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

BACKGROUND: Conventional three-access laparoscopic appendectomy (CLA) is currently the gold standard treatment, however, Single-Port Laparoscopic Appendectomy (SILA) has been proposed as an alternative. The aim of this systematic review/meta-analysis was to evaluate safety and efficacy of SILA compared with conventional approach. METHODS: Per PRISMA guidelines, we systematically reviewed randomised controlled trials (RCTs) comparing CLA vs SILA for acute appendicitis. The randomised Mantel-Haenszel method was used for the meta-analysis. Statistical data analysis was performed with the Review Manager software and the risk of bias was assessed with the Cochrane "Risk of Bias" assessment tool. RESULTS: Twenty-one studies (RCTs) were selected (2646 patients). The operative time was significantly longer in the SILA group (MD = 7,32), confirmed in both paediatric (MD = 9,80), (Q = 1,47) and adult subgroups (MD = 5,92), (Q = 55,85). Overall postoperative morbidity was higher in patients who underwent SILA, but the result was not statistically significant. In SILA group were assessed shorter hospital stays, fewer wound infections and higher conversion rate, but the results were not statistically significant. Meta-analysis was not performed about cosmetics of skin scars and postoperative pain because different scales were used in each study. CONCLUSIONS: This analysis show that SILA, although associated with fewer postoperative wound infection, has a significantly longer operative time. Furthermore, the risk of postoperative general complications is still present. Further studies will be required to analyse outcomes related to postoperative pain and the cosmetics of the surgical scar.

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

BACKGROUND: This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a definitive treatment in high-risk patients with acute cholecystitis (AC). MATERIAL AND METHODS: A systematic literature search was performed until December 2022 using the Scopus, Medline/PubMed and Web of Science databases. RESULTS: Seventeen studies have been included with a total of 783,672 patients (32,634 treated with PTGBD vs. 4663 who underwent laparoscopic cholecystectomy, 343 who had open cholecystectomy and 746,032 who had some form of cholecystectomy, but without laparoscopic or open approach being specified). An analysis of the results shows that PTGBD, despite being less invasive, is not associated with lower morbidity with respect to EC (RR 0.77 95% CI [0.44 to 1.34]; I2 = 99%; p = 0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) with respect to the PTGBD group (13.78%) (RR 4.21; 95% CI [2.69 to 6.58]; p < 0.00001); furthermore, the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I2 = 48%; p < 0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; p < 0.00001) were lower in the EC group. CONCLUSIONS: In our systematic review, the majority of studies have very low-quality evidence and more RCTs are needed; furthermore, PTGBD is inferior in the treatment of AC in high-risk patients. The definition of high-risk patients is important in interpreting the results, but the methods of assessment and definitions differ between studies. The results of our systematic review and meta-analysis failed to demonstrate any advantage of using PTGBD over ER as a definitive treatment of AC in critically ill patients, which suggests that EC should be considered as the treatment of choice even in very high-risk patients. Most likely, the inferiority of PTGBD versus early LC for high-risk patients is related to an association of various patient-side factor conditions and the severity of acute cholecystitis.

Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review.

BACKGROUND: The gastroesophageal reflux disease (GERD) worldwide prevalence is increasing maybe due to population aging and the obesity epidemic. Nissen fundoplication is the most common surgical procedure for GERD with a failure rate of approximately 20% which might require a redo surgery. The aim of this study was to evaluate the short- and long-term outcomes of robotic redo procedures after anti-reflux surgery failure including a narrative review. METHODS: We reviewed our 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary, and 11 for revisional surgery. RESULTS: Patients included in the redo series underwent primary Nissen fundoplication with a mean age of 57.6 years (range, 43-71). All procedures were minimally invasive and no conversion to open surgery was registered. The meshes were used in five (45.45%) patients. The mean operative time was 147 min (range, 110-225) and the mean hospital stay was 3.2 days (range, 2-7). At a mean follow-up of 78 months (range, 18-192), one patient suffered for persistent dysphagia and one for delayed gastric emptying. We had two (18.19%) Clavien-Dindo grade IIIa complications, consisting of postoperative pneumothoraxes treated with chest drainage. CONCLUSION: Redo anti-reflux surgery is indicated in selected patients and the robotic approach is safe when it is performed in specialized centers, considering its surgical technical difficulty.

Retroperitoneal and iliopsoas abscess as Crohn's disease onset mimicking a common lumbosciatic pain.

Crohn's Disease (CD) refers to a chronic transmural bowel inflammation affecting a range between 5 and 15 per 100,000 person-years worldwide 1. In patients with stricturing CD, the transmural pattern of inflammation may trigger the development of sinus tracts able to connect to other tissues, leading to the formation of fistulas or abscesses 2. Intra-psoas abscesses are rare, affecting between 0.4-4.3% of patients with CD 3. We present the case of a 36-year-old male with no past medical history except for a two-week worsening lumbosciatalgia not responding to standard nonsteroidal anti-inflammatory drugs, who complained sudden abdominal pain, with right lower abdominal stiffness combined to a severe edema and erythema of the right lower limb, extended from the gluteus down to the knee, involving the anteromedial and posteromedial areas of his thigh. Patient was septic and CT scans revealed a large complex air-fluid collection within the right iliac region, involving terminal ileum, right retroperitoneum and right lateral abdominal wall towards the inner edge of his thigh. Diagnosis of CD was made on histopathology and the patient gained full recovery thanks to a prompt surgical intervention followed by high-dose antibiotic infusion and vacuum-assisted wound closure. Intra-psoas abscesses, albeit rare, are a known manifestation of CD and frequently lead to misdiagnosis because of their rarity and their unusual location easily mimicking other diseases. Therefore, clinician's awareness must be heightened for complicated CD in the setting of intra-psoas abscesses in order to avoid delayed treatment. KEY WORDS: Crohn disease, Psoas abscess, Sciatica, Late onset disorders, Negative pressure Wound therapy.

Rectal perforation and perirectal abscess following stapled hemorrhoidectomy for prolapsed hemorrhoids successfully managed with Endo-SPONGE endoluminal vacuum-assisted wound closure system.

Active drains, which work by negative pressure, are commonly used to drain closed airtight wounds. Higher negative pressure is used in vacuum-assisted wound closure dressings. Gastrointestinal leaks may be difficult to treat by surgical approach because of their association with high morbidity and mortality. Recently, endoscopic approaches have been applied with several degrees of success. Most recently, endoluminal vacuum-assisted wound closure (EVAC) has been employed with high success rates in decreasing both morbidity and mortality. In the present paper, the authors describe the successful use of Endo-SPONGE (B. Braun Medical B.V.) EVAC system therapy to drain an open rectal wound, following a perforation occurred during stapled hemorrhoidectomy.

Laparoscopic mechanical latero-lateral esophagojejunostomy after total gastrectomy for cancer in the elderly: technical notes and results.

BACKGROUND: The realization of an esophagojejunostomy is a critical step in total gastrectomy. Several techniques based on a Roux-En-Y restoration of gastrointestinal continuity were described with similar results. We report our laparoscopic experience in intracorporeal esophagojejunostomy. METHODS: Adults who underwent laparoscopic total gastrectomy for cancer with latero-lateral (functional termino-terminal) Roux en Y intracorporeal esophagojejunostomy with linear stapler from January 2014 to December 2018 were included. Demographics, intra- and postoperative outcomes including 30-day readmissions and mortality were considered. RESULTS: Thirty-two patients were included. Nodal dissection D1 was 16. Median operative time was 280'. Median blood loss was 200 mL. Fluid oral intake is usually resumed on the second postoperative day and soft solid diet is started on the third postoperative day. Three patients had minimal anastomotic leakage and they underwent nonoperative management. Median postoperative stay was 8.5 days. CONCLUSIONS: This technique may improve the ergonomics of esophagojejunostomy creation. The procedure is suitable for experienced laparoscopic surgeons.

An extremely rare finding of goblet cell carcinoid of the appendix. A case report.

Goblet cell carcinoid or carcinoma (GCC) refers to an extremely rare appendiceal tumor usually diagnosed on post-operative histology as an incidental finding. Primary cancers of the vermiform appendix are quite rare, representing less than 1% of all gastrointestinal malignancies. GCCs are considered as a distinct entity of appendiceal tumors, consisting of both epithelial (glandular) and neuroendocrine elements containing goblet cells. This entity tends to be more aggressive than typical carcinoid tumors as it often presents with metastatic disease. Therefore, an early recognition and an appropriate grading is essential. The 5-year overall survival is 14-22% in stage III-IV disease. As a matter of fact, GCC warrants more aggressive surgical and medical (chemotherapy) treatments than typical carcinoid tumors. We, hereby, report a case of a 67-year old male presenting with an acute abdominal obstruction and a severe tenderness predominant in his right lower quadrant, together with an endoscopic and radiological suspect of left colonic malignancy and acute appendicitis. Left hemicolectomy and appendicectomy were performed and pathological specimens revealed a lowgrade adenocarcinoma of the descending colon and a high-grade appendiceal goblet cell carcinoid. Subsequent right hemicolectomy was performed according to the current guidelines. GCCs are more aggressive compared with conventional appendiceal tumors but less aggressive compared with adenocarcinomas and they often present with serosal and mesoappendiceal involvement. The lack of a standardized classification system for GCC and the discrepancies in specific reliable markers are responsible for an insufficient prognostic and predictive value at diagnosis. KEY WORDS: Appendiceal neoplasms, Carcinoid tumor, Colectomy, Goblet cells, Immunochemistry.

A rare finding of Actinomyces odontolyticus abdominal actinomycosis presenting as abdominal wall and pericolic pseudotumoral mass.

Abdominal actinomycosis refers to a rare chronic suppurative infectious occurrence, caused by filamentous Gram-positive microaerophilic and anaerobic bacteria Actinomyces, that may appear as an abdominal mass and/or abscess, feasibly mimicking a malignancy 1,2. Due to its rarity and unspecific clinical evidence, the majority of cases are diagnosed after tissue specimen. We hereby report a case of a 69-year-old patient with a one week worsening abdominal pain and swelling. A large tender palpable mass in the epigastric region was noted on physical exam. An ultrasound-guided drainage followed by a surgical excision approach became both a way to confirm the diagnosis and a therapeutic tool. Diagnosis of actinomycosis was made on histopathology and microbiology. Even though the incidence of actinomycosis has decreased, the abdominal presentation has been observed with increasing frequency 3. KEY WORDS: Actinomycosis, Abdominal wall, Abdominal abscess, foreign-body reaction, Colonic neoplasms.

Amyand's hernia during laparoscopy hernioplasty. Case eport

Amyand's hernia refers to a rare occurrence in which the vermiform appendix, either inflamed or normal, happens to be found in an inguinal hernia sac. Due to its rarity and unspecific clinical evidence, it is most commonly presented as an intra-operative finding. A laparoscopic approach becomes both a way to confirm the diagnosis and a therapeutic tool. Case report: We hereby report a case of a 62-year-old patient presenting with an asymptomatic bilateral inguinal hernia, previously treated on his right side in 2011 with an open approach. The elective laparoscopic surgery, during the right groin exploration, revealed a vermiform appendix, with no signs of inflammation, within the hernia sac. . A prosthetic laparoscopic hernioplasty without appendicectomy was performed and both early outpatient follow-up and 30-day outcome demonstrated excellent recovery. Conclusions: Appendicectomy, when necessary, and primary hernia repair at the same time can be safely performed by laparoscopy which may be considered an advantageous management giving its role in diagnosing, in confirming an Amyand's hernia, in exploring the abdominal cavity and in being a therapeutic tool at the same time(AU)

La hernia de Amyand se refiere a una ocurrencia rara en la que el apéndice vermiforme, ya sea inflamado o normal, se encuentra dentro de un saco inguinal herniario. Debido a su rareza y evidencia clínica inespecífica, se presenta más comúnmente como un hallazgo intraoperatorio. Un abordaje laparoscópico se convierte tanto en una forma de confirmar el diagnóstico como en una herramienta terapéutica. Caso clínico: Presentamos un caso de un paciente de 62 años que presenta una hernia inguinal bilateral asintomática, previamente tratada en su lado derecho en 2011 con un abordaje convencional abierto. La cirugía laparoscópica electiva, durante la exploración de la ingle derecha, reveló un apéndice vermiforme, sin signos de inflamación, dentro del saco de la hernia. Se realizó una hernioplastia laparoscópica protésica sin apendicectomía y tanto el seguimiento ambulatorio temprano como el resultado a 30 días demostraron una excelente recuperación. Conclusión: La apendicectomía, cuando es necesario, y la reparación de la hernia primaria al mismo tiempo se pueden realizar de forma segura por laparoscopia que puede considerarse una gestión ventajosa dando su papel en el diagnóstico, en la confirmación de una hernia de Amyand, explorando la cavidad abdominal y siendo una herramienta terapéutica al mismo tiempo(AU)

Inhibition of platelet function after ocular administration of non-steroidal anti-inflammatory drugs.

INTRODUCTION: The use of topical NSAIDs is frequent in ophthalmology to reduce the local inflammatory reaction resulting from surgical procedures. Ocular use of some drugs was previously found to lead to significant systemic absorption with possible systemic effects. NSAIDs may enhance the hemorrhagic risk of anticoagulant and antiplatelet drugs. Aim of our study was to evaluate the systemic effects of two NSAIDs given by eyedrops on platelet COX-1 and on ex vivo and in vivo platelet activation. MATERIALS AND METHODS: 20 patients planned to undergo cataract surgery were randomized to the use of an ophthalmic solution containing Diclofenac or Indomethacin. Blood was taken at enrollment (baseline) and after 3 days of therapy (1 drop, 4 times a day). Arachidonic Acid (AA)-induced light transmission aggregometry (LTA), PFA-100® C-EPI, circulating platelet P-Selectin expression by flow cytometry and serum and AA-induced TxB2 production were evaluated before and after eyedrop therapy. RESULTS: AA (0.1-0.2 mM)-induced LTA was significantly reduced after ocular indomethacin but not after diclofenac. PFA-100® C-EPI closure time was also significantly prolonged in the indomethacin group but not in the diclofenac group. Circulating platelet P-selectin expression was significantly reduced after treatment with indomethacin compared with diclofenac. Finally, treatment with eyedrop indomethacin, but not with diclofenac, strikingly suppressed AA-induced TxB2 generation, while treatment with diclofenac did not modify it. CONCLUSIONS: Our data show that indomethacin administered by ophthalmic eye drops has a relevant systemic antiplatelet effect. This should be taken into account in patients under concurrent therapy with antiplatelet or anticoagulant agents.