Botulinum Toxin and Progressive Pneumoperitoneum in Loss of Domain Ventral Hernias: A Systematic Review.

Introduction: Preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTX) have been used together in the preoperative preparation of patients with loss of domain hernias. This study aims to evaluate the efficacy and safety of the combined use of PPP and BTX. Methods: A systematic electronic search was performed according to the PRISMA criteria. A literature search of scientific articles was conducted up to December 2023. Articles were chosen based on the reference to BTX and PPP in loss of domain ventral hernias with a defect width greater than 10 cm before surgery. The GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies. Results: The research yielded seven articles, with 217 patients analysed in total. BTX was performed 29.5 ± 1.7 days before surgery and PPP was inflated 14.8 ± 5.8 days before surgery. PPP complications were reported in 25.6% of patients, The average reduction of the volume of hernia (VH)/volume of the abdominal cavity (VAC) ratio was 7.6% (range 0.9%-15%). Only 40 patients (18.4%) required a PCS or TAR to repair the loss of domain hernias. The SSI and SSO rates were 17.5% and 26.2%, respectively. No differences in SSI and SSO rates were found between the different repair techniques. The recurrence rate was 5.9% (13/217). Recurrence was significantly higher in patients who underwent IPOM repair than other techniques (p < 0.001). Conclusion: BTX and PPP may be useful tools for the management of loss of domain hernias presenting lower SSI and SSO. The combination of BTX and PPP reduces the use of more invasive repair techniques.

Laparoscopic management of colovesical fistula in different clinical scenarios.

INTRODUCTION: Colovesical fistula (CVF) is a condition with various aetiologies and presentations. Surgical treatment is necessary in most cases. Due to its complexity, open approach is preferred. However, laparoscopic approach is reported in the management of CVF due to diverticular disease. The aim of this study was to analyse the management and outcome of patients with CVF of different aetiologies treated with laparoscopic approach. PATIENTS AND METHODS: This was a retrospective study. We retrospectively reviewed all patients undergoing elective laparoscopic management of CVF from March 2015 to December 2019. STATISTICAL ANALYSIS USED: None. RESULTS: Nine patients underwent laparoscopic management of CVF. There were no intraoperative complications or conversions to open surgery. A sigmoidectomy was performed in eight cases. In one patient, a fistulectomy with sigmoid and bladder defect closure was performed. In two cases of locally advanced colorectal cancer with bladder invasion, a multi-stage procedure with temporary colostomy was chosen. In three cases, with no intraoperative leakage, we did not perform bladder suture. Four Clavien I-II complications were recorded. Two fragile patients died in the post-operative period. No patients required re-operation. At a median follow-up of 21 months (interquartile range: 6-47), none of the patients had recurrence of fistula. CONCLUSIONS: CVF can be managed with laparoscopic approach by skilled laparoscopic surgeons in different clinical scenarios. Bladder suture is not necessary if leakage is absent. Informed counselling to the patient must be guaranteed concerning the risk of major complications and mortality in case of CVF due to malignant disease.

Management of colovesical fistula: a systematic review.

INTRODUCTION: Colovesical fistulas (CVFs) account for approximately 95% enterovesical fistulas (EVFs). About 2/3 CVF cases are diverticular in origin. It mainly presents with urological signs such as pneumaturia and fecaluria. Diagnostic investigations aim at confirming the presence of a fistula. Although conservative management can be chosen for selected individuals, most patients are mainly treated through surgical interventions. CVF represents a challenging condition, which records high rates of morbidity and mortality. Our systematic review aimed at achieving deeper knowledge of both indications, in addition to short- and long-term outcomes related to CVF management. EVIDENCE ACQUISITION: We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Pubmed/MEDLINE, Embase, Scopus, Cochrane Library and Web of Science databases were used to search all related literature. EVIDENCE SYNTHESIS: The 22 included articles covered an approximately 37 years-study period (1982-2019), with a total 1365 patient population. CVF etiology was colonic diverticulitis in most cases (87.9%). Pneumaturia (50.1%), fecaluria (40.9%) and urinary tract infections (46.6%) were the most common symptoms. Abdomen computed tomography (CT) scan (80.5%), colonoscopy (74.5%) and cystoscopy (55.9%) were the most frequently performed diagnostic methods. Most CVF patients underwent surgery (97.1%) with open approach (63.3%). Almost all patients had colorectal resection with primary anastomosis with or without ostomy and 53.2% patients underwent primary repair or partial/total cystectomy. Four percent anastomotic leak, 1.8% bladder leak and 3.1% reoperations rates were identified. In an average 5-68-month follow-up, overall morbidity, overall mortality and recurrences rates recorded were 8-49%, 0-63% and 1.2%, respectively. CONCLUSIONS: CVF mainly affects males and has diverticular origin in almost all cases. Pneumaturia, fecaluria and urinary tract infections are the most characteristic symptoms. Endoscopic tests and imaging are critical tools for diagnostic completion. Management of CVFs depends on the underlying disease. Surgical treatment represents the final approach and consists of resection and reanastomosis of offending intestinal segment, with or without bladder closure. In many cases, a single-stage surgical strategy is selected. Perioperative and long-term outcomes prove good.

Diagnostic challenges in synchronous ovarian metastasis from rectal cancer: A case report.

INTRODUCTION: Ovarian metastases from rectal cancer are infrequent; thus it might be hard to diagnose and treat them. Our study introduces a challenging case which highlights our method in addressing such an issue. PATIENTS CONCERNS: A 74-year-old woman was admitted to our Unit showing abdominal pain, vomit, and a gross abdominal mass located in the right iliac fossa and mesogastrium. Oncological markers recorded following abnormalities: carbohydrate antigen 19.9 (Ca19.9) = 453.40 U/mL, carbohydrate antigen 125 (Ca125) = 88.3 U/mL. DIAGNOSIS: Such a metastatic tumor being difficult to diagnose, we could not achieve a precise preoperative diagnosis. We entered the operating room with a histologic diagnosis that was highly suspicious of colon adenocarcinoma. During surgery, frozen section analysis was positive for primary ovarian cancer. Thanks to the immunohistochemistry test on the histologic specimen, which might be very helpful in diagnosing such metastatic tumor, final pathology report documented ovarian metastasis from rectal cancer. INTERVENTIONS: We performed total hysterectomy with bilateral salpingo-oophorectomy and low anterior resection of the rectum with a terminal colostomy. Adjuvant chemotherapy was administered for 6 months using FOLFOX plus panitumumab in first-line therapy. OUTCOME: At 8 months from surgery, during follow-up, a local pelvic progression of disease was detected, leading to second-line chemotherapy treatment. CONCLUSION: Correct differential diagnosis between primary and metastatic ovarian tumors is paramount in choosing the best treatment which leads to the best possible outcome. In ovarian metastatic tumors, immunohistochemistry could represent an optimal diagnostic tool.

Gluteal, abdominal, and thoracic multiple impalement injuries: A case report on management of a complex polytrauma.

RATIONALE: Historically, traumatic injuries include penetrating and blunt lesions. Impalement injury represents one of the rarest and potentially dramatic forms of penetrating trauma. If patient reaches hospital alive and is hemodynamically stable, there is a good chance that patient overcomes the traumatic event. However, non-removal of foreign body represents the cornerstone in initial treatment of this type of patients. PATIENT CONCERNS: A stable 55-year-old woman was admitted to the Emergency Department after falling out of a tree onto a wooden fence. One fence pole transfixed left gluteus, left abdominal wall, left abdominal cavity, and left thoracic wall by transdiaphragmatic way. DIAGNOSIS: Due to patient stability, a chest-abdomen CT scan with contrast medium was performed. It showed multiple parietal and visceral traumatic penetrating injuries from a foreign object. INTERVENTIONS: After primary and secondary advanced trauma life support (ATLS) assessment, patient underwent successful surgery. OUTCOMES: Patient was discharged on 9th postoperative day in good general clinical condition. LESSONS: Impalement injury represents a rare and potentially lethal traumatic event. Unstable patients rarely reach Emergency Department alive. On the contrary, stable patients have a good chance of successful treatment, if they are quickly taken to tertiary Trauma Center. In this case, chest X-ray and Focused Assessment with Sonography for Trauma (FAST) represent useful diagnosing investigations, although CT scan remains gold standard. Conservative treatment is not possible, while thoracoscopy/laparoscopy/laparotomy is/are mandatory.

Axillary nodal metastases in Italian early breast cancer patients with positive sentinel lymph node: can axillary node dissection be avoided by using predictive nomograms?

AIMS AND BACKGROUND: Clinical guidelines recommend axillary lymph node dissection (ALND) in cases of metastatic sentinel lymph node (SNL) in patients with clinically node-negative early breast cancer. However, a relevant number of ALND could be avoided in a subset of patients in whom the risk of non-SNL metastases is low. In order to define this population, several authors have proposed mathematical models, which have been validated in many studies. These studies reached different conclusions regarding which model demonstrated the best statistical discrimination power, mainly due to differences in clinical and pathologic variables used, and particularly differences in the number of dissected SLNs. METHODS: We retrospectively reviewed clinically node-negative patients who underwent ALND in our surgical ward after the diagnosis of breast cancer metastases on SLN biopsy from January 2000 to December 2012. The predictive accuracy of the widely used nomograms to predict the risk of additional nodal disease in our patients with SLN breast cancer metastases was measured by receiver operating characteristic curve. We then attempted to develop a new nomogram by analyzing the dataset. RESULTS: A total of 105 patients were included in this study, with ratio of metastatic lymph node/removed lymph node of about 0.89; we found axillary nodal metastases on ALND in only 31 patients (29.5%). Applied to our dataset, Mayo nomogram showed the best area under the receiving operator characteristic curve (0.74) followed by our model (0.71). Instead, the Memorial Sloan-Kettering model showed poor discrimination, as did Tenon (0.56). CONCLUSIONS: Based on our data, we cannot recommend the clinical use of validated predictive nomograms in order to avoid ALND. We suggest setting up a multicenter Italian study to build a model specific to our setting and based on larger series.

Emergency laparoscopic splenectomy for haemoperitoneum because of ruptured primary splenic pregnancy: a case report and review of literature.

BACKGROUND: Primary abdominal pregnancies are potentially life-threatening, particularly without an accurate preoperative diagnosis. CASE: A 41-year-old woman presented to the emergency room with 2 days-lasting left upper quadrant abdominal pain, irradiated to the left shoulder. An urine beta-human chorionic gonadotropin test was positive. Transvaginal sonography raised a suspicion of ectopic pregnancy. The patient was then submitted to abdominal laparoscopy that revealed no sign of active bleeding or ectopic pregnancy. Because of worsening of abdominal pain and progressive anaemia, the patient underwent abdominal ultrasound and multislice computerized tomography scan (TC) that showed the presence of a mass at the superior splenic pole with haemoperitoneum. The patient was taken to the operating room and submitted to a laparoscopic total splenectomy. The post-operative course was uneventful, and the patient was discharged 8 days after intervention. CONCLUSION: Abdominal pregnancy should be considered in the differential diagnosis of acute abdomen in women of reproductive age. Abdominal ultrasound and computerized tomography studies must be performed before operative treatment if an ectopic pregnancy is suspected and no intrauterine gestational sac could be showed on transvaginal sonography.

Intrahepatic rupture of a caudate lobe adenoma in liver adenomatosis.

Hepatic adenomatosis is a rare benign disease that is more common in young and middle-aged women who are non-steroid dependent; it is usually symptomatic, progressive, and susceptible to hemorrhagic complications. Malignant transformation within adenomas is rare. The management of hepatic adenomatosis remains difficult due to the absence of predictive signs of complications, other than the size of the adenomas. Resective surgery is usually indicated, but liver transplantation could be an indication in highly symptomatic or progressive forms of the disease and represents the treatment of choice in cases of malignant transformation. We report a case of intrahepatic rupture of a caudate lobe adenoma which occurred in an adolescent with hepatic adenomatosis; we also present a brief review of the literature.

Spleen-preserving total pancreatectomy with conservation of the spleen vessels:: operative technique and possible indications.

Conventional distal pancreatectomy (cDP) and total pancreatectomy (cTP) also involve removal of the spleen. The spleen, however, is an important organ in the immunologic defense of the host and is worthy of preservation if this can be safely achieved. We performed a spleen-preserving total pancreatectomy (SPTP), with good results, in a Caucasian woman, 66-year-old, affected by pancreatic metastases of renal clear cell carcinoma. This is the first report of a SPTP for pancreatic metastases to our knowledge, and we therefore wish to describe the surgical technique and to suggest the possible indications for this new technique.