Mesoappendix and appendix stump treatment in laparoscopic appendectomy: a retrospective study in 1084 patients.

BACKGROUND: Laparoscopic appendicectomy (LA) rapresents a standard but questionable approach in the treatment of acute appendicitis. The scope of this study is to show our experience using different methods in the mesoappendix and appendix stump treatment. MATERIALS AND METHODS: A retrospective analysis of all patient with acute appendicitis that underwent to LA was obtained. The results have been analysed compareing the single techniques used in the treatment of mesoappendix and appendix stump. RESULTS: The study included 1084 patients (M=648; F=436; mean age 28,4 years). During laparoscopic procedure we have founded in 296 cases a CAA (27.3%). The rate of conversion to open has resulted 3,2%; the mean operative time was 57,1'; mean postoperative stay was 2,7 days. Eighteen patients have experienced surgical complications. From our data, in the treatment of mesoappendix (Clip =863, bipolar coagulation = 165, stapler = 22) and the appendix stump (endoloop =784; stapler = 265) we found no statistically difference about postoperative stay, and incidence of IAA; the operative time was longer (54,2 vs 66' p<0.05) when the surgeon prefered stapling the appendix stump; but in this group there was a higher incidence of CAA (35.2 % vs 18.7%). CONCLUSIONS: Laparoscopic appendicectomy is safe and effective. We judge that there isn't a better technique than others but various options that should be evaluated taking care about costs, the experience of the surgeon and the degree of inflammation of the appendix.

Oxidative stress impairs endothelial function in nondipper hypertensive patients.

AIMS: Essential hypertension, as well as other established cardiovascular risk factors, is associated with endothelial dysfunction. Hypertensive patients with a nondipper circadian pattern have a greater risk of cerebrovascular and cardiovascular complications in comparison with those with a dipper circadian pattern. In this study, we evaluated the association between nondipper pattern and endothelial function in patients with essential hypertension. METHODS: We evaluated the forearm blood flow (FBF) response to intraarterial acetylcholine (ACh), an endothelium-dependent vasodilator, and sodium nitroprusside (SNP), an endothelium-independent vasodilator, infusions in 190 hypertensive patients stratified according to dipper and nondipper status. The FBF was measured by strain-gauge plethysmography. Effects of oxidative stress on FBF were evaluated by intraarterial infusion of vitamin C. Ambulatory BP monitorings were obtained by a validated oscillometric device (SpaceLabs 90207 Monitor Inc., Issaquah, WA, USA). RESULTS: Systolic and diastolic blood pressures were higher during daytime and lower during night-time in dipper subjects than in nondippers. The peak percent increase in ACh-stimulated FBF was higher in dippers than in nondippers (473% vs. 228%, P < 0.001). The FBF responses to SNP were similar in dipper and nondipper patients. The FBF response to ACh during coinfusion of vitamin C was higher in nondippers rather than in dipper hypertensives. CONCLUSIONS: Present data demonstrate that endothelium-dependent vasodilation is impaired in patients who have nondipper hypertension. The effects of vitamin C on impaired ACh-stimulated vasodilation support the hypothesis that oxidative stress contributes to endothelial dysfunction of nondipper hypertensive patients.

Laparoscopic transcystic exploration for single-stage management of common duct stones and acute cholecystitis.

BACKGROUND: Common bile duct (CBD) stones are found in 10% of patients who undergo elective laparoscopic surgery for gallstone disease and in 10-20% of patients who present with acute cholecystitis (AC). For the latter, the role of laparoscopic transcystic exploration of the common duct (LTCE) as part of a single-stage procedure is still unknown. METHODS: This study, based on a "laparoscopy first" policy, included 201 subjects with cholecystocholedocholithiasis: 104 underwent a scheduled laparoscopic surgery (group A), and 97 where admitted for AC and had urgent laparoscopy (group B). Group B patients were significantly older (68.4 vs. 62.1 years; P = 0.0045), had a higher proportion of women (56% vs. 41%; P = 0.0345), and included more patients in the ASA III-IV class (39% vs. 21%; P = 0.0006). LTCE was performed by using basket-wired catheters. CBD clearance, operating time, conversion rate, morbidity and mortality, postoperative hospital stay, readmission, and residual CBD stones were the main outcome measures. RESULTS: Clearance of CBD was obtained in 84% of patients of group A and in 80% of patients of group B (P = not significant). Time spent in the operating room was longer for group B (175 vs. 141 min; P = 0.0003). There were no significant differences for postoperative hospital stay (group A 4.9 vs. group B 5.2 days), readmission rate (3.7% vs. 3.7%), and residual CBD stones (2.8% vs. 3.1%). Need to convert and morbidity occurred more frequently in group B (11.7% vs. 4.6% and 28.7% vs. 16.8%, respectively), but differences were not significant. In group A, one patient died from MOFS. CONCLUSIONS: LTCE has proved to be a simple technique with a high yield of CBD clearance in the acute setting. Courses are comparable to those observed for the same procedure in elective surgery despite the fact that patients with AC are more at risk for drawbacks.

[Outcome of laparotomy for severe secondary peritonitis]. / La laparostomia nelle peritoniti secondarie severe.

BACKGROUND: Temporary abdominal closure with planned re-operations is a treatment method for several critical abdominal conditions. Aim of the study was to evaluate the effectiveness of laparostomy and the risk factors for survival in patients presenting with severe secondary peritonitis (SSP). METHODS: 52 patients (mean age 66.5) with a SSP were analyzed. The peritonitis developed spontaneously (n=34) or complicated a recent surgical operation (n=18). 18 patients were operated on for a bowel cancer and 6 of them had a metastatic disease. Skin closure (n=21), bogota bag (n=16) and vacuum-pack (n=15) were the methods employed to achieve temporary abdominal closure for planned re-operations. The severity of the disease was calculated by using APACHE II and Mannheim Peritonitis Index (MPI) scoring systems. Survival was the main outcome measure. RESULTS: Mortality was 38% (n=20). Age, sex, pathogenesis of the peritonitis, type of temporary abdominal closure, number of re-operations and occurrence of entero-atmospheric fistula did not differ significantly between survivors and nonsurvivors. APACHE II (19.6 vs. 14.3; p=. 0015) and MPI (35.5 vs. 27.8; p=. 001) scores were significantly greater in the non-survivors group. The occurrence of perforated left colon/rectum was also significantly greater among non-survivors. By multivariate analysis only MPI resulted to be a significant independent risk factor for survival (p < 0.05). CONCLUSIONS: SSP is a life-threatening condition. Laparostomy may have a role in controlling the source of abdominal infection but even with this outmost invasive surgical measure, mortality still remains high. For these patients, MPI may have a role as outcome predictor.

Uncommon cause of acute abdomen: volvulus of gallbladder with necrosis. Case report and review of literature.

Gallbladder volvulus is a rare condition which can mimic an acute cholecystitis. This condition is characterized from a rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. Preoperative diagnosis is difficult. This is an acute surgical emergency that must be treated with immediate detorsion and cholecystectomy. We report a case of acute gallbladder torsion in an elderly man and review the clinical aspects of the disease in the context of the available literature.