Laparoscopic appendectomy with single port vs conventional access: systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Conventional three-access laparoscopic appendectomy (CLA) is currently the gold standard treatment, however, Single-Port Laparoscopic Appendectomy (SILA) has been proposed as an alternative. The aim of this systematic review/meta-analysis was to evaluate safety and efficacy of SILA compared with conventional approach.

METHODS

Per PRISMA guidelines, we systematically reviewed randomised controlled trials (RCTs) comparing CLA vs SILA for acute appendicitis. The randomised Mantel-Haenszel method was used for the meta-analysis. Statistical data analysis was performed with the Review Manager software and the risk of bias was assessed with the Cochrane "Risk of Bias" assessment tool.

RESULTS

Twenty-one studies (RCTs) were selected (2646 patients). The operative time was significantly longer in the SILA group (MD = 7,32), confirmed in both paediatric (MD = 9,80), (Q = 1,47) and adult subgroups (MD = 5,92), (Q = 55,85). Overall postoperative morbidity was higher in patients who underwent SILA, but the result was not statistically significant. In SILA group were assessed shorter hospital stays, fewer wound infections and higher conversion rate, but the results were not statistically significant. Meta-analysis was not performed about cosmetics of skin scars and postoperative pain because different scales were used in each study.

CONCLUSIONS

This analysis show that SILA, although associated with fewer postoperative wound infection, has a significantly longer operative time. Furthermore, the risk of postoperative general complications is still present. Further studies will be required to analyse outcomes related to postoperative pain and the cosmetics of the surgical scar.

Management of Acute Cholecystitis in High-Risk Patients: Percutaneous Gallbladder Drainage as a Definitive Treatment vs. Emergency Cholecystectomy-Systematic Review and Meta-Analysis

BACKGROUND

This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a definitive treatment in high-risk patients with acute cholecystitis (AC).

MATERIAL AND METHODS

A systematic literature search was performed until December 2022 using the Scopus, Medline/PubMed and Web of Science databases.

RESULTS

Seventeen studies have been included with a total of 783,672 patients (32,634 treated with PTGBD vs. 4663 who underwent laparoscopic cholecystectomy, 343 who had open cholecystectomy and 746,032 who had some form of cholecystectomy, but without laparoscopic or open approach being specified). An analysis of the results shows that PTGBD, despite being less invasive, is not associated with lower morbidity with respect to EC (RR 0.77 95% CI [0.44 to 1.34]; I2 = 99%; p = 0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) with respect to the PTGBD group (13.78%) (RR 4.21; 95% CI [2.69 to 6.58]; p < 0.00001); furthermore, the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I2 = 48%; p < 0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; p < 0.00001) were lower in the EC group.

CONCLUSIONS

In our systematic review, the majority of studies have very low-quality evidence and more RCTs are needed; furthermore, PTGBD is inferior in the treatment of AC in high-risk patients. The definition of high-risk patients is important in interpreting the results, but the methods of assessment and definitions differ between studies. The results of our systematic review and meta-analysis failed to demonstrate any advantage of using PTGBD over ER as a definitive treatment of AC in critically ill patients, which suggests that EC should be considered as the treatment of choice even in very high-risk patients. Most likely, the inferiority of PTGBD versus early LC for high-risk patients is related to an association of various patient-side factor conditions and the severity of acute cholecystitis.

Clinical Experience on Eight Cases of Merkel Cell Carcinoma

Merkel cell carcinoma is a rare neuroendocrine neoplasm of the skin. The tumor most frequently affects elderly patients, with a preference for the head and neck. Eight patients affected by Merkel cell carcinoma have been observed at the General Surgery Unit II of the “Istituti Ospitalieri” hospital in Cremona, each in different stages of the disease; 75% of the cases involved the extremities, and in nearly all of the cases the tumor was nodular in appearance, with an average diameter of 2.2 cm. In 2 cases, the tumor was associated with rheumatoid arthritis, suggesting a dependency on the part of the neoplasm on the immune disorder and on steroid treatment. The available data confirm that in stage I of the disease, surgical treatment should be associated with radiotherapy in order to control the development of local relapses or metastases over time. In this stage, we observed a survival of 34 months (range, 24-48). In stages II and III, survival time falls, with very short duration of responses and poor quality of life as a result of the administration of cytotoxic molecules. Bearing in mind that any local relapse tends to appear within 12 months of the removal of the primitive tumor, that lymph node metastases appear in almost half of the patients, and that metastases over time are manifested in over a third of patients, it is essential to adopt a treatment capable of balancing the demand for longer remissions with a better quality of life. In this situation, we observed that treatment with somatostatin analogues achieves interesting responses without side effects, which suggests a close biological relationship between the tumor and somatostatin and that making a careful assessment of the prognostic factors of the disease can guarantee a correct therapeutic choice.

A Pilot Phase ii Study of Chemotherapy with Oxaliplatin, Folinic acid, 5-Fluorouracil and Irinotecan in Metastatic Gastric Cancer

Aims and background

Previous phase II studies have reported that combinations of oxaliplatin, folinic acid and 5-fluorouracil or irinotecan, folinic acid and 5-fluorouracil are associated with good efficacy and an acceptable safety profile in metastatic gastric cancer. The aim of this study was to evaluate chemotherapy with oxaliplatin, folinic acid, 5-fluorouracil and irinotecan (COFFI regimen) in metastatic gastric cancer.

Methods

Patients received oxaliplatin (85 mg/m2 d 1), irinotecan (140 mg/m2 d 1), and L-folinic acid (200 mg/m2 d 1) followed by 5-fluorouracil bolus (400 mg/m2 d 1) and then 5-fluorouracil (2,400 mg/m2 48-h continuous infusion), every 14 days.

Results

Seventeen patients with metastatic gastric cancer were enrolled. Eight patients were pretreated for advanced disease. Of the 9 chemo-naïve patients, 8 were evaluated for response (1 patient was lost to follow-up): one complete response, 5 partial responses and 2 progressions of disease occurred, giving an overall response rate, at intention-to-treat analysis, of 67%. Of the 8 pretreated patients, 6 were evaluated for response (2 patients had nonmeasurable disease): one partial response, 2 disease stabilizations and 3 progressions of disease occurred, giving an overall response rate, at intention-to-treat analysis, of 12%. Median progression-free and overall survival in chemo-naïve patients were 8.2 and 10.2 months, respectively, and in pretreated patients 2.7 and 3 months. Grade 3-4 neutropenia occurred in 55% of chemo-naïve patients. Thrombocytopenia, and anemia were observed in 18% and 29%, respectively. Grade 3 nausea/vomiting occurred in 12% and grade 3 diarrhea in 6%.

Conclusions

The COFFI regimen is active and well tolerated, therefore phase III studies are warranted.

Dose-dense Chemotherapy in Metastatic Gastric Cancer with a Modified Docetaxel-Cisplatin-5-Fluorouracil Regimen

Aims and background

Previous studies have reported that in early breast cancer, lymphomas and advanced bladder cancer, dose-dense chemotherapy may be more effective than conventional treatments. In metastatic gastric cancer, chemotherapy with docetaxel, cisplatin and 5-fluorouracil (TCF) q3w is very active, and, even though there is no international consensus on the subject, it is the regimen of choice of many European centers as first-line chemotherapy in this subset of patients. Based on these studies, we tested for the first time the feasibility and activity of an intensified dose-dense TCF regimen (q2w) modifying the 5-fluorouracil infusion with l-folinic acid/5-fluorouracil according to the “De Gramont regimen”.

Methods and study design

Patients with histologically confirmed measurable metastatic gastric cancer, ECOG performance status ≤1, and not previously treated for advanced disease received docetaxel, 85 mg/m2 (75 mg/m2 after the first 6 patients, 70 mg/m2 after the 19th patient) on day 1, cisplatin, 75 mg/m2 on day 1 (60 mg/m2 after the 19th patient), l-folinic acid, 100 mg/m2 on days 1 and 2, followed by 5-fluorouracil, 400 mg/m2 bolus on days 1 and 2 and then 600 mg/m2 as a 22-h continuous infusion on days 1 and 2, every 14 days, plus pegfilgrastim, 6 mg on day 3. Patients aged ≥65 years received the same schedule with a dose reduction of 30%.

Results

Thirty-two consecutive patients were enrolled (63% male, 37% female); median age, 64 years (range, 40–81). A median of 4 cycles (range, 1–7) per patient was administered. Eleven of 32 patients (34%) required a dose reduction, mostly for hematological grade III-IV toxicity and severe asthenia. Twelve patients (38%) completed the first 4 cycles of therapy within 7 weeks, thereby finishing without delay the initially planned dose-density schedule. Twenty-eight patients were evaluated for response (1 early suspension after the first cycle because of toxicity, 3 deaths before response evaluation due to progression of disease). There were 3 complete responses (9%), 15 partial responses (47%), 7 stable disease (22%) and 3 progression of disease (9%), for an overall response rate, by intention to treat, of 56% (95% CI, 39–73). The most frequent grade 3–4 toxicities were: neutropenia (53%), thrombocytopenia (34%), anemia (16%) febrile neutropenia (22%), asthenia (38%) and diarrhea (19%). Median time to progression was 9.1 months (95% CI, 6.0–12.2); median overall survival was 10.1 months (95% CI, 8.8–12.2).

Conclusions

A dose-dense TCF regimen in metastatic gastric cancer is feasible, with activity comparable to previous results achieved with epirubicin-based chemotherapy and TCF q3wk in terms of overall survival and time to progression, and deserves to be further tested in randomized phase III studies.

[Endometriosis of the caecum and ileo-caecal valve. A case report and review of the literature]

Endometriosis is a non-cancerous disorder characterised by development of endometrial epithelium outside the uterus, in which involvement of the gastrointestinal tract is most common. The most frequent site is the rectosigmoid colon (72%), whereas the caecum is involved in 4% of cases. Endometriosis may present with abdominal pain, constipation, and sometimes intestinal bleeding. The treatment of the disease is surgical when medical therapy fails and in cases of surgical urgency. We report the case of a patient with bowel obstruction due endometriosis of the caecum and ileo-caecal valve in association with metrorrhagia. A segmentectomy of the right colon was performed. Since endometriosis is more frequent on the left side of the pelvis probably due to regurgitated endometrial cells, the case observed is not very frequent and is worth reporting.

Non-tunneled central venous catheters in adult stem cell transplantation recipients: An effective option

Stem cell transplantation (SCT) recipients require central venous catheter (CVC) insertion for the administration of chemotherapy, antibiotics and total parenteral nutrition. Traditionally, tunneled CVC have been considered as the golden standard although they require surgery for both insertion and removal. We prospectively evaluated the use of a non-tunneled CVC in 182 consecutive patients who had undergone allogenic or autologous SCT. The median duration of CVC was 4 weeks (range 1-24) with a significant difference between allogenic (8 weeks, range 2-24) and autologous SCT (4 weeks, range 1-24) (p<0.0001). The life expectancy of the CVC was significantly influenced by spontaneous removal, which occurred in 26 patients (13.8%). There was a significant increase of this complication in allogenic SCT (p=0.039). The overall incidence of sepsis was 24.5%, although catheter-related sepsis was microbiologically documented by positive culture of the tip only in 17 cases (9%). Non-tunneled CVC in adult SCT recipients allowed (a) bedside insertion and removal, (b) guidewire replacement for diagnostic or therapeutic purposes (dialysis or pheresis procedures) thus reducing the need for repeated venipunctures. (The Journal of Vascular Access 2001; 2: 168-174).

Dose-dense chemotherapy (CT) with modified TCF regimen (TCF-DD) in metastatic gastric cancer (MGC): A Phase II study

15068

Background: Previous studies reported that in lymphomas, early breast and bladder cancer, dose-dense CT is more effective than conventional treatment. We reported for the first time, in 2006 ASCO meeting, the feasibility of an intensified dose-dense TCF regimen (q2w) in MGC. This is the subsequent phase II study. Methods: patients (pts) with histologically confirmed measurable MGC, ECOG PS 0–3, received up to 6 cycles of Docetaxel 85 mg/m2 (75 mg/m2 after first 12 pts, 70 mg/m2 after the 28th patient) day 1, Cisplatin 75 mg/m2 day 1 (60 mg/m2 after the 28th patient) l-Folinic Acid 100 mg/m2 day 1 and 2, followed by 5-Fluorouracil 400 mg/m2 bolus day 1 and 2, and then 600 mg/m2 as a 22 hour continuous infusion day 1 and 2, every 14 days, plus Pegfilgrastim 6 mg on day 3. Pts with a PS > 1 and/or age > 65 years and/or pre-treated for the metastatic disease, received the same schedule with a dose reduction by 30%. Results: 31 consecutive pts were enrolled (81% male, 19% female; median age: 60, range 40–79; median ECOG PS: 1, range 0–3; 3 pts pre-treated). Primary end points were response rate and safety. A median of 4 cycles (range 1–6) per pts were administered. 15 pts (48%) required a dose reduction, mostly because of hematologic toxicity and severe asthenia. 10 pts (32%) were treated with full dose without any delay on at least the first 4 cycles. 25 pts were evaluated for response (3 too early, 1 early suspension because of severe allergic reaction to Docetaxel; 2 early deaths: 1 bowel perforation and 1 sepsis) and 30 for toxicity. 2 CR (multiple liver metastases), 12 PR, 4 SD and 7 PD were observed, for an ORR (RECIST criteria and intention-to-treat principle) of 50% (95% CI 30–65). At a median follow-up of 10 months (range 1–24), overall median survival was 6 months (range 1–20). Frequent grade 3 to 4 toxicities were: neutropenia (65%), thrombocytopenia (31%), anemia (14%) febrile neutropenia (31%), asthenia (62%), diarrhoea (21%) and stomatitis (14%). Conclusions: TCF-DD regimen in MGC is feasible and very active. The recommended dose (with reduction by 30% as above) for further randomised studies comparing TCF-DD with standard TCF is Cisplatin 60 mg/m2 and Docetaxel 70 mg/m2.

No significant financial relationships to disclose.

Dose-dense chemotherapy with modified TCF regimen (TCF-DD) in metastatic gastric cancer (MGC): A feasibility study

14117

Background: Previous studies reported that in early breast cancer, lymphomas and bladder, dose-dense chemotherapy is more effective than conventional treatments. In MGC chemotherapy with Docetaxel, Cisplatin and 5-FU (TCF) q3w is very active. Based on these studies, we tested for the first time the feasibility and activity of an intensified dose-dense TCF regimen (q2w) modifying the 5-FU continuous infusion with Folinic Acid/5-FU, according to the “De Gramont regimen.” Methods: patients (pts) with histologically confirmed measurable MGC, ECOG PS 0–3 received up to six cycles of Docetaxel 85 mg/m2 day (d) 1, Cisplatin 75 mg/m2 d 1, L-Folinic Acid 100 mg/m2 d 1 and 2, followed by 5-FU 400 mg/m2 bolus d 1 and 2 and then 600 mg/m2 as a 22-hour continuous infusion d 1 and 2, every 14 days, plus Granulocyte-Colony Stimulating Factor 5 μg/kg/d, from day 4 to 10 of each cycle or pegfilgrastim 6 mg on day 3. Pts with a PS > 1 and/or age > 65 years and/or pre-treated for the advanced disease, received the same schedule with a dose reduction by 30%. Results: 16 consecutive pts were enrolled (81% male, 19% female; median age: 60, range 40–79; median ECOG PS:1, range 0–3). Two pts received previously chemotherapy for the advanced disease. A median of 4 cycles (range 1–6) per patient were administered. Eleven pts were evaluated for response (3 too early, 2 early deaths) and 13 for toxicity; 1 CR (multiple liver metastases), 6 PR, 2 SD and 2 PD were observed, for an overall disease control rate, by intention to treat, of 69% (95% CI 44–95). No treatment delays were observed in 5 pts (PS 0–1, < 65 years old and all but one chemo-naïve); 8 pts did not respect the schedule (4 had PS >1, two of whom were > 65 years old; 4 were > 65 years old with PS 0–1). Grade 3/4 neutropenia (all not febrile), thrombocytopenia, and anemia occurred in 61%, 23% and 0% of pts, respectively. Grade 3/4 nausea/vomiting occurred in 15%. Conclusion: A dose-dense TCF regimen in MGC is feasible and active and deserves to be tested in randomised studies.

No significant financial relationships to disclose.

Tension-free inguinal hernia repair in "one-day surgery". Experience of 1091 cases

BACKGROUND/AIMS

In recent years new techniques to repair inguinal hernia have evolved in order to reduce recurrence rate and the overall costs of treatment of this pathology. This paper analyses our experience in verifying the theoretical advantages of the "tension-free" technique, after six years of this surgical practice.

METHODOLOGY

We describe the experience of 1091 "tension-free" hernia repairs with open placement of a mesh in 1034 patients, under local anesthesia with a "one-day surgery" regimen; these patients were observed during the period 1994 to 1999 at the Surgical Unit of Catholic University of Rome. The patients were between American Society of Anesthesia Status I to IV. Eight hundred patients underwent a mean follow-up of 29.7 months (range: 4-72) to evaluate the occurrence of late complications and recurrences.

RESULTS

No mortality or major intraoperative complications was observed. The only minor intraoperative or postoperative complications encountered were easily managed. Early pain disappearance, fast convalescence and rapid resumption of working activity were observed. Six recurrences occurred in the patients undergoing follow-up (0.75% recurrence rate).

CONCLUSIONS

Our data confirm the safety, rapidity, and reproducibility of the "tension-free" technique under local anesthesia performed with a "one-day surgery" regimen for inguinal hernia repair. These characteristics explain the diffusion of this surgical procedure with reduction of social costs.

[Central venous catheterization: complications of different placements]

STUDY AIM

The aim of this prospective multicentric non-randomised trial was to report the complications of the central venous catheter insertion with different techniques and to assess the advantages of the low lateral approach to the internal jugular vein, according to the technique originally described by Jernigan et al, with our own modifications.

PATIENTS AND METHOD

From January 1993 to August 1997, 2,290 CVC (2,286 by percutaneous puncture and 4 by surgical approach) were placed. The following complications were analysed prospectively: pneumothorax, accidental arterial puncture, more than two punctures of the same vein, necessity to shift to another venous approach, complete failure, malposition of catheter.

RESULTS

The veins the most frequently used were internal jugular vein (48.7%), femoral vein (27%) and subclavian vein (24.2%). Internal jugular vein was punctured especially by low lateral approach (75%) and subclavian vein by infraclavicular approach (92%). With these two placements, the rate of pneumothorax was 0% and 3.1% respectively (p < 0.001), the rate of accidental arterial puncture was 1% and 2.7% respectively (p < 0.03) and the rate of more than two consecutive punctures was 3.1% and 6.3% respectively (p < 0.008).

CONCLUSION

On our experience, we advocate the low lateral approach to the internal jugular vein as first choice technique for venipuncture in both adults and children for both short and long-term central venous approach, because it is associated to high rate of outcome and to low rate of complications in comparison with other techniques.

Splenic hemangiosarcoma. A case report

Splenic hemangiosarcoma is a rare and aggressive tumor. Up to now, less than 150 cases have been reported. We describe a patient with a rapide course. The diagnosis of hemangiosarcoma was based on immunohistochemical tests (factor-VIII-associated antigen, CD31, CD34). Despite the improvement of diagnostic techniques, pathological examination and immunohistochemistry remain the only methods available for the diagnosis.

Carcinoma of the pancreatic head area. Therapy: resectability and surgical management of resectable tumors

Surgical resection is being increasingly performed for carcinomas of the area of the head of the pancreas with curative intent. Pre-and intraoperative assessment of the site of origin and the stage of the lesion is of the utmost importance for a more favorable prognosis of non pancreatic forms and for a better evaluation of long term results of treatment adopted. Staging of non pancreatic periampullary tumors is usually very precise since they are most often shown to be resectable on laparotomy. Surgical resection by pancreaticoduodenectomy is the treatment of election based on good long term results. To the contrary, problems involved in the carcinoma of the head of the pancreas are non negligible. Some aspects related to the criteria of resectability of these tumors (diameter of primary lesion, infiltration of adjacent organs and large vessels, lymph node involvement) are discussed. How extensive pancreatic resection (subtotal, total or regional pancreatectomy) should be, is still a debated subject. In fact, it is not directly proportional to an improvement in prognosis. Complementary treatments directed to the improvement of the disappointing results at present achieved with surgery alone, are desirable.

Endoscopic diagnosis and treatment of malignant biliary strictures: review of 505 patients

The role of ERCP and endoscopic drainage in the diagnosis and treatment of patients with malignant biliary obstruction is well established. Endoscopic drainage is an effective therapy for palliation of malignant obstructive jaundice and does not preclude definitive treatment in appropriate candidate. We report our experience, in a retrospective review, of 505 patients with malignant biliary obstruction. In this series, endoscopic biliary drainage is shown to be safe and effective management for these patients. Relief of obstruction was obtained in a large majority of patients with a low, procedure related, morbidity and mortality. We conclude that ERCP, to diagnose and localize obstructive lesions, followed by endoscopic biliary drainage can be strongly considered in all patients with suspected malignant obstructive jaundice.