Ethanol endometrioma sclerotherapy: safety through 8 years of experience

STUDY QUESTION

What are the complications of transvaginal ethanol sclerotherapy for the treatment of endometriomas?

SUMMARY ANSWER

Sclerotherapy is a reliable, minimally invasive method applicable in outpatient procedures but with specific and potential life-threatening complications that need to be identified and prevented.

WHAT IS KNOWN ALREADY

There are currently few data on the use of transvaginal ethanol sclerotherapy, and we mainly note septic complications.

STUDY DESIGN, SIZE, DURATION

A retrospective observational cohort study was carried out. The study was conducted at an academic hospital and included 126 women aged 31.9 ± 5.5 years (mean ± SD), between November 2013 and June 2021. We analyzed a total of 157 ethanol sclerotherapy treatment (EST), treated by 131 EST procedures, in 126 women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included women with an indication for transvaginal ethanol sclerotherapy. Indications were women with at least one endometrioma over 10 mm, isolated or associated with other endometriosis locations, requiring treatment for pain or infertility before assisted reproductive treatment. We followed a standardized transvaginal ethanol sclerotherapy procedure consisting of an ultrasound-guided transvaginal puncture of one or more endometriomas under general anesthesia. The cyst content was completely removed and flushed with saline solution. Ethanol (96%) was injected at 60% of the initial volume of the endometrioma, remained in the cyst for 10 min and was then completely removed. Ethanol loss was defined as a loss of 5 ml or more than 10% of the initial volume of the injected ethanol. Failure was defined by the contraindication of endometrioma puncture because of interposition of the digestive tract, ethanol loss in the previous endometrioma treated (in case of multiple ESTs), failure to aspirate the endometriotic fluid, contraindication to start ethanol injection owing to saline solution leakage, or contraindication to continue ethanol injection owing to suspicions of ethanol leakage at sonography. Intraoperative complications were defined by ethanol loss, positive blood alcohol level, and ethanol intoxication. Postoperative complications were defined by fever, biological inflammatory syndrome, and ovarian abscess. Complications were classified according to the Clavien and Dindo surgical classification, which is a system for classifying postoperative complications in five grades of increasing severity.

MAIN RESULTS AND THE ROLE OF CHANCE

We reported a total of 17/157 (10.8%) transvaginal ethanol sclerotherapy failures during 14/131 (10.7%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. In the same sets of data, complication was reported for 15/157 (9.5%) transvaginal ethanol sclerotherapy in 13/131 (9.9%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. Nine of 126 women (7.1%) had a grade I complication, one (0.8%) had a grade II complication (medical treatment for suspicion of pelvic infection), two (1.6%) had a grade III complication (ovarian abscess) and one (0.8%) had a grade IV complication (ethanol intoxication). We did not observe any grade V complications.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective study and pain assessment not considered. The benefit-risk balance of endometrioma transvaginal ethanol sclerotherapy was not evaluated.

WIDER IMPLICATIONS OF THE FINDINGS

Our study is the first to evaluate the complications of transvaginal ethanol sclerotherapy with such a large cohort of women in a standardized protocol. Transvaginal ethanol sclerotherapy seems to be an effective alternative to laparoscopic surgery in the management of endometriomas and limits the alteration of ovarian reserve. Transvaginal ethanol sclerotherapy is a reliable, minimally invasive method applicable on an outpatient basis. The majority of complications are Clavien-Dindo ≤IV, for which preventative measures, or at least early diagnosis and treatment, can be easily performed. The risk of ethanol intoxication is rare, but it is a life-threatening risk that must be avoided by appropriate implementation and promotion of the sclerotherapy procedures.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

Aix Marseille University's ethics committee registration number 2021-06-03-01.

Minimally-invasive pancreatic surgery in high volume centers in the Czech Republic - current status and possible implementations

INTRODUCTION

Minimally-invasive surgical methods have been becoming ever more common also in the segment of pancreatic surgery. The aim of this paper was to analyze the current state of minimally-invasive surgery in the Czech Republic and the justification and potential of implementing such procedures.

METHODS

Analysis of high volume centers using healthcare providers´ and payers´ data.

RESULTS

Thirteen pancreatic surgical centers meet the proposed criteria for being called a high volume center - a center of highly specialized care in pancreatic surgery based on the annual number of at least 17 major resections of the pancreas. According to data from healthcare payers, laparoscopy was used in 0.6%-65.7% of procedures in individual centers. However, these are not resection procedures. The centers themselves report a significantly smaller number of minimally-invasive pancreatic resection procedures. The actual numbers of minimally-invasive resection procedures in the current system are practically impossible to verify. The potential for implementing minimally-invasive pancreatic surgery in the Czech Republic can be estimated based on the identification of candidate patients.

CONCLUSION

Due to the fragmentation of this operative segment, its costs and small numbers of patients suitable for minimally-invasive pancreatic surgery even among high volume centers, the implementation rate of these methods is very slow. The need to centralize this segment of care appears to be very urgent from all points of view.

Innovative trends in surgery: a robotic approach to retrotracheal goitre

The retrotracheal form is a rare variant of retrosternal goitre. The incidence is low, representing approximately 4% of all retrosternal goitres. The traditional approach to the treatment of this type of pathology is the cervical approach combined with high thoracotomy. Recently, however, new methods and technologies have begun to emerge that also open new possibilities for the surgical management of these conditions. The aim of this case report was to present the potential of a video-robotic approach in the treatment of retrotracheal goitre. The authors have successfully used this innovative method in the treatment of retrotracheal lesions, bringing hope for more effective and less invasive surgical interventions in this difficult-to-access area.

Frontal site surgery for chronic migraine therapy

BACKGROUND

According to the most current theories, chronic inflammation of some cranial nerves give rise to an inflammatory chain that would result in migraines. As for frontally located attacks, the nerves involved are two (on each side): the supraorbital and the supratrochlear. Surgical treatment includes complete neurolysis of both of these nerves.

METHODS

In this work, we describe our experience with this type of surgery. From 2011 to 2022, we treated 98 cases suffering from chronic migraine not responsive to drugs with frontal localization. The results were evaluated through a specific questionnaire three months and one year after surgery.

RESULTS

After three months post-surgery, we observed a success rate (reduction of monthly attacks equivalent to or greater than 50%) in 87% of patients (32% complete recovery). These results were essentially confirmed one year after surgery. The rare complications (mainly paresthesias and dysesthesias of the frontal area) have always resolved spontaneously within a few months.

CONCLUSION

The surgical approach allowed to obtain good therapeutic results with a low rate of complications.

Sacrocolpopexy after sub-total hysterectomy vs. sacral hysteropexy for advanced urogenital prolapse: A propensity-matched study

OBJECTIVE

To compare objective and subjective outcomes of laparoscopic sacral colpopexy with supracervical hysterectomy (L-SCP) and robotic sacral hysteropexy (R-SHP).

METHODS

This is a multicenter retrospective propensity score matched study. In the period between January 2014 and December 2018, we enrolled 161 patients with apical prolapse stage 2 or above, alone or with multicompartment descensus.

RESULTS

After propensity-match analysis, there were 44 women for each group. Patients of the two groups had similar preoperative characteristics. No difference was found in terms of estimated blood loss, hospital stay, operative time, and intraoperative or postoperative complications. Subjective success rate, 12 months after surgery, was statistically better in the L-SCP group (P = 0.034): 81.8% and 97.8% women had Patient Global Impression of Improvement scores less than 3, in R-SHP and L-SCP, respectively. The objective cure rate was high in both groups without any significant differences in recurrence rate (P = 0.266).

CONCLUSION

Both procedures are safe and effective in pelvic organ prolapse treatment. Patients who no longer desire uterine preservation could be encouraged to consider L-SCP. R-SHP is an alternative in women who are strongly motivated to preserve their uterus in the absence of abnormal uterine findings.

Scarless preventive surgery

Oncogenetic risk‐reduction surgeries could be better accepted if innovation allowed the scars to be hidden. Adnexectomies, vNotes, and endoscopic mastectomies presented here are examples.

Management of Esophago-Gastric Junction Carcinoma: A Narrative Multidisciplinary Review

Esophagogastric junction (EGJ) carcinoma represents a specific site of disease, given the opportunities for multimodal clinical care and management and the possibilities of combined treatments. It encompasses various clinical subgroups of disease that are heterogeneous and deserve different treatments; therefore, the guidelines have progressively evolved over time, considering the evidence provided by clinical trials. The aim of this narrative review was to summarize the main evidence, which orientates the current guidelines, and to collect the main ongoing studies to address existing gray areas.

Occurrence and Definitions of Intra and Postoperative Complications Related to Laparoscopy in Equids: A Scoping Review

Simple Summary

Laparoscopy and laparoscopic-assisted procedures in equines are nowadays common procedures with several advantages compared to laparotomy. However, despite the numerous benefits of minimally invasive surgery, there can be surgical complications which could have important welfare and economic consequences. Nevertheless, standard definitions of intra and postoperative complications are rarely reported and there is a lack of standard criteria to define and classify complications, limiting comparison of complication rates between studies. Thus, there is a need for implementation of rigorous criteria for defining complications and for greater numbers of research study with high quality of evidence. Adoption of classification systems and standard definitions would help surgeons to have a complete picture of the efficacy of a procedure or treatment and it is also essential to allow comparisons between studies, centers or time periods.

Abstract

Laparoscopy is a common approach in equine surgery and has the advantage of improved visibility and diagnostic accuracy, decreased morbidity and hospitalization time. However, despite the numerous benefits, there can be intraoperative and postoperative complications which could have important welfare and economic consequences. The aim of this study was to perform a scoping review to identify current evidence on the occurrence, definition and classification of intra and postoperative complications in equine laparoscopy. A scoping review was conducted in scientific databases. Peer-reviewed scientific articles in the English language on laparoscopy in equids between 1992 and 2022 were included. Data on the study method, sample size, surgical procedure, intra and postoperative complications were extracted and charted. One hundred sixty-four articles met the final inclusion criteria. A definition of “intraoperative complication” was given in one study. Difference between “minor” or “major” intraoperative complications were reported in 12 articles and between “minor” or “major” postoperative complications in 22 articles. A total of 22 intraoperative and 34 postoperative complications were described. The most reported intraoperative complication was hemorrhage from ovary or mesovary (12.7%), while the most reported postoperative complications were incisional complications (64.2%) and postoperative pain (32.7%). There is a need for implementation of criteria for defining complications. The adoption of classification systems and standard definitions would help surgeons to make decisions about the most appropriate treatment, and it is also essential to allow comparisons between research results.

Robot-Assisted Versus Laparoscopic Approach for Splenectomy in Children: Systematic Review and Meta-Analysis

Aim: To compare the outcomes of pediatric splenectomies for hematologic diseases performed by robot-assisted laparoscopic surgery (RALS) and laparoscopic approach. Materials and Methods: Web of Science, Scopus, and PubMed databases were systematically searched for publications in English language from January 2000 to March 2020. All the studies dealing with pediatric elective splenectomies performed by RALS were included. The primary outcomes were the rate of postoperative complications and conversion. The secondary outcomes were the length of hospital stay and the operative time. Results: The search yielded 969 articles. Ten articles were included in the systematic review. Eighty patients underwent RALS splenectomy. Thirteen postoperative complications (16%) were reported and RALS was converted to open surgery in five cases (6.3%). Five of the included articles, three retrospective studies and two case series, were considered relevant for the meta-analysis and dealt with 130 patients. Of them, 71 children (55%) underwent RALS. No difference in the rate of complications was found between the two approaches (P = .235). RALS presented a similar rate of conversion to open surgery (P = .301). The mean operative times and length of hospital stays for RALS, reported in three different studies, were 107.5, 159.6, 140.5 minutes and 4.2, 3.93, 2.1 days, respectively. Conclusion: Even if few studies were included in the review, this meta-analysis reported similar rates of complication and conversion for RALS when compared with laparoscopy. Further studies are required to prove that this innovative technique was as safe and feasible as the current gold standard technique.

Tentative Assessment of Treatment of Supracondylar Humerus Fractures in Children

BACKGROUND

Supracondylar humerus fractures are a serious problem in children. The complicated anatomy of the elbow joint necessitates careful assessment of the damage before individually adapting treatment methods. The aim of the study was to evaluate the effectiveness of comprehensive treatment of children in Group A in relation to children in Group B. Moreover, the impact of rehabilitation on the function of the affected elbow joint was examined.

MATERIALS AND METHODS

The study enrolled 40 children divided into two groups: Group A and Group B. In Group A, the dominant method of treatment was percutaneous K-wire stabilization. The results demonstrate that the use of this treatment method and the implementation of systematic rehabilitation made it possible to achieve very good results. In Group B, stabilization was performed in less than half of the children and rehabilitation was carried out at home. The initial and follow-up examinations were carried out in both groups according to a medical test card. In Group A, the initial examination was performed on the day the rehabilitation commenced, and the follow-up examination after the completion of a 10-day rehabilitation cycle. In Group B, the initial examination was carried out after immobilization was removed and a follow-up examination was performed after 3 weeks of home-based rehabilitation.

RESULTS

The treatment model used in Group A was more effective than the model used in Group B.

CONCLUSIONS

1. Correct repositioning, the use of percutaneous K-wire stabilization and elbow rehabilitation performed at the earliest possible time give very good functional results. 2. The use of percutaneous stabilization shortens the hospitalization period, which is of great importance in the treatment of young patients.

Updates on the Latest Surgical Approach of the Aortic Stenosis

Over the last twenty years, we marked significant progresses in the field of tissue engineering and the development of new aortic valve structural and delivery systems. These continuous iterations on the field, have completely changed the surgical indications and approaches for AVR. Nowadays, therapeutic decisions are endorsed by international guidelines; however, new technical advances need a new integrated approach. The clinical scenarios issued from the interaction between the Guidelines and the newest approaches and technologies are regularly on debate by the Heart Team. We will present some of our most encountered situations and the pattern of our therapeutic decisions. To easily navigate through Guidelines and clinical scenarios, we reported in this review a simplified and easy to use Clinical decision-making algorithm that may be a valuable tool in our daily practice.

Minimally invasive sinus tarsi approach in Sanders II-III calcaneal fractures in high-demand patients

Aim To evaluate if the sinus tarsi approach treated with open reduction and internal fixation (ORIF), without using plate fixation, provided good functional results in active adult population. The hypothesis was that the sinus tarsi approach with limited incision provided good results comparable to other approaches. Methods A total of 78 patients (81 feet) surgically treated for articular calcaneus fracture were reviewed according to inclusion criteria: Sanders fracture type II-III, minimum follow-up of 2 years, patients aged 18-65 years. Exclusion criteria were smokers, diabetics, non-collaborative patients and patients with Sanders fracture type I and IV. A mean follow-up was 52.6 months. Radiographic changes of the Bohler's angle were reported. For the clinical evaluation, Visual Analogue Scale (VAS) for calcaneal fractures, American Orthopaedic Foot and Ankle Society (AOFAS) score and Maryland Foot Score (MFS) were used. Results A statistically significant restitution of Böhler's angle from preoperative to postoperative (13.5°-27°; p<.001) was found. The AOFAS and MFS showed pain relief and good/excellent functional activities at the final follow-up in 65 of 78 (83.3%) patients. In eight (out of 81; 10%) feet a superficial wound infection was observed. In three (3.8%) patients a subtalar arthrodesis was performed. Conclusion The mini-invasive sinus tarsi approach for active adult population is a valid and reproducible technique with a low rate of major complications, but it is mandatory advice to patients regarding the expectation of the results.

Laparoscopic versus open partial nephrectomy for the management of highly complex renal tumors with PADUA score ⩾10: A single center analysis

INTRODUCTION

The aim of this study was to compare laparoscopic and open partial nephrectomy (PN) for renal tumors of high surgical complexity (PADUA score ⩾10).

METHODS

We retrospectively evaluated 93 consecutive patients who underwent PN at our department from January 2015 to September 2019. 21 patients underwent open partial nephrectomy (OPN) (Group A) and 72 underwent laparoscopic partial nephrectomy (LPN) (Group B). All OPNs were performed with a retroperitoneal approach, while all LPNs were performed with a transperitoneal approach by a single surgical team. Post-operative complications were classified according to the Clavien-Dindo system.

RESULTS

The two groups showed no difference in terms of patients' demographics as well as tumor characteristics in all variables. Group A was found to be similar to group B in terms of operation time (p = 0.781), conversion to radical nephrectomy (p = 0.3485), and positive surgical margins (p = 0.338) while estimated blood loss (p = 0.0205), intra-operative (p = 0.0104), and post-operative (p = 0.0081) transfusion rates, drainage time (p = 0.0012), pain score at post-operative day 1 (<0.0001) were significantly lower in Group B. The rate of enucleation and enucleoresection/polar resection was similar (p = 0.1821) among the groups. Logistic regression analysis indicated that preoperative factors were not independently associated with the surgical approach. There was a statistically significant difference in complication rate (<0.0001) between the two groups even if no significant difference in terms of grade ⩾3 post-operative complications (p = 0.3382) was detected.

DISCUSSION

LPN represents a feasible and safe approach for high complex renal tumors if performed in highly experienced laparoscopic centers. This procedure offers good intraoperative outcomes and a low rate of post-operative complications.

Impact of a Province-wide Endometrial Cancer Guideline on Daily Practice

BACKGROUND/AIM

Most women are managed by a general gynaecologist rather than being centralized in an oncogynaecology unit, resulting in different clinical management. In 2006, a hub & spoke model was introduced in the Provincial Healthcare System of Reggio Emilia, and shared guidelines were written. We aimed to verify the adherence to guidelines and the consequent improvements in quality care.

PATIENTS AND METHODS

All patients who underwent a hysterectomy for endometrial cancer in the Reggio Emilia Province hospitals from 2000 to 2016 were included in the study. Clinical and pathological data were carefully recorded for each patient included.

RESULTS

This study included 132 and 277 patients in the periods before and after the implementation of the guideline, respectively. In the post-guideline period, the use of hysteroscopy, magnetic resonance, laparoscopy and adjuvant treatment significantly increased.

CONCLUSION

Common shared guidelines and a clinical audit can help in improving centralization, resulting in an increased quality of care.

Robotics-Assisted Pediatric Oncology Surgery-A Preliminary Single-Center Report and a Systematic Review of Published Studies

AIM

The use of robotics-assisted surgery in oncology has been proved effective and safe in adults. Despite these results, the use of robotics has been rarely reported for pediatric oncology. Our review aims to evaluate the safety and feasibility of robotics-assisted surgery in this field, analyzing our experience and performing a systematic review of the most recent studies.

METHODS

We reviewed all patients affected by an oncological disease who underwent a robotics-assisted procedure at our institute. We performed a systematic review of the literature from 2012 to 2021 on the subjects.

FINDINGS

A total of 14 patients underwent robotics-assisted tumor resection. Eleven procedures (median age 13.2-years old) were carried out in children with adnexal lesions (seven tumor excision and four ovariectomies). Histological diagnosis was mature teratoma (six), serous papillary cystadenofibromas of the fallopian tube (two), ovarian serous cystadenoma (one), ovarian mucinous cystadenoma (one), and ovarian seromucinous cystadenoma. The median length of stay was 2 days. No recurrences or complications at a median follow-up of 2.1-years were observed. A 5-year-old girl underwent a complete posterior resection of a type 3 sacrococcygeal tumor with a robotics-assisted approach for the dissection of a possible intraabdominal residual component of the lesion. No intra- and postoperative complications were recorded. Complete excision of a recurrent differentiating neuroblastoma of the left para-renal region was performed on a 9-year-old girl. An idiopathic anaphylactic shock occurred 1 day after the procedure. At 9 months' follow-up, no local recurrences of the lesion were observed. Overall, we reported no conversion to open surgery. Lastly, a robotic excision of a growing left superior mediastinal intermixed ganglioneuroblastoma was performed on an 8-year-old girl with no postoperative complications. Follow-up was uneventful (7 months). In the literature, the rate of complications ranges from 0 to 28%, mainly related to difficult dissection and impaired anatomy. Conversion is reported in 5% of all oncological procedures, due to more invading tumors and altered anatomical features. No robotics-related complications were reported.

CONCLUSION

Robotics-assisted surgery in pediatric oncology has proven to be feasible. Nevertheless, its use should be limited to selected cases and performed by highly trained oncological surgeons. Preparation and patient positioning, alongside a correct port placement, are crucial to carrying out these procedures. Further innovations in robotics may allow a wider application of this technology in pediatric oncology.

The Role of Video-Assisted Thoracoscopic Surgery in Pediatric Oncology: Single-Center Experience and Review of the Literature

Aim: Video-assisted thoracoscopic surgery (VATS) has been widely used in the last decades. Nevertheless, the pros and cons of thoracoscopy vs. open surgery in pediatric oncology are still under debate. In literature, VATS has been applied for both diagnostic and ablative surgery to treat neurogenic tumors, thymic neoplasms, lung tumors and metastases, germ cell tumors, lymphoproliferative diseases, and other rare tumors. Recent reviews described excellent outcomes in pediatric oncology as well as in the treatment of adult lung cancer, with a significantly higher rate of mortality and complication in thoracotomy compared to VATS. We reviewed our experience on thoracoscopy in pediatric malignancy and compared it to the literature. Materials and Methods: This was a retrospective cohort-study of pediatric oncological patients who underwent VATS at our institution from 2007 to 2020, and a review of the recent literature on the topic. Results: A total of 43 procedures were performed on 38 oncological patients (18 males, 20 females). Median age was years 7.72 (0.35-18.6). Diagnosis: 10 neurogenic tumors, nine hematological diseases, five metastases, four lypoblastomas, three thymic pathologies, three germ cell tumors, two pleuropneumoblastomas, two myofibroblastic tumors, one myoepithelial carcinoma, one liposarcoma, and three suspected oncological mass. In three cases, a 3D model was elaborated to better plan the surgical approach. Diagnostic biopsies were 22 (51.1%), and ablative surgeries, 21 (48.9%). One neurogenic tumor was resected with the Da Vinci Robot. Median operative time was 120 min (30-420). A drain was left in place in 20 (46.5%) for a median of 4 days. Median length of hospitalization was 5 days (1-18). One case (2.3%) was converted (intraoperative bleeding). There were three post-operative complications (7.0%): one pneumonia, one pleural effusion, and one diaphragmatic paralysis (need for plication). Results were compared to recent literature, and morbidity and conversion rate were comparable to reviewed publications. Conclusion: VATS represents a valuable tool for diagnostic and therapeutic procedures in pediatric oncology. Nonetheless, it is a challenging technique that should be performed by expert surgeons on oncological and mini-invasive surgery. Three-dimensional reconstruction can optimize the pre-operative planning and guarantee a safer and more targeted treatment. Finally, the advent of robotics-assisted surgery represents a new challenge that may further implement the advantages of VATS.

Anterior Minithoracotomy vs. Transcatheter Closure of Patent Ductus Arteriosus in Very Preterm Infants

Introduction: Patent ductus arteriosus (PDA) is common in preterm infants and contributes to morbidity and mortality. Several studies have shown the feasibility and safety of percutaneous PDA closure. Minimally invasive surgical ligation by anterior thoracotomy is an alternative, bedside technique for PDA closure in very low birth weight preterm infants. Our study aimed to compare short- and medium-term morbidity and mortality between anterior minithoracotomy and transcatheter PDA closure. Methods: From 2010 to 2020, 92 preterm infants <1,600 g underwent PDA closure in two centers: 44 surgical anterior minithoracotomies (center 1) and 48 transcatheter closures (center 2). Using a 1:1 propensity score match analysis, 22 patients in each group were included. The primary outcome was time to extubation after intervention. Results: Preoperative characteristics were similar in both groups after propensity matching (mean weight at procedure, 1,171 ± 183 g; p = 0.8). Mean time to extubation was similar: 10 ± 15 days in the surgical group vs. 9 ± 13 days in the transcatheter group (p = 0.9). Mean age at hospital discharge was 114 ± 29 days vs. 105 ± 19 days (p = 0.2). Two deaths occurred in the surgical group and one in the transcatheter group (p = 0.61). Five complications (pneumothorax n = 2, chylothorax n = 2, phrenic nerve injury n = 1) occurred in three patients after surgery. Three complications (chylothorax n = 1, endocarditis n = 1, renal vein thrombosis n = 1) occurred in two patients after percutaneous closure (p = 0.63). Conclusion: Equivalent efficiency and safety of surgical mini-invasive vs. transcatheter PDA closure in preterm infants <1,600 g are in favor of applying these alternative techniques according to centers' facilities and competences.

Laparoscopic Management of Giant Ovarian Cysts Using the Alexis Laparoscopic System®: A Case Series

Objective: The aim of this study was to review the characteristics of patients who underwent laparoscopic removal of giant ovarian cysts using the Alexis Laparoscopic System® and confirm the safety and feasibility of this technique.

Method: We conducted a retrospective review of data of women undergoing the procedure from March 2014 to February 2019. Inclusion criteria were ovarian cysts of at least 15 cm. Exclusion criteria were the presence of solid components and suspicion of neoplasia on imaging.

Results: Six patients were included in the series. Median size of the cysts at imaging was 22.8 cm (range 15–30 cm), while median volume was 5.9 L (range 1.9–15.6 L). Mean age of operated women was 59 years (range 21–88 years). All patients underwent exclusive laparoscopic management except one patient who underwent a conversion into midline laparotomy. The size of the skin incision initially performed to puncture the cyst ranged from 2.5 to 4 cm. On final pathological reports, two cysts were mucinous cystadenomas, and four were serous cystadenomas. There was no epithelial ovarian cancer or borderline tumor in any of the specimen operated.

Conclusion: Laparoscopic management of giant ovarian cysts using the Alexis Laparoscopic System® is safe and feasible in well-selected cases. Midline laparotomy can thus be avoided, decreasing the risk of post-operative complications and increasing quality of life of patients.

Inframammary approach for addressing anterior mediastinal tumours: initial experience

Background

Anterior mediastinal tumours account for 50% of all mediastinal masses. Surgical intervention is the standard approach for their diagnosis or treatment. Minimally invasive techniques have gained significant popularity in the last few decades due to the obvious advantages that they offer. We will describe a series composed of the first 20 patients who were submitted to a new minimally invasive video-assisted technique, which uses an inframammary incision approach involving a Thoratrak rib spreader and a Rultract Skyhook retractor.

Methods

A retrospective study was undertaken, involving all the patients in our department who were submitted to a resection of their anterior mediastinal masses by inframammary incision, using a Thoratrak rib spreader, a Rultract Skyhook retractor and video assistance.

Results

A total of 20 patients were included, with a mean age of 52.6. The mean surgery duration was 47 minutes, with an intraoperative blood loss of 70 mL. The mean period of hospitalisation was 2.9 days. No patients underwent conversion to open surgery, and there were no major complications. The mean size of the masses that were excised was 13.9 cm, with a mean weight of 77.3 g. The surgical margins were all free of tumour tissue, and no early recurrence was observed during the postoperative follow-up period.

Conclusions

Video-assisted thoracoscopic surgery (VATS) and robot assisted thoracic surgery (RATS) account for most of the minimally invasive procedures. However, VATS has certain limitations in terms of deep perception and manoeuvrability, and RATS has the disadvantage of lacking tactile and force feedback for the surgeon. The inframammary technique allows for safe direct dissection around the vascular and nervous structures, ensuring a complete observation of the anterior mediastinum and its structures. The findings in the present study suggest that this technique is useful. We had good surgical results, short surgery times and very low blood loss, and all tumours were totally resected, with tumour-free surgical margins. The size and the right lateralisation of the mass did not present any contraindications, and the learning curve and investment were minimal. In conclusion, the inframammary approach could be a safe and useful approach for treating anterior mediastinal pathology.

Laparoscopy-Assisted Versus Open Surgery in Treating Intestinal Atresia: Single Center Experience

INTRODUCTION

Surgical management of jejuno-ileal atresia/stenosis (JIA) is shifting to a minimally invasive approach. Our purpose is to evaluate the safety and feasibility of laparoscopy-assisted surgery (LAS) in JIA by comparing outcomes with a control group of open surgery (OS).

METHODS

A retrospective review of JIA cases was performed. Demographic, surgical, and outcomes data were extracted. LAS cases were compared with OS. Fisher's exact-test for qualitative and Mann-Whitney-test for quantitative values were used. p values <0.05 were considered significant.

RESULTS

Forty-seven patients (24/23, F/M) were included. In 19 (40%), the LAS technique was successfully performed, while 3 (17%) required conversion to OS. No differences were observed between the LAS and OS (n = 28) groups concerning demographic data (sex, mean gestational age, mean weight, associated anomalies) and type of JIA. Operative time was shorter in LAS (112 ± 46 min) compared to OS (138 ± 40 min), p = 0.04. Time to start enteral feeding and time to full enteral was shorter in LAS compared to OS, p = 0.04. No difference was observed between the two groups concerning duration of parenteral nutrition, length of hospitalization and weight at discharge. Overall rate of postoperative complications was 14% (n = 7), with a slightly prevalence in OS (18%) compared to LAS (10%), p = 0.68.

CONCLUSIONS

The LAS technique in the treatment of neonatal JIA is safe and feasible. LAS is associated with shorter operative and restoration of enteral feeding times. The post-operative outcomes in LAS are similar with OS, with a lower rate of postoperative complications.

Minimally invasive surgery and one-day care

Due to population aging in developed countries, it has become necessary to prepare a functional health care plan for the elderly. One of the possibilities to improve postoperative outcomes and recovery in elderly patients is to perform common surgical procedures in the regime of one-day surgery. We compared elderly patients who underwent surgery in a large university hospital with elderly patients who underwent surgery in a facility dedicated to one-day surgery. The homogeneity and clinical outcomes of the two groups were statistically analyzed. Complications were assessed according to the Clavien-Dindo classification. There were no statistically significant differences in demographic data and pre-operative risk assessment (ASA). The one-day surgery group had fewer complications and a shorter average hospital stay. Advanced age is not the only criterion for assessing the biological state of the patient and therefore does not always necessitate surgical care in a university hospital setting with a high volume of acute and complicated cases. Many elderly patients will benefit from a more individualized approach and healthcare facilities that specialize solely in elective procedures. When indicating elderly patients for one-day surgery, their health status is more important than their calendar age.

Laparoscopic vs. Abdominal Radical Hysterectomy for Locally Advanced Cervical Cancer

This study is to compare the survival outcomes of laparoscopic radical hysterectomy (LRH) to those of abdominal radical hysterectomy (ARH) for patients with locally advanced cervical cancer (LACC). Patients with the International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB2 to IIB LACC who underwent radical hysterectomy between 2001 and 2015 were identified. The disease-free survival (DFS) and overall survival (OS) were compared according to the surgical approach and were adjusted based on clinicopathologic characteristics. A total of 396 patients were included in the study, with 179 (45.2%) and 217 (54.8%) patients in the ARH and LRH groups, respectively. The LRH group showed a significantly lower amount of estimated blood loss, lower blood transfusion rate and shorter length of hospital stay. Overall, there were no significant differences in the 5-year DFS and 5-year OS between the LRH and ARH groups with the Kaplan-Meier method. However, multivariate analyses identified LRH as an independent prognostic factor for a poor DFS (hazard ratio [HR] 2.5; 95% confidence interval [95% CI] 0.19 to 0.87; p = 0.02). The analysis of stage IB2 disease and the squamous subtype (61.9% and 87.9% of all participants, respectively) reached the same conclusion. When stratifying by FIGO stage, the patients with IB2 (n = 348) in the ARH group had a significantly better DFS (HR 0.14, 95% CI 0.05–0.42, p < 0.01) and OS (HR 0.17, 95% CI 0.04–0.67, p = 0.11) than those in the LRH group in the Cox regression model. However, no differences were found in patient with stage IIA1, IIA2, or IIB in Cox regression model. When stratifying by histological types, for the patients with squamous carcinomas (n = 375), in Cox model, ARH had a significantly superior DFS compared with those who underwent LRH (HR 0.45, 95% CI 0.25–0.82, p = 0.01), but the OS was not statistically significant (HR 0.57, 95% CI 0.27–1.20, p = 0.14). However, no differences were found in patient with adenocarcinoma and adenosquamous carcinomas in the Cox model. Therefore, ARH was associated with a higher DFS than LRH in patients with LACC, especially in patients with stage IB2 disease or the squamous subtype.

Functional endoscopic sinus surgery in a cat with nasal tumor

An 11-year-old, 5.8-kg, male European cat was presented with a 4-month history of sneezing, nasal discharge, respiratory distress and bilateral conjunctivitis. Physical examination showed bilateral hemorrhagic mucopurulent nasal discharge and stertorous respiratory sounds. An irregular shaped mass involving the aboral portion of the right nasal cavity and sphenoidal sinus was identified by computed tomography. The mass was localized endoscopically in the medium meatus and an endoscopic-guided biopsy was performed. B-cell lymphoma was diagnosed by histopathological and immunochemistry exams. Functional endoscopic sinus surgery allowed to completely remove the tumor and restore a normal nasal flow. The cat showed no recurrence of the neoplasia for 15 months after the functional endoscopic sinus surgery.

Prostate Imaging Reporting and Data System in prostate cancer staging and planning for radical prostatectomy

Introduction

The Prostate Imaging Reporting and Data System (PI-RADS) was mainly developed for the purposes of prostate cancer (PCa) detection. However, its widespread use suggests that it may play a role in a preoperative workup prior to endoscopic radical prostatectomy (ERP).

Aim

To evaluate the prognostic value of PI-RADS in predicting extraprostatic extension (EPE) and its influence on surgical planning of ERP.

Material and methods

The analysis involved data of 154 consecutive prostate cancer patients, in whom multiparametric 3.0T magnetic resonance imaging (mpMRI) was performed before ERP. Standard descriptive assessment of mpMRI images was compared with the PI-RADS system with respect to prostate cancer staging and subsequent potential surgical template adjustment.

Results

PI-RADS significantly outperformed the standard way of mpMRI reporting in staging (AUC = 0.615 vs. 0.552, p = 0.036) with PI-RADS 5 established as the best threshold. After reevaluation of imaging, the initial surgical plan was modified based on mpMRI in terms of feasibility and extent of neurovascular bundle preservation during ERP on 96 (31.2%) sides, while on the remaining 212 (68.8%) sides the templates were left unchanged. Decisions based on mpMRI were not associated with increased risk of a positive surgical margin (PSM).

Conclusions

The PI-RADS outperforms the standard staging method using mpMRI and may assist the decision-making process regarding the extent of resection during ERP without increasing the risk of PSM.

Resection for hepatocellular cancer: overpassing old barriers

Several recent studies have shown that the selection limits commonly used for patients with hepatocellular cancer (HCC) potentially requiring a liver resection (LR) are too restrictive. The present review aims at investigating the studies showing that LR is no longer a treatment suitable only for highly selected patients, but also for patients selectively presenting one-to-more negative factors. Several specific variables have been investigated, none of them showing to be an absolute contraindication for LR: age; single vs. multiple diseases; the dimension of the nodule; hyperbilirubinemia; clinically relevant portal hypertension; Child-Pugh status; macrovascular invasion. As a consequence, LR for the treatment of HCC-on-cirrhosis is a safe and effective procedure not only in "ideal cases", but also for selected patients presenting risk factors. The presence of only one of these factors does not represent an absolute contraindication for LR. On the opposite, the contemporaneous presence of risk factors should contraindicate the procedure. Further studies investigating the "borderline" cases are required, mainly looking at the possible decisive role of laparoscopy in this setting.

Association of Robotic Totally Endoscopic Coronary Artery Bypass Graft Surgery Associated With a Preliminary Cardiac Enhanced Recovery After Surgery Program: A Retrospective Analysis

OBJECTIVES

The robotic totally endoscopic coronary artery bypass graft (TECAB) surgery reduces patients' recovery time. The present trial investigated the feasibility and safety of an initial enhanced recovery after surgery (ERAS) path for patients undergoing robotic beating-heart TECAB and compared it with both conventional surgery and traditional perioperative care. It was hypothesized that the preliminary ERAS pathway associated with a beating-heart TECAB procedure could have a synergistic effect on postoperative patient care.

DESIGN

Observational retrospective study.

SETTING

University hospital.

PARTICIPANTS

Patients scheduled for coronary artery bypass graft and undergoing robotic beating-heart TECAB (n = 38) were compared with those undergoing standard surgery and perioperative care (n = 33). The outcomes were the possibility of tracheal extubation at the end of the surgery and the incidence of postoperative complications.

MEASUREMENTS AND MAIN RESULTS

The main comorbidities were similar between the 2 groups. Extubation on the operating table in the TECAB group was possible in all cases without requiring prompt endotracheal tube reinsertion. The proportion of patients transfused was significantly lower in the TECAB group (p = 0.009). In addition, the duration of intensive care unit and hospital stay were reduced significantly by 24 hours and by 4 days, respectively, in the TECAB group compared with the standard group (p< 0.05).

CONCLUSIONS

The present results suggested that a program coupling a beating-heart TECAB with a preliminary ERAS path for patients requiring a single coronary revascularization is feasible and safe. This approach could reduce postoperative mechanical ventilation time, transfusion rate, and both intensive care unit and hospital stay.

Shortness of filum terminale represents an anatomical specific feature in fibromyalgia: a nuclear magnetic resonance and clinical study

BACKGROUND

we aimed to assess whether shortness of filum terminale (FT) can represent a specific feature of fibromyalgia. Therefore we investigated benefits coming from FT section with a mini-invasive technique in patients with fibromyalgia. Filum terminale disease (FD), described firstly in 1996, is consequence of an abnormal traction exerted on spinal cord since FT is shorter than usual. Fibromyalgia syndrome (FS) is featured by chronic widespread musculoskeletal pain associated with stiffness and extra-skeletal symptoms affecting many organs and systems. Filum terminale disease and fibromyalgia syndrome share common clinical features in at least one subset of patients.

METHODS

we evaluated 42 patients firstly diagnosed for FS and then re-evaluated by nuclear magnetic resonance. 38 out of 42 had also FD and 20 of them underwent surgical treatment, i.e., FT section according to Royo-Salvador technique.

RESULTS

after physical therapy, surgically treated patients showed significant improvement of symptoms in terms of reduction of pain and increment of quality of life, compared to group, which refused surgery and performed physical therapy only.

CONCLUSION

we suggest that FT shortness can be considered one of predisposing causes for developing FS and that FD surgical treatment in patients with FS can improve overall treatment outcome.

Mini-invasive mitchell-kramer method in the operative treatment of hallux valgus deformity

BACKGROUND

The mini-invasive Mitchell-Kramer procedure is a new method of operative correction of mild to moderate hallux valgus deformity. The aim of this study was to describe the technique and evaluate the results of the procedure.

METHODS

We evaluated 54 patients who underwent mini-invasive distal metatarsal osteotomy of the first metatarsal with preservation of the lateral cortex of the distal fragment. We did percutaneous 2-mm K-wire stabilization of the osteotomy and did not use cast immobilization with postoperative offloading of the forefoot. We used anteroposterior and lateral foot standing X-rays, visual analog scale (VAS), and American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale for the clinical assessment at 18 months' follow-up.

RESULTS

Preoperatively, mean hallux valgus angle was 33.9 degrees; intermetatarsal angle, 14.8 degrees; VAS, 8.9; and AOFAS, 37.0. At follow-up period, hallux valgus angle was 14.2; intermetatarsal angle, 9.7; VAS, 2.6; and AOFAS, 90.7. The average first metatarsal shortening was 2.7 mm. No transfer metatarsalgia was noted at 18 months' follow-up. We found 1 superficial infection, but all patients were satisfied.

CONCLUSIONS

The mini-invasive Mitchell-Kramer method was indicated in mild to moderate hallux valgus deformity. Cast immobilization was unnecessary, and full weightbearing was allowed early. Using the minioscillating saw allowed for reduced surgical exposure. The technique of the osteotomy also allowed for rotational stability of the osteotomy.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Minimally invasive reconstruction of chronic achilles tendon ruptures using the ipsilateral free semitendinosus tendon graft and interference screw fixation

BACKGROUND

Achilles tendon ruptures represent more than 40% of all tendon ruptures requiring surgical management. About 20% of acute Achilles tendon tears are not diagnosed at the time of injury and become chronic, necessitating more complicated management than fresh injuries. Several techniques for the reconstruction of chronic tears of the Achilles tendon have been described, but the superiority of one technique over the others has not been demonstrated.

HYPOTHESIS

Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft will result in improvement of the overall function with a low rate of complications.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2008 and 2010, the authors prospectively enrolled 28 consecutive patients (21 men and 7 women; median age, 46 years) with chronic closed ruptures of the Achilles tendon who had undergone reconstruction with a free semitendinosus tendon graft. They assessed the Achilles tendon Total Rupture Score (ATRS), maximum calf circumference, and isometric plantarflexion strength before surgery and at the last follow-up. Outcome of surgery and rate of complications were also recorded. The median follow-up after surgery was 31.4 months.

RESULTS

The overall result of surgery was excellent/good in 26 (93%) of 28 patients. The ATRS improved from 42 (range, 29-55) to 86 (range, 78-95) (P < .0001). In the operated leg, the maximum calf circumference and isometric plantarflexion strength were significantly improved after surgery (P < .0001); however, their values remained significantly lower than those of the opposite side (P < .0001). All patients were able to walk on tiptoes and returned to their preinjury working occupation. No infections were recorded.

CONCLUSION

Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft provides a significant improvement of symptoms and function, although calf circumference and ankle plantarflexion strength do not recover fully.

Laparoscopic surgery for colon cancer

Colon cancer is a major problem in Western countries and complete surgical resection is the main treatment. Since its introduction the laparoscopic approach has been used to achieve bowel resection with a better postoperative course and better aesthetic outcomes. Initial concerns about the radicality of the resection and the oncologic outcomes have been overcome in the last decade. All over the world large trials have been conducted to compare the laparoscopic approach and the traditional laparotomic one. A review of literature has been conducted to find evidence about this issue, revealing 24 relevant trials. The laparoscopic approach showed short-term benefits without compromising oncological safety. However intraoperative complication rates during laparoscopic colon resections seem to be increased, mainly due to the increased rate of intraoperative bowel injury. This finding confirms a great need for training and a wide learning curve for the surgeon. Our review supports the continued use of laparoscopic surgery in patients with colon cancer.

Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach

The anterior mini-invasive (MI) approach to performing total hip arthroplasty (THA) is associated with less soft tissue damage and shorter postoperative recovery than other methods. Our hospital recently abandoned the traditional lateral Hardinge (LH) approach in favour of this new method. We compared the first 100 patients operated after the changeover to the new method (MI group) to the last 100 patients operated using the traditional method (LH group). Clinical and radiological parameters and complications were recorded pre- and postoperatively and the collected data of the two groups were statistically compared. There were no statistically significant differences between either group with regard to patient demographics or procedural data, placement of the femur component, postoperative leg discrepancy, prosthesis dislocation, blood transfusion, or postoperative dislocation of the components. The MI group had a significantly longer operating time, more bleeding, higher rate of nerve damage, and a higher percentage of acetabular component malposition whilst having a significantly shorter hospital stay and significantly fewer infections of the operative site in comparison to the LH group. Additionally, and perhaps most worrying was the clinically significant increase in intraoperative femur fractures in the MI group. The changeover to the anterior mini-invasive approach, which was the surgeons' initial experience with the MI technique, resulted in a drastic increase in the number of overall complications accompanied by less soft tissue damage and a shorter period of rehabilitation. Our results suggest that further analysis of this surgical MI technique will be needed before it can be recommended for widespread adoption.