The role of laparoscopic IPOM in the treatment of abdominal hernias: lesson learned after 400 surgeries using single mesh.

BACKGROUND: Abdominal wall hernias and incisional hernias are a common benign disorder affecting quality of life, potentially leading to life-threatening complications. Laparoscopic IPOM (intraperitoneal onlay mesh) approach can offer good results in selected cases. METHODS: Patients who underwent laparoscopic incisional/ventral abdominal hernia repair operated with standardized technique and the same mesh, from January 2011 to December 2022, were retrospectively considered. RESULTS: Four hundred consecutive patients underwent laparoscopic abdominal wall repair. There were 255 ventral hernia (63%) and 145 (37%) primitive hernia (epigastric and umbilical). Mean size of the defect was 4.2 cm, W3 were 19 (4%). After a mean follow-up of 1906 days (range 45-4109), no mesh-related complications have been detected. There were 10 (2.5%) recurrences and 20 (5%) bulging. CONCLUSIONS: In this study we emphasized the role of patient selection and standardized technique which represents "the lesson" learned over a period of 15 years of activity. In this setting, we believe that laparoscopic approach can achieve very good results in abdominal wall repair.

Intraperitoneal mesh open repair without dissection technique for large ventral hernia repair: an alternative to component separation technique.

BACKGROUND: Incisional hernias (IH) are one of the major complications following abdominal surgery and the treatment of large abdominal hernias represents a challenge for the surgeon. We present our own modified open intraperitoneal mesh technique, named "IPOW technique" (intra-peritoneal mesh open repair without dissections). METHODS: We analyzed early postoperative complications (seroma, wound infection, hematoma) and the late ones (recurrence, chronic pain), in 50 unselected patients treated for IH and primary hernia (PH) larger than 5 cm using the proposed laparotomic technique. RESULTS: From January 2019 to September 2021, 50 unselected patients with, at least, one year of follow-up, with hernias ranging from 5 to 25 cm in width, were surgically repaired using IPOW technique. Mean Body Mass Index (BMI) was 29 (range 22-44). In our series, we report 2 (4%) complications and, after a mean follow-up of 847 days (range 481-1357), 2 (4%) recurrences. No patients reported chronic pain. CONCLUSIONS: In our experience, we consider IPOW technique easily reproducible, ensuring excellent results with a reduction of invasiveness, comparing to other techniques. Anyway, definitive conclusions require a larger number of patients.

Predictive factors of recurrence for laparoscopic repair of primary and incisional ventral hernias with single mesh from a multicenter study.

Laparoscopic ventral hernia repair (LVHR) is a widely practiced treatment for primary (PH) and incisional (IH) hernias, with acceptable outcomes. Prevention of recurrence is crucial and still highly debated. Purpose of this study was to evaluate predictive factors of recurrence following LVHR with intraperitoneal onlay mesh with a single type of mesh for both PH and IH. A retrospective, multicentre study of data collected from patients who underwent LVHR for PH and IH with an intraperitoneal monofilament polypropylene mesh from January 2014 to December 2018 at 8 referral centers was conducted, and statistical analysis for risk factors of recurrence and post-operative outcomes was performed. A total of 1018 patients were collected, with 665 cases of IH (65.3%) and 353 of PH (34.7%). IH patients were older (p < 0.001), less frequently obese (p = 0.031), at higher ASA class (p < 0.001) and presented more frequently with large, swiss cheese type and border site defects (p < 0.001), compared to PH patients. Operative time and hospital stay were longer for IH (p < 0.001), but intraoperative and early post-operative complications and reinterventions were comparable. IH group presented at major risk of recurrence than PH (6.7% vs 0.9%, p < 0.001) and application of absorbable tacks resulted a significative predictive factor for recurrence increasing the risk by 2.94 (95% CI 1.18-7.31). LVHR with a light-weight polypropylene mesh has low intra- and post-operative complications and is appropriate for both IH and PH. Non absorbable tacks and mixed fixation system seem to be preferable to absorbable tacks alone.

EUS-guided gallbladder drainage in high-risk surgical patients with acute cholecystitis-procedure outcomes and evaluation of mortality predictors.

BACKGROUND: Recent evidences suggest that gallbladder drainage is the treatment of choice in elderly or high-risk surgical patients with acute cholecystitis (AC). Despite better outcomes compared to other approaches, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is burdened by high mortality. The aim of the study was to evaluate predictive factors for mortality in high-risk surgical patients who underwent EUS-GBD for AC. METHODS: A retrospective analysis of a prospectively maintained database was performed. Electrocautery-enhanced lumen-apposing metal stents were used; all recorded variables were evaluated as potential predictive factors for mortality. RESULTS: Thirty-four patients underwent EUS for suspected AC and 25 (44% male, age 78) were finally included. Technical, clinical success rate and adverse events rate were 92%, 88%, and 16%, respectively. 30-day and 1-year mortality were 12% and 32%. On univariate analysis, age-adjusted Charlson Comorbidity Index (CCI) (OR 20.8[4-68.2]), acute kidney injury (AKI) (OR 21.4[2.6-52.1]) and clinical success (OR 8.9[1.2-11.6]) were related to 30-day mortality. On multivariate analysis, CCI and AKI were independently related to long-term mortality. Kaplan-Meier curves showed an increased long-term mortality in patients with CCI > 6 (hazard ratio 7.6[1.7-34.6]) and AKI (hazard ratio 11.3[1.4-91.5]). CONCLUSIONS: Severe comorbidities and AKI were independent predictive factors confirming of long-term mortality after EUS-GBD. Outcomes of EUS-GBD appear more influenced by patients' conditions rather than by procedure success.

Treatment of acute cholecystitis in high-risk surgical patients.

INTRODUCTION: Acute cholecystitis (AC) is the most common biliary stone disease complication. While there is consensus regarding cholecystectomy for AC, gallbladder drainage is indicated in elderly or high-risk surgical patients. EVIDENCE ACQUISITION: We systematically reviewed available evidence in the field of EUS-guided gallbladder drainage (EUS-GBD) for AC in high-risk surgical patients. The studies were classified according to their level of evidence (LE) according to the Oxford Centre for Evidence Based Medicine classification. EVIDENCE SYNTHESIS: Literature search retrieved 175 manuscripts; most of them were expert opinions (LE V, N.=53) or case-series (LE IV, N.=29). There was no meta-analysis of RCT (LE Ia), while two randomized controlled trials (LE Ib) demonstrated that EUS-GBD was superior to percutaneous transhepatic-GBD (PT-GBD) regarding long-term outcomes (adverse events, recurrent cholecystitis, and reintervention). Several meta-analyses of cohort studies (LE IIa, N.=11) were designed to compare the three available drainage strategies (endoscopic, echoendoscopic and percutaneous) and to assess the pooled risk of adverse events. Comparison between surgery and EUS-GBD was done in a single retrospective study with a propensity score analysis (LE III). The outcomes of conversion from PT-GBD to EUS-GBD were covered by few retrospective studies (LE III). Several manuscripts (N.=69) were published on EUS-GBD as a rescue strategy in case of malignant biliary obstruction. CONCLUSIONS: The levels of evidence of EUS-GBD in the literature have evolved from initial descriptive studies to recent randomized controlled trials and meta-analysis of cohort studies. While several articles addressed the comparison among different techniques for GBD, in our opinion some topics and questions have not been adequately investigated. are still debated.

EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series.

BACKGROUND AND AIMS: Pelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. A percutaneous approach to deep PFCs could be challenging and result in a longer, painful recovery. The transvaginal approach has been considered easy but is limited by the difficulty of leaving a stent in place. The transrectal approach has been described, but issues related to fecal contamination were hypothesized. Data on EUS-guided transrectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes. The aim of this study was to evaluate the safety and efficacy of EUS-TRD with LAMSs in patients with PFCs. METHODS: A retrospective analysis of a prospectively maintained database on therapeutic EUS was conducted. All EUS-TRD procedures were included. RESULTS: Five patients (2 male, age 44-89 years) were included. Four patients had postoperative PFCs, and 1 presented with a pelvic abscess complicating acute diverticulitis. Two of 5 had fecal diversion; the remaining 3 had unaltered large-bowel anatomy. One case had a concomitant abdominal collection, treated with percutaneous drainage in the same session. An electrocautery-enhanced LAMS delivery system (15 × 10 mm) was used in all cases. EUS-TRD was performed with the direct-puncture technique and lasted less than 10 minutes in 4 cases; in the remaining case, needle puncture and LAMS placement over a guidewire was required, and the procedure length was 14 minutes. The clinical success rate was 100%. LAMSs were removed after a median of 14 (range, 12-24) days. One patient reported partial proximal LAMS migration after 24 days (mild adverse event). No PFC recurrence was observed. CONCLUSION: EUS-TRD with LAMSs is a safe and effective technique for treatment of PFCs. The use of 15- × 10-mm LAMSs allows rapid PFC resolution. EUS-TRD could be performed not only in patients with fecal diversion but also in cases of unaltered anatomy.

"Imola-Montecatone" subtotal colectomy to improve bowel management in spinal cord injury patients. Retrospective analysis in 19 cases.

STUDY DESIGN: Retrospective single-center study. OBJECTIVES: Persons with spinal cord injury live with neurogenic bowel dysfunction. Difficulties with management of neurogenic bowel can increase over time with age and time post injury, with a negative impact on autonomy and quality of life. Many conservative treatments are available to improve bowel management; however, in case of failure, a colostomy may be considered. SETTING: Specialized Care Unit, Montecatone Rehabilitation Institute and General Surgery Division, Imola Hospital, Imola, Italy. METHODS: From 2016 to 2019, selected patients affected by SCI and bowel dysfunction failing conservative care were treated with subtotal colectomy associated with placement of a bioabsorbable prosthesis, to prevent parastomal hernia. The surgical procedure is presented along with results. RESULTS: Overall, 19 individuals underwent the described procedure; after 1 year of follow-up, we observed four minor complications: two cases of dehiscence of the abdominal incision, easily treated during hospital stay, and two cases of leakage of mucorrhoea. CONCLUSION: Our results demonstrate the efficacy of the procedure to improve bowel management in persons with spinal cord injury.

Gastric GISTs. Personal experience.

BACKGROUND: With term GIST is now defined a group of mesenchimal tumours of the gastrointestinal tract expressing immunopositivity for kit protein kinase (CD117). Surgical therapy remains the gold standard for these rare tumours. Imatinib Mesylate (STI-571) is a potent inhibitor of Kit Kinase activity and different reports demonstrated its efficacy in unresectable or metastatic Gists. AIM OF THE PAPER: To value the incidence of GISTs among gastric mesenchimal neoplasms and analyzed their clinical presentation, prognostic parameters and surgical treatment. The response to Imatinib Mesylate in a case of metastatic GIST is then valued. METHODS: Twelve cases of gastric mesenchimal neoplasms are retrospectively reviewed and tested by CD117 immmunopositivity identifyng 8 GISTs. The median follow-up was 37 (range7-120) months. We describe in details the case of a metastatic Gist treated for 15 months with Imatinib Mesylate. RESULTS: The 67 per cent of mesenchimal gastric tumours were CD117+. Gastrointestinal bleeding was the most common presenting symptom. The 50% of patiens with malignant GISTS had a palpable abdominal mass at diagnosis. All tumors < 5 cm in diameter had a mitotic count (MC) <5/50 high-power fields (HPFs) except a case of high grade leiomyosarcoma. Surgical therapy was complete tumour resection with free margins. No recurrence was observed in lesions <5cm and < 5 mitosis/50 High Power Fields (HPFs). A good response to Imatinib Mesylate was reported in a metastatic GIST. CONCLUSION: The surgeon's role in gastric Gist's treatment is to achieve a complete cancer resection with free margins. In advanced lesions, even in presence of hepatic metastases, surgical resection of the mass is indicated because is possible to obtain a stabilization or a partial remission with Imatinib Mesylate palliative treatment in some patients.