I Reccia

Meta-analysis of studies comparing single-incision laparoscopic appendectomy and conventional multiport laparoscopic appendectomy

BACKGROUND There is no consensus that single-incision laparoscopic appendectomy (SILS-A) is on a par with conventional multiport laparoscopic appendectomy (CMLA). The aim of this meta-analysis was to assess feasibility, safety, and potential benefits of SILS-A when compared with CMLA. METHODS A literature search for studies comparing SILS-A and CMLA was performed. Studies were reviewed for the outcome of interest: patient characteristics, operative outcome, postoperative recovery, postoperative morbidity, patient satisfaction, and cosmetic results. RESULTS Thirteen studies comparing SILS-A and CMLA were reviewed: two prospective randomized trials, four prospective studies, and seven retrospective studies. Overall, 893 patients were operated on: by SILS-A in 402 cases (45.0%) versus 491 cases (55.0%) by CMLA. Patients in the SILS-A group were significantly younger than those in the CMLA group (31.2 versus 33.5 y). No other differences were found. Patient satisfaction score was impossible to meta-analyze. CONCLUSIONS Appendectomy via SILS-A may be considered as an alternative to CMLA. However, these results must be approached with caution as they are based on data from nonrandomized observational studies. The feasibility and safety of SILS-A must be mainly assessed for difficult clinical situations such as severe obesity, localized abscess, or diffuse peritonitis from a ruptured appendix in the setting of new prospective randomized trials.

Acute Diverticulitis in the Young: The Same Disease in a Different Patient

Background. Natural history and risk factors for diverticulitis in young patients are still debatable. This study aimed to assess whether difference exists in patients aged 50 and younger when compared to older patients and to identify risk factors for acute diverticulitis in the young. Patients and Methods. From January 2006 to December 2011, 80 patients were admitted to our department for acute diverticulitis. We carried out a cross-sectional study in 23 patients (28.7%) aged 50 and younger and 57 older patients (71.3%). Results. Acute diverticulitis in the young was not more aggressive than in the older patient. Diverticulitis at patients admission was similar with respect to Hincheys stage and prior history of diverticulitis. No significant difference was found for both medical and surgical treatment. The rate of recurrent diverticulitis in nonoperated patients was similar. Male gender, body mass index ≥25, and assumption of alcohol were independent risk factors for the occurrence of an acute diverticulitis in the young. Conclusions. The same disease seems to be affecting young patients such as overweight or obese male individual. Current policies to prevent diverticular disease and its related complications must include obesity control together with high-fiber diet and regular exercise.

Sternohyoid muscle flap interposition in the treatment of an acquired tracheoesophageal fistula

Tracheoesophageal fistula caused by prolonged intubation is a rare clinical entity. We report the case of a patient successfully treated by interposition of a sternohyoid muscle flap.

A rare cause of an unresolving liver abscess.

We report the case of a hepatic abscess trigged by a foreign body, which caused long hospital stay and prolonged medical therapy. A 68-year-old man was admitted to our surgical department for the treatment of an idiopathic liver abscess. A few weeks before, he developed upper abdominal pain with nausea and fever. Initial investigations revealed a hepatic abscess (Fig. 1) of unknown origin and antibiotic therapy was started. No improvement was observed and the patient manifested complications of prolonged antibiotic therapy. Further abdominal sonography (Fig. 2) finally showed the presence of a toothpick embedded in the liver and the patient was submitted to surgical treatment (Fig. 3). Foreign-body ingestion is a rare cause of liver abscess. Diagnosis is difficult and sometimes achieved only at surgery (1). There are several cases of foreign body ingestion described in the literature. In most of the cases, the patient experienced no consequences. When present, however, complications can widely range in severity mostly depending on delay in correct diagnosis and appropriate treatment. Diagnostic imaging (ultrasound and computed tomography scans) can accurately define liver lesions, assess intra-abdominal pathologies and additionally identify foreign bodies (2, 3). In spite of that, foreign body can be missed and a high level of suspicion is essential (1). Adequate treatment is essential in avoiding complications and must include the removal of the foreign body. Surgical management still remains the most appropriate treatment, when no other less invasive options are applicable (1, 4).

Letter to the editor, reply to "commentary on meta-analysis of prospective randomized studies comparing single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC)" by Pisanu et al. (J Gastrointest Surg 2012; 16:1790-1801).

Sir, Thank you very much to Dr. Christensen for the interest in our meta-analysis comparing the outcomes of single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC), which has been published in the Journal of Gastrointestinal Surgery in July 2012. For the aim of this meta-analysis, variables were considered only if evaluated by three or more studies in order to reduce the occurrence of a type II error related to the small number of cases, as data could also be combined from only two studies. All outcomes of interest were tested for heterogeneity and adjusted for small sample bias. Those studies that not reported data about the outcomes of interest were excluded from the meta-analysis. The case of major biliary injury after SILC cholecystectomy, however, is a different matter. As you surely noticed, data about major biliary injury have not been summarized in a forest plot because, fortunately, no cases of this feared complication occurred in the included trials. Thus, the impossibility to meta-analyze data about major biliary injury was related to the absence of this complication rather than to the small number of pooled patients or to the unreported data. The absence of major biliary injury in cholecystectomies performed in the setting of randomized studies and in specialized centers must not create a false sense of security in the community of surgeons until the processes of SILC standardization will be completed. The uncontrolled diffusion of SILC has been considered as responsible for an increased number of bile duct injuries that have been reported with prevalence as high as 0.7 %, which is an unacceptable complication rate. Our pooled analysis included 12 clinical trials for a total of 892 patients randomized for both SILC and CMLC techniques. At the time of the survey, these were the best possible summarized results from the literature. We are aware that this is not enough to consider the processes of SILC standardization as completed. Indeed, we concluded that SILC cholecystectomy is a safe and effective procedure for the treatment of uncomplicated benign gallbladder disease andmay be proposed as an alternative for cholecystectomy in “properly selected patients and in experienced hands.” The need for new larger prospective multicenter studies to better assess the SILC technique has also been advocated at the end of our paper. The overall morbidity rate was higher in the SILC group (13.1 vs. 9.8 %), and it was mainly represented by the surgical site infection and postoperative incisional hernia at the umbilical site. This difference did not reach statistically significant difference. Meta-analysis increases the statistical power of the outcomes by pooling data from several studies, as the size of individual clinical trial is often too small to detect outcome consistency. In the case of overall morbidity, there was no heterogeneity among the included trials and the weighted summary OR 1.16 was calculated under the fixed effects model. This means that all included trials were homogeneous with regard to the assessment of overall morbidity, and if all studies were infinitely large, they would yield identical estimate of the effect. The too short follow-up suggests approaching the result A. Pisanu : I. Reccia :G. Porceddu :A. Uccheddu Department of Surgery, Clinica Chirurgica, University of Cagliari, Monserrato, Italy

Encapsulated papillary thyroid carcinoma: Is it a distinctive clinical entity with low-grade malignancy?

Background: Encapsulated papillary thyroid carcinoma (EPTC) is commonly retained as a tumor with indolent clinical courses. Herein we focused on the search for factors predicting biological behavior and influencing prognosis of EPTC in comparison with the non-encapsulated counterpart of papillary thyroid carcinoma (NEPTC). Methods: From January 1998 to May 2009, 348 patients underwent thyroidec-tomy in our surgical department because of papillary thyroid carcinoma (PTC). A cross-sectional study of 52 patients with EPTC and 296 patients with NEPTC was carried out: demographic data, tumor characteristics, diagnostic results, patient management, post-operative and follow-up results were evaluated. Results: EPTC patients were significantly younger than patients with NEPTC (44.5 vs 48.8 yr, p<0.04). Mean tumor size was significantly greater for EPTC than for NEPTC (2.36 vs 1.41 cm, p<0.001). Tumor multifocality, thyroid capsular invasion, and lymph node involvement at diagnosis were significantly associated with NEPTC (p=0.0001, p<0.0001, and p=0.027, respectively). Multivariate analyses showed that NEPTC classical variant were at risk for both thyroid capsular invasion and nodal involvement (odds ratio 6.870 and 9.514, respectively) while EPTC were not. Nodal metastasis at diagnosis was the only factor influencing recurrence. Conclusions: The majority of EPTC had risk-free clinical courses as a result of their low risk of locoregional spread. However, definitive recommendations need a longer follow-up and a comparison with a lesser treated group of patients belonging to the same category of risk at diagnosis.