Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Acute Esophageal Necrosis as a Rare Complication of Metabolic Acidosis in a Diabetic Patient: A Case Report

BACKGROUND Acute esophageal necrosis, or Gurvits syndrome, is a rare clinical process often secondary to a systemic low-flow state. It can be caused by several medical conditions, and it is thought to arise from a combination of impaired mucosal barrier and chemical and ischemic insults to the esophagus. Acute esophageal necrosis usually presents with severe complications due to delayed diagnosis and only rarely has surgical indications. We present a case of Gurvits syndrome, presumably triggered by metabolic acidosis in a diabetic patient. CASE REPORT A 61-year-old man with history of hypertension and type 2 diabetes mellitus treated with metformin, canagliflozin, glimepiride, and pioglitazone came to our attention with persistent vomiting, odynophagia, chest pain after each meal, and progressive weight loss. Arterial blood analysis showed mild metabolic acidosis, while the first esophagogastroduodenoscopy performed revealed a circumferential black appearance of the esophageal mucosa, as in concentric necrosis of the distal esophagus with possible fungal superinfection. Brushing cytology confirmed the infection by Candida spp. and the patient was treated with intravenous fluconazole. The second esophagogastroduodenoscopy, performed after 2 weeks, showed almost complete healing of the esophageal mucosa; in this case, biopsy confirmed mucosal ischemia and necrosis, without showing deep impairment of the mucosa by fungal agents. CONCLUSIONS Due to its high lethality, often caused by the underlying medical diseases, acute esophageal disease should be considered in the differential diagnosis of digestive symptoms, even without upper gastrointestinal bleeding. Prompt diagnosis and treatment of contextual collateral conditions can help clinicians to avoid the worst outcomes of the disease. Among the causative factors of metabolic acidosis leading to esophageal necrosis we recognized metformin and dapagliflozin.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

Predictive Factors of Recurrence After Laparoscopic Incisional Hernia Repair: A Retrospective Multicentre Cohort Study

Background: The main purpose of this study was to analyze patient-related factors that may influence the risk of hernia recurrence following laparoscopic incisional hernia repair (LIHR), including the potential role of chosen materials. Materials and Methods: A multicenter, retrospective cohort study was conducted on all patients who were aged >18 years and who underwent elective laparoscopic incisional hernia mesh repair at the Departments of Surgery of the S. Anna University Hospital in Ferrara and Sassuolo Hospital in Modena, Italy. Exclusion criteria were as follows: patients undergoing an open or emergency incisional hernia repair or with primary ventral hernia. All hernia and operative variables that may favor hernia recurrence were collected and analyzed. Follow-up was conducted through a standardized telephone interview, followed by an outpatient visit and diagnostic imaging if needed. Results: From September 2002 to September 2017, 312 consecutive patients underwent elective laparoscopic incisional hernia mesh repair. At a mean 22-month follow-up, 273 patients presented no recurrence of incisional hernia and 39 had relapsed. Intra- and postoperative complications were similar between groups. Unadjusted Cox regression analysis showed a statistically significant association between both the partially absorbable mesh (P < .0001) and absorbable tacks (P = .001) and recurrence, while after adjusting for potential confounders, only the partially absorbable mesh was significantly associated with recurrence (P = .007). Conclusions: The laparoscopic approach may be considered safe for incisional hernia mesh repair. In this multicenter, retrospective cohort study, the use of a partially absorbable mesh in LIHR was the only predictor of hernia recurrence. The partially absorbable mesh that was investigated, however, has been withdrawn from the market.

Swab test in biological fluids as predictor of COVID-19 transmission risk during surgery: a prospective cross-sectional study from an Italian COVID center

BACKGROUND

The contamination of body fluids by Severe Acute Respiratory Syndrome Coronavirus 2 during surgery is current matter of debate in the scientific literature concerning CoronaVIrus Disease 2019. Surgical guidelines were published during the first wave of the COVID-19 pandemic and recommended to avoid laparoscopic surgery as much as possible, in fear that the chimney effect of high flow intraperitoneal gas escape during, and after, the procedure would increase the risk of viral transmission.

AIM

The aim of this study was to evaluate the possibility of SARS-CoV-2 transmission during surgery by searching for viral RNA in serial samplings of biological liquids.

METHODS

This is a single center prospective cross-sectional study. We used a real-time reverse transcriptase (RT) polymerase chain reaction (PCR) test to perform swab tests for the qualitative detection of nucleic acid from SARS-CoV-2 in abdominal fluids, during emergency surgery and on the first post-operative day. In the case of thoracic surgery, we performed a swab test of pleural fluids during chest drainage placement as well as on the first post-operative day.

RESULTS

A total of 20 samples were obtained: 5 from pleural fluids, 13 from peritoneal fluids and two from biliary fluid. All 20 swabs performed from biological fluids resulted negative for SARS-CoV-2 RNA detection.

CONCLUSION

To date, there is no scientific evidence of possible contagion by laparoscopic aerosolization of SARS-CoV-2, neither is certain whether the virus is effectively present in biological fluids.

COVID-19: identifying the main outcome predictors. A retrospective cohort study in Northern Italy

OBJECTIVE

The need for efficient drugs and early treatment of patients with SARS-CoV-2 infection developing COVID-19 symptoms is of primary importance in daily clinical practice and it is certainly among the most difficult medical challenges in the current century. Recognizing those patients who will need stronger clinical efforts could effectively help doctors anticipate the eventual need for intensification of care (IoC) and choose the best treatment in order to avoid worse outcomes.

PATIENTS AND METHODS

We enrolled 501 patients, consecutively admitted to our two COVID hospitals, and collected their clinical, anamnestic and laboratory data on admission. The aim of this retrospective study was to identify those data that are strictly associated with COVID-19 outcomes (IoC and in-hospital death) and that could somehow be intended as predictors of these outcomes. This allowed us to provide a "sketch" of the patient who undergoes, more often than others, an intensification of care and/or in-hospital death.

RESULTS

Males were found to have a double risk of needing an IoC (OR=2.11) and a significant role was played by both the PaO2/FiO2 ratio on admission (OR=0.99) and serum LDH (OR=1.01). The main predictors of in-hospital death were age (OR=1.08) and the PaO2/FiO2 ratio on admission (OR=0.99).

CONCLUSIONS

Male patients with high serum LDH on admission are those who undergo more often an intensification of care among COVID-19 inpatients. Both age and respiratory performances on admission modify the prognosis within the hospitalization period.

The Berne-Donovan technique for diverticulization of a severe lateral non-traumatic duodenal fistula

BACKGROUND

The duodenal «diverticulization» is a surgical technique described by Berne and colleagues in 1968 for the treatment of combined duodenal pancreatic injuries. It consisted of closure of the duodenal injury by suture and tube duodenostomy, gastric antrectomy with end-to-side isoperistaltic Billroth II gastrojejunostomy, and abdominal drainage. As evidenced from the literature in few reports, this technique has also been adopted for lateral duodenal lacerations in non traumatic conditions. Most biliary disease may be responsible for duodenal injury.

CASE PRESENTATION

Herein, we describe the application of this emergency technique for the treatment of a wide lateral duodenal laceration discovered intra-operatively during laparoscopic cholecystectomy for acute cholecystitis. A comprehensive critical review of the different surgical methods proposed for duodenal protection in case of severe duodenal lesions has been performed and discussed.

CONCLUSION

Duodenal injuries represent a challenging condition, especially for surgeons with limited experience in this field. The key-message of this report is to consider emergency surgical techniques in difficult unexpected intra-operative situations which may occur during routine surgical practice.

KEY WORDS

Duodenal diverticulization, Duodenal fistula, Laparoscopic cholecystectomy, Surgical repair.

LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery

OBJECTIVE

To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery.

SUMMARY BACKGROUND DATA

Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological.

METHODS

A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL.

RESULTS

There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL.

CONCLUSIONS

This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.

COVID-19 inpatients with gastrointestinal onset: sex and care needs' differences in the district of Ferrara, Italy

Background

COVID-19 is characterized by interstitial pneumonia, but a presentation of the disease with digestive symptoms only may occur.

This work was aimed at evaluating: (1) the prevalence of presentation with digestive symptoms only in our cohort of COVID-19 inpatients; (2) differences between patients with and without gastrointestinal onset; (3) differences among males and females with gastrointestinal presentation; (4) outcomes of the groups of subjects with and without gastrointestinal onset.

Method

We retrospectively divided the patients hospitalized with COVID-19 into two groups: (1) the one with digestive symptoms (DSG) and (2) the other without digestive symptoms (NDSG). We compared the subjects of DSG with those of NDSG and males with females in the DSG group only, in terms of demographics (age, sex), inflammation and organ damage indexes, length of stay, in-hospital and 100-day mortality.

Results

The prevalence of gastrointestinal symptoms at presentation was 12.5%. The DSG group showed a prevalence of females, and these tended to a shorter hospital stay; DSG patients were younger and with a higher load of comorbidities, but no differences concerning inflammation and organ damage indexes, need for intensification of care, in-hospital and 100-day mortality were detected. Among DSG patients, males were younger than females, more comorbid, with higher serum CRP and showed a longer length of hospital stay. Survival functions of DSG patients, in general, are more favourable than those of NDSG if adjusted for sex, age and comorbidities.

Conclusions

(1) The prevalence of gastrointestinal presentation among hospitalized COVID-19 patients was 12.5%; (2) DSG patients were on average younger, more comorbid and with a prevalence of females, with a shorter hospital stay; (3) in the DSG group, males had a higher Charlson Comorbidity Score and needed a longer hospital stay; (4) DSG subjects seem to survive longer than those of the NDSG group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06476-y.

Impact of Covid-19 on surgical activities and personnel: lessons for the future

BACKGROUND

Covid-19 pandemic has impacted professional, economic and social activities. In the surgical field, it has brought changes to operating activities, the organization of workforces, the protection measures for patients and personnel against possible intraoperative transmissions as well as training young surgeons. This study intends to assess the extent of this impact in our institution.

METHODS

The patients operated on in nine Operating Units(OUs) in the period February 1 - March 31 2020 with follow-ups on April 30 2020 were evaluated both retrospectively and prospectively. Organizational, clinical and impact parameters on staff were evaluated.

RESULTS

Of the 833 consecutive admitted patients, 742 were operated on ,705 of whom were recruited for the study. Compared to the same period in 2019 there was a decrease in the number of operations (742 compared to 1187), similar use of intensive care unit (ICU), a diagnostic activity only for symptomatic patients, heterogeneity in organizational behaviors, an impact on staff who highlighted concerns about getting sick or passing the infection on to others (87.64%) or their family members (75.14%).

CONCLUSIONS

The study made it possible to detect the need to make significant changes in the clinical, organizational and teaching fields, for which some operational proposals are suggested.

Enhanced Recovery Program in Laparoscopic Colorectal Surgery: An Observational Controlled Trial

Background: Most of the evidence for enhanced recovery programs (ERPs) in colorectal surgery relies on nonrandomized studies with control groups either historical or operated on at different facilities. The aim of this study was to investigate ERP in coeval groups admitted in different wards at the same hospital. Materials and Methods: A prospective cohort of consecutive patients (n = 100) undergoing elective laparoscopic colorectal resection completing a standardized ERP (ERP group) was compared with patients (n = 100) operated with traditional perioperative care in the same period at the same institution (non-ERP group). The two groups were located in separate wards and shared the same anesthesiologists. The exclusion criteria were: >80 years old, American Society of Anesthesia (ASA) IV, metastatic disease, and inflammatory bowel disease. The primary outcome was hospital length of stay (LoS), used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, readmission rate, mortality, and protocol adherence. Results: The ERP group protocol adherence was 81%. The LoS was significantly reduced in the ERP group (4 versus 7 days). The number of 30-day postoperative complications was lower in the ERP group (P < .001). No increase was found in 30-day readmission or mortality. Conventional perioperative protocol was the only predictor of any postoperative complication and, together with male sex and age 65-74 years old, was the only factor associated with prolonged LoS. Conclusion: Implementing a colorectal ERP is feasible, safe, and efficient for functional recovery, but high protocol adherence is needed. Following traditional perioperative care is associated with more postoperative complications and prolonged LoS.

Risks of COVID-19 transmission in blood and serum during surgery A prospective cross-sectional study from a single dedicated COVID-19 center

The present pandemic caused by the SARS COV-2 coronavirus is still ongoing, although it is registered a slowdown in the spread for new cases. The main environmental route of transmission of SARS-CoV-2 is through droplets and fomites or surfaces, but there is a potential risk of virus spread also in smaller aerosols during various medical procedures causing airborne transmission. To date, no information is available on the risk of contagion from the peritoneal fluid with which surgeons can come into contact during the abdominal surgery on COVID-19 patients. We have investigated the presence of SARS-CoV-2 RNA in the peritoneal cavity of patients affected by COVID-19, intraoperatively and postoperatively. KEY WORDS: Covid-19, Laparotomy, Surgery.

Laparoscopic versus open transverse-incision right hemicolectomy: a retrospective comparison study

BACKGROUND

The optimal surgical approach to right colon cancer is still under debate. The aim of the present study was to compare the short- and long-term outcomes of laparoscopic and transverse-incision open approaches to right hemicolectomy for colon cancer.

METHODS

Data on 99 adult patients with right-side colon cancer undergoing either laparoscopic or open transverse-incision right hemicolectomy at two different university hospitals, between January 2013 and December 2016, were retrospectively reviewed. Data concerning patients' characteristics, operative details and post-operative recovery were retrieved from prospective databases and analysed.

RESULTS

Forty-nine subjects were operated on laparoscopically, while 50 through an open transverse incision. Operating time was significantly longer in the laparoscopic group compared with the open group (182 versus 105 min; P < 0.01). Patients treated laparoscopically had a shorter time to first bowel movement, while time to resume a normal diet and post-operative length of hospital stay were comparable in between groups. The median number of lymph nodes harvested was higher in the laparoscopic group (25.6 versus 18.6; P < 0.01), but no significant difference in overall survival between groups was detected. At long-term follow-up, the incidence of incisional hernia was higher in the laparoscopic group as compared to the open group (24.5% versus 0%; P = 0.0002).

CONCLUSION

Our results show that laparoscopic right hemicolectomy when compared to the transverse-incision open procedure may guarantee the same oncological radicality, but short-term functional benefits are still unclear. Randomized control studies are warranted to better clarify the comparison of these two approaches for right-sided colon cancers.

A rare case of ileo-ileal intussusception due to a bleeding lipomatous mass treated by laparoscopic ileal resection

INTRODUCTION

Adult intussusception is a rare cause of bowel obstruction with atypical presentation. It can be associated with primary or secondary intestinal tumors and, rarely, with lipomatous masses.

CASE REPORT

We report the case of a 69-year old man presenting with a history of gastrointestinal bleeding and anemia. Upper and lower endoscopies were negative for bleeding. On abdominal contrast enhanced computerized tomography (CT) scan, a trans-omental hernia in the right lower abdominal quadrant was diagnosed with no active bleeding or evidence of tumor. On exploratory laparoscopy we detected an ileo-ileal intussusception caused by a submucosal mass in the distal ileum, which was reduced and we then performed a segmental resection of the involved small bowel tract. The patient fully recovered by postoperative day 3 when he was discharged home. Final pathology confirmed an ileal lipoma.

CONCLUSION

Ileal intussusception caused by lipoma is a rare condition, which can be diagnosed with endoscopy, barium enema, and abdominal ultrasound or CT scanning, but preoperative diagnosis may be difficult. The treatment of choice is the reduction of the intussusception and the resection (laparoscopic or open) of the involved tract.

KEY WORDS

Intussusception, Lipoma, Ileum, Laparoscopy, Bleeding.

Upregulation of the alternative splicing factor NOVA2 in colorectal cancer vasculature

Background

Tumor-specific isoforms generated by alternative splicing (AS) are demonstrated to contribute to tumor progression and can represent potential biomarkers. NOVA2 is an AS factor that in physiological conditions regulates endothelial cells' (ECs) polarity and vessel lumen maturation, likely by mediating AS of apical-basal polarity regulators. However, NOVA2 expression in tumor ECs and its regulation have never been investigated.

Methods

To elucidate this, 40 colorectal cancer patients were enrolled and NOVA2 expression was investigated by immunohistochemistry in samples bearing both the normal mucosa and the tumor tissue.

Results

NOVA2 was found expressed in ECs of tumor vasculature and, importantly, it was upregulated in tumor ECs with respect to normal mucosa ECs in all cases (P<0.001). The same samples analyzed by immunohistochemistry for the expression HIF1α, a marker of hypoxia, showed a positive and significant association with NOVA2 levels (P=0.045). Of note, NOVA2 was upregulated by hypoxia also in an in vitro ECs model.

Conclusion

Our results provide, for the first time, evidence of NOVA2 expression and upregulation in tumor ECs and highlight hypoxia as a potential regulatory factor. These findings open a completely new perspective to study tumor vasculature and to uncover NOVA2 as a potential source of biomarkers and therapeutic targets based on AS isoforms.

Laparoscopic versus open incisional hernia repair: a retrospective cohort study with costs analysis on 269 patients

PURPOSE

To compare clinical outcomes and institutional costs of elective laparoscopic and open incisional hernia mesh repairs and to identify independent predictors of prolonged operative time and hospital length of stay (LOS).

METHODS

Retrospective observational cohort study on 269 consecutive patients who underwent elective incisional hernia mesh repair, laparoscopic group (N = 94) and open group (N = 175), between May 2004 and July 2014.

RESULTS

Operative time was shorter in the laparoscopic versus open group (p < 0.0001). Perioperative morbidity and mortality were similar in the two groups. Patients in the laparoscopic group were discharged a median of 2 days earlier (p < 0.0001). At a median follow-up over 50 months, no difference in hernia recurrence was detected between the groups. In laparoscopic group total institutional costs were lower (p = 0.02). At Cox regression analysis adjusted for potential confounders, large wall defect (W3) and higher operative risk (ASA score 3-4) were associated with prolonged operative time, while midline hernia site was associated with increased hospital LOS. Open surgical approach was associated with prolongation of both operative time and LOS.

CONCLUSIONS

Laparoscopic approach may be considered safely to all patients for incisional hernia repair, regardless of patients' characteristics (age, gender, BMI, ASA score, comorbidities) and size of the wall defect (W2-3), with the advantage of shorter operating time and hospital LOS that yields reduced total institutional costs. Patients with higher ASA score and large hernia defects are at risk of prolonged operative time, while an open approach is associated with longer duration of surgical operation and hospital LOS.

Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients

BACKGROUND

Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy.

THE AIMS OF OUR STUDY WERE

(1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy.

METHODS

This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed.

RESULTS

The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94).

CONCLUSIONS

Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

Preoperative endoscopic tattooing to mark the tumour site does not improve lymph node retrieval in colorectal cancer: a retrospective cohort study

BACKGROUND

A direct correlation between number of lymph nodes retrieved and evaluated after a colectomy for colorectal cancer and survival of the patient has been reported, and consensus guidelines recommend to assess at least 12 lymph nodes for adequate staging. Many factors (i.e., patients' and tumour characteristics, surgeon, and pathologist) may influence the evaluation of the presence of neoplastic disease in lymph nodes as well as the total number of lymph nodes examined. Preoperative endoscopic tattooing to mark the site of the tumour has recently been suggested to facilitate the retrieval of lymph nodes in colorectal specimens. The aim of this study was to investigate its association with adequate lymphadenectomy (≥12 nodes) after colorectal resection for cancer.

RESULTS

All patients undergoing elective colorectal resection for cancer between 2009 and 2011 at the S. Anna University Hospital in Ferrara, Italy (N = 250) were retrospectively divided into two cohorts according to whether ink tattooing to mark the tumour site was performed during preoperative colonoscopy. The two cohorts were comparable regarding age, gender, body mass index, tumour location and size, TNM staging, and DNA microsatellite instability-high status. No difference between the tattoo (N = 107) and control (N = 143) groups could be detected in the rate of adequate lymphadenectomies performed (78% vs. 79%, p = 0.40). All factors known to influence lymph nodes retrieval from colorectal specimen were specifically evaluated. Rectal and colonic cancers were analysed together and separately. Full adjusted logistic regression analysis in patients who underwent colonic resection showed that right hemicolectomy (OR 4.72; CI95% 1.09-20.36) was the only factor associated to adequate lymphadenectomy. No association between ink tattooing performed preoperatively to mark the site of the tumour and adequate lymphadenectomy after colorectal resection was found with logistic regression analysis.

CONCLUSION

This study shows that preoperative ink tattooing utilized to mark the site of the tumour does not improve adequate lymphadenectomy and lymph nodes yield from colorectal cancer specimens. Further studies are therefore needed to determine if preoperative colonoscopic tattooing to mark the tumour site can refine staging.

Radio-guided selective compartment neck dissection improves staging in papillary thyroid carcinoma: a prospective study on 345 patients with a 3-year follow-up

BACKGROUND

Prospective uncontrolled study to investigate in papillary thyroid carcinoma (PTC) patients: (1) Distribution of lymph node metastases within the neck compartments, (2) factors predicting lymph nodes metastases, and (3) disease recurrence after thyroidectomy associated with radio-guided selective compartment neck dissection (RSCND).

METHODS

We studied 345 consecutive PTC patients operated on between February 2004 and October 2011 at the S. Anna University Hospital, Ferrara (Italy). Patients with cervical lymph node metastases on preoperative ultrasonography and fine needle aspiration cytology were excluded. All patients underwent total thyroidectomy associated with SLN identification followed by RSCND in the SLN compartment, without SLN frozen section.

RESULTS

In patients with lymph node metastases, metastatic nodes were not in the central neck compartment in 22.6% of the cases. The presence of infiltrating or multifocal PTC was a predicting factor for lymph nodes metastases. The median follow-up was 35.5 months. RSCND was associated with a false-negative rate of 1.1%, a persistent disease rate of 0.6%, and a recurrent disease rate of 0.9%. The permanent dysphonia rate was 1.3%.

CONCLUSION

RSCND associated with total thyroidectomy may improve: (1) the locoregional lymph node staging, and (2) the identification of the site of lymphatic drainage within the neck compartments. Thus, considering the high false-negative rate of sentinel lymph node biopsy (SLNB), a radio-guided technique in PTC patients may guide the lymphadenectomy (ie, RSCND) to increase the metastatic yield and improve staging of the disease rather than avoid prophylactic lymphadenectomy (ie, SLNB).

Strangulated adenoma of the liver: a unique cause of acute abdomen

Hepatic adenomas are uncommon benign tumours of the liver which may eventually present with acute onset following rupture of the lesion and haemorrhage. We present here a unique case of strangulated adenoma of the liver presenting as acute abdomen. A 27-year-old woman taking oral contraceptives, presented to the emergency department with abdominal pain, palpable abdominal mass, fever, and neutrophilia. An abdominal ultrasound showed a 3-cm hepatic nodule and an 11-cm mesogastric mass. Computed tomography of the abdomen revealed a 2.3-cm liver adenoma and a 13-cm pedunculated mass of the liver showing no contrast enhancement suggestive of pedicle torsion with ischemia of the mass. The patient underwent an emergent open resection of the strangulated liver mass, she recovered without complications, and was discharged home after three days. Final pathology confirmed an hepatocellular adenoma with areas of necrosis and hemorrhage. The clinical significance of the disease is discussed.

The surgical treatment of paraesophageal hernias

Paraesophageal hernias account for about 5 to 10% of all hiatal hernias. The surgical approach to these hernias has radically changed over the last 15 years, as mostly patients who are symptomatic are operated on nowadays, and preferably by a laparoscopic approach rather than by laparotomy or thoracotomy. We reviewed the surgical repair of paraesophageal hernias, focusing particularly on the operative approach and technique.

Enhanced recovery after surgery (ERAS) strategies: possible advantages also for head and neck surgery patients?

Enhanced recovery after surgery (ERAS) programs have recently been developed in order to reduce morbidity, improve recovery, and shorten hospital stays of surgical patients. Since the 1990 s, ERAS programs have been successfully applied in many centres, especially in northern Europe and America, to perioperative management for colorectal surgery, vascular surgery, thoracic surgery, and then also to urological and gynaecologic surgery. Purpose of this paper is to evaluate and discuss the very recent introduction of ERAS programs also in head and neck surgery. Embase and Pubmed database searches were performed for relevant published studies. There are still no reports concerning the results of the application of ERAS protocols in the head and neck field. ERAS programs, however, could offer also to head and neck surgery patients an advantage in terms of fastening recovery, reducing hospital stay, and favouring early return to daily activities after hospital discharge. Therefore, the investigation of specific ERAS protocol in head and neck surgery patients should be encouraged.

Unusual presentation and treatment of biliary ileus with long term follow up: case report and review of the literature

Gallstone ileus is a rare complication of cholelithiasis. It accounts for 25% of nonstrangulated small bowel obstructions in patients over the age of 65 years. The morbidity and mortality rate of gallstone ileus remains very high, partly because of misdiagnosis or delayed diagnosis. The two surgical options are: a) enterolithotomy with removal of impacted stone, cholecystectomy, and fistula repair at the same surgical operation (i.e., "one-stage" procedure) and b) enterolithotomy with stone extraction followed or not by elective biliary surgery. The latter is the most popular surgical approach, whereas enterolithotomy combined with cholecistectomy and fistulectomy is indicated only in selected cases. In this article, a case of biliary ileus with unusual presentation treated by entherolithotomy alone with long term follow up is described, and the literature on this subject is reviewed and discussed.

Infiltrating lobular carcinoma of the breast presenting as gastrointestinal obstruction: a mini review

One in twelve American women will develop breast cancer, with infiltrating lobular carcinoma (ILC) comprising approximately 15% of these cases. The incidence of ILC has been increasing over the last several decades. It has been hypothesized that this increase is associated with combined replacement hormonal therapy. Although pathologically distinct from infiltrating ductal carcinoma (IDC), ILC is treated in the same manner as IDC. However, ILC demonstrates significantly different patterns of late local recurrence and distant metastasis. The incidence of extra-hepatic gastrointestinal metastases is reported to be 6% to 18%, with stomach being most common. Herein, we present a brief review of the literature and a typical case involving ILC initially presenting as a small bowel obstruction. Evidence suggests that the late clinical patterns of ILC are distinctly separate from IDC and physicians need be cognizant of its late local recurrence and unique late metastatic pattern. Different follow up strategy should be entertained in patients with ILC.

Importance of a multidisciplinary approach for the treatment of Barrett's esophagus

Barrett's esophagus is a consequence of gastroesophageal reflux disease. Today, it is the most common cause of esophageal adenocarcinoma. Cancer is usually the end results of a cascade of events whereby metaplasia changes into low- and high-grade dysplasia and eventually cancer. Today, we have the unique opportunity to block this cascade and avoid the development of esophageal cancer. A multidisciplinary approach with a team composed of radiologists, gastroenterologists, pathologists, and surgeons allows individualization of care and the best results.

Fast track postoperative management after elective colorectal surgery: a controlled trail

In the attempt to reduce postoperative complications and costs and improve outcomes, the concept of fast track surgery has been proposed. Improvements in anesthesia techniques and a better understanding of the pathophysiologic events occurring during and after surgery have made it possible. A group of patients undergoing colorectal resections with a fast track approach were investigated; specifically, the effects on postoperative morbidity, resumption of intestinal function, and duration of hospitalization. Fifty patients were managed according to a protocol, which included epidural analgesia, early ambulation, and oral feeding (fast track group); they were compared with 50 patients managed with a different protocol: no epidural analgesia, early ambulation, and early oral diet (control group). Primary outcome end-points reported include morbidity, time to passage of flatus and stool, and length of hospital stay. Fourteen complications occurred in the fast track group and 13 in the control group (P = not significant (NS)). Resumption of intestinal function occurred after 3 days, and length of hospital stay was 5 days in the fast track group compared with 4 and 7 days respectively in control patients (P = NS, P < 0.01). Patients undergoing elective colorectal resections can be managed safely with fast track protocols reducing hospital stay.

Fast Track Postoperative Management after Elective Colorectal Surgery: A Controlled Trail

In the attempt to reduce postoperative complications and costs and improve outcomes, the concept of fast track surgery has been proposed. Improvements in anesthesia techniques and a better understanding of the pathophysiologic events occurring during and after surgery have made it possible. A group of patients undergoing colorectal resections with a fast track approach were investigated; specifically, the effects on postoperative morbidity, resumption of intestinal function, and duration of hospitalization. Fifty patients were managed according to a protocol, which included epidural analgesia, early ambulation, and oral feeding (fast track group); they were compared with 50 patients managed with a different protocol: no epidural analgesia, early ambulation, and early oral diet (control group). Primary outcome end-points reported include morbidity, time to passage of flatus and stool, and length of hospital stay. Fourteen complications occurred in the fast track group and 13 in the control group ( P = not significant (NS)). Resumption of intestinal function occurred after 3 days, and length of hospital stay was 5 days in the fast track group compared with 4 and 7 days respectively in control patients ( P = NS, P < 0.01). Patients undergoing elective colorectal resections can be managed safely with fast track protocols reducing hospital stay.

Colonoscopy surveillance in asymptomatic subjects with increased risk for colorectal cancer: clinical evaluation and cost analysis of an Italian experience

The aim of this study was three-fold: (a) to present a surveillance plan for colorectal cancer prevention with colonoscopy, focused on first-degree relatives of colorectal cancer patients in the province of Ferrara (Italy); (b) to analyse the cost of colonoscopy at the University Hospital of Ferrara; and (c) to analyse the cost of the surveillance plan in our province. In January 2000, in the province of Ferrara, following a campaign of public sensitization, a plan of surveillance with colonoscopy was started, addressing the population at an increased risk for colorectal cancer (i.e. over 45-year-old first-degree relatives of patients with either colorectal cancer or adenomatous polyps revealed before 60 years of age). In addition, we estimated the cost of colonoscopy both at the University Hospital of Ferrara and of the surveillance plan. Between January 2000 and October 2003, 585 individuals at increased risk were interviewed. Five hundred and forty-four (94%) accepted to undergo a colonoscopy. By October 2003, 439 (81%) colonoscopies had been performed. Colonoscopy was normal in 330 individuals (75%). In 109 individuals (25%), 144 lesions were found: 35 patients (32%) had hyperplastic polyps, 66 (61%) had adenomas, and eight (7%) adenocarcinomas (six Dukes A, one Dukes B, and one Dukes C stage). Out of a total of 101 adenomas, 68 were tubular adenomas (67%), 24 tubulo-villous adenomas (24%), and nine adenomas with high-grade dysplasia (9%). The cost of colonoscopy at our hospital and the costs of the surveillance plan amounted to euro 130.84 (euro 169.57 with single biopsy) and euro 43,103.66 (euro 42 310.34/year), respectively. These data show (a) the efficacy of colonoscopy in the early diagnosis of colorectal cancer and premalignant lesions in first-degree relatives of colorectal cancer patients; (b) the low cost of colonoscopy at the centre performing the surveillance; and (c) the feasibility of screening and surveillance programmes for colorectal cancer prevention.

Clinical and Therapeutic Importance of Sentinel Node Biopsy of the Internal Mammary Chain in Patients with Breast Cancer: A Single-Center Study with Long-Term Follow-Up

BACKGROUND

We evaluated the incidence of sentinel lymph nodes (SLNs) in the internal mammary chain, calculated the lymphoscintigraphy and surgical detection rates, and evaluated the clinical effect on staging and the therapeutic approach in patients with breast cancer.

METHODS

The study involved 741 women diagnosed with breast cancer eligible for the SLN technique. Lymphoscintigraphy was performed on the day before the operation by peritumoral injection of (99m)Tc-labeled nanocolloid. During the operation, a gamma probe was used to detect the SLN, which was then removed.

RESULTS

A total of 719 SLNs were found in the axillary chain and 72 in the internal mammary chain. Preoperative lymphoscintigraphy showed 107 hot spots in the internal mammary chain, but only 72 SLNs in 65 patients were identified by the gamma probe and then removed with no complications. Of these 65 patients, 10 had a positive internal mammary chain SLN on final pathologic examination, whereas 55 patients had >or=1 negative SLNs on final pathologic analysis. Thirty-five (53%) of 65 patients had also an axillary SLN, but only 5 patients (8%) had a positive SLN on pathologic analysis.

CONCLUSIONS

Evaluation of the SLNs in the internal mammary chain may provide more accurate staging in breast cancer patients. If an internal mammary sampling is not performed, patients may be understaged. This technique may allow better selection of those patients who will be submitted to adjuvant locoregional radiotherapy.

Randomized clinical trial of the effect of preoperative dexamethasone on nausea and vomiting after laparoscopic cholecystectomy

Background

Preoperative dexamethasone may reduce disabling symptoms such as pain, nausea and vomiting after laparoscopic cholecystectomy.

Methods

This was a randomized, double-blind, placebo-controlled trial. Between March and December 2004, 101 patients undergoing laparoscopic cholecystectomy were randomized to receive 8 mg dexamethasone (n = 49) or placebo (n = 52) intravenously before surgery. Six patients were excluded from the study. All patients received a standardized anaesthetic, surgical and multimodal analgesic treatment. The primary endpoints were: first, postoperative nausea, vomiting and pain; second, postoperative analgesic and antiemetic requirements. The pain scores (visual analogue and verbal response scales), the episodes of nausea (verbal response scale) and vomiting were recorded at 1, 3, 6 and 24 h, respectively, after the operation. Analgesic and antiemetic requirements were also recorded.

Results

No apparent drug side-effects were noted. Seven patients (14 per cent) in the treatment group reported nausea and vomiting compared with 24 (46 per cent) in the control group (P = 0·001). In the group of patients treated with dexamethasone, five (10 per cent) required antiemetics versus 23 (44 per cent) of those receiving placebo (P &lt; 0·001). No difference in postoperative pain scores and analgesic requirements was detected between groups.

Conclusion

Preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy, with no side-effects, and may be recommended for routine use.

Thoracoscopic Localization Techniques for Patients With Solitary Pulmonary Nodule and History of Malignancy

BACKGROUND

Our aim was to evaluate the best intrathoracoscopic localization technique in patients with single pulmonary nodule and a history of malignancy.

METHODS

We divided 50 patients in two groups, well matched for diameter and depth of the pulmonary lesion. In 25 patients we performed intrathoracoscopic ultrasound to locate the pulmonary nodule (group A), whereas in the other 25 patients the radio-guided technique was adopted (group B). In both group A and group B, the localization techniques were compared with finger palpation. In group A, 12 nodules were in the left lung and 13 in the right one; in group B, 11 lesions were in the left and 14 in the right lung. In both groups, the distance of the nodule from the pleural surface was 2.6 +/- 0.5 cm (2 to 2.5 cm in 14 patients, and >2.5 cm for the remaining 11). The diameter of the nodule was 1.26 +/- 0.22 (< or =1 cm in 10 patients, and 1 to 1.5 cm in 15) in both groups. All patients underwent thoracoscopic wedge resection, and 10 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy.

RESULTS

In group A, ultrasound localized the nodule in 24 of 25 patients (96%) whereas finger palpation localized it in 19 of 25 (76%; not significant). In group B, both the radio-guided and finger palpation techniques localized the nodule in 20 of 25 patients (80%; not significant). No complications were recorded with the ultrasound technique; however, 10 cases of pneumothorax were detected after the radio-guided technique (p < 0.01).

CONCLUSIONS

Both the ultrasound and radio-guided techniques are accurate to detect solitary pulmonary nodules, but the radio-guided method yields complications as compared with the ultrasound.

Early oral feeding after colorectal resection: a randomized controlled study

BACKGROUND

Nasogastric (NG) intubation is widely used following elective abdominal operations although it is associated with morbidity and discomfort. The present study is a randomised controlled trial on the effect of early oral feeding without NG decompression following elective colorectal resection for cancer.

METHODS

One hundred patients were randomized to group A (NG catheter and fasting until passage of flatus, followed by liquid diet advanced to soft-solid) or group B (no NG tube, clear liquids the day after surgery, followed by soft-solid food). The endpoints were: (i) morbidity; (ii) resumption of intestinal function; (iii) length of hospital stay; and (iv) patients' well being evaluated by short-form health survey [36 items] (SF-36).

RESULTS

Twelve complications occurred in group A (50 patients) and 13 in group B (50 patients) (P = NS). Seven patients developed vomiting in group A as compared to 16 in group B (P < 0.05). Twenty per cent of patients required NG decompression in group B hence 80% did not need NG tubes. Resumption of intestinal function occurred after 4 days, and length of hospital stay was 7 days in both groups. No significant difference was detected between groups (P = NS) in the SF-36 score change before and after the operation.

CONCLUSION

Patients undergoing elective colorectal resection can be managed without postoperative NG catheters, starting oral feeding on the first postoperative day. Albeit, no reduction in postoperative hospital stay or patients' well being could be detected, abolition of postoperative NG intubation with early oral feeding was a safe approach, with only 20% of patients requiring NG decompression because of repeated episodes of vomiting.

[Emergency surgery for complicated colorectal cancer. Retrospective study]

INTRODUCTION

Emergency surgery for the complications of colorectal cancer poses a significant surgical problem with published mortality rates as hight as 25% to 30%. We reviewed the results of the analysis and quantification of the influence of complications on the outcome of the patients who underwent emergency colectomy for colorectal cancer.

MATERIALS AND METHODS

Retrospective study of the clinical features from, a series of 63 patients operated on from 1991 to 1997 (12% of all colorectal cancer operations in the same period). The correlations between complications and cancer stages were estimated by the KW (ANOVA method).

RESULTS

Fifty-three patients underwent colorectal resection for intestinal occlusion (84%), 5 for perforation (8%) and 5 for lower gastrointestinal bleeding (8%). When the cancer complications were correlated to the different cancer stage at operation, the complications rate were 32%, 32%, and 36% in the stage II, stage III, and stage IV, respectively. This data was statistically significant: (KW = 58, p = 0.0001). The overall mortality rate was 8% (5 patients) and the total postoperative morbity rate was 32% (21 patients). The overall 5-year, 3-year, and 1-year survival was 47%, 48%, and 76% respectively.

CONCLUSIONS

Emergency surgery for complicated colorectal cancer can be performed safely with low postoperative morbidity and mortality rate and can be advocated to realize both short and long-term survival rates comparable to elective surgery; the KW test supports the hypothesis that the a complication in the natural history of colorectal cancer doesn't correlate with the stage of disease.

Thoracoscopic Localization Techniques for Patients with a Single Pulmonary Nodule and Positive Oncological Anamnesis: A Prospective Study

INTRODUCTION

Our aim was to evaluate the best intrathoracoscopic localization technique in patients with a single pulmonary nodule and a history of malignancy.

METHOD

We divided 30 patients into two groups, well matched for diameter and depth of the pulmonary lesion. In 15 patients (group A) we performed intrathoracoscopic ultrasound (US) to locate the pulmonary nodule, while in the other 15 patients (group B) intrathoracoscopic radioguided occult lesion localization (ROLL) was used. In both groups, the localization technique was compared to finger palpation. In group A, 6 nodules were in the left lung and 9 in the right; in group B, 7 lesions were in the left and 8 in the right lung. In each group, the distance of the nodule from the pleural surface was 2-2.5 cm in 8 patients, and > 2.5 cm in the remaining 7. In both groups, the diameter of the nodule was </= 1 cm in 6 patients, and 1-1.5 cm in 9 patients. All patients underwent thoracoscopic wedge resection, and 6 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy.

RESULTS

In group A, US localized the nodule in 15 of 15 patients (100%) while finger palpation located the nodule in 11 of 15 (73%) (P = NS). In group B, both ROLL and finger palpation localized the nodule in 12 of 15 patients (80%) (P = NS).

CONCLUSION

Intrathoracoscopic US seems superior to radioguided and finger palpation localization techniques for single pulmonary nodules. Thus, we are now routinely using intraoperative US to identify single pulmonary nodules.

[The ideal length of hospital stay in the surgical treatment of colorectal cancer]

In order to verify the safety of an ideal length of hospital stay (5-6 days) after open colectomy, we reviewed complications after 371 consecutive, elective colorectal resections for cancer at our institution between April 1991 and December 1998. Specifically, age of the patient, length of hospital stay and when the complication was diagnosed were registered. The median postoperative hospital stay was 9 days (range, 4-34 days). No difference in length of hospital stay was detected in patients < or = 65 years old versus > 65 years old (P = NS). All major complications (anastomotic leak, intestinal bleeding, intestinal occlusion, pneumonia, pulmonary embolism, pulmonary edema, stroke, angina pectoris, and fascial dehiscence) were diagnosed before the fifth postoperative day (P < 0.05). Among the minor complications (vomiting, packed red blood cells transfusion, diarrhea, wound infection, urinary tract infection, and pleural effusion), none requiring hospitalization was detected later then 5 days after the operation. We conclude that postoperative length of stay after colorectal resection for cancer can be reduced safely to five to six days after the operation.

[Malignancy: treatment and prognosis of gastrointestinal and pancreatic endocrine neoplasia: retrospective study of a series of 16 cases]

The aim of this study was to review our experience with endocrine tumours of the gastrointestinal tract and pancreas (ETGIP). Between February 1991 and March 2000, sixteen patients with ETGIP were operated on at our institution. Of these patients we reviewed preoperative symptoms, diagnostic techniques (ultrasound, CT, MRI, radiolabelled octreotide scintigraphy, angiography, immunohistochemical study), treatment (surgical operation, neoadjuvant and adjuvant chemotherapy, and radiometabolic therapy) and survival. Nine patients (56%) had a carcinoid tumour, three (19%) an unspecified endocrine tumour, and four (25%) an endocrine tumour associated with a non-endocrine neoplasm. Only five patients (31%) had a preoperative diagnosis of endocrine tumour. Eight patients (50%) had metastatic disease at the time of the operation. All patients without preoperative metastasis (eight patients, 50%) are still alive without recurrent disease, with a mean postoperative survival of 36 months (12-60 months). Of eight patients with metastatic disease, six (75%) died after a mean of 20.5 months (3-60 months) and two (25%) are still alive with the disease after 3 and 6 months, respectively. These data show that presence of metastasis strongly influence survival. Furthermore, survival of patients with metastatic disease seems to be longer as compared to other gastrointestinal tract malignancies. ETGIP are more common and aggressive than previously believed and, therefore, early diagnosis is crucial for cure. Nowadays, however, new diagnostic tools such as radiolabelled octreotide scintigraphy are available for diagnosis and postoperative follow-up. The optimal treatment for ETGIP is a multimodal approach with surgical operation, chemoradiation, radiometabolic, and genetic therapies.

Laparoscopic approach for esophageal achalasia with epiphrenic diverticulum

We report the case of a 65-year-old woman with a 10-year history of dysphagia, regurgitation, cough, and 10-kg weight loss caused by an epiphrenic diverticulum associated with esophageal achalasia managed with a laparoscopic approach. A preoperative barium swallow showed a dilated sigmoid esophagus with a 6-cm epiphrenic diverticulum. Esophageal manometry confirmed the absence of peristalsis in the esophageal body. We performed a laparoscopic diverticulectomy and a 7-cm distal esophageal myotomy with a Dor fundoplication. The postoperative course was uneventful. On the third postoperative day a barium swallow showed no leak, and the patient started oral intake. She was discharged home 5 days after the operation free of symptoms and tolerating a soft diet. Sixteen months after surgery, she was asymptomatic and had gained 8 kg. A barium swallow showed a normal-size esophagus with regular emptying. We reaffirm the feasibility, safety, and efficacy of the laparoscopic diverticulectomy and distal myotomy with Dor fundoplication to manage epiphrenic diverticula resulting from esophageal achalasia.

[Short-stay surgery of inguino-crural hernia]

BACKGROUND

To evaluate the hospital stay, morbidity, and patients' compliance for short stay inguinal hernia repair.

METHODS

Retrospective analysis of 669 patients (594 men and 75 women) who underwent short stay inguinal hernia repair (706 inguinal and 45 femoral repairs) at the Institute of General Surgery, University of Ferrara. Mean age was 60.7 years (range, 18-84 years). The anesthesia was: loco-regional in 495 patients (74%) and general or epidural in 174 (26%).

RESULTS

Mean hospital stay was 1.2 days. Postoperative complications were: three scrotal hematomas, two ischemic orchitis, three prosthetic infections, one local anesthetic intolerance, and three high fever. Eighty-five percent of patients were satisfied of the surgical procedure in short hospital stay. Mean follow-up was 36 months.

CONCLUSIONS

Short hospital stay in inguinal hernia repair is safe, effective, and widely accepted by patients.

Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms

Laparoscopic fundoplication controls heartburn and regurgitation, but the effects on the respiratory symptoms of gastroesophageal reflux disease (GERD) are unclear. Confusion stems from difficulty preoperatively in determining whether cough or wheezing is actually caused by reflux when reflux is found on pH monitoring. To date, there is no proven way to pinpoint a cause-and-effect relationship. The goals of this study were to assess the following: (1) the value of pH monitoring in establishing a correlation between respiratory symptoms and reflux; (2) the predictive value of pH monitoring on the results of surgical treatment; and (3) the outcome of laparoscopic fundoplication on GERD-induced respiratory symptoms. Between October 1992 and October 1998, a total of 340 patients underwent laparoscopic fundoplication for GERD. From the clinical findings alone, respiratory symptoms were thought possibly to be caused by GERD in 39 patients (11%). These 39 patients had been symptomatic for an average of 134 months. They were all taking H2-blocking agents (21%) or proton pump inhibitors (79%). Seven patients (18%) were also being treated with bronchodilators, alone (3 patients) or in combination with prednisone (4 patients). Median length of postoperative follow-up was 28 months. In 23 patients (59%) a temporal correlation was found during 24-hour pH monitoring between respiratory symptoms and episodes of reflux. Postoperatively heartburn resolved in 91% of patients, regurgitation in 90% of patients, wheezing in 64% of patients, and cough in 74% of patients. Cough resolved in 19 (83%) of 23 patients in whom a correlation between cough and reflux was found during pH monitoring, but in only 8 (57%) of 14 of patients when this correlation was absent. Cough persisted postoperatively in the two patients who did not cough during the study. These data show that pH monitoring helped to establish a correlation between respiratory symptoms and reflux, and it helped to identify the patients most likely to benefit from antireflux surgery. Following laparoscopic surgery, respiratory symptoms resolved in 83% of patients when a temporal correlation between cough and reflux was found on pH monitoring; heartburn and regurgitation resolved in 90%.