Laparoscopic treatment of an infected urachalcyst and diverticulum in a young adult: Presentation of a case and review of the literature.

INTRODUCTION: A urachal remnant is a rare anomaly in adults, with a heterogeneous presentation. We report a case of an infected urachal cyst associated with a urachal diverticulum. PRESENTATION OF CASE: We report the case of a 16-year-old male who presented to our hospital with lower abdominal pain without any other signs of general infection. A physical examination revealed umbilical erythema with associated tenderness. All laboratory tests were normal. An ultrasound scan revealed an urachal cyst near the umbilicus and a second cyst near the bladder dome. We decided on a staged treatment with antibiotic administration followed by surgical excision of the urachus during laparoscopy. The patient was discharged on day 10 without complications. Pathology revealed chronic inflammatory tissue without signs of malignancy. DISCUSSION: Urachus is a fibrous remnant of the allantois that progressively obliterates after birth, forming the median umbilical ligament. Incomplete regression of the urachal lumen results in several anomalies. These anomalies require treatment when discovered because of an increased risk of infection and neoplastic differentiation. A urachal cyst is the most common type of anomaly, and infection is the usual mode of presentation. Surgical intervention with complete excision of the urachus is the treatment of choice. A staged approach with antibiotic administration followed by surgery is recommended if signs of infection are present. CONCLUSION: Urachal anomalies in adulthood are rare, with a nonspecific presentation. However, identifying a urachal anomaly is important because of the increased risk for infection and neoplastic differentiation. The laparoscopic approach is safe and patients recover rapidly.

Long-term Outcomes of a Telementoring Program for Distant Teaching of Endovascular Aneurysm Repair.

PURPOSE: To prospectively evaluate the long-term outcomes after a telementoring program for distant teaching of endovascular aneurysm repair (EVAR) and the degree of EVAR procedure assimilation into routine practice. METHODS: A telementoring protocol using stepwise introduction of EVAR was implemented between a university care center and a remote vascular health care site; from March 1999 to October 2003, 49 EVAR patients (mean age 72 years; 48 men) were treated during telementoring at the remote center. After the telementoring period, 86 patients (mean age 71 years; 77 men) underwent EVAR procedures carried out at the secondary care center from November 2003 to July 2011. The long-term outcomes were compared between the EVAR procedures performed during telementoring with the procedures performed independently thereafter. RESULTS: No significant difference was appreciated between telementored and not telementored procedures either in 30-day mortality (4.1% vs 2.3%, p=0.621) or in the initial technical success (93.9% vs 97.7%, p=0.353). The telementored group showed no significant difference in overall aneurysm-related mortality (6.1% vs 2.3%, p=0.353) or in the overall complication rates (p=0.985). The reintervention rate was significantly lower among the unmentored procedures (11.6% vs 32.7%, p=0.004). In particular, significantly fewer patients underwent late endovascular procedures (1.2% vs 12.2%, p=0.009) and late percutaneous interventions (7.0% vs 20.4%, p=0.027) after telementoring ceased. CONCLUSION: The telementoring program followed here allowed excellent EVAR skill assimilation into the routine practice of a remote health care site. Telementoring is a feasible strategy to support skill introduction in remote medical facilities.

Laparoscopic gastric bypass versus laparoscopic sleeve gastrectomy: A retrospective multicenter comparison between early and long-term post-operative outcomes.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly performed procedures for morbid obesity. METHODS: We performed a retrospective review of patients undergoing LRYGB or LSG between August 2000 and November 2014. RESULTS: Data from 581 (280 LSG and 301 LRYGB) were gathered. Operating time (77.6 vs 250.5 min; p < 0.001), post-operative complication rate (3.9% vs 11.6%; p < 0.001), overall occlusions (p = 0.004), need for re-intervention (p < 0.001), hospital stay (5.7 vs 9.2 days; p < 0.001) and mean 1-year EWL (49% vs 61%; p = 0.001) resulted statistically significant lower in LSGs compared with LRYGBs. Not statistically significant differences were found about leakage, bleeding requiring transfusion, infections, short-term mortality and mean 2- and 3-years EWL. Upon univariate analysis, basal weight, basal BMI, age and gender were not associated with the rate of re-intervention and with the combination of re-intervention or death. CONCLUSIONS: LRYGB resulted associated with higher post-operative morbidity rate and increased 1-year EWL than LSG. Prospective studies are needed to assess the impact of these two surgical procedures on the long-term weigh loss.

Antecolic or Retrocolic Alimentary Limb in Laparoscopic Roux-en-Y Gastric Bypass? A Meta-Analysis.

Internal hernia (IH) is a severe complication after laparoscopic Roux-en-Y gastric bypass. The orientation of the alimentary limb has advocated to affect IH. Available data regarding the incidence of IH, gastro-jejunostomy leakage, obstructive symptoms, anastomotic obstruction, adhesion, incisional hernia, total complications, and recurrent IH were meta-analyzed according to the orientation of the alimentary limb. Fourteen studies (13,660 patients) were included. Antecolic orientation resulted associated with a lower incidence of IH and obstructive symptoms, while the route of the alimentary limb did not show to affect the other outcomes. Antecolic orientation decreases the IH. However, the role and the technique of the closure of mesenteric defects cannot be stated due to the lack of adequate data to date. Well-designed randomized controlled trials (RCTs) are needed.

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.

Endovascular abdominal aneurysm repair and impact of systematic preoperative embolization of collateral arteries: endoleak analysis and long-term follow-up.

PURPOSE: To report our results of endovascular aneurysm repair (EVAR) over a 10-year period using systematic preoperative collateral artery embolization. METHODS: From 1999 until 2009, 124 patients (117 men; mean age 70.8 years) with abdominal aortic aneurysm (AAA) underwent embolization of patent lumbar and/or inferior mesenteric arteries prior to elective EVAR procedures. Embolization was systematically attempted and, whenever possible, performed using microcoils and a coaxial technique. Follow-up included computed tomography and/or magnetic resonance imaging and abdominal radiography. RESULTS: The technical success for EVAR was 96% (119/124), with 4 patients dying within 30 days (3.2% perioperative mortality) and 1 type III endoleak accounting for the failures. Collateral arteries were occluded spontaneously or by embolization in 60 (48%) of 124 patients. The endoleak rate was 50.9% (74 in 61 patients), most of which were type II (19%). Over a mean clinical follow-up of 60.5±34.1 months (range 1-144), aneurysm sac dimensions decreased in 66 patients, increased in 19 patients, and were stable in 35. The endoleak rate was significantly higher in the patients with increasing sac diameter (p<0.001). Among the patients with patent collateral arteries, 38/64 (59.3%) developed 46 leaks, while 28 leaks appeared in 23 (41%) of 56 patients with collateral artery occlusion (p=0.069). The type II endoleak rate significantly differed between these two groups (47.8% vs. 3.6%, p<0.001). CONCLUSION: Preoperative collateral embolization seems to be a valid method of reducing the incidence of type II endoleak, improving the long-term outcome.

Randomised comparison of complications from three different permanent central venous access systems.

PRINCIPLES: We present a prospective randomised trial comparing complications from three different permanent central venous access systems (PCVAS). METHODS: The PCVAS trial groups were I, polyurethane ChemoSite (AutoSuture); II, polyurethane Port-a-Cath (Pharmacia-Upjohn); and III, silicone Port-a-Cath. The PCVAS were inserted under local anaesthesia by direct puncture of the subclavian vein, using the Seldinger technique. Every complication and ist evolution was recorded and analysed. The follow-up period was closed five years after the last PCVAS was implanted, and interrupted when for any reason the device was removed. RESULTS: Over a period of 45 months, we included 228 patients (96 men, 132 women, average age 58 yr). Patients were followed from six days to 103 mo (median 14.7 mo). We observed 10 pneumothorax (4.3%), seven of them requiring drainage. Out of 10 infected ports (4.3%), eight were removed. We observed 46 complications (20.1%) related to the device (rupture, displacement, disconnection, and occlusion of the catheter). Most of the thirteen ruptures (5.7%) occurred in the space between the clavicle and the first rib. Catheters of group I ruptured more often than those of groups II and III (p <0.05). Polyurethane catheters ruptured more often than silicone catheters (p <0.01). CONCLUSION: The polyurethane catheters that ruptured more often had a larger diameter and a thicker wall than the other polyurethane catheters, and were probably subjected to greater shearing between the clavicle and the first rib. Silicone catheters, although thicker and of larger diameter than the two other catheters, seemed more resistant to shearing.