to October 2014. The Odds ratio, Risk difference and Mean difference were used as the summary statistics.

Results

A total of 12 studies, which included a total of 4,148 patients who had undergone robotic or laparoscopic colectomy, were included and analyzed. RC demonstrated a longer operative time (MD 41.52, P<0.00001) and higher cost (MD 2.42, P<0.00001) than did LC. The time to first flatus passage (MD -0.51, P = 0.003) and the length of hospital stay (MD -0.68, P = 0.01) were significantly shorter after RC. Additionally, the intraoperative blood loss (MD -16.82, P<0.00001) was significantly less in RC. There was also a significantly lower incidence of overall postoperative complications (OR 0.74, P = 0.02) and wound infections (RD -0.02, P = 0.03) after RC. No differences in the postoperative ileus, in the anastomotic leak, or in the conversion to open surgery rate and in the number of harvested lymph nodes outcomes were found between the approaches.

Conclusions

The present meta-analysis, mainly based on observational studies, suggests that RC is more time-consuming and expensive than laparoscopy but that it results in faster recovery of bowel function, a shorter hospital stay, less blood loss and lower rates of both overall postoperative complications and wound infections.

Robotic pylorus-preserving pancreaticoduodenectomy: Technical considerations

Laparoscopy has revolutionized the way of thinking abdominal surgery, however, to date there are still limitations making it difficult to apply this technique to some types of surgical procedures considered technically demanding even when performed by open surgery, such as the pancreaticoduodenectomy. This technical note provides a complete description of the surgical procedure performed for the execution of a robotic pancreaticoduodenectomy through the use of the "Da Vinci Si" robotic system. Robotic systems represent a real evolution in minimally invasive surgery. We wish to emphasize this concept, highlighting the application of this technology to complex procedures in digestive surgery.

Can the measurement of amylase in drain after distal pancreatectomy predict post-operative pancreatic fistula?

INTRODUCTION

The most frequent reason for performing a distal pancreatectomy is the presence of cystic or neuroendocrine tumors, in which the distal pancreatic stump is often soft and non fibrotic. This parenchymal consistence represents the main risk factor for post-operative pancreatic fistula. In order to identify the fistula and assessing its severity postoperative monitoring of amylase from intraperitoneal drains is important.

METHODS

From a retrospective multicentric database analysis were included 33 patients who underwent distal pancreatectomy for pancreatic neoplastic disease.

RESULTS

Postoperative pancreatic fistula occurred in four cases. One patient had a ductal adenocarcinoma, two presented with pancreatic endocrine neoplasms and the last one had an intraductal papillary mucinous neoplasia. Two patients underwent open, the other two laparoscopic distal pancreatectomy.

DISCUSSION

Postoperative pancreatic fistulas after distal pancreatectomy worsen the quality of life, prolong the post-operative stay and delay further adjuvant therapy. In patients who underwent distal pancreatectomy literature exposed some advantages deriving from the placement of abdominal drainages only in selected cases and from their early removal. Patients presenting a high risk of pancreatic fistula had higher amylase levels of drainage fluid in the first postoperative day.

CONCLUSION

POPF is the most frequently complication after pancreatectomy. In our analysis DFA1>5000 can be considered as a predictive factor for pancreatic fistula. For this reason, the systematic measurement of amylase in drain fluid in first-postoperative day can be considered a good clinical practice.

A rare nosological entity: the perforated solitary cecal diverticulum. Research article

AIM

To describe three cases of solitary cecal diverticulum, and trying to evaluate the better method of diagnosis and treatment with analysis of the literature.

MATERIAL OF STUDY

Description of three cases of solitary cecal diverticulum's perforation admitted in the Department of General and Oncologic Surgery, Santa Maria della Misericordia Hospital, Perugia, during the period January 2011 - January 2012.

RESULTS

In all patients the clinical presentation was very similar to that of acute appendicitis. Preoperative diagnosis was achieved in one case through abdominal CT scan, other two cases were identified at final pathology. At one year from the treatment all patient are still alive.

DISCUSSION

Cecal diverticulum is a rare condition, often diagnosed either casually or because of inflammatory or perforative complications. The highest incidence is found in Western population. Because of the clinical presentation, very similar to the appendicitis, and the inflammatory reaction involving the colon and its surrounding tissues, the pre- and intra-operative diagnosis are very difficult. The diagnosis is almost always histological. The treatment may vary from simple expectant medical management, carried out with bowel rest, parenteral support and antibiotics as for left-sided diverticulitis, to surgical approach, performed through simple diverticulectomy or by classical right hemicolectomy.

CONCLUSION

Pre-surgical and, also intra-operative, diagnosis of perforated solitary cecal diverticulum is clearly difficult. CT scan represents the gold standard for the differential diagnosis. Right hemicolectomy is an effective and safe approach, allowing accurate control, preventing complications and recurrences, and it represents the optimal management of the disease.

The surface landmarks of the abdominal wall: a plea for standardization

Despite centuries of anatomical studies, controversies and contradictions still exist in the literature regarding the definition, anatomical terminology and the limits of the abdominal wall. We conducted a systematic research of books published from 1901 until December 2012 in Google Books. After the index screening, 16 remaining books were further assessed for eligibility. We decided to exclude journals. The aim of the study was to focus on surface landmarks and borders of the abdominal cavity. After this revision of the literature, we propose that the surface landmarks of the abdominal wall should be standardized.

Transverse skin crease versus vertical midline incision versus laparoscopy for right hemicolectomy: a systematic review--current status of right hemicolectomy

PURPOSE

The right hemicolectomy may be conducted through laparoscopic or laparotomic surgery, transverse or midline incisions. The transverse laparotomy offers some advantages compared to the midline laparotomy and laparoscopy. A literature review was performed to evaluate the possible advantages of the transverse incision versus midline incision or laparoscopic right hemicolectomy.

METHODS

A systematic research was performed in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, and the Science Citation Index.

RESULTS

Laparotomic right hemicolectomy with transverse incision is preferable to laparotomic hemicolectomy with midline incision. A transverse incision offers a lessened postoperative pain following physical activity, a lessened need to administer analgesic therapy during the post-operative time, better aesthetic results, and a better post-operative pulmonary function. Open surgery with transverse or midline incision ensured a shorter operative time, lower costs and a greater length of the incision compared to the laparoscopic. However, there are no differences in the oncological outcomes.

CONCLUSIONS

It was not possible to identify significant differences between the open right hemicolectomy with transverse incision versus the open right hemicolectomy with midline incision or laparoscopic hemicolectomy.

Effects of laparoscopic sleeve gastrectomy in patients with morbid obesity and metabolic disorders

PURPOSES

Obesity and its correlation with other pathological conditions determine the onset of the metabolic syndrome, which exposes the patient to a higher risk of major cardiovascular complications. Laparoscopic sleeve gastrectomy (LSG) is a bariatric surgical procedure that appears to influence both the reduction of fat mass and the action of some gastrointestinal hormones.

PATIENTS AND METHODS

Between January 2011 and July 2013, 23 patients with morbid obesity underwent LSG and follow-up. In the evaluation of patients, the criteria for metabolic syndrome given by the International Diabetes Federation were followed. A multidisciplinary team of experts evaluated patients before surgery and in subsequent scheduled postoperative visits at 7, 30, 60, and 90 days and 4, 5, 6, 9, and 12 months. Anthropometric and metabolic parameters were analyzed.

RESULTS

The mean excess weight loss was 8.57±3.02%, 17.65±6.40%, 25.47±7.90%, 33.76±9.27%, 41.83±10.71%, 46.02±13.90%, 52.60±14.05%, 58.48±16.07%, and 62.59±21.29% at 7, 30, 60, and 90 days and 4, 5, 6, 9, and 12 months, respectively. In the same observational period there was an excellent improvement of metabolic indices. None of the patients previously taking prescribed hypoglycemic drugs restarted therapy. Mean fasting plasma glucose significantly decreased compared with the preoperative values. Blood pressure had a statistically significant improvement. Modification in the lipid profile was more variable. During the period of observation 22 of 23 patients reported in this study did not fit the criteria for metabolic syndrome.

CONCLUSIONS

Morbid obesity and related diseases may benefit from a surgical approach in selected patients. Randomized controlled trials are needed to evaluate the role of LSG.

Requirement for a standardised definition of advanced gastric cancer

Each year, ~988,000 new cases of stomach cancer are reported worldwide. Uniformity for the definition of advanced gastric cancer (AGC) is required to ensure the improved management of patients. Various classifications do actually exist for gastric cancer, but the classification determined by lesion depth is extremely important, as it has been shown to correlate with patient prognosis; for example, early gastric cancer (EGC) has a favourable prognosis when compared with AGC. In the literature, the definition of EGC is clear, however, there is heterogeneity in the definition of AGC. In the current study, all parameters of the TNM classification for AGC reported in each previous study were individually analysed. It was necessary to perform a comprehensive systematic literature search of all previous studies that have reported a definition of ACG to guarantee homogeneity in the assessment of surgical outcome. It must be understood that the term ‘advanced gastric cancer’ may implicate a number of stages of disease, and studies must highlight the exact clinical TNM stages used for evaluation of the study.

Current status of robotic bariatric surgery: a systematic review

Background

Bariatric surgery is an effective treatment to obtain weight loss in severely obese patients. The feasibility and safety of bariatric robotic surgery is the topic of this review.

Methods

A search was performed on PubMed, Cochrane Central Register of Controlled Trials, BioMed Central, and Web of Science.

Results

Twenty-two studies were included. Anastomotic leak rate was 8.51% in biliopancreatic diversion. 30-day reoperation rate was 1.14% in Roux-en-Y gastric bypass and 1.16% in sleeve gastrectomy. Major complication rate in Roux-en-Y gastric bypass resulted higher than in sleeve gastrectomy ( 4,26% vs. 1,2%). The mean hospital stay was longer in Roux-en-Y gastric bypass (range 2.6-7.4 days).

Conclusions

The major limitation of our analysis is due to the small number and the low quality of the studies, the small sample size, heterogeneity of the enrolled patients and the lack of data from metabolic and bariatric outcomes. Despite the use of the robot, the majority of these cases are completed with stapled anastomosis. The assumption that robotic surgery is superior in complex cases is not supported by the available present evidence. The major strength of the robotic surgery is strongly facilitating some of the surgical steps (gastro-jejunostomy and jejunojejunostomy anastomosis in the robotic Roux-en-Y gastric bypass or the vertical gastric resection in the robotic sleeve gastrectomy).

The integrated role of ultrasonography in the diagnosis of soft tissue metastases from melanoma: preliminary report of a single-center experience and literature review

Currently melanoma has the fastest growing incidence of all cancers in men and the second in women (after lung cancer) in Western countries. Since prognosis of skin melanoma is excellent in early stages but dramatically worsens in advanced stages, an early diagnosis is fundamental in granting patients a favorable outcome. Sentinel node (SN) biopsy represents the gold standard for accurately staging melanoma, but other tests are commonly endorsed both in the initial staging work-up and in the follow-up, such as ultrasonography, computed tomography (CT)-scan and positron emission tomography (PET)-CT. PET-CT, among others, has high sensitivity and specificity for the study of distant metastases, the assessment of soft tissues and lymph node involvement, and for the guidance of surgical biopsies. Ultrasonography (US) is a non-invasive procedure whose use has recently expanded in our service, both preoperatively, intraoperatively and postoperatively, thanks to its wide availability, low costs and easy and fast reproducibility; ultrasonography even surpassed the reliability of PET-CT or CT-scan in the seven cases presented herein. US is operator-dependent, and this is probably the major limitation of the procedure, together with lack of prospective studies validating its strength, but our preliminary study demonstrates that ultrasound can assume an important role in melanoma, both for staging and the follow-up of patients, especially with lymph nodal or subcutaneous involvement.