Aspiration versus peritoneal lavage in appendicitis: a meta-analysis

BACKGROUND

Acute appendicitis is one of the most frequent abdominal surgical emergencies. Intra-abdominal abscess is a frequent post-operative complication. The aim of this meta-analysis was to compare peritoneal irrigation and suction versus suction only when performing appendectomy for complicated appendicitis.

METHODS

According to PRISMA guidelines, a systematic review was conducted and registered into the Prospero register (CRD42020186848). The risk of bias was defined to be from low to moderate.

RESULTS

Seventeen studies (9 RCTs and 8 CCTs) were selected, including 5315 patients. There was no statistical significance in post-operative intra-abdominal abscess in open (RR 1.27, 95% CI 0.75-2.15; I2 = 74%) and laparoscopic group (RR 1.51, 95% CI 0.73-3.13; I2 = 83%). No statistical significance in reoperation rate in open (RR 1.27, 95% CI 0.04-2.49; I2 = 18%) and laparoscopic group (RR 1.42, 95% CI 0.64-2.49; I2 = 18%). In both open and laparoscopic groups, operative time was lower in the suction group (RR 7.13, 95% CI 3.14-11.12); no statistical significance was found for hospital stay (MD - 0.39, 95% CI - 1.07 to 0.30; I2 = 91%) and the rate of wound infection (MD 1.16, 95% CI 0.56-2.38; I2 = 71%).

CONCLUSIONS

This systematic review has failed to demonstrate the statistical superiority of employing intra-operative peritoneal irrigation and suction over suction-only to reduce the rate of post-operative complications after appendectomy, but all the articles report clinical superiority in terms of post-operative abscess, wound infection and operative times in suction-only group.

The measurement of amylase in drain fluid for the detection of pancreatic fistula after gastric cancer surgery: an interim analysis

Background

Pancreatic fistula is still one of the most serious and potential complications after D2-D3 distal and total gastrectomy (4% to 6%). Despite their importance, pancreatic fistulas still have not been uniformly defined. Amylase concentration of the drainage fluid after surgery for gastric cancer can be considered as a predictive factor of the presence of pancreatic fistula.

Methods

From January 2009 to April 2013, 53 patients underwent surgery for gastric cancer. Amylase concentration in the drainage fluid was measured on the first postoperative day and if it was ≥1,000 UI, it was measured again on the third postoperative day. Pancreatic fistula occurred in four cases (7.5%). Pancreatic fistulas were classified using the International Study Group on Pancreatic Fistula (ISGPF) criteria into different grades of severity. Two fistulas were Grade A, one was Grade B, and one was Grade C.

Results

Management of drainage tubes is still crucial after gastrectomy, not only for the likelihood of anastomotic leaks but also the eventual diagnosis and management of pancreatic fistula. High amylase drainage content and then the presence of the pancreatic fistula may be due to several causes: the operation itself when it includes splenectomy or pancreatic tail-splenectomy, the extended lymphadenectomy but even the ‘gently and softly’ pancreatic manipulation, according literature, may be a risk factor.

Conclusions

The authors assessed amylase concentration in the drainage fluid collected from the left subphrenic cavity on POD1 and POD3 in 53 patients who had undergone curative gastrectomy for cancer and concluded that amylase drainage content >3 times the serum amylase was a useful predictive risk factor for pancreatic fistula. Our work is an interim analysis and the aim of this study is to increase the accrual of the number of patients to have a significant number. For this reason, a protocol for a multicenter trial will be designed to verify whether the systematic measurement of amylase in drain fluid is better than abdominal ultrasound for the detection of pancreatic fistula after gastric cancer surgery.

Case of fake acute abdomen by metastatic melanoma

Malignant melanoma is the neoplasm with highest probability of cardiac metastatization. Cardiac involvement by metastatic melanoma is rarely identified ante-mortem (5-30% of cases) for non-specificity of cardiac symptoms. In fact we show in this case report that abdominal pain can represent the predominant symptom. Furthermore we show the importance of linkage between clinical & anamnestic data which if underestimated can lead to an improper management and to the patient exitus.

Synchronous colorectal neoplasias: our experience about laparoscopic-TEM combined treatment

Synchronous colorectal neoplasias are defined as 2 or more primary tumors identified in the same patient and at the same time. The most voluminous synchronous cancer is called "first primitive" or "index" cancer. The aim of this work is to describe our experience of minimally invasive approach in patients with synchronous colorectal neoplasias.Since January 2001 till December 2009, 557 patients underwent colectomy for colorectal cancer at the Department of General and Emergency Surgery of the University of Perugia; 128 were right colon cancers, 195 were left colon cancers while 234 patients were affected by rectal cancers. We performed 224 laparoscopic colectomies (112 right, 67 left colectomies and 45 anterior resections of rectum), 91 Transanal Endoscopic Microsurgical Excisions (TEM) and 53 Trans Anal Excisions (TAE). In the same observation period 6 patients, 4 males and 2 females, were diagnosed with synchronous colorectal neoplasias. Minimal invasive treatment of colorectal cancer offers the opportunity to treat two different neoplastic lesions at the same time, with a shorter post-operative hospitalization and minor complications. According to our experience, laparoscopy and TEM may ease the treatment of synchronous diseases with a lower morbidity rate.

[The sentinel lymph node mapping in colon cancer]

BACKGROUND

malignant tumors of the colon can metastases along the lymphatic system in a sequential way, which means that there will be a first node to be involved and then from this disease will pass to another node and so gradually. The sentinel lymph node is the first lymph node or group of nodes reached by metastasizing cancer cells from a tumor.

OBJECTIVES

the present work aims to determine the predictive value of the sentinel lymph node procedure in the staging of non-metastatic colon cancer.

PATIENTS AND METHODS

in this prospective study joined up only 26 patients with adenocarcinoma of the colon T2-T3, without systemic metastases, and with these criteria for inclusion: a) minimum age: 18 years old; b) staging by total colonoscopy, chest X-ray and CT scan; c) patients classified as ASA 1-3; d) informed consent. Within 20 minutes from the colic resection, the bowel was cut completely along the antimesenteric margin and is performed submucosal injection of vital dye within 5 mm from the lesion at the level of the four cardinal points; then the lymph nodes are placed in formalin and sent to the pathologist. The lymph nodes were subjected to histological examination with haematoxylin-eosin and with the immunohistochemistry technique.

RESULTS

from January to December 2008 only 26 patients joined up in this prospective study. From the study were excluded the 4 patients with T4 and M1 tumour. Also 7 patients with stenotic lesions were excluded. Patients considered eligible for our study were only 14. The histopathological examination of haematoxylin-eosin revealed: a) in 4 cases were detected mesocolic lymph node metastases; b) in 10 cases were not detected mesocolic lymph node metastases. In cases there were no metastases, the mesocolic sentinel lymph nodes lymph nodes were examined with immunohistochemical technique; in 2 cases were revealed the presence of micrometastases. In one case was identified aberrant lymphatic drainage patterns (skip metastasis); the sentinel lymph node (negative examination wit eaematoxylin-eosin) was studied with immunohistochemical technique that has not revealed the presence of micrometastases.

CONCLUSIONS

the examination of the sentinel node is feasible with the ex vivo method. Using the immunohistochemical technique we detect micrometastasis in 20% of the cases, not revealed with the classical haematoxylin-eosin examination. The study of sentinel lymph node with multilevel microsections and immunohistochemical techniques allow a better histopathological staging.

[Presacral myelolipoma: a case report]

BACKGROUND

Presacral tumors are more frequently benign, and only occasionally malignant, showing a slow growth and an incidence of 1:40.000. They are asymptomatic in the 26-50% of the cases. When symptoms occur, these are related to the dimensions of the tumor, to its location and to the presence of infection.

CASE REPORT

We report the case of a 69-year old woman with a lower abdominal pain associated with paresthesia and ipostenia of the right inferior limb. Digital rectal examination showed a fixed, mild tender and hard tumor of the posterior rectal wall. CT, MR and CT-guided biopsy sequently performed revealed a solid, dishomogeneous mass, located in the presacral region, with a connective likely origin, without pelvic lymphoadenopathy. The operation allowed to esteem a mass which was tenaciously adherent to the sacrum. We performed a total excision. Final histological diagnosis was myelolipoma.

CONCLUSIONS

The Authors' opinion is that the en-bloc resection of these tumors with an anterior surgical approach allows a histological diagnosis of the nature, representing the best treatment for potentially malignant lesions, which are frequently radio and chemo-resistant.

Meta-analysis of fibrin glue versus surgery for treatment of fistula-in-ano

AIM

To evaluate the convenience in terms of recurrence and fecal incontinence rates of fibrin glue versus surgical treatment in the management of fistula-in-ano.

MATERIALS AND METHODS

Randomized controlled trials (RCTs) and non-randomized studies (CCTs) comparing conventional surgical treatment versus fibrin glue treatment in patients with perianal fistulae were identified using a predefined search strategy. The post treatment anal incontinence rate and the fistula recurrence rates between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions. The lack of homogeneity of results between the different studies did not allow to analyze other secondary outcomes. Patients with cryptoglandular and Crohn's anal fistula were enrolled in the analysis. The employed fibrin glue came from commercial kits: Beriplast (Aventis Behring, Sussex, United Kingdom) and Tisseal or Tissucol (Baxter, Inc, Mississauga, Ontario). Surgical conventional treatment consisted of fistulotomy, placement of a cutting or loose latex seton and advancement mucosal flap closure. All patients were followed up at 6 and 12 weeks, the longest follow up was 6 months.

RESULTS

Two RCTs (106 patients) and 1 non randomized studies (232 patients) were identified. The recurrence rate is higher, although still not statistically significant, in those patients who underwent fibrin glue injection (44/81) versus conventional surgical treatment (108/230), (OR: 0.44; 95 %CI: 0.12-1.68; P = 0.23). Furthermore in the analysis of the subgroup of RCTs alone there were not significant differences with the previous results of RCTs with CCT analysis (OR: 0.33; 95 %CI: 0.03-3.66; P = 0.37). In the same way the analysis of the subgroup of RCTs with complex anal fistulae were not statistically significant and similar to the previous results regarding all type of fistulas (OR: 0.86; 95 %CI: 0.01-72.36; P = 0.95). The analysis of post-operative anal incontinence showed no difference between the group who underwent fibrin glue injection (9/230) and the conventional surgical treatment group (10/81), (OR: 1.00; 95 %CI: 0.43-2.34; P = 1.00). A very low heterogeneity in the analysis was detected (Chi-square = 0.04 - P = 0%).

CONCLUSION

Our statistical analysis does not show any significant statistical difference between fibrin glue treatment versus conventional surgical treatment for all perianal fistulae in terms of recurrence (P = 0.23) and anal incontinence (P = 1.00).

Fibrin glue in the treatment of anal fistula: a systematic review

Background

New sphincter-saving approaches have been applied in the treatment of perianal fistula in order to avoid the risk of fecal incontinence. Among them, the fibrin glue technique is popular because of its simplicity and repeatability. The aim of this review is to compare the fibrin glue application to surgery alone, considering the healing and complication rates.

Methods

We performed a systematic review searching for published randomized and controlled clinical trials without any language restriction by using electronic databases. All these studies were assessed as to whether they compared conventional surgical treatment versus fibrin glue treatment in patients with anal fistulas, in order to establish both the efficacy and safety of each treatment. We used Review Manager 5 to conduct the review.

Results

The healing rate is higher in those patients who underwent the conventional surgical treatment (P = 0,68), although the treatment with fibrin glue gives no evidence of anal incontinence (P = 0,08). Furthermore two subgroup analyses were performed: fibrin glue in combination with intra-adhesive antibiotics versus fibrin glue alone and anal fistula plug versus fibrin glue. In the first subgroup there were not differences in healing (P = 0,65). Whereas in the second subgroup analysis the healing rate is statistically significant for the patients who underwent the anal fistula plug treatment instead of the fibrin glue treatment (P = 0,02).

Conclusion

In literature there are only two randomized controlled trials comparing the conventional surgical management versus the fibrin glue treatment in patients with anal fistulas. Although from our statistical analysis we cannot find any statistically significant result, the healing rate remains higher in patients who underwent the conventional surgical treatment (P = 0,68), and the anal incontinence rate is very low in the fibrin glue treatment group (P = 0,08). Anyway the limited collected data do not support the use of fibrin glue. Moreover, in our subgroup analysis the use of fibrin glue in combination with intra-adhesive antibiotics does not improve the healing rate (P = 0.65), whereas the anal fistula plug treatment compared to the fibrin glue treatment shows good results (P = 0,02), although the poor number of patients treated does not lead to any statistically evident conclusion. This systematic review underlines the need of new RCTs upon this issue.

Virtual colonoscopy in stenosing colorectal cancer

BACKGROUND

Between 5 and 10% of the patients undergoing a colonoscopy cannot have a complete procedure mainly due to stenosing neoplastic lesion of rectum or distal colon. Nevertheless the elective surgical treatment concerning the stenosis is to be performed after the pre-operative assessment of the colonic segments upstream the cancer. The aim of this study is to illustrate our experience with the Computed Tomographic Colonography (CTC) for the pre-operative assessment of the entire colon in the patients with stenosing colorectal cancers.

METHODS

From January 2005 till March 2009, we observed and treated surgically 43 patients with stenosing colorectal neoplastic lesions. All patients did not tolerate the pre-operative colonoscopy. For this reason they underwent a pre-operative CTC in order to have a complete assessment of the entire colon. All patients underwent a follow-up colonoscopy 3 months after the surgical treatment. The CTC results were compared with both macroscopic examination of the specimen and the follow-up coloscopy.

RESULTS

The pre-operative CTC showed four synchronous lesions in four patients (9.3% of the cases). The macroscopic examination of the specimen revealed three small sessile polyps (3-4 mm in diameter) missed in the pre-operative assessment near the stenosing colorectal cancer. The follow-up colonoscopy showed four additional sessile polyps with a diameter between 3-11 mm in three patients. Our experience shows that CTC has a sensitivity of 83,7%.

CONCLUSION

In patients with stenosing colonic lesions, CTC allows to assess the entire colon pre-operatively avoiding the need of an intraoperative colonoscopy. More synchronous lesions are detected and treated at the time of the elective surgery for the stenosing cancer avoiding further surgery later on.

[Abdominal compartimental syndrome as a complica-tion of Fournier's gangrene]

Analyzing a complex case and referring to the literature, the authors describe abdominal compartmental syndrome as a complication of Fournier's gangrene, stressing out the importance of an early diagnosis to perform prompt and effective treatment. The characteristic of this case is not represented only by the Fournier's gangrene rarity, but also by the appearance of an abdominal compartmental syndrome due to the gangrene extension from the scrotum to the abdominal wall and cavity through the spermatic funiculus. The treatment of the abdominal compartmental syndrome was the surgical toilette of the necrotic regions (scrotum, abdominal wall and cavity) together with an orchiectomy.

An unusual case of rectal carcinoid removed by transanal endoscopic microsurgery

The name ''carcinoid'' was invented by Oberndorfer in 1907, when the nature of those histological entities was little understood. Usually, they were found in various locations in the gastrointestinal (GI) apparatus (67%), most of them in the small intestine (25%), appendix (12%), and rectum (14%).The techniques used for their removal are various. The authors present here a case of rectal carcinoid removed using the transanal endoscopic microsurgery technique, and referred to the diagnosis and treatment of this uncommon tumor. A 37-year-old male was admitted to the Santa Maria Hospital of Terni (Italy) with a chief complaint of intermittent pain in the lower right quadrant, that began three years ago. Complete blood count (CBC) and laboratory data as tumor markers and urinary 5-hydroxyindoleacetic acid (5-HIAA) showed no abnormalities, while urinary vanilmandelic acid level was elevate (18 mg/24 h). The patient was submitted to a colonoscopy with magnifying endoscopy and biopsy. The histological finding demonstrated a nodule characterized by cellular proliferation, with few microscopical abnormalities, arranged in small cords with a glandular pattern, separated by dense connective tissue. Histochemically the tumor cells were cytocheratins +/-, chromogranin positive, synaptophysine positive, CD56 positive and Growth Index MIB1-Ki67 which was almost zero. The patient also underwent an endoscopic ultrasonography and an Octreoscan. He was operated using a transanal endoscopic microsurgery technique. The use of Transanal Endoscopic Microsurgery (TEM) as a safe and feasible technique for exciding rectal tumors can be easily understood, for the excellent view and precise dissection. The use of new surgical devices as Harmonic Scalpel has improved the precision of this kind of approach, increasing the appropriateness of this approach compared to other kind of resection. A full diagnostic course and an immunohistochemistry are mandatory for precise diagnosis of rectal carcinoid. Careful attention must be paid to these tumors because of their unexpected behaviour.

[Minimally invasive treatment of synchronous colorectal tumours]

In patients with colorectal cancers synchronous neoplastic lesions are an increasingly frequent finding at preoperative staging; 3% of the cases are other cancers while 33-35% of the synchronous lesions are villous adenomas. The treatment of most colorectal adenomas can be performed by endoscopic poplypectomy. In 5% of cases there are synchronous colorectal lesions also requiring surgical treatment. From January 1995 to June 2007 we treated 5 patients with rectal lesions by transanal endoscopic microsurgery (TEM) together with a laparoscopic colectomy for the presence of synchronous lesions at the "Clinica Chirurgica Generale e d'Urgenza" of the University of Perugia,. Surgical timing involved performing a sequential exeresis characterised by a cancer resection, followed by resection of the voluminous adenoma: TEM for rectal cancer followed by a laparoscopic right hemicolectomy with an extracorporeal anastomosis for a voluminous villous adenoma (1 patient) and laparoscopic right hemicolectomy with an extracorporeal anastomosis for cancer followed by TEM for a voluminous villous adenoma (2 patients). One patient with left colon cancer associated with a voluminous villous rectal adenoma first underwent TEM for the rectal adenoma and then a left laparoscopic hemicolectomy with an extracorporeal anastomosis in order to ease the transit of the circular mechanical stapler. Another patient with rectal and right colon adenomas first underwent TEM for a voluminous rectal sessile adenoma and later a right hemicolectomy. The use of this minimally invasive approach allowed rectum preservation and less invasive surgery.

[Virtual colonoscopy in stenosing colorectal cancer]

In 5-10% of patients it is not possible to achieve a complete endoscopic examination of the colon, because of obstructing cancer, excessive length of the colon, anatomical abnormalities or adhesions. Virtual colonoscopy is currently capable of investigating the colic lumen with a non-invasive technique, with high specificity and sensitivity. From January 2005 to July 2007 we treated 21 patients with obstructing neoplastic colorectal lesions, preventing a complete endoscopic examination. In all patients we performed a virtual colonoscopy, which revealed the presence of synchronous lesions (19%): a pedunculated polyp in two cases, a sessile polyp in one case and a right colonic vegetating lesion. In the 21 patients studied we performed a follow-up colonoscopy 3 months after the surgical treatment. No other endoluminal lesions were found, confirming the results of virtual colonoscopy. In our experience virtual colonoscopy presented 100% sensitivity and specificity. In this selected group of patients with obstructing lesions of the colon, virtual colonoscopy enables the surgeon to evaluate the entire colon, avoiding the execution of an intraoperative colonoscopy and possible surgical reintervention due to the finding of synchronous neoplastic lesions at postoperative follow-up endoscopy.

[Torsion of uterine fibroma associated with incarcerated inguinal hernia in pregnancy. Case report]

The incidence of inguinal hernias in pregnancy is 1:1000 about. Much more frequent are uterine leiomyomas, reported in 0.5-2.6% cases. We describe a rare case of a 31 old woman at the 20th week of pregnancy affected with a torsion of uterine leiomyoma associated with right inguinal incarcerated hernia, operated urgently (myomectomy and Bassini inguinal plastic).

[Locoregional complications of stomas. Therapeutic approach]

Principal local complications of ostomies are examined. Etiologic factors and possibilities of treatment are analyzed. These pathologies are often extremely troublesome and their resolution very difficult, unless appropriate therapy is established and, when possible, causal factors removed. However, because of the particular problems of these patients it would be better for them to be assisted by a specialized staff, in qualified centers.