Perforated vs. nonperforated acute appendicitis: evaluation of short-term surgical outcomes in an elderly population.

BACKGROUND: Acute appendicitis is a common acute surgical abdominal condition and despite the majority of cases are observed in children and young adults, its occurrence in the elderly seems to be increasing, with a higher risk of perforation. The aim of this study was to evaluate the surgical outcomes following appendectomy for acute appendicitis in the elderly, making a comparison between perforated and nonperforated groups regarding operative time, hospital stay and postoperative complications. METHODS: The medical records of 48 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis from January 2011 to December 2016 were retrospectively reviewed. Patients were grouped into those with perforated and those with non-perforated appendicitis (NPA) and a comparison was made between both groups regarding demography, operative time, length of hospital stay and postoperative complications. RESULTS: From 48 patients over 60 years diagnosed with acute appendicitis, a PA was removed from 10 patients (20.8%). The PA group consisted of 3 males and 7 females, and their mean age was 71.6 years (range 65-84). The NPA group included 22 males and 16 females, and their mean age was 76.5 years (range 63-96). The mean operative time was 58±18.7 minutes and 43.3±9.9 minutes in the perforated and nonperforated groups respectively, with statistically significant difference (P=0.0013). The mean length of hospital stay was similar in the PA group and in the NPA group, being 6.5±1.8 days and 5.4±1.8 days respectively, but these differences were not statistically significant (P=0.093). The frequency of postoperative complications was similar in both groups as they were observed in 3 patients (30%) of the PA group and 10 patients (26%) of the NPA group (P=0.2488). No postoperative intraabdominal abscess was observed in both groups and there was no death after the surgery. CONCLUSIONS: PA, despite requiring a longer mean operative time, in our series is not producing a longer hospital stay or more postoperative complications compared to NPA. The non-operative management of uncomplicated appendicitis is a reasonable option in frail patients in order to avoid the burden of morbidity related to operation, nevertheless surgery remains the standard of care in all age groups.

A New Surgical Device for Anterograde Intraoperative Rectal Washout.

BACKGROUND: Colorectal cancer is the fourth most diffuse cause of death in the world and local recurrence is associated with a reduced long-term life expectancy, with a reduced quality of life. Rectal washout at the anastomosis site leads to a statistically significant reduction of local recurrences. METHODS: We developed the idea of a new laparoscopic stapler with an integrated washout system that could decontaminate the rectal stump before resection, without the need to enlarge the standard surgical incision or even to distort the incision site, closing the rectal stump just below the inferior part of the cancer, and then proceeding with the resection and stapling of the distal part of the tumor. Combined with these canonical functionalities, the new device, equipped with a patented washout system (patent number EP 3103401A1) will also allow to inject in the closed bowel a physiologic saline liquid. RESULTS: In force of the mechanical action of the liquid injected, carcinogenic exfoliated cells eventually floating in the affected region of the colonic lumen will be expelled through the anal orifice. The intraoperative rectal washout, both in minimally invasive and in traditional open surgery, thus becomes a simple, effective, and reproducible procedure. CONCLUSIONS: We describe the technical features and the possible clinical applications of a potentially new surgical laparoscopic stapler coupled with an integrated irrigation system. We have patented the system and we are developing a prototype with the aim to start an experimental pilot study.

The management of bilateral myelolipoma: Case report and review of the literature.

INTRODUCTION: Bilateral adrenal myelolipoma is a rare benign neoplasm. We presented the case of a young man affected by a bilateral myelolipoma and the analysis of the literature of bilateral cases of myelolipoma. Our purpose is to give a suggestion of clear terms of reference regarding the management of this kind of bilateral neoplasm. PRESENTATION OF CASE: We reported the case of a 41-year-old healthy man complained of abdominal pain in the upper quadrants. No significant alterations were found in routine blood and endocrinological tests. The imaging (CT and MRI) showed a huge right adrenal mass and a smaller lesion at the left adrenal gland. The preoperative pathological characterization was suggestive for a myelolipoma. A right open adrenalectomy was performed, and a radiological surveillance was planned for the left tumor. The pathological exam confirmed the diagnosis. DISCUSSION: In literature, there are 36 cases described. The clinical presentation consisted of symptomatic tumors, incidentally diagnosed lesions or myelolipomas in patients with an associated endocrinal disorder. Symptomatic tumors or those bigger than 7cm, because of the potential risk of rupture, are usually treated surgically. In smaller (<7cm) and asymptomatic ones the surgical treatment is not univocal. CONCLUSION: In the setting of the surgical treatment, it is important to preserve in some way the hormonal function. For that reason, the bilateral adrenalectomy has to be reserved for symptomatic or sizeable (>7cm) cases. As far as we know, this is the first review on bilateral myelolipomas.

Is robot-assisted laparoscopic right colectomy more effective than the conventional laparoscopic procedure? A meta-analysis of short-term outcomes.

AIM: The use of robotic technology procedures has proved to be safe and effective, arising as a helpful alternative to standard laparoscopic surgery in a variety of colorectal procedures. However, the role of robotic assistance in laparoscopic right colectomy is still not demonstrated. METHODS: A systematic review of the literature was carried out performing an unrestricted search in MEDLINE, EMBASE, the Cochrane Library and Google Scholar up to 30th August 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We meta-analyzed the currently available data regarding the incidence of anastomotic leakage, operative time, intra-operative blood loss, conversion rate, retrieved lymphnodes, post-operative hemorrhage, intra-abdominal abscess, time to 1st flatus, post-operative ileus, wound infection, incisional hernia, not-surgical complications, total complications, hospital stay, post-operative mortality, surgery-related costs and total costs, in conventional laparoscopic right colectomy (LRC) compared to robot-assisted laparoscopic right colectomy (RRC). RESULTS: Overall 8 studies were included, thus resulting in 616 patients. The meta-analysis showed that the RRC decreases the intra-operative blood loss and the time to the 1st flatus, if compared to the LRC. On the other hand, the robotic assistance increases the operative time and the surgery-related costs. No statistically significant differences were found about the other post-operative outcomes. CONCLUSION: RRC may ensure limited improvements in post-operative outcome, thus increasing procedural costs and without a proved enhanced oncological accuracy to date, if compared to the LRC.

Symptomatic schwannoma of the abdominal wall: A case report and review of the literature.

Schwannoma is a rare, benign tumor that arises from the nerve sheath. This tumor usually involves the extremities, but can also be found in the head and neck, trunk, pelvis, retroperitoneum, mediastinum and gastrointestinal tract. In numerous cases, the tumors are asymptomatic and are identified incidentally on physical examination or imaging. Occasionally, schwannoma is symptomatic due to compression of surrounding large nerves. In the present study, a 57-year-old female presented to the surgical outpatient's department due to a well-localized parietal pain in the left lower quadrant. The onset of the pain occurred three years prior to presentation, without apparent cause and in the absence of other symptoms. Ultrasound and a computed tomography scan revealed a small solid tumor in the anterior abdominal wall, which was dimensionally stable over time, but was not noted in a preliminary analysis by a radiologist. The lesion was surgically removed using an anterior surgical approach. Histopathology revealed the tumor to be benign schwannoma. The painful symptoms completely disappeared. To the best of our knowledge, this is the third case of an abdominal wall benign schwannoma in the medical literature, and the first symptomatic case.

A randomized study on 1-week versus 4-week prophylaxis for venous thromboembolism after laparoscopic surgery for colorectal cancer.

OBJECTIVE: To compare the efficacy and safety of antithrombotic prophylaxis given for 1 week or 4 weeks in patients undergoing laparoscopic surgery for colorectal cancer. BACKGROUND: Extending antithrombotic prophylaxis beyond 1 week reduces the incidence of venous thromboembolism (VTE) after open abdominal surgery for cancer. METHODS: In consecutive patients who underwent laparoscopic surgery for colorectal cancer, complete compression ultrasonography of the lower limbs was performed after 8 ± 2 days of antithrombotic prophylaxis. Patients with no evidence of VTE were randomized to short (heparin withdrawal) or to extended (heparin continued for 3 additional weeks) prophylaxis. Complete compression ultrasonography was repeated at day 28 ± 2 after surgery by investigators blinded to treatment allocation. The primary outcome of the study was the composite of symptomatic and ultrasonography-detected VTE at day 28 ± 2 after surgery. RESULTS: Overall, 301 patients were evaluated for inclusion in the study and 225 were randomized. VTE occurred in 11 of 113 patients randomized to short (9.7%) and in none of the 112 patients randomized to extended heparin prophylaxis (P = 0.001). The incidence of VTE at 3 months was 9.7% and 0.9% in patients randomized to short or to extended heparin prophylaxis, respectively (relative risk reduction: 91%, 95% confidence interval: 30%-99%; P = 0.005). The rate of bleeding was similar in the 2 treatment groups. Two patients died during the study period, 1 in each treatment group. CONCLUSIONS: After laparoscopic surgery for colorectal cancer, extended antithrombotic prophylaxis is safe and reduces the risk for VTE as compared with 1-week prophylaxis (NCT01589146).

Isolated extrahepatic bile duct rupture: a rare consequence of blunt abdominal trauma. Case report and review of the literature.

A 16-year-old girl suffered blunt abdominal trauma. Clinically, a severe motor impairment with paraesthesia of the legs was found. Posterior osteosynthesis in T10-L1 with laminectomy in T10-T12 and posterolateral arthrodesis in T11-T12 was performed because of a dorsal traumatic vertebral fracture. On hospital day 7, because of an acute abdomen, surgical laparoscopic exploration showed sterile bloody fluid without any evident hemorrhagic injury. On hospital day 11, the patient was reoperated on by the laparoscopic approach for increasing abdominal pain and fever: a peritoneal biliary fluid was aspirated. After conversion to open surgery, cholecystectomy was performed. Intraoperative cholangiography was considered as normal. On arrival at our institution 13 days after injury, the patient was operated on for a biliary peritonitis. Intraoperatively, a trans-cystic cholangiography showed a biliary leakage of the common bile duct; a T-tube was placed into the common bile duct; a subhepatic drainage was placed too. On postoperative day 30, a T-tube cholangiography showed a normal biliary tree, without any leakage, and the T-tube was subsequently removed. The patient had a complete recovery.

Laparoscopic left hepatectomy with intraoperative biliary exploration for hepatolithiasis.

Major liver resections remain a challenge for liver surgeons. This video illustrates, step by step, a totally laparoscopic technique for left hepatectomy with intraoperative exploration of the remaining biliary tree in a patient with unilateral hepatolithiasis.

Leiomyosarcoma of the inferior vena cava involving the renal veins: a simple method of right renal vein reimplantation.

In this report we describe a case of leiomyosarcoma of the inferior vena cava involving the renal veins. The abdominal computed tomography scan showed a tumor in the infrahepatic portion of the inferior vena cava and the confluence of the renal veins. After resection of the tumor, venous reconstruction involved the replacement of the inferior vena cava with a prosthetic graft and the implantation of the right renal vein into the portal vein. The left renal vein was ligated distally, with preservation of collateral pathways. To our knowledge, no other reports of such venous reconstruction have been published. After a follow-up of 30 months, the patient has shown no further symptoms, and the abdominal computed tomography scan demonstrates patency of the renal portal anastomosis. Tests indicated normal renal and hepatic function, suggesting good tolerance of the renal portal anastomosis. We believe that the technique described in this report should be adopted routinely for tumors located in the renal veins, provided complete resection of the tumor with a comfortable resection margin is possible.