Characterising oesophageal motility disorders by high-resolution impedance manometry in dermatomyositis patients

OBJECTIVES

We studied high-resolution impedance manometry (HRiM) findings in dermatomyositis (DM) to detect oesophageal dysmotility, even in asymptomatic patients, and correlated the alterations to clinical and serological disease domains.

METHODS

We performed a cross-sectional study of DM patients, enrolled between December 2021 and December 2022. All patients underwent rheumatological, laboratory and HRiM assessment. HRiM findings were compared with different clinical and serological profiles.

RESULTS

The study population consisted of 15 DM patients (13 women and 2 men, age 54±15.2 years). The mean disease duration was 6.6 years. According to HRiM findings, three different groups of oesophageal disease severity were identified (in order of severity G0, G1 and G>1, 5 patients per group). G>1 group was significantly associated with MDA5 antibodies (80% vs. 20%, p<0.05). Interstitial lung disease (ILD) did not show any significant association with HRiM findings. However, a diffusing lung capacity for carbon oxide (DLCO) < 80% was present in 100% of G>1 (p<0.05). No associations between dysphagia, creatine kinase (CK) level, muscle weakness, skin, articular involvement and treatment were found.

CONCLUSIONS

Oesophageal involvement is frequent and should be evaluated in the comprehensive work-up of DM. We used for the first time HRiM in DM, which proved to be an accurate and objective technique in assessing oesophageal disease, even in the subclinical stage. Interestingly, the MDA5-positive group had a higher burden of HRiM pathological findings, suggesting a greater severity of oesophageal involvement, often asymptomatic.

Evaluation of predictive factors for i-CLARAS (intraoperative complications in laparoscopic renal and adrenal surgery): a multicentre international retrospective cohort study

The laparoscopic approach represents the standard of treatment for renal and adrenal diseases, and its use is increasing even outside referral centres. Although most procedures are routinely performed, intraoperative complications do not occur, and the rate and predictive factors of these complications have not been established. The aim of this study was to evaluate the incidence and type of intraoperative complications and to identify predictive factors in patients undergoing laparoscopic renal and adrenal surgery. This was a cohort, multicentre, international retrospective study. Patients who underwent laparoscopic renal and adrenal surgeries between April 2017 and March 2022 were included in the study. Bivariate analysis was performed using contingency tables and the χ2 test for independent samples to compare qualitative variables and the T test and Mood test for continuous variables. Multivariate analysis was performed using a logistic regression model to obtain adjusted odds ratios. A total of 2374 patients were included in the study. Intraoperative complications were reported for 8.09% of patients who underwent renal surgery, with the most common complications reported being hollow viscus and vascular complications, and for 6.75% of patients who underwent adrenal surgery, with the most common complication reported being parenchymatous viscous complications. Multivariate analysis revealed that both adrenal and renal surgery radiological preoperative factors, such as invasive features during adrenalectomy and the RENAL score during nephrectomy, are predictive factors of intraoperative complications. In contrast to existing data, surgeon experience was not associated with a reduction in the incidence of perioperative complications.

Factors affecting quality of life in rectal cancer survivors who have undergone laparoscopic surgery: patient-reported outcomes over 10 years at a single institution

INTRODUCTION

Colorectal cancer survivors have many problems affecting their quality of life (QOL). Traditional follow-up focuses on the detection of recurrence rather than QOL. Efforts are being made to assess patient-reported outcomes (PROMS) more formally. Such changes may enable patients to consider QOL factors when deciding on treatment.

METHODS

Patients who underwent laparoscopic surgery for rectal cancer between 2005 and 2015 at a single institution were identified and sent European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR29 QOL questionnaires. QOL and the impact of radiotherapy, chemotherapy and formation of end colostomy were assessed.

RESULTS

Some 141 patients were identified: 12 died and 118 (83.7%) responded, of whom 101 completed the questionnaires and 17 declined to participate; 11 were lost to follow-up. Mean age was 67 years, median follow-up was 58 months. Median QOL score was 6 (maximum 7) and 4.5% of patients reported a poor QOL score (<4). Significant rectal/perianal pain, sexual dysfunction and urinary symptoms were reported in 3.6%, 10.9% and 2.7% of respondents, respectively. Significant differences between treatment groups were uncommon. All cohorts reported similar QOL, functional and symptom scores.

CONCLUSIONS

These results compare favourably with the published data. Future studies may benefit from baseline assessment to better assess treatment impact, prescient in an increasingly elderly and comorbid population. This paper establishes that good PROMs are achievable with laparoscopic surgery for rectal cancer. It identifies limited differences in QOL between treatment modalities. Restoration of intestinal continuity and end colostomy result in similar QOL. This may address common concerns regarding stomata, sexual function and low anterior resection syndrome in this cohort.

Randomized open-label controlled study of cancer vaccine OSE2101 versus chemotherapy in HLA-A2-positive patients with advanced non-small-cell lung cancer with resistance to immunotherapy: ATALANTE-1

BACKGROUND

Patients with advanced non-small-cell lung cancer (NSCLC) treated with immune checkpoint blockers (ICBs) ultimately progress either rapidly (primary resistance) or after durable benefit (secondary resistance). The cancer vaccine OSE2101 may invigorate antitumor-specific immune responses after ICB failure. The objective of ATALANTE-1 was to evaluate its efficacy and safety in these patients.

PATIENTS AND METHODS

ATALANTE-1 was a two-step open-label study to evaluate the efficacy and safety of OSE2101 compared to standard-of-care (SoC) chemotherapy (CT). Patients with human leukocyte antigen (HLA)-A2-positive advanced NSCLC without actionable alterations, failing sequential or concurrent CT and ICB were randomized (2 : 1) to OSE2101 or SoC (docetaxel or pemetrexed). Primary endpoint was overall survival (OS). Interim OS futility analysis was planned as per Fleming design. In April 2020 at the time of interim analysis, a decision was taken to prematurely stop the accrual due to coronavirus disease 2019 (COVID-19). Final analysis was carried out in all patients and in the subgroup of patients with ICB secondary resistance defined as failure after ICB monotherapy second line ≥12 weeks.

RESULTS

Two hundred and nineteen patients were randomized (139 OSE2101, 80 SoC); 118 had secondary resistance to sequential ICB. Overall, median OS non-significantly favored OSE2101 over SoC {hazard ratio (HR) [95% confidence interval (CI)] 0.86 [0.62-1.19], P = 0.36}. In the secondary resistance subgroup, OSE2101 significantly improved median OS versus SoC [11.1 versus 7.5 months; HR (95% CI) 0.59 (0.38-0.91), P = 0.017], and significantly improved post-progression survival (HR 0.46, P = 0.004), time to Eastern Cooperative Oncology Group (ECOG) performance status deterioration (HR 0.43, P = 0.006) and Quality of Life Questionnaire Core 30 (QLQ-C30) global health status compared to SoC (P = 0.045). Six-month disease control rates and progression-free survival were similar between groups. Grade ≥3 adverse effects occurred in 11.4% of patients with OSE2101 and 35.1% in SoC (P = 0.002).

CONCLUSIONS

In HLA-A2-positive patients with advanced NSCLC and secondary resistance to immunotherapy, OSE2101 increased survival with better safety compared to CT. Further evaluation in this population is warranted.

Surgical Challenges in Infective Endocarditis: State of the Art

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Tentacle Mesh for Fixation-Free Spigelian Hernia Repair: Mini-Invasive Approach Granting Broad Defect Overlap

BACKGROUND

Compared to other types of abdominal protrusions, Spigelian hernias are not very common. In prosthetic repair of abdominal protrusions, mesh fixation and defect overlap are an open issue, as they are a source of complications. A newly developed tentacle-shaped mesh has been used to ensure a fixation-free repair with a broader defect overlap in the repair of abdominal hernias. This study describes the long-term results of a fixation-free repair of Spigelian hernias carried out with a tentacle mesh.

METHODS

A proprietary mesh composed of a central body with integrated radiating arms was used for repairing Spigelian hernias in 54 patients. The implant was positioned in preperitoneal sublay, and the straps were delivered across the abdominal musculature with a needle passer, and then, after fascia closure, cut short in the subcutaneous layer.

RESULTS

The friction of the straps passing through the abdominal wall served to hold the mesh in place, guaranteeing a wide overlap over the defect without fixation. In a long-term follow-up of 6 to 84 months (mean 64 months), a very low rate of complications occurred, but no recurrence was reported.

CONCLUSIONS

The tentacle strap system of the prosthesis allowed for an easy, fast and safe fixation-free placement granting a wide overlap, avoiding intraoperative complications. Greatly reduced pain and a negligible amount of postoperative complications characterized the postoperative outcome.

Acute appendicitis and situs viscerum inversus: radiological and surgical approach-a systematic review

INTRODUCTION

Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on clinical features and radiologic findings. One-third of patients with acute appendicitis present unusual symptoms. There are several circumstances that may cause misdiagnosis and unclear prognostic prediction. Among these, situs viscerum inversus totalis and midgut malrotation can be challenging scenarios, leading to a delay in treatment, especially when these conditions are unknown. We decided to carry on a systematic review of published cases of acute appendicitis in the context of anatomical anomalies.

METHODS

We used the MESH terms "appendicitis" AND "situs inversus" AND/OR "gut malrotation" to search for titles and abstracts. Inclusion criteria were patients with clinical and/or radiological diagnosis of acute appendicitis, with conservative or surgical management and with preoperative/intraoperative findings of situs viscerum inversus or gut malrotation. Additionally, previous reviews were examined. Exclusion criteria of the studies were insufficient patient clinical and demographic data.

RESULTS

We included in this review 70 articles concerning 73 cases of acute appendicitis with anatomical anomaly. Patients were aged from 8 to 86 years (median: 27.0 years). 50 were male and 23 were female. 46 patients (63%) had situs viscerum inversus, 24 (33%) had midgut malrotation, 2 (2.7%) had Kartagener's syndrome, one of them (1.4%) had an undetermined anomaly In 61 patients the anatomical anomaly was unknown previously (83.6%), while 16,4% already were aware of their condition.

CONCLUSION

Acute appendicitis can occur in association of rare anatomical anomalies and in these cases diagnosis can be challenging. Situs viscerum inversus and midgut malrotation should always be considered in the differential diagnosis of a patient with left lower quadrant pain, especially in younger population. Besides clinical features, it is fundamental to implement the diagnostic progress with radiological examination. Laparoscopic approach is useful to identify and treat acute surgical emergency and it is also a diagnostic tool and can be tailored in order to offer the best exposition of the operatory field for each single case.

Role of preoperative CT angiography with multimodality imaging reconstruction to perform laparoscopic Complete Mesocolic Excision (CME) and Central Vascular Ligation (CVL) in right-sided colon cancer: Is it really useful? A prospective clinical study

BACKGROUND

The concept of complete mesocolic excision (CME) and central vascular ligation (CVL) in right colonic resections appears to improve the oncological outcomes. The highest rate of complications reported in the literature in patients undergoing CME is related to difficult surgical manuevers and intraoperative bleeding due to the central vascular dissection.

METHODS

We used preoperative findings obtained with the CT angiography, multiplanar reformation (MPR), maximum intesity projection (MIP) and 3D volume rendering (VR) technique to verify if this preoperative radiological assessment had significant benefits regarding the difficulty of dissection of the embryological planes, the identification of vascular structures and central lymph nodes with reduction in mean operative time, intraoperative complications and better short-term outcomes versus standard contrast enhanced CT scan. We also have administered a questionnaire to investigate the subjective responses on the degree of difficulty of the surgical procedure both by the surgical team expert in CME and by a group of young surgeons.

RESULTS

Statistical analysis showed that overall operative time was significant shorter in patients underwent to radiological assessment (224,5 min; range 160-300 versus 252,6 min; range 200-340; p-value 0.023) with a significant lower rate of intraoperative complication (2.7% versus 4.2%; p-value 0.043). No differences were reported with respect to blood loss, conversion rate, anastomotic leakage or other surgical results. Analysis of the questionnaire underlined a progressive awareness of the correspondence between the radiological imaging and the surgical field.

CONCLUSION

The possibility of identifying the characteristics and course of the vascular structures along the axis of the superior mesenteric vessels certainly increases the surgeon's knowledge of the operating field, making him more confident with surgical maneuvers and significantly reducing the duration of the operating time and intraoperative complications.

A review of modeling pesticides in freshwaters: Current status, progress achieved and desirable improvements

This study comprises a critical review of modeling of pesticides in surface waters. The aim was to update the status of the use of models to simulate the fate of pesticides from diffuse sources. ISI papers were selected on Scopus and the information concerning the study areas, type of pesticides (herbicides, fungicides and insecticides), the model, and the methodology adopted (i.e., calibration and/or validation, spatial and temporal scales) were analyzed. The studies were carried out in Europe (55.5%), North America (22.3%), Asia (13.9%) and South America (8.3%). The Soil and Water Assessment Tool proved to be the most used model (45.95%). Herbicides were the most modeled pesticides (71.4%), followed by insecticides (18.2%) and fungicides (10.4%). The main herbicides modeled were atrazine, metolachlor, isoproturon, glyphosate, and acetochlor. Insecticides such as chlorpyrifos and metaldehyde. Chlorothalonil, and fungicides (i.e., tebuconazole) were the most widely investigated. Based on published studies, it was found that modeling approaches for assessing the fate of pesticides are constantly evolving and the model algorithms work well with diverse watershed conditions, management strategies, and pesticide properties. Several papers reported concentrations of pesticides exceeding ecotoxicological thresholds revealing that water contamination with pesticides used in agriculture and urban areas is a priority issue of current global concern.

Laparoscopic prosthetic repair of laparocele. A comparison of techniques and a review of the literature

Incisional hernia, or post-laparotomy hernia, is a defect in the abdominal wall, which can produce mechanical and systemic changes in both respiratory and splanchnic circulation. This pathology has an important impact on Health and Society, with an incidence ranging from 2% to 20%, stimulating the improvement or development of surgical techniques, to reduce discomfort and complications, e.g. imprisonment, strangulation and recurrences. The growing availability of prostheses, with greater resistance and lower risk of visceral adhesions, has improved the result and reduced relapses. Over the past 15 years, further improvements have been achieved, thanks to the greater use of laparoscopy, decreasing relapses and complications and improving patient comfort. In this regard, the Ventralight Echo PS prosthesis, introduced for the first time in 2013 and routinely used by our team, have shown encouraging results. In this work, a retrospective study aims to compare in different aspects two groups of patients, suffering from defects on the abdominal wall and undergoing reconstructive surgery with laparoscopic technique. It has been used simple prostheses for the first, whereas the Echo PS~ Positioning System with Ventralight - ST Mesh or Composix - L/P Mesh for the second group. In our experience, we conclude that the use of prostheses, such as the Ventralight Echo PS, in the treatment of incisional hernias, regardless of the location of the defect, is a valid and safe alternative to the use of non-self-expandable prostheses. KEY WORDS: Incisional Hernia, Hernia Repair, Laparoscopic Technique.

Dynamic Responsive Inguinal Scaffold Activates Myogenic Growth Factors Finalizing the Regeneration of the Herniated Groin

BACKGROUND

Postoperative chronic pain caused by fixation and/or fibrotic incorporation of hernia meshes are the main concerns in inguinal herniorrhaphy. As inguinal hernia is a degenerative disease, logically the treatment should aim at stopping degeneration and activating regeneration. Unfortunately, in conventional prosthetic herniorrhaphy no relationship exists between pathogenesis and treatment. To overcome these incongruences, a 3D dynamic responsive multilamellar scaffold has been developed for fixation-free inguinal hernia repair. Made of polypropylene like conventional flat meshes, the dynamic behavior of the scaffold allows for the regeneration of all typical inguinal components: connective tissue, vessels, nerves, and myocytes. This investigation aims to demonstrate that, moving in tune with the groin, the 3D scaffold attracts myogenic growth factors activating the development of mature myocytes and, thus, re-establishing the herniated inguinal barrier.

METHODS

Biopsy samples excised from the 3D scaffold at different postoperative stages were stained with H&E and Azan-Mallory; immunohistochemistry for NGF and NGFR p75 was performed to verify the degree of involvement of muscular growth factors in the neomyogenesis.

RESULTS

Histological evidence of progressive muscle development and immunohistochemical proof of NFG and NFGRp75 contribution in neomyogenesis within the 3D scaffold was documented and statistically validated.

CONCLUSION

The investigation appears to confirm that a 3D polypropylene scaffold designed to confer dynamic responsivity, unlike the fibrotic scar plate of static meshes, attracts myogenic growth factors turning the biological response into tissue regeneration. Newly developed muscles allow the scaffold to restore the integrity of the inguinal barrier.

Totally laparoscopic treatment of intestinal tuberculosis complicated with bowel perforation: The first case report in worldwide literature with a brief review

Introduction

Bowel perforation is a relatively rare presentation of abdominal tuberculosis, whose diagnosis is challenging but fundamental to minimize morbidity and mortality. Laparoscopy is considered an effective modality for diagnosis, but its role in surgical treatment is still not established. We reported the first worldwide case of totally laparoscopic treatment of intestinal tuberculosis complicated with bowel perforation.

Case presentation

A 30-year-old man with a history of weight loss, preceded by 2 years of nonproductive cough, was admitted to the Infectious Disease Department with a presumed diagnosis of tuberculosis. A microbiological culture test confirmed the diagnosis, and the patient undertook quadruple antituberculous therapy. During hospitalization, he presented sudden abdominal pain, fever, and vomit. An abdominal CT scan showed small bowel perforation with granulomatous reaction. Laparoscopy was performed and revealed a 2 cm perforation on the medium ileum. Small bowel resection and totally intracorporeal side-to-side anastomosis were performed. No complication occurred until a clinical follow-up of 2 months.

Conclusion

In consideration of the increasing incidence of intestinal TB in both underdeveloped and Western countries, the diagnosis of this pathology should be taken into account in high-risk patients. Probably, the diagnostic challenges and emergency settings of intestinal TB with perforation and peritonitis, together with the lack of standardized guidelines regarding surgical management, make the use of laparoscopy apparently arduous, but the known advantages of laparoscopy and its technical feasibility should make it a conceivable option for the treatment of complicated cases.

Uterine Involvement in Klippel–Trenaunay Syndrome: A Rare But Relevant Event. Review of the Literature

Introduction

Klippel–Trenaunay syndrome (KTS) is a rare vascular congenital disorder characterized by the classical triad of port-wine stains, abnormal growth of soft tissues and bones, and vascular malformations. The involvement of the genitourinary tract and of the uterus in particular is extremely infrequent but relevant for possible consequences.

Methods

We performed an extensive review of the literature using the Pubmed, Scopus and ISI web of knowledge database to identify all cases of KTS with uterine involvement. The search was done using the MeSH term “Klippel–Trenaunay syndrome” AND “uterine” OR “uterus.” We considered publications only in the English language with no limits of time. We selected a total of 11 records of KTS with uterine involvement, including those affecting pregnant women.

Results

Klippel–Trenaunay syndrome was described for the first time in the year 1900 in two patients with hemangiomatous lesions of the skin associated with varicose veins and asymmetric soft tissue and bone hypertrophy. Uterine involvement is a rare condition and can cause severe menorrhagia. Diagnosis is based on physical signs and symptoms. CT scans and MRI are first-choice test procedures to evaluate both the extension of the lesion and the infiltration of deeper tissues before treatment. The management of Klippel–Trenaunay syndrome should be personalized using careful diagnosis, prevention and treatment of complications.

Conclusion

Klippel–Trenaunay syndrome is a rare vascular malformation with a wide variability of manifestations. There are no univocal and clear guidelines that suggest the most adequate monitoring of the possible complications of the disease. Treatment is generally conservative, but in case of recurrent bleeding, surgery may be needed.

Intact parathyroid hormone value on the first postoperative day following total thyroidectomy as a predictor of permanent hypoparathyroidism: a retrospective analysis on 426 consecutive patients

INTRODUCTION

Hypoparathyroidism represents a common complication following total thyroidectomy. To date, there is still no reliable and immediate postoperative parameter to establish which patients with postsurgical hypoparathyroidism will develop permanent hypoparathyroidism. The main purpose of the present study was to assess whether the intact parathyroid hormone (iPTH) value on the first postoperative day is a good predictor of permanent hypoparathyroidism.

MATERIAL AND METHODS

Patients undergoing thyroidectomy in our unit between March 2018 and January 2020 were analysed. According to the iPTH value on the first postoperative day and on the basis of the detection threshold of the iPTH test used, patients were divided into two groups: Group A (iPTH ≥ 4.6 pg/mL) and Group B (iPTH < 4.6 pg/mL, undetectable).

RESULTS

In total 426 patients were included: 364 in Group A and 62 in Group B. Permanent hypoparathyroidism occurred in 3 (0.82%) patients from Group A and in 26 (41.94%) from Group B (p < 0.001). When iPTH levels were < 4.6 pg/mL on the first postoperative day the sensitivity for the prediction of permanent hypoparathyroidism was 89.66%, the specificity was 90.93%, the positive predictive value (PPV) was 41.94%, the negative predicitive value (NPV) was 99.18% and the accuracy was 90.85%.

CONCLUSIONS

An iPTH value < 4.6 pg/mL on the first postoperative day following total thyroidectomy has proven to be a good parameter for early identification of patients at high risk for permanent hypoparathyroidism. Moreover, we want to underline that in our experience no patient with an iPTH level > 6.5 pg/mL developed this complication.

Prognostic stratification of patients with low-risk hypertrophyc cardiomyopathy: the role of myocardial deformation imaging and myocardial fibrosis

Funding Acknowledgements

Type of funding sources: None.

Background

Hypertrophic cardiomyopathy (HCM) is associated with a high incidence of adverse cardiovascular events. Risk stratification for major cardiac events and management of HCM patients are still a serious challenge in cardiology. Current ESC guidelines recommend stratifying the risk of sudden cardiac death (SCD) at 5 years using a prediction model which evaluates clinical and echocardiographic criteria but this model does not include parameters of myocardial deformation at echocardiography and myocardial fibrosis at cardiac magnetic resonance.

Purpose

The aim of this study was to evaluate the predictive prognostic role of myocardial deformation imaging parameters derived by echocardiography (left ventricular global longitudinal strain GLS and PALS) and magnetic resonance parameters (extension of delayed enhancement DE) in a population of patients with HCM with low-risk of SCD, considering ESC prediction model.

Methods

We enrolled 166 patients, mean age 56.25 ± 16 with hypertrophic cardiomyopathy. A complete echocardiogram and a cardiac magnetic resonance were performed. After a period of 2.5 years, adverse cardiovascular events were evaluated: number of ICD shocks and ventricular arrhythmias, occurrence of atrial fibrillation (AF) or other supraventricular arrhythmias, symptoms of heart failure (HF) and or hospitalizations, heart transplant and death.

Results

7 heart transplants, 8 deaths, 29 patients developed AF, 6 patients developed ventricular arrhythmias and/or ICD shock, 17 patients were hospitalized, 16 patients developed HF. Patients with cardiovascular events had significantly lower PALS values than patients without events (PALS 4.6 ± 2.6 vs 17.5 ± 3.26, p-value &lt; 0.0001) and higher values left atrial volume (179 ± 81 vs 76 ± 37, p-value &lt; 0.001); significantly greater DE extension (57 ± 20 vs 17 ± 19, p-value 0.0082), lower GLS and EF values (GLS 10 ± 3 vs 15 ± 4, p value 0.0033; EF p-value 0,0001). Patients who developed ventricular arrhythmias, did not show significant changes in EF (p-value 0.26), left atrial volume (90 ± 17, p-value 0.36) and PALS (18 ± 1, p-value 0.7), but they had significantly lower GLS values (5.7 ± 12, p-value 0.02) and a greater extent of DE (p-value 0.04). Patients with AF showed a significantly increased left atrial volume (100 ± 43, p 0.0034) and the PALS (10.8+ 5.9, p-value &lt; 0.0001) was significantly reduced compared to patients without events; EF, GLS (-11.8 ± 8, p-value 0.08) and DE were not significantly reduced (14.8 ± 8, p-value 0.14). In patients who developed HF, both EF, GLS (p-value 0.035), left atrial volume , PALS (p-value &lt; 0.0001) and DE (65 ± 22.5 p-value &lt; 0.0001) were altered compared to patients without events.

Conclusion

Low PALS, reduced EF and GLS and higher DE extension and left atrial volume, appear to be prognostic factors in patients with HCM. PALS and left atrial volume are predictors of death, heart failure and AF. Low GLS and DE are predictors of ventricular arrhythmias and heart failure.

Sensitivity of the Preclinical Alzheimer's Cognitive Composite (PACC), PACC5, and Repeatable Battery for Neuropsychological Status (RBANS) to Amyloid Status in Preclinical Alzheimer's Disease -Atabecestat Phase 2b/3 EARLY Clinical Trial

BACKGROUND

Cognitive composites commonly serve as primary outcomes in Alzheimer's disease (AD) secondary prevention trials.

OBJECTIVE

To evaluate the association between amyloid (Aβ) burden level (+/-) and performance on three separate composite endpoints: Preclinical Alzheimer's Cognitive Composite (PACC), PACC+Semantic Fluency (PACC5), and Repeatable Battery for Neuropsychological Status (RBANS).

DESIGN

Screening data from the randomized, double-blind, placebo-controlled, phase 2b/3 atabecestat EARLY study in preclinical AD participants were used in this analysis.

SETTING

The EARLY study was conducted at 143 centers across 14 countries.

PARTICIPANTS

3,569 cognitively unimpaired older adults (Clinical Dementia Rating of 0; aged 60-85 years) screened for inclusion in the EARLY study with Aβ status and at least PACC or RBANS at screening were included. Participants were categorized as those with non-pathological Aβ levels (Aβ-, n=2,824) and those with pathological Aβ levels (Aβ+, n=745) based on florbetapir uptake or levels of cerebrospinal fluid Aβ1-42.

MEASUREMENTS

Analysis of Covariance models controlling for age, sex, and education were used to examine the difference in PACC, PACC5, and RBANS between Aβ groups. Nonparametric bootstrap was used to compare sensitivity of composites to differentiate between Aβ status.

RESULTS

Of 3,569 participants, 2,116 were women (59%); 3,006 were Caucasian (84%); mean (SD) age was 68.98 (5.28) years. Aβ+ participants performed worse versus Aβ- participants on all cognitive composites though the magnitude of the Aβ effect was generally small. The Aβ+/- effect size for the PACC (Cohen's d=-0.15) was significantly greater than the RBANS (d=-0.097) while the PACC5 effect size (d=-0.139) was numerically larger than the RBANS. When examining subscores from the composites, memory tests (i.e., Free and Cued Selective Reminding Test, Figure Recall) and speed of processing (i.e., Digit-Symbol/Coding on the PACC/RBANS) exhibited the largest Aβ+/- effect sizes.

CONCLUSIONS

Cross-sectional relationships between Aβ and cognition among clinically unimpaired older adults are detectable on multi-domain cognitive composites but are relatively small in magnitude. The Aβ+/- group effect was statistically larger for PACC and marginally larger for PACC5 versus RBANS. However, interpretation of composite sensitivity to Aβ status cross-sectionally cannot be generalized to sensitivity to change over time.

A regenerative 3D scaffold for inguinal hernia repair. MR imaging and histological cross evidence. Qualitative study

BACKGROUND

Inguinal hernia is a degenerative disease occurring in a high motile surround. Stopping degeneration and promoting tissue regeneration should be the treatment goal. Groin hernias are conventionally managed with static flat meshes, mostly fixated to the delicate inguinal environment. Far from a regenerative effect, the biologic response of conventional hernia meshes is characterized by a foreign body reaction leading to a stiff/shrunken scar plate, which is often the source of unpleasant complications. Recently, a newly engineered 3D device for inguinal hernia repair - ProFlor-has been developed to produce a regenerative biological response. Unlike conventional hernia meshes, this regenerative 3D hernia scaffold seems to demonstrate suitable features for a pathogenetical and physiological coherent treatment of the disease. The aim of this manuscript is to cross evidence these features through magnetic resonance imaging (MRI) and histology.

STUDY DESIGN

The biological response of ProFlor at three defined post-implantation stages has been evaluated through MRI signal intensity and compared to neighbouring muscles and fat. As additional proof, histology of tissue specimens excised at the same post-implantation periods from porcine models during an experimental attempt were also evaluated.

RESULTS

MRI of newly ingrown tissue in ProFlor demonstrated similar signal intensity of muscles while fat tissue showed remarkably higher values. These data matched with the histology of ProFlor biopsies excised from pigs.

CONCLUSIONS

The motile compliance to groin movements of ProFlor appears to induce a probiotic biologic response comparable to a regenerative scaffold, allowing to physiologically resolve the degenerative source of inguinal hernia disease.

Inguinal Hernia: Defect Obliteration with the 3D Dynamic Regenerative Scaffold Proflor™

Prosthetic inguinal hernia repair presents significant challenges. Some of these, such as mesh fixation and quality of the biologic response, are still debated among surgeons. For example, there is no strong consensus regarding a specific condition that characterizes the surgical procedure during herniorrhaphy. This issue concerns management of the hernia defect, which in conventional hernia repair with flat meshes remains patent. However, a critical analysis of typical postoperative complications after inguinal hernia repair reveals that some of these adverse events are related to patency of the hernial opening. Postoperative discomfort, pain with specific movements and even hernia recurrence can be caused by incomplete or defective management of the hernia defect. For this reason, a deeper understanding of this topic would be useful for improving postoperative outcomes. A recently updated concept for inguinal hernia repair takes this technical aspect into consideration. It is based on the use of a newly developed 3D scaffold-ProFlor™ (Insightra Medical, Inc., Clarksville, TN, USA)-that is intended to be deployed into the defect. This novel hernia repair device has interesting and original features, such as dynamic responsivity in compliance with inguinal movement, fixation-free mode and regenerative behavior that counteracts the degenerative effects of the disease. Another additional proprietary feature of this 3D scaffold is the full and permanent obliteration of the defect, which is a crucial aspect to improve outcomes by avoiding the typical adverse effects of this surgical procedure. Obliteration of the hernia defect with the 3D dynamic regenerative scaffold ProFlor™ appears to be superior to coverage by means of static (passive) flat meshes/plugs used in conventional hernia repair. This report highlights the principles of this procedural approach.

Enhanced angiogenesis in the 3D dynamic responsive implant for inguinal hernia repair ProFlor

Biologic response to hernia prostheses represents a continuous source of debate. Conventional hernia meshes, in their typical static, passive configuration have been used for decades to reinforce the herniated abdominal wall. These flat implants, mainly fixated with sutures or tacks, induce poor quality fibrotic ingrowth that shrinks the mesh. In groin hernia repair, flat meshes are applied in the delicate inguinal surrounding where uncontrolled development of a scar plate can impair movement and may incorporate the sensitive nerves crossing this area. Complications deriving from mesh fixation and nerve entrapment are frequent and unpleasant for patients. To remedy these problems, a multilamellar shaped 3D device with a dynamic responsive behavior has recently been developed to repair inguinal hernia. Its inherent dynamic compliance during inguinal movements has shown to induce enhanced biological response with ingrowth of newly formed connective tissue, muscle fibers, and nerves. The function of these highly specialized tissue structures is supported by the contextual development of newly formed arteries and veins. The scope of the study was to assess quantity and quality of vessels, which had ingrown in the 3D hernia device in the short-term, medium-term, and long-term post-implantation, in biopsy specimens gathered from inguinal hernia patients operated with the 3D device. Starting from an early stage, widespread angiogenesis was evident within the 3D structure. Arteries and veins increased in quantity showing progressive development until full maturation of all specific vascular components throughout the mid-term, to long-term, post-implantation. High quality biologic ingrowth in hernia prosthetics needs an adequate vascular support. The broad network of mature arteries and veins evidenced herewith seems to confirm the enhanced biological features of the dynamic responsive 3D device whose features resemble a regenerative scaffold, an ideal feature for the treatment of the degenerative source of inguinal hernia disease.

Splenic lymphoma with complex gastro-spleno-diaphragmatic fistula: 3D laparoscopic multivisceral resection. The first literature case report

INTRODUCTION

Gastrosplenic fistula is a rare disease involving stomach and spleen that can lead to dangerous complications like massive gastrointestinal bleeding. Diffuse large B-cell lymphoma (DLBC) is the principal pathological cause of gastrosplenic fistula.

CASE REPORT

We report a case of A 76-year-old caucasian woman came to the emergency room with fever for two week and gravative pain in left upper quadrant of the abdomen. CT scan of thorax and abdomen demonstrated an inhomogeneous hypodense large lymphomatous mass (10 × 6 cm) of upper pole of the spleen deformating medial profile and infiltrating gastric fundus and left diaphragm. with the diagnosis of complex gastro-splenic-diaphragmatic fistula we performed an en-block resection using a 3D laparoscopic vision system.

DISCUSSION

Gastrosplenic fistula is a rare complication of several clinical conditions. Among the different causes diffuse large B-cell lymphoma is the most frequent although diffuse histiocytic lymphoma, Hodgkin's lymphoma and extranodal NK/T-cell lymphoma are also described. After a literature review we found less then 30 cases of gastrosplenic fistula secondary to lymphoma. In our case report we do the first description of three-organs fistula envolvement, stomach, spleen and diaphragmatic dome, managed with 3D laparoscopic approach.

CONCLUSION

Gastrosplenic fistula can represent a fatal evolution of splenic or gastric lymphoma independently from chemotherapy treatment. The diagnosis of this condition is very difficult and related to its rarity. To our opinion, laparoscopy represents a valid and safe alternative to open surgery in management of these patients.

Can thyroidectomy be considered safe in obese patients? A retrospective cohort study

BACKGROUND

Obesity is a growing public health concern in most western countries. More and more patients with high body mass index (BMI) are undergoing surgical procedures of all kinds and, in this context, obese patients are undergoing thyroid surgery more than ever before. The aim of the present study was to evaluate whether thyroidectomy can be considered safe in obese patients.

METHODS

Patients undergoing thyroidectomy in our Unit between January 2014 and December 2018 were retrospectively analysed. Patients were divided into two groups: those with BMI < 30 kg/m² were included in Group A, while those with BMI ≥ 30 kg/m² in Group B. Univariate analysis was performed to compare these two groups. Moreover, multivariate analyses were performed to evaluate whether the BMI value (considered in this case as a continuous variable) had a significant role in the development of each individual postoperative complication.

RESULTS

A total of 813 patients were included in this study: 31 (3.81%) were underweight, 361 (44.40%) normal-weight, 286 (35.18%) overweight, 94 (11.57%) obese and 41 (5.04%) morbidly obese. Six hundred and seventy-eight patients were included in Group A and 135 in Group B. At univariate analysis, the comparison between the two groups, in terms of operative time and thyroid weight resulted in statistically significant results (P = 0.001, P = 0.008; respectively). These features were significantly higher in Group B than in Group A. About postoperative stay and complications, no statistically significant difference was found between the two groups. At multivariate analyses, only the development of cervical haematoma was statistically significantly correlated to the BMI value. Patients with high BMI had a lower risk of cervical haematoma (P = 0.045, OR 0.797, 95% CI 0.638-0.995).

CONCLUSIONS

This study showed that obesity, in the field of thyroid surgery, is not associated with any increase of postoperative complications. Thus, it is possible to conclude that thyroidectomy can be performed safely in obese patients. Our result about operative times had no clinical significance.

Unusual giant chromophobe renal cancer totally managed with laparoscopic technique: Report of a case

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We describe a case report of giant renal cell chromophobe carcinoma totally treated by laparoscopic surgery.

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The size of renal lesion represents a critical point in surgical approach because to perform a laparoscopic radical nephrectomy can be challenging even for skilled surgeons in giant renal tumors.

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A brief review of literature was performed to identify outcomes and potentially surgical advantages of laparoscopic approach for retroperitoenal liposarcoma.

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The possibility of the laparoscopic approach derives from from the preoperative identification of adipose cleavage, from the absence of invasion of major vascular axes, from the absence of distant metastatic lesions.

Introduction

Chromophobe carcinoma of the kidney is a rare pathological entity generally smaller and asymptomatic than other renal cell carcinomas and with a lower risk of metastatic disease. We describe a case of a giant renal chromophobe carcinoma successfully treated by laparoscopy.

Case report

A 37-years-old Caucasian man presented at physical examination a rigid elastic mass in right upper abdominal quadrant. CT abdominal scan revealed an enhancing well-defined heterogeneous large mass measuring 17 × 15 cm and originating from the upper pole of the right kidney, with necrotic and solid areas within the lesion. Considering the young age of the patient and the absence of local invasiveness, despite the large size of the lesion, we decided to perform a laparoscopic transperitoneal right nephrectomy. The morphological and immunophenotypic characteristics (CK7+, CD10+, CD117+) confirmed the diagnosis of chromophobe renal cell carcinoma.

Results

Chromophobe renal cell cancer is an unusual hystological entity. The pathological diagnosis of chromophobe tumor is based on atypia with nuclear irregularities, binucleation, and nucleolar prominence. In our case reports the pathological examination showed no tumor necrosis, mitosis or sarcomatoid differentiation and perirenal tissues were free from tumor infiltration with low risk of tumor progression after surgery.

Conclusion

Laparoscopic approach is today considered the standard treatment for localized renal cancer. Nevertheless, the size of renal lesion represents a critical point in surgical approach because to perform a laparoscopic radical nephrectomy can be challenging even for skilled surgeons in giant renal tumors.

Acute appendicitis in a patient with situs viscerum inversus totalis: Role of laparoscopic approach. A case report and brief literature review

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Abdominal pain due to acute appendicitis in one of the most causes of access to Emergency Room requiring surgical consult and treatment.

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The occurrence of anatomical anomalies should be considered especially when clinical and imaging features are misleading. In these cases laparoscopic surgery can be a safe tool in order to confirm uncertain diagnosis.

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We report a case of acute appendicitis in a 23-year-old Caucasian men with situs viscerum inversus detected on radiological investigation.

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Laparoscopic approach was used to confirm the diagnosis and to perform appendectomy. Trocars placement was tailored for this peculiar case.

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Situs viscerum inversus and midgut malrotation should be taken into consideration in patients with findings of the physical examination suspicious for left-sided acute appendicitis.

Introduction

Abdominal pain due to acute appendicitis in one of the most causes of access to Emergency Room requiring surgical consult and treatment. The occurrence of anatomical anomalies should be considered especially when clinical and imaging features are misleading. In these cases laparoscopic surgery can be a safe tool in order to confirm uncertain diagnosis.

Case report

We report a case of acute appendicitis in a 23-year-old Caucasian men with situs viscerum inversus detected on radiological investigation. Laparoscopic approach was used to confirm the diagnosis and to perform appendectomy. Trocars placement was tailored for this peculiar case.

Discussion

One third of patient with acute appendicitis complains abdominal pain in an unexpected location due to various anatomical position of appendix. Left-sided acute appendicitis is a cause of misdiagnosis and it can occur in association with anatomical anomalies such as situs viscerum inversus and midgut malrotation. Laparoscopic surgery may represent a valuable approach in terms of differential diagnosis and treatment in these patients.

Conclusion

Left-sided acute appendicitis should always be considered in young male patients with left lower quadrant pain. Laparoscopic approach is useful and safe procedure both for diagnosis and treatment of these unclear clinical pictures.

Laparoscopic treatment of mesenteric avulsion and intestinal perforation after blunt abdominal trauma: A report of a case

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Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen.

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The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

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We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion treated with laparoscopic approach.

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Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment.

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The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Introduction

Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen. The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

Case report

We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion. Since the patient was hemodynamically stable, a laparoscopic approach was carried on.

Discussion

Blunt abdominal trauma are responsible of 6–14.9% of all traumatic injuries (Galia et al., 2017). The frequency of small bowel lesions ranges from 5% to 15%, while small bowel mesenteric injuries are approximately found in 5% of patients after blunt abdominal trauma. There are different biomechanical reasons explaining how a blunt trauma can cause damages to small bowel and its mesentery. Clinical diagnosis of small bowel perforation after blunt abdominal trauma is often challenging for non-specific objective clinical signs and because peritoneal irritation symptoms are present only in collaborative patients.

Conclusion

Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment. The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Duodenal perforation as presentation of gastric neuroendocrine tumour: A case report

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Gastric neuroendocrine neoplasms (g-NENs) represent the most frequent digestive NENs and are increasingly recognized thanks to diffusion of upper gastrointestinal endoscopy.

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g-NENs can be sporadic or associated with multiple endocrine neoplasia type 1 (MEN-1) and present with a functional Zollinger-Ellison syndrome.

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We described a case of a 60 years old Caucasian male came to emergency room with diffuse abdominal pain and leukocytosis on blood tests.

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At the level of the pyloric portion we found irregularly thickened walls associated with a small fluid collection and bubbles of free air. On exploratory laparoscopy we found a large perforation (about 5 cm of size) in the first duodenum portion.

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Histological examination revealed a gastric NET perforation as a consequence of hypergastrinemia secondary to gastrinoma.

Introduction

Neuroendocrine tumors (NETs) represent uncommon neoplasms with different characteristics. They can be asymptomatic and benign or they can also proliferate and manifest themselves with neoplastic mass symptoms such as intestinal occlusion or with carcinoid syndrome. Gastric neuroendocrine neoplasms (g-NENs) are the most frequent digestive NENs while duodenal neuroendocrine neoplasms (d-NENs) may be sporadic or associated with multiple endocrine neoplasia type 1 (MEN-1) and present a functional syndrome (e.g. gastrinoma with Zollinger-Ellison syndrome).

Presentation of case

We report a case of duodenal perforation due to a unknown gastrinoma responsible of Zollinger-Ellison Syndrome. He underwent an emergency contrast enhanced CT abdominal scan that showed a perforation. We performed a distal gastrectomy. The histopathological examination revealed a g-NET configuring a possible picture of Zollinger-Ellison Syndrome.

Discussion

The management of NETs is diffulcult and controversial because of their rarity. It is useful to know the pathologic assessment of tumor differentiation and/or grade, evaluate surgical resectability and control the carcinoid syndrome symptoms.

Conclusion

This case report shows that gastric NETs can be found in cases of duodenal perforation. Our future goal is to evaluate the possibilities to diagnose the Zollinger Ellison Syndrome as early as possible and to treat it with targeted therapy in order to prevent its related complications.

The colovescical fistula in diverticular disease: Laparoscopic approach in two different cases

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The colovescical fistula is one of the complications of diverticular disease.

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It can cause typical symptoms like pneumaturia and fecaluria affecting the quality of life and sometimes leading to death, usually secondary to sepsis.

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We studied two patients with clinical, radiological and endoscopic diagnosis of colovescical fistula as a consequence of diverticular disease.

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We performed a totally laparoscopic treatment with colonic resection and closure of the fistula with intracorporeal sutures.

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The presence of a colovescical fistula significantly increases the difficult of the laparoscopic colonic resection.

Introduction

The colovescical fistula is one of the complications of diverticular disease. It can cause significant symptoms like pneumaturia and fecaluria affecting the quality of life and sometimes leading to death, usually secondary to sepsis. We describe two cases of colovescical fistula treated by laparoscopic approach in patients with diagnosis of complicated acute diverticulitis.

Case report

We studied two patients with clinical, radiological and endoscopic diagnosis of colovescical fistula as a consequence of diverticular disease. We performed a totally laparoscopic treatment with colonic resection and colo-proctoanastomosis after the closure of the fistula with intracorporeal sutures.

Discussion

Colovescical fistula should be suspected in patients who present fever with persistent dysuria, pneumaturia or fecaluria. The diagnosis is confirmed by a CT abdominal scan, a colonoscopy in order to rule out a colon cancer and a cystoscopy to assess the grade of bladder involvement.

Conclusion

Although colovescical fistulas caused by diverticular disease were once considered a contraindication to laparoscopic resection, nowadays they are increasingly treated by experienced surgeons using laparoscopic techniques. Compared with laparoscopic surgery for uncomplicated diverticulitis the mini-invasive treatment of colovescical fistulas requires a longer operative time and advanced surgical skills.

Combined endo-laparoscopic treatment of large gastrointestinal stromal tumor of the stomach: Report of a case and literature review

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We report a case of 75-year-old Caucasian men with unknown voluminous gastric GIST, who came to our attention complaining melena. We decided to perform a laparoscopic-endoscopic combined surgical approach.

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Intraoperative endoscopy identified gastric GIST and confirmed the submucosal origin and the integrity of the capsule. A 10 cm laparoscopic gastrotomy was carried out along the gastric found in order to realize a laparo-endoscopic rendez-vous technique.

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Laparoscopy has rapidly become a preferable approach for gastric GISTs surgical treatment. The magnified view and the lesser invasiveness of laparoscopic technique allow the surgeon to perform a more meticulous dissection, preventing unexpected bleeding and causing less muscular trauma and less bowel manipulation. All these favourable short-term outcomes associated with laparoscopy do not compromise oncologic results.

Introduction

Gastrointestinal stromal tumours (GISTs) are the most common malignant subepithelial lesions of gastrointestinal tract, originating from Cajal’s cells and characterized by the over expression of tyrosine kinase receptor C-KIT. The prognosis of this disease is associated with tumour size and mitotic index. Standard treatment of a GIST with no metastasis is surgical resection.

Presentation of case

We report a case of a 75-year-old Caucasian man with unknown voluminous gastric GIST, who came to our attention complaining black stool. We decided to perform a laparoscopic-endoscopic combined surgical approach. Intraoperative gastroscopy identified the gastric GIST and confirmed the submucosal origin and the integrity of the tumor capsule. A 10 cm laparoscopic gastrotomy was carried out along the gastric fundus in order to realize a laparo-endoscopic rendez-vous procedure.

Discussion

Laparoscopic approach is feasible and safe for Gastric GIST both in elective and urgent settings. Even for lesions greater than 5 cm, laparoscopy shows a recurrence rate similar to open surgery when radical resection are performed. An important point to take in consideration is surgical team experience, which seems to be one of the most important factors reducing the incidence of operative complications with better long-term outcomes, both postoperative and oncological.

Conclusion

Mini-invasive approaches for gastric GIST are safe and feasible. The combined approach both laparoscopic and endoscopic has shown to be an effective technique and it may allow a better exposure of the tumour which ensure a radical resection.

Small bowel volvulus due to a large intestinal lipoma: A rare case report

INTRODUCTION

A lipoma of the small bowel mesentery is a uncommon clinical entity. It rarely causes obstruction and volvulus of the small bowel.

CASE REPORT

A 63 year old man was admitted to the emergency department with acute abdominal pain. Contrast-enhanced CT abdominal scan revealed small bowel obstruction due to a large fat density lesion suspected to be a lipoma. We performed a laparotomy in urgent setting that confirmed a small bowel volvulus secondary to a large antimesenteric lipoma. En-bloc resection with antiperistaltic side-to-side ileal anastomosis was done.

DISCUSSION

Mesenteric lipoma is rare. They are usually asymptomatic but when have large sizes can cause several symptoms related to small bowel obstruction or volvulus. The diagnosis is difficult and is rarely made prior to exploratory laparoscopy or laparotomy. CT scan is the gold-standard imaging technique. It can shows the typical characteristics of tumor and may demonstrate the typical "vortex" pattern of a volvulus. In patients with acute clinical presentation en-bloc resection of the lipoma with the affected small bowel loops is often necessary. This treatment may also be reserved in asymptomatic patients with large mesenteric lipomas to avoid future complications.

CONCLUSION

Volvulus of the small bowel caused by an antimesenteric lipoma is a very rare entity. It is diagnosed by CT scan and surgery represents the standard treatment.

Postoperative treatment with phytotheraphy Graminex G63 (CERNILEN-Flogo®) after greenlight laser XPS (180W) photovaporization of the prostate (PVP), can affect patient's quality of life?

OBJECTIVE

Phytotherapic treatment as Cernilen-flogo® is commonly used to treat chronic pelvic pain, chronic prostatitis, and BPE (benign prostatic enlargement). In our study, for the first time, we aim to evaluate postoperatively Cernilen-flogo® therapy in patients with BPE/LUTS (lower urinary tract symptoms) previously treated with Greenlight laser XPS (180W) photovaporization of prostate (PVP) to improve surgical outcomes.

MATERIALS AND METHODS

We collected data from patients treated with PVP for BPE/LUTS international prostate symptom score (IPSS) >20 unresponding to conventional treatment. Two groups of patients were analyzed: Group A including 15 patients (50%) treated postoperatively with Cernilen-flogo® vs. no treatment Group B. One expert surgeon performed all the procedures.

RESULTS

30 patients included with BPE/LUTs previously treated with PVP. There was no difference between patients' demographic, median age, prostate volume and PSA (prostate specific antigen) level. All patients had a postoperative evaluation after 30-45 days. Patients with postoperative complications (acute urinary retention, postoperative hematuria) were excluded from our study. All patients had a preoperative and postoperative evaluation of IPSS, bother score (BS) and pelvic discomfort (visual analogic scale VAS). Preoperatively there was no significative difference in IPSS, BS and VAS. IPSS Group A was postoperatively 7.13 (SD 1.64) and Group B was 7.33 (SD 1.58) (p=0.67); BS Group A was postoperatively 1.33 (SD 0.81), Group B was 1.73 (SD 1.09) (p=0.30), and VAS Group A was 2.73 (SD 1.9) and Group B was 4.33 (SD 1.58) (p=0.004) showing a statistically significative difference between the two groups in pelvic discomfort with a better outcome in patients treated with Cernilen-flogo®.

CONCLUSIONS

Our study showed that Cernilen-flogo® treatment after PVP is effective and minimize patient's pelvic discomfort showed by lower VAS level resulting in better postoperatively patient's quality of life (QOL).

Recurrent intussusception of small bowel in a young patient due to metastases from cardiac undifferentiated pleomorphic sarcoma: A first ever case report

INTRODUCTION

Undifferentiated metastatic pleomorphic sarcoma (Malignant Fibrous Histiocytoma) is a rare entity in the small intestine, especially when the primary tumor is of cardiac origin.

CASE REPORT

We report a case of metastatic intestinal undifferentiated pleomorphic sarcoma in a young patient with a history of primary cardiac tumor in the left atrium and recurrent small bowel intussusception. He was admitted for abdominal pain and constipation. A segmental resection of the small intestine was performed with side-to-side entero-enteroic anastomosis.

DISCUSSION

Intussusception of the small bowel is rare in adults and it represents about 1-3% of intestinal obstructions. It mainly affects the fifth decade with a male/female ratio of 1:5 More than 60% of patients with intussusception have a tumor with 50% being malignant. This type of intussusception can be diagnosed on the CT abdominalscan. Radiological features include a typical "target" sign with overdistention of the proximal intestine and air-fluid levels, but the diagnosis of certainty is made by exploratory laparotomy.

CONCLUSION

The metastatic tumors that cause intussusception represent a rare clinical condition in adult patients, but much more common than primary ones. Metastasis to the small intestine are part of differential diagnosis in patient with a history of tumor who present with intussusception.

Ureteral injury during left colectomy for cancer: Laparoscopic management. A case report

INTRODUCTION

Iatrogenic ureteral lesions may occur after any abdominal and pelvic surgery. They are severe and can affect renal function and even vital prognosis. This study aimed to determine the clinical aspects and the therapeutic approaches of a lower third injury of the ureter during a laparoscopic left colectomy.

PRESENTATION OF CASE

An 81 year-old-man with left-sided colon cancer underwent laparoscopic left colectomy. During surgery there was a continuous full-thickness solution of the left ureter for which an end-to-end ureteral anastomosis was performed. In the postoperative period the patient underwent multiple urological and radiological interventional procedures due to the aforementioned injury.

DISCUSSION

Ureteral injury was defined as any laceration, transection or ligation of the ureter that required an unexpected procedure for repair, stent or drainage. It can be managed with several procedures. An appropriate repair should be chosen according to length and position of ureteral injuries. The lower third of the ureter, as the lesion of our patient, has a profuse blood supply resulting in this way less susceptible to ischemia.

CONCLUSION

In the last decade urological surgery, laparoscopy, ureteroscopic procedures and gynecological surgery are the main causes of iatrogenic ureteral lesions. Prognosis is conditioned by early diagnosis and the anatomic condition of the ureter. Laparoscopic end-to-end ureteral anastomosis could be considered a good option in the case of intraoperative iatrogenic lower ureteral injuries.

Small bowel obstruction after laparoscopic gastrectomy: An atypical clinical presentation. Report of a case

INTRODUCTION

Postoperative adhesions represent the most common cause of acute small bowel obstruction (80%) and are usually a consequence of abdomino-pelvic surgery performed with open technique.

PRESENTATION OF CASE

A 45-year-old black man arrived at the emergency room with abdominal pain and distension three months after laparoscopic distal gastrectomy with Roux-en-Y anastomosis performed for benign pyloric stenosis. CT abdominal scan revealed some air-fluid levels in the center of the abdomen with distension of proximal jejunal loops caused by intestinal adhesions. Laparoscopic adhesiolysis was performed to restore the intestinal transit.

DISCUSSION

The formation of adhesions is more frequent after abdomino-pelvic surgery. CT abdominal scan is very useful tool to identify the level and the aetiology of obstruction and it may predict the need for surgery, the location of different adhesive bands in order to identify wich patients are likely candidates for laparoscopic treatment.

CONCLUSION

In selected cases, laparoscopic approach for small bowel obstruction is a good surgical option. In patients with adbominal dense adhesions or clinical signs of intestinal ischemia, conversion to laparotomy should be considered an alternative.

Antibiotic Prophylaxis for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis

Objective

Although thyroid and parathyroid surgery is considered a clean procedure with a low incidence of surgical site infections (SSIs), a great number of endocrine surgeons use antibiotic prophylaxis (AP). The aim of this study was to assess whether AP is significantly effective in reducing the incidence of SSIs in this kind of surgery.

Data Sources

A systematic literature search was performed with PubMed, Scopus, and ISI–Web of Science. Studies addressing the efficacy of AP in reducing the incidence of SSIs in thyroid and parathyroid surgery were included in the systematic review and meta-analysis.

Review Methods

The random effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated.

Results

A total of 6 studies with 4428 patients were included in the quantitative analysis. The incidence of SSI was 0.6% in the case group and 0.4% in the control group (odds ratio, 1.07; 95% CI, 0.3-3.81; P = .915). There was no evidence of heterogeneity among the studies ( Q = 8.36, P = .138; I2 = 40.17). The analysis of several continuous moderators, including age, use of drain, and duration of surgery, did not generate any significant result.

Conclusion

AP is not effective in reducing the incidence of SSI in thyroid and parathyroid surgery and should be avoided, notwithstanding the negative impact on social costs and the risk of development of antibiotic resistance.

Integra® dermal regeneration template for full thickness carcinologic scalp defects: Our 6 years' experience retrospective cohort and literature review

BACKGROUND

The aim of the study is the use of Integra® dermal regeneration template (DRT) in scalp reconstruction after tumor resection by comparing results of literature and Gustave Roussy Institut' series of 20 patients.

MATERIEL AND METHODS

A systematic review, with a PubMed search was performed using the following key words "artificial dermis OR DRT" AND "scalp". Eligible articles were selected to study patients and defects characteristics, operative modalities, and the follow up results. This case series presents the experience of immediate DRT reconstruction after scalp full thickness carcinologic surgery, in the plastic surgery service of Gustave Roussy cancer center.

RESULTS

Twenty patients with primary scalp tumors underwent two steps DRT reconstruction for full thickness scalp defect. The mean surface defect was 72cm². The mean operative combined time was 94min, with a total healing delay of 68 days. All patients successfully recovered. Five patients had minor complications (3 delayed healing and 2 DRT infections) with no need of additional surgery. Fourteen articles, totalizing n=210 patients, were included and reviewed. Reported ages ranged from 58 to 82 years old. Almost all patients were operated for oncologic resections. The mean surface defect was 73cm². The mean follow-up was 15 months. The skin graft taking rates ranged from 95% up to 100%.

CONCLUSION

In large scalp full thickness defects after cancer resection, DRT appears to be a suitable reconstruction option for patients with comorbidities, and aggressive tumors. This technique allows immediate coverage of the calvarium with short operative time and prevents from healing delay. The oncologic follow-up is no disturbed and cancer recurrences are easily diagnosed.

Inguinal Hernia: The Destiny of the Inferior Epigastric Vessels and the Pathogenesis of the Disease

INTRODUCTION

While many scientific reports deal with inguinal hernia, including treatment methods and prosthetic devices proposed to provide a cure, few studies have sought to deepen our understanding of the etiology of this disease. The genesis of inguinal protrusion seems to be a neglected subject, even though addressing hernia genesis may be helpful for improving techniques and materials for surgical treatment. To clarify the source of inguinal protrusions, macroscopic and histological alterations of the inferior epigastric vessels in the herniated groin have been studied. These vascular structures exhibit significant features that could help to illuminate hernia genesis.

MATERIAL AND METHODS

In patients with double ipsilateral inguinal hernia, composed of distinct direct and indirect protrusions, a tissue septum separates the two defects. Macroscopic observation and histological examination of this septal arrangement were carried out in 23 patients to highlight characteristics of the inferior epigastric vessels in the posterior aspect of this anatomical area.

RESULTS

The examined inferior epigastric vessels presented notable alterations of the gross anatomy and histologically significant damage, with a typical trait of chronic compressive damage. All degrees of degeneration were observed, including complete disbanding of the vascular structure.

CONCLUSIONS

In pantaloon hernias, excised inferior epigastric vessels suffered from chronic compressive degeneration but had no contact with the protrusions. Therefore, protrusion expansion does not produce the degenerative injuries seen in the epigastric vessels. In the inguinal area, there is no source of chronic compression except visceral impact. Consequently, orthostatic visceral impact could be hypothesized to cause structural weakening of the groin, leading to tissue disbanding and visceral protrusion through the weakened inguinal floor.

Single-center experience with partial support device in destination therapy for end-stage heart failure

Ventricular assist devices (VADs) are considered the standard of care for end-stage heart failure (HF) patients. Despite increasing confidence in the technology, evidence data, endorsement by scientific societies and guidelines, the number of implants reached a steady state and is not increasing at the expected pace. This is most likely related to complications that are still burdening the technology and consequently excluding the most needy, ill, and fragile population. In this manuscript we are reporting a single-center experience in a very fragile, elderly and end-stage HF population, with a superficial, partial support device: the CircuLite Synergy. The patients were included in the pre-CE mark clinical study and consequently the device underwent technical adjustment during the support, based on the complications recorded. At our institution were implanted 6 patients overall: 3 patients survived to discharge and 2 survived up to 5 years. Most of the complications recorded were due to patients' frailty and overall clinical conditions. The initial experience with the CircuLite Synergy device is proving that a more "superficial" device might be more tolerable in an elderly, frail population. Partial support has proven hemodynamically efficacious and efficient in relieving heart failure symptoms, improving medical therapy tolerability, and improving quality of life. Unfortunately, the technology was not made available due to financial uncertainty and poor management, but we hope that once the concept has been proved someone will collect the legacy.

Laparoscopic management of cholecystocolonic fistula: A case report and a brief literature review

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Cholecystoenteric fistula is a rare and late complication of cholelithiasis.

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We report a case of cholecysto-colonic fistula with hepatic flexure management by laparoscopic approach, a 64 years old male patients with fever of an unknown origins for two months and abdominal pain.

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We performed laparoscopic cholecystectomy and repaired colonic wall with intra-corporeal sutures.

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The laparoscopic management of cholecystoeneteric fistula is a feasible and safe procedure but the operative strategy should be individualized.

Introduction

Cholecystoenteric fistula is a rare and late complication of cholelithiasis. The clinical presentation is mostly chronic and is not distinguishable from the dyspeptic symptoms of non-complicated cholelithiasis. For this reason, the preoperative diagnosis is difficult and uncertain, and it is often made up primarily intraoperatively and incidentally during cholecystectomy. In this article, we report a case of cholecystocolonic fistula management by laparoscopic approach.

Presentation of case

We studied a 64 years old male patient with fever of an unknown origin for two months and abdominal pain. He underwent a contrast enhanced CT abdominal scan that showed a sclerotic gallbladder with a disorganized fluid collection. The colonoscopy identified a cholecystocolonic fistula with hepatic flexure. A laparoscopic cholecystectomy was performed to repair the colonic wall with intra-corporeal sutures.

Discussion

Thanks to the advancements in CT scan’s resolution and the application of endoscopic technology such as ERCP or colonscopy, preoperative diagnosis of cholecystoenteric fistula has been greatly improved. In addition, cholecystoenteric fistula has been successfully managed laparoscopically with laparoscopic cholecystectomy and closure of the fistula tract.

Conclusion

The laparoscopic management of cholecystoeneteric fistula is a feasible and safe procedure but the operative strategy should be individualized on diagnosis, patient characteristics, availability of resources and experience of surgical team.

Influence of stomach mucosa tissue on the efficacy of intragastric antibacterial PDT

In the field of photodynamic therapy (PDT), optimization of the in vivo therapeutic efficacy needs a comprehensive study of the photo-killing action spectrum that depends on both the photosensitizer (PS) absorption and the tissue optical properties. This is especially true in the case of gastric infections by Helicobacter pylori: PS absorption has been largely investigated in vitro, while the contribution of tissue optical properties and illumination geometry has been poorly studied, despite being parameters that reflect the specific in vivo conditions. To investigate their influence, we focussed on the case of a point-like light source positioned in the antrum. This models a therapeutic device developed by our team which consists of a LED-based ingestible pill. By a simple 3D illumination model, our approach mediates light-tissue interaction over the illuminated stomach wall surface, then calculates its average transmittance T by means of a 1D model representative of the mean gastric mucosa structure. Finally, by merging T(λ) with the photosensitizers' absorption we obtained the in vivo action spectrum. This shows two peaks at about 500 and 630 nm, indicating a noticeable influence of the tissue with respect to in vitro studies, where the action spectrum reflects PS absorption only. Our approach defines one average action spectrum for this specific therapeutic context, which reflects the need to choose one emission spectrum for the light source used. The proposed methodology could be applied to any other illumination geometry of cave organs, provided appropriate model modifications for the light source and tissue characteristics are made.

[Anomalous origin of the right coronary artery from the pulmonary artery or coronary artery fistula: when the diagnosis is uncertain]

The anomalous origin of the right coronary artery from the pulmonary artery is a rare congenital coronary anomaly with a reported incidence of approximately 0.002%. Usually, the diagnosis is made by echocardiography leaving computed tomography or angiography only to diagnostic completion in doubtful cases or for interventional procedures.Herein we report a doubtful case of a patient with a diagnosis of coronary fistula between the right coronary and the pulmonary artery that proved to be an anomalous origin of the coronary artery from the pulmonary artery. The patient underwent corrective surgery with translocation of the coronary artery on the aorta.

Improving the operational skills of the health personnel working in the emergency departments

Key messages

There is a huge difference regarding the way in which the emergency system is organized within single countries around Europe. Comparing high-level organisations we have benefited in terms of ideas, projects and potential objectives to be set in order to improve our work and to improve results for patients.