Comparison of purse-string technique vs linear suture for skin closure after ileostomy reversal. A randomized controlled trial.

BACKGROUND: Protective stoma after rectal surgery has been associated with important complications. The most common is surgical site infection (SSI) high rates after stoma reversal reported in literature. Our study compared the rate of SSI of two skin closure techniques, linear closure, and purse string closure. METHODS: We carried out a single center, prospective, randomized controlled trial in the Department of Colorectal Surgery of Fondazione Policlinico Campus Bio-Medico of Rome between January 2018 through December 2021, to compare LC vs PS closure of ileostomy sites. RESULTS: A total of 117 patients (53.84% male) with a mean age of 65.68 ± 14.33 years were finally evaluated in the study. 58 patients were included in the PS group and 59 patients in the LC one. There was a marked difference in the SSI rate between the two arms of the study: 3 of 58 patients in the purse-string arm versus 11 of 59 in the control arm (p = 0.043). The outcome of cosmesis was also higher in PS, with a statistical significance (mean ± DS 4,01 ± 0,73 for PS group vs mean ± DS 2,38 ± 0,72 for LC group, p < 0,001). CONCLUSION: Our study demonstrated that the PS technique had a significantly lower incidence of stoma site SSI compared with LC technique. Our findings are in line with other randomized studies and suggest that PS closure could be considered as standard of care for wound closure after ileostomy reversal.

Laparoscopic versus Open Emergency Surgery for Right Colon Cancers.

BACKGROUND: A laparoscopic approach to right colectomies for emergency right colon cancers is under investigation. This study compares perioperative and oncological long-term outcomes of right colon cancers undergoing laparoscopic or open emergency resections and identifies risk factors for survival. METHODS: Patients were identified from a prospectively maintained institutional database between 2009 and 2019. Demographics, clinicopathological features, recurrence, and survival were investigated. Cox regression analysis was performed for risk factor analysis. RESULTS: A total of 202 right colectomies (114 open and 88 laparoscopic) were included. ASA III-IV was higher in the open group. The conversion rate was 14.8%. Laparoscopic surgery was significantly longer (156 vs. 203 min, p < 0.001); pTNM staging did not differ. Laparoscopy was associated with higher lymph node yield, and showed better resection clearance (R0, 78.9 vs. 87.5%, p = 0.049) and shorter postoperative stay (12.5 vs. 8.0 days, p < 0.001). Complication rates and grade were similar. The median length of follow-up was significantly higher in the laparoscopic group (20.5 vs. 33.5 months, p < 0.001). Recurrences were similar (34.2 vs. 36.4%). Open surgery had lower five-year overall survival (OS, 27.1 vs. 51.7%, p = 0.001). Five-year disease-free survival was similar (DFS, 55.8 vs. 56.5%). Surgical approach, pN, pM, retrieved LNs, R stage, and complication severity were risk factors for OS upon multivariate analysis. Pathological N stage and R stage were risk factors for DFS upon multivariate analysis. CONCLUSIONS: A laparoscopic approach to right colon cancers in an emergency setting is safe in terms of perioperative and long-term oncological outcomes. Randomized control trials are required to further investigate these results.

Long-term patient-reported outcomes after anti-reflux surgery for gastroesophageal reflux disease and hiatal hernia repair: a single-center experience.

BACKGROUND: Patients with gastroesophageal reflux disease (GERD) and hiatal hernia who are candidates for surgery should be treated with minimally invasive partial or total fundoplication. As data on long-term clinical and functional outcomes after laparoscopic surgery for GERD are limited, the aim of this study was to evaluate the long-term effectiveness of fundoplication in terms of patient-reported symptoms and proton pump inhibitor (PPI) use. METHODS: The data of 88 patients who underwent laparoscopic anti-reflux surgery for GERD between January 2007 and September 2020 were retrospectively reviewed. Preoperative and postoperative patient-reported outcomes were investigated after surgery using a 13-items Likert-Scale questionnaire based on the frequency (events/week) and severity of typical and atypical symptoms, dysphagia, and dyspepsia. Furthermore, variations in the use of PPIs were investigated as a secondary endpoint. RESULTS: A total of 76 patients participated in the questionnaire survey. The median follow-up duration was 77 (2-165) months. The postoperative rate of mild and severe typical symptoms was significantly lower than the preoperative rate (P<0.01). Similarly, the atypical symptom rates decreased after surgery (P<0.05). Dysphagia was more frequent after fundoplication (P<0.01). Before the anti-reflux surgery, 94.7% of the patients were prescribed a PPI. At the time of follow-up, this proportion had decreased to 73.7% (P<0.01). However, the PPI intake rate was 90.9% in the group of patients interviewed >10 years after surgery. CONCLUSIONS: In this cohort of patients, laparoscopic anti-reflux fundoplication reduced the rate typical and atypical symptoms of GERD. However, surgery appeared to have no impact on PPI intake over time.

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study).

Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure.

Oncological outcomes of rectal cancer patients with anastomotic leakage: A multicenter case-control study.

Introduction: This study aimed to evaluate the impact of anastomotic leakage (AL) on oncological outcomes after restorative rectal cancer surgery. Methods: Patients who underwent anterior resection for rectal adenocarcinoma between January 2011 and December 2017 were retrospectively reviewed. Data were collected from three colorectal surgery centers. Patients with grade B and C leaks according to the International Study Group of Rectal Cancer classification were identified and compared with the control group. Estimated recurrence and survival rates were compared using the log-rank method and Cox regression analysis. Results: A total of 367 patients were included in the study, with a mean follow-up of 59.21 months. AL occurred in 64 patients (17.4%). Fifteen patients with AL (23.5%) developed local recurrence (LR) compared to 17 (4.8%) in the control group (p < 0.001). However, distant recurrence rates were similar (10.9% vs. 9.6%; p = 0.914) between the groups. Kaplan-Meier curves showed that patients with AL had a reduced 5-years local recurrence-free survival (96% vs. 78%, log-rank p < 0.001). AL (OR 4.576; 95% CI, 2.046-10.237; p < 0.001) and node involvement (OR 2.911; 95% CI, 1.240-6.835; p = 0.014) were significantly associated with LR in multivariate analysis. AL was significantly associated with DFS only at univariate analysis (HR 1.654; 95% CI: 1.024-2.672; p = 0.037), with a difference between 5-year DFS of patients with and without AL (71.6% vs. 86.4%, log-rank p = 0.04). Only male gender, pT3-4 stage, and node involvement were identified as independent prognostic factors for reduced DFS in the multivariate Cox regression analysis. Conclusion: In this cohort of patients, AL was associated with a significant risk of LR after rectal cancer surgery.

Metabolic Syndrome (MetS), Systemic Inflammatory Response Syndrome (SIRS), and Frailty: Is There any Room for Good Outcome in the Elderly Undergoing Emergency Surgery?

Background: Patients with MetS or SIRS experience higher rates of mortality and morbidity, across both cardiac and noncardiac surgery. Frailty assessment has acquired increasing importance in recent years as it predisposes elderly patients to a worse outcome. The aim of our study was to investigate the influence of MetS, SIRS, and with or without frailty on elderly patients undergoing emergency surgical procedures. Methods: We analyzed data of all patients with nonmalignant diseases requiring an emergency surgical procedure from January 2017 to December 2020. The occurrence of MetS was identified using modified definition criteria used by the NCEP-ATP III Expert Panel: obesity, hypertension, diabetes, or if medication for high triglycerides or for low HDL cholesterol was taken. Systemic inflammatory response syndrome (SIRS) was evaluated according to the original consensus study (Sepsis-1). The frailty profile was investigated by the 5-modified Frailty Index (5-mFI) and the Emergency Surgery Frailty Index (EmSFI). Postoperative complications have been reported and categorized according to the Clavien-Dindo (C-D) classification system. Morbidity and mortality have been mainly considered as the 30-day standard period definition. Results: Of the 2,318 patients included in this study, 1,010 (43.6%) fulfilled the criteria for MetS (MetsG group). Both 5-Items score and EmsFI showed greater fragility in patients with MetS. All patients with MetS showed more frequently a CACI index greater than 6. The occurrence of SIRS was higher in MetSG. LOS was longer in patients with MetS (MetSG 11.4 ± 12 days vs. n-MetSG 10.5 ± 10.2 days, p = 0.046). MetSG has a significantly higher rate of morbidity (353 (35.%) vs. 385 (29.4%), p = 0.005). The mortality rate in patients with MetS (98/1010, 10%) was similar to that in patients without it (129/1308, 10%). Considering patients with MetS who developed SIRS and those who had frailty or both, the occurrence of these conditions was associated with a higher rate of morbidity and mortality. Conclusion: Impact of MetS and SIRS on elderly surgical patient outcomes has yet to be fully elucidated. The present study showed a 43.6% incidence of MetS in the elderly population. In conclusion, age per se should be not considered anymore as the main variable to estimate patient outcomes, while MetS and Frailty should have always a pivotal role.

Age and comorbidities do not affect short-term outcomes after laparoscopic rectal cancer resection in elderly patients. A multi-institutional cohort study in 287 patients.

Postoperative complications and mortality rates after rectal cancer surgery are higher in elderly than in non-elderly patients. The aim of this study is to evaluate whether, like in open surgery, age and comorbidities affect postoperative outcomes limiting the benefits of a laparoscopic approach. Between April 2011 and July 2020, data of 287 patients with rectal cancer submitted to laparoscopic rectal resection from different institutions were collected in an electronic database and were categorized into two groups: < 75 years and ≥ 75 years of age. Perioperative data and short-term outcomes were compared between these groups. Risk factors for postoperative complications were determined on multivariate analysis, including age groups and previous comorbidities as variables. Seventy-seven elderly patients had both higher ASA scores (p < 0.001) and cardiovascular disease rates (p = 0.02) compared with 210 non-elderly patients. There were no significative differences between groups in terms of overall postoperative complications (p = 0.3), number of patients with complications (p = 0.2), length of stay (p = 0.2) and death during hospitalization (p = 0.9). The only independent variables correlated with postoperative morbidity were male gender (OR 2.56; 95% CI 1.53-3.68, p < 0.01) and low-medium localization of the tumor (OR 2.12; 75% CI 1.43-4.21, p < 0.01). Although older people are more frail patients, short-term postoperative outcomes in patients ≥ 75 years of age were similar to those of younger patients after laparoscopic surgery for rectal cancer. Elderly patients benefit from laparoscopic rectal resection as well as non-elderly patient, despite advanced age and comorbidities.

Laparoscopic segmental resection for tumours of the Angle of Treitz: a challenging but feasible surgical option. Results from a retrospective case-series analysis.

Tumours of the small intestine are rare and account for about 5% of gastrointestinal tract neoplasms. The angle of Treitz (AT) could be defined as the intestinal loop comprised between the third duodenal portion and the first 10 cm of jejunum. A gold standard surgical treatment for AT neoplasm has not yet been well defined. This paper is focused on a very rare disease and at the best of our knowledge this is the largest case series in the literature about the Laparoscopic Segmental Resection (LSR) of AT tumours. Using a prospectively collected database, all data of consecutive patients, from January 2007 to May 2019, who underwent LSR for AT tumours at two different institutions were analysed. Patients' demographics, intra and post-operative data, 30-day mortality and overall survival were collected. A total of 16 patients were retrieved from our database. The mean operative time was 206,5 ± 79 min. Conversion to open surgery was needed in two cases due to tumor size and, respectively, invasion of the transverse colon which required a multivisceral resection. The mean distal and proximal resection margins were 7.4 ± 2.2 and 3.9 ± 1.2 cm. The median number of harvested nodes was 9 ± 3. Pathological diagnosis was GIST in 11 cases, adenocarcinoma in 4 and sarcoma in 1 case. In conclusion, in experienced hands, LSR appears to be a safe and effective treatment option for tumours of the AT. Prospective studies are needed to confirm these findings.

How to do hernioscopy for incarcerated femoral hernia with laparoscopic O-ring retractor system.

Incarcerated groin hernia management often required emergency surgery. Hernioscopy is a safe alternative to repair hernia and explore intra-abdominal cavity. Alexis Laparoscope System is a useful device to perform hernioscopy.

Ileo-ileal intussusception caused by small bowel leiomyosarcoma: A rare case report.

INTRODUCTION: Intussusception is the telescoping of one segment of the bowel into an adjacent bowel segment, causing venous congestion, edema, and blood supply reduction. We present a case of ileo-ileal intussusception in an adult patient with intestinal obstruction caused by a rare mesenchymal malignant lesion of the distal ileum: Leiomyosarcoma (LMS). PRESENTATION OF CASE: A 90-year-old Caucasian man presented to the hospital with a two-day history of abdominal pain, nausea, and bowel occlusion. Preoperative Computer Tomography (CT) showed a solid mass with stratified walls in the lumen of the cecum with the classics "bulls-eye" appearance with concentric rings, suggestive of intussusception. The patient underwent emergency laparotomy with evidence of a small bowel wall tumor driving ileo-ileal intussusception with ischemic damage. Ileocecal resection was performed without postoperative complications. Histopathological examination showed a tumor on the muscular layer of the small bowel. The definitive diagnosis was LMS. DISCUSSION: Adult intussusception is a rare condition, with an incidence of 2/1 000 000 cases per year worldwide. About 60% of patients suffering from this disease require surgery. Clinical presentation can be non-specific because of its no characteristic signs and symptoms. The most common presenting symptom is abdominal pain with bowel obstruction sings. Intussusception can occur anywhere along the small and large intestine and it is typically associated with a Lead Point (LP). The LP may be benign or malignant conditions. Infrequent malignant causes include LMS. CONCLUSION: Diagnosis of intussusception is relatively challenging because of its non-specific symptoms. CT scan is the examimation of choice for the diagnosis because of its peculiar images. In adults, surgical treatment is recommended with laparoscopic or open approach according to surgeon expertise, sometimes in an emergency setting.

Correction to: Skin bridge loop stoma: outcome in 45 patients in comparison with stoma made on a plastic rod.

The name of the author was incorrectly spelled as "Filippo Carannant". The correct spelling is "Filippo Carannante" and is now presented correctly in this article.

Skin bridge loop stoma: outcome in 45 patients in comparison with stoma made on a plastic rod.

BACKGROUND: Loop stoma reduces the complications related to anastomotic leak. The skin bridge loop stoma is a recently described technique with many potential advantages over the current technique involving a plastic rod. Our experience shows early results (3 weeks after surgery) comparing skin bridge and plastic rod stoma creation. METHODS: In 45 patients operated from January 2016 to December 2018, a loop ileostomy was performed with the skin bridge technique. We compared functional results with a prospective series of 45 patients on which ileostomy was performed on a plastic rod. The report of the routine stoma care visit at 7 and 15 days was compared, as well as the "Stoma quality of life" questionnaire when available. RESULTS: We observed more inflammatory changes of the skin around the stoma in the group with a plastic rod (33 vs 10 patients). The patient-reported evaluation of quality of life showed a better quality of life in skin bridge group. The rate of exchanged stoma wafers was 2.6 vs 5.2 per week in the skin bridge group (p < 0.05). CONCLUSIONS: The skin bridge stoma creation resulted in better early management of the stoma, better adhesion of the stoma appliances, and better quality of life of the patient. As an increased number of stoma appliances are required in the early postoperative period, the economic burden of this treatment is relevant in relation to the major number of medical equipment used in the early period.