Alessandra Pancaldi

Role of CT angiography with three-dimensional reconstruction of mesenteric vessels in laparoscopic colorectal resections: a randomized controlled trial

BackgroundLaparoscopic surgery, despite its well-known advantages and continuous technological innovations, still has limitations such as the lack of tactile sensation and reduced view of the operative field. These limitations are particularly evident when performing laparoscopic colorectal resection due to the variability of the number and course of mesenteric vessels. Today, the patient’s vascular anatomy can be mapped using computed tomography (CT) angiography and processing of the images with rendering software to reconstruct a three-dimensional model of the mesenteric vessels. To assess how prior knowledge of the patient’s mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resections, we conducted a randomized, parallel, single-blinded controlled trial.MethodsFrom January 2010 to January 2012, all patients with surgical indication to undergo standardized right or left hemicolectomy and anterior rectal resections were randomly assigned to two groups and subjected to CT angiography with three-dimensional reconstruction of mesenteric vessels. In the first group the surgeon was able to view the 3D reconstruction before and during surgery, while in the second group the surgeon was only able to view the 3D reconstruction after surgery.ResultsEvaluation of data from 112 patients shows statistically significantly lower operative time, episodes of difficult identification of right anatomy, and incidence of intraoperative and postoperative complication related to difficult or erroneous identification of mesenteric vessels in the group in which the surgeon was able to view the 3D reconstruction before and during surgery compared with the control group.ConclusionThis study shows that prior knowledge of the patient’s mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resection. Registration number NCT01540448 (http://www.clinicaltrials.gov).

Laparoscopic cholecystectomy in day surgery: Feasibility and outcomes of the first 400 patients

BACKGROUND The aim of this study was to evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in a day surgery setting in Italy. MATERIAL AND METHODS Between March 2003 and June 2011, in our institution 439 patients were selected for day surgery LC. To evaluate the efficacy and safety of the procedure, postoperative complications, pain, nausea and vomiting were monitored at 4, 8, and 24 h after surgery. Patients admitted for an overnight stay or readmitted after discharging were also monitored. RESULTS Over 8 years we performed 400 LC in day surgery setting and no conversion or major intraoperative complication were detected. A total of 387 patients (96.7%) were successfully discharged after 8-10 h of observation. Postoperative monitoring showed good pain control (mean VAS score 1.5) and only 3 (0.7%) of the 7 patients who experienced major pain were admitted. Twenty-seven patients (6.7%) experienced PONV and 9 (2.2%) of these required admission. None of the patients needed to be readmitted after discharging. The satisfaction questionnaire administered at 1 month office visit showed that 380 patients (95%) were satisfied with day surgery LC. CONCLUSIONS Our success rate of 96.7% can be attributed to strict adherence to the patient selection criteria. The main reasons for hospital admission were pain and PONV; adequate control of these represents the key of success for day surgery LC. This study confirms the feasibility and safety of LC performed in day surgery setting.

Topical glyceryl trinitrate ointment for pain related to anal hypertonia after stapled hemorrhoidopexy: a randomized controlled trial.

BACKGROUND: Postoperative pain after stapled hemorrhoidopexy is cause for considerable concern and may be related to contracture of continence muscles. OBJECTIVE: We compared glyceryl trinitrate 0.4% ointment with lidocaine chlorohydrate 2.5% gel as topical therapy to relieve the pain of anorectal muscular spasm after stapled hemorrhoidopexy. DESIGN: This was a single-blind, parallel-group, randomized controlled trial. SETTING: The study was conducted at a university teaching hospital in Rome, Italy. PATIENTS: Patients with severe postoperative anal pain after stapled hemorrhoidopexy, clinical evidence of anal hypertonia, and elevated anal resting pressure on manometric assessment were enrolled. Patients treated for concomitant anorectal disease were excluded. INTERVENTIONS: Participants were randomly assigned to receive twice-daily, local topical application of glyceryl trinitrate or lidocaine for a total of 14 days. MAIN OUTCOME MEASURES: Pain intensity was measured on a visual analog scale at baseline and after 2, 7, and 14 days of therapy. Anal resting pressure was measured pre- and postoperatively and after 14 days of therapy. RESULTS: Of 480 patients undergoing stapled hemorrhoidopexy, 121 had severe postoperative pain (score >3) and underwent clinical examination; 45 patients (13 women, 28 men) had clinically evident anal hypertonia and underwent anorectal manometry; 41 patients had elevated anal resting pressure and entered the study. Mean pain scores were significantly lower with glyceryl trinitrate than with lidocaine on day 2 (2.5±1.0 vs 4.0±1.1, p < 0.0001); day 7 (1.4 vs 2.8, p < 0.0001); and day 14 (0.4 vs 1.4, p = 0.003). Anal resting pressure was significantly lower with glyceryl trinitrate than with lidocaine on day 14 (75.4±7.4 mmHg vs 85.6±7.9 mmHg, p < 0.0001). LIMITATIONS: GTN-induced reduction in sphincter tone could not be evaluated during the initial period, when pain was most intense. Because anorectal manometry was performed only in patients with severe pain and clinical evidence of anal hypertonia, firm conclusions cannot be drawn as to frequency of hypertonia after SH. Bias may have been introduced because the surgical team could not be blinded. CONCLUSION: Topical 0.4% glyceryl trinitrate is effective in relieving pain and reducing anal resting pressure in patients with anal hypertonia after stapled hemorrhoidopexy.

Feasibility and safety study of day-case Transtar™ procedure.

BACKGROUND Short hospitalization surgery is cost effective and convenient for both patients and healthcare system. Stapled transanal rectal resection (STARR) conducted with the new curved device, Contour Transtar, has proved an effective and safe procedure for treatment of obstructed defecation syndrome. The aim of this study was to determine the safety and feasibility of STARR, performed as a day-case procedure. MATERIAL AND METHODS Retrospective review was performed of all STARR performed as day-case surgery between September 2009 and February 2011. The entire study (intervention, data collection and data analysis) was conducted at the One-day Surgery Unit of the St. Andrea Hospital, Rome, Italy. All patients with surgical indication to STARR for the presence of an obstructed defecation syndrome were included in the study. We excluded from day-case protocol, patients over 65 years old, with an ASA score of III-IV or with a BMI over 35. The surgical technique reflects the original technique proposed by Antonio Longo with the exception of the longitudinal prolapse opening, which was created with the use of an electric scalpel between two Kocher clamps and not by an application of Transtar stapler. To evaluate the feasibility and safety of performing this procedure with short hospitalization, we investigated the presence and the time of presentation of post-operative complications. RESULTS Eighty-nine patients underwent STARR as a day-case regimen, and none presented major complications or required an extension of hospital stay or readmission. CONCLUSIONS STARR performed with Contour Transtar, in selected patients, is safe and feasible in day-case regimen if performed by expert surgeons and in a structure that allows the physician to keep the patient hospitalized or to re-admit and promptly treat those patients who present major surgical complication.

Does the removal of retained staples really improve postoperative chronic sequelae after transanal stapled operations

BACKGROUND: Transanal stapled procedures are increasingly being used. Several postoperative complications can be referred to their application, including those related to the presence of retained staples at the level of the staple line. OBJECTIVE: This study was conducted to assess whether the removal of the retained staples is a useful approach to improve some of the most common postoperative complications of these surgical techniques. DESIGN: This is a retrospective study. SETTINGS: The study was conducted at the One-Day Surgery Unit of St. Andrea Hospital. PATIENTS: All of the patients who underwent a stapled transanal procedure from January 2003 to December 2011 were included in the study. Patients included in the study were followed postoperatively for 1 year after surgery to identify the presence of retained staples. INTERVENTIONS: If identified, the retained staples were removed endoscopically or transanally. MAIN OUTCOME MEASURES: After the staple removal, patients were followed with biweekly office visit for 2 months to evaluate the progression of symptoms. RESULTS: From the 566 patients included in the study, 165 experienced postoperative complications, and in 66 of these cases, retained staples were found and removed. With the removal of retained staples, symptoms were almost all resolved or improved. In only 1 case did the retained staples removal not modify the symptoms. LIMITATIONS: The study design may have introduced potential selection bias. In addition, the study was limited by the lack of a specific questionnaire for the evaluation of symptoms improvement. CONCLUSIONS: The removal of the retained staples is an efficacious and safe procedure to solve or improve postoperative complications and should be always considered.