Fabio Rondelli

Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis

AbstractBackgroundSphincter-saving surgery for the treatment of middle and low rectal cancer has spread considerably when total mesorectal excision became standard treatment. In order to reduce leakage-related complications, surgeons often perform a derivative stoma, a loop ileostomy (LI), or a loop colostomy (LC), but to date, there is no evidence on which is the better technique to adopt.MethodsWe performed a systematic review and meta-analysis of all randomized controlled trials until 2007 and observational studies comparing temporary LI and LC for temporary decompression of colorectal and/or coloanal anastomoses.Clinically relevant events were grouped into four study outcomes: general outcome measures: dehydratation and wound infection GOMconstruction of the stoma outcome measures: parastomal hernia, stenosis, sepsis, prolapse, retraction, necrosis, and hemorrhageclosure of the stoma outcome measures: anastomotic leak or fistula, wound infection COM, occlusion and herniafunctioning of the stoma outcome measures: occlusion and skin irritation.ResultsTwelve comparative studies were included in this analysis, five randomized controlled trials and seven observational studies. Overall, the included studies reported on 1,529 patients, 894 (58.5%) undergoing defunctioning LI. LI reduced the risk of construction of the stoma outcome measure (odds ratio, OR = 0.47). Specifically, patients undergoing LI had a lower risk of prolapse (OR = 0.21) and sepsis (OR = 0.54). LI was associated with an excess risk of occlusion after stoma closure (OR = 2.13) and dehydratation (OR = 4.61). No other significant difference was found for outcomes.ConclusionOur overview shows that LI is associated with a lower risk of construction of the stoma outcome measures.

Venous thromboembolism after laparoscopic bariatric surgery for morbid obesity: clinical burden and prevention

BACKGROUND The clinical benefit of prophylaxis for venous thromboembolism (VTE) in laparoscopic bariatric surgery is unclear. Our objective was to assess the clinical burden of VTE after laparoscopic bariatric surgery. METHODS We performed a systematic review and meta-analysis. Studies were considered for the review if they reported on the methods used for antithrombotic prophylaxis and on the incidence of objectively confirmed VTE in patients who had undergone laparoscopic bariatric surgery. RESULTS Overall, 19 studies were included in the analysis. The weighted mean incidence (WMI) of pulmonary embolism was .5% (12 events in 3991 patients, 12 studies; 95% confidence interval [CI] .2-.9%; I(2) 38%) with unfractionated heparin (5000 UI twice or 3 times daily) or low-molecular-weight heparin (30 mg twice daily or 40 mg once daily). The WMI of major bleeding as originally reported in 7 of these studies was 3.6% (2741 patients; 95% CI .9-7.95; I(2) 94%). The WMI of screened VTE in 3 high-quality studies with different regimens of heparin prophylaxis was 2.0% (8 events in 458 patients; 95% CI .9-3.5%; I(2) 0%). The WMI of symptomatic VTE was .6% (4 studies; 7 events in 1328 patients; 95% CI .3-1.1%; I(2) 0%) and that of major bleeding was 2.0% (95% CI 1.0-3.4%; I(2) 55%), with weight-adjusted doses of heparin prophylaxis. CONCLUSION The rate of VTE after laparoscopic bariatric surgery seems to be relatively low with standard regimens for antithrombotic prophylaxis. The incidence of major bleeding seems to increase using weight-adjusted doses of heparin with no advantage in terms of VTE reduction.

A Randomized Study on 1-Week Versus 4-Week Prophylaxis for Venous Thromboembolism After Laparoscopic Surgery for Colorectal Cancer

Objective:To compare the efficacy and safety of antithrombotic prophylaxis given for 1 week or 4 weeks in patients undergoing laparoscopic surgery for colorectal cancer. Background:Extending antithrombotic prophylaxis beyond 1 week reduces the incidence of venous thromboembolism (VTE) after open abdominal surgery for cancer. Methods:In consecutive patients who underwent laparoscopic surgery for colorectal cancer, complete compression ultrasonography of the lower limbs was performed after 8 ± 2 days of antithrombotic prophylaxis. Patients with no evidence of VTE were randomized to short (heparin withdrawal) or to extended (heparin continued for 3 additional weeks) prophylaxis. Complete compression ultrasonography was repeated at day 28 ± 2 after surgery by investigators blinded to treatment allocation. The primary outcome of the study was the composite of symptomatic and ultrasonography-detected VTE at day 28 ± 2 after surgery. Results:Overall, 301 patients were evaluated for inclusion in the study and 225 were randomized. VTE occurred in 11 of 113 patients randomized to short (9.7%) and in none of the 112 patients randomized to extended heparin prophylaxis (P = 0.001). The incidence of VTE at 3 months was 9.7% and 0.9% in patients randomized to short or to extended heparin prophylaxis, respectively (relative risk reduction: 91%, 95% confidence interval: 30%–99%; P = 0.005). The rate of bleeding was similar in the 2 treatment groups. Two patients died during the study period, 1 in each treatment group. Conclusions:After laparoscopic surgery for colorectal cancer, extended antithrombotic prophylaxis is safe and reduces the risk for VTE as compared with 1-week prophylaxis (NCT01589146).

Large-artery stiffness: A reversible marker of cardiovascular risk in primary hyperparathyroidism

OBJECTIVE Patients with primary hyperparathyroidism (pHPT) are at increased risk of cardiovascular mortality. We investigated whether aortic stiffness, an early marker of arteriosclerosis and a strong predictor of cardiovascular risk, is increased in pHPT, and whether it improves after parathyroidectomy. METHODS Twenty-four patients with mild pHPT (age 56 ± 10 years, blood pressure 136/85 mmHg, serum calcium 2.55-3.00 mmol/L) and 48 control subjects individually matched with cases by age, sex and blood pressure underwent aortic (carotid-femoral) and upper-limb (carotid-radial) pulse wave velocity (PWV) determination by applanation tonometry in a case-control study. Subjects with renal disease, diabetes, treated hypertension or overt cardiovascular disease were excluded from the study. Seventeen of the patients with pHPT were re-examined 4 weeks after surgical parathyroidectomy. RESULTS Aortic PWV was significantly higher among pHTP patients (11.4 ± 2 vs 9.6 ± 2 m/s, p<0.001). In a conditional logistic regression analysis, pHPT was independently associated with an increased risk of having an aortic PWV >12 m/s (odds ratio 3.28, 95% confidence interval 1.21-8.93). As expected, surgery was accompanied by a reduction in serum calcium (from 2.77 ± 0.2 to 2.25 ± 0.1 mmol/L, p<0.001) and parathyroid hormone (from 29.6 ± 10 to 3.3 ± 2 pmol/L, p<0.001). Aortic PWV decreased after surgery (from 10.9 ± 2 to 9.8 ± 2 m/s, p=0.003). The change in aortic PWV remained significant also after adjustment for changes in blood pressure (p<0.01). Changes in upper-limb PWV generally paralleled those in aortic PWV. CONCLUSION pHPT is associated with increased aortic stiffness, which improves after parathyroidectomy. Our data demonstrate that aortic stiffness may improve upon removal of hyperparathyroid stimuli.

Is laparoscopic right colectomy more effective than open resection? A meta‐analysis of randomized and nonrandomized studies

Aim  The aim of this systematic review was to compare laparoscopic and/or laparoscopic‐assisted right colectomy (LRC) with open right colectomy (ORC). Many randomized clinical trial have shown that laparoscopic colectomy benefits patients with improved short‐term outcomes and comparable overall survival in respect to the open approach. These results, however, could not be applied to right colectomy owing to its wide range of resection and more complicated vascular regional anatomy.

Total thyroidectomy with ultrasonic dissector for cancer: multicentric experience

BackgroundWe conducted an observational multicentric clinical study on a cohort of patients undergoing thyroidectomy for thyroid carcinoma. The aim of this study was to evaluate the benefits of the use of ultrasonic dissector (UAS) vs. the use of a conventional technique (vessel clamp and tie) in patients undergoing thyroid surgery for cancer.MethodsFrom June 2009 to May 2010 we evaluated 321 consecutive patients electively admitted to undergo total thyroidectomy for thyroid carcinoma. The first 201 patients (89 males, 112 females) presenting to our Department underwent thyroidectomy with the use of UAS while the following 120 patients (54 males, 66 females) underwent thyroidectomy performed with a conventional technique (CT): vessel clamp and tie.ResultsThe operative time (mean: 75 min in UAS vs. 113 min in CT, range: 54 to 120 min in UAS vs. 68 to 173 min in CT) was much shorter in the group of thyroidectomies performed with UAS. The incidence of transient laryngeal nerve palsy (UAS 3/201 patients (1.49%); CT 1/120 patients (0.83%)) was higher in the group of UAS; the incidence of permanent laryngeal nerve palsy was similar in the two groups (UAS 2/201 patients (0.99%) vs. CT 2/120 patients (1.66%)). The incidence of transient hypocalcaemia (UAS 17/201 patients (8.4%) vs. CT 9/120 patients (7.5%)) was higher in the UAS group; no relevant differences were reported in the incidence of permanent hypocalcaemia in the two groups (UAS 5/201 patients (2.48%) vs. 2/120 patients (1.66%)). Also the average postoperative length of stay was similar in two groups (2 days).ConclusionThe only significant advantage proved by this study is represented by the cost-effectiveness (reduction of the usage of operating room) for patients treated with UAS, secondary to the significant reduction of the operative time. The analysis failed to show any advantages in terms of postoperative transient complications in the group of patients treated with ultrasonic dissector: transient laryngeal nerve palsy (1.49% in UAS vs. 0.83% in CT) and transient hypocalcaemia (8.4% in UAS vs. 7.5%in CT). No significant differences in the incidence of permanent laryngeal nerve palsy (0.8% in UAS vs. 1.04% in CT) and permanent hypocalcaemia (2.6% in UAS vs. 2.04% in CT) were demonstrated. The level of surgeons’ expertise is a central factor, which can influence the complications rate; the use of UAS can only help surgical action but cannot replace the experience of the operator.

To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis

Anastomotic leakage is the one of the most serious complications in rectal cancer surgery and is associated with high mortality, morbidity and an increased incidence of local recurrence. Although many studies have compared drained and undrained colorectal anastomoses, to date the role of pelvic drainage in extraperitoneal colorectal anastomosis remains undefined.

Prognostic role of sentinel node biopsy in patients with thick melanoma: a meta-analysis.

Objectives  Sentinel lymph node (SLN) biopsy is a prognostic tool for patients with intermediate‐thickness melanomas. However, controversies exist regarding its role in patients with thick melanomas (tumour thickness greater than 4.0 mm). We performed a meta‐analysis to assess the prognostic role of SLN in thick melanoma in terms of disease‐free survival (DFS) and overall survival (OS).

Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis.

Aim  The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer.

Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical extraperitoneal colorectal anastomosis: a retrospective study.

AIM Loop ileostomy is a suitable procedure for transitory faecal diversion after low colorectal anastomosis, but it causes relevant morbidities (discomfort, peristomal infections, dehydration) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI) that can be removed without surgery. METHOD The data of 143 consecutive patients, undergoing elective laparoscopic anterior resection of the rectum for adenocarcinoma and low mechanical colorectal anastomosis, 68 with conventional loop ileostomy (CLI) and 75 with TPI, were analyzed. RESULTS Neither intra-operative complications nor deaths occurred during the follow-up period. Clinical anastomotic leakage occurred in 4 patients with CLI and in 1 with TPI (p = 0.191). The median time required for the emission of gases and faeces through the stoma was respectively 1 and 2.5 days in the CLI group, and 1 and 2 days in the TPI group (p = 0.259 and p = 0.126). The median post-operative stay was 8 days in the CLI group and 11 days in the TPI group (p < 0.001). PTIs were removed on the median of 9 days after surgery without major complications, whereas the CLIs were re-canalized in 79.4% of patients on an average of 106 days, with 2 major complications. CONCLUSION The temporary percutaneous ileostomy seems to be a valid alternative to conventional ileostomy, ensuring optimal faecal diversion and less patient discomfort. It can be easily removed without surgery, allowing patients a better outcome.