Piero Covarelli

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.

Fibrin glue in the treatment of anal fistula: a systematic review.

BackgroundNew sphincter-saving approaches have been applied in the treatment of perianal fistula in order to avoid the risk of fecal incontinence. Among them, the fibrin glue technique is popular because of its simplicity and repeatability. The aim of this review is to compare the fibrin glue application to surgery alone, considering the healing and complication rates.MethodsWe performed a systematic review searching for published randomized and controlled clinical trials without any language restriction by using electronic databases. All these studies were assessed as to whether they compared conventional surgical treatment versus fibrin glue treatment in patients with anal fistulas, in order to establish both the efficacy and safety of each treatment. We used Review Manager 5 to conduct the review.ResultsThe healing rate is higher in those patients who underwent the conventional surgical treatment (P = 0,68), although the treatment with fibrin glue gives no evidence of anal incontinence (P = 0,08). Furthermore two subgroup analyses were performed: fibrin glue in combination with intra-adhesive antibiotics versus fibrin glue alone and anal fistula plug versus fibrin glue. In the first subgroup there were not differences in healing (P = 0,65). Whereas in the second subgroup analysis the healing rate is statistically significant for the patients who underwent the anal fistula plug treatment instead of the fibrin glue treatment (P = 0,02).ConclusionIn literature there are only two randomized controlled trials comparing the conventional surgical management versus the fibrin glue treatment in patients with anal fistulas. Although from our statistical analysis we cannot find any statistically significant result, the healing rate remains higher in patients who underwent the conventional surgical treatment (P = 0,68), and the anal incontinence rate is very low in the fibrin glue treatment group (P = 0,08). Anyway the limited collected data do not support the use of fibrin glue. Moreover, in our subgroup analysis the use of fibrin glue in combination with intra-adhesive antibiotics does not improve the healing rate (P = 0.65), whereas the anal fistula plug treatment compared to the fibrin glue treatment shows good results (P = 0,02), although the poor number of patients treated does not lead to any statistically evident conclusion. This systematic review underlines the need of new RCTs upon this issue.

The single-photon emission computed tomography/computed tomography: a new procedure to perform the sentinel node biopsy in patients with head and neck melanoma.

The aim of this study was to define and validate a new technique to detect the sentinel node (SN) in patients treated for head and neck melanoma. In a small series of 23 head and neck melanoma patients, lymphatic mapping was followed by SN biopsy, using in 12 patients a new diagnostic imaging technique, single-photon emission computed tomography/computed tomography. The procedure is described and the major problems encountered are discussed. The preliminary data show that identification of SN using single-photon emission computed tomography/computed tomography never failed in 12 patients, and biopsies performed, compared with those in a standard group, took significantly less time (Mann–Whitney test P=0.006). In conclusion, the authors underline the possibility of a wide use for this technique.

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).

Surgical treatment of primitive gastro-intestinal lymphomas: a systematic review

Primitive Gastrointestinal Lymphomas (PGIL) are uncommon tumours, although time-trend analyses have demonstrated an increase. The role of surgery in the management of lymphoproliferative diseases has changed over the past 40 years. Nowadays their management is centred on systemic treatments as chemo-/radio- therapy. Surgery is restricted to very selected indications, always discussed in a multidisciplinary setting. The aim of this systematic review is to evaluate the actual role of surgery in the treatment of PGIL.A systematic review of literature was conducted according to the recommendations of The Cochrane Collaboration. Main outcomes analysed were overall survival (OS) and disease free survival (DFS).There are currently 1 RCT and 4 non-randomised prospective controlled studies comparing surgical versus medical treatment for PGIL. Seven hundred and one patients were analysed, divided into two groups: 318 who underwent to surgery alone or associated with chemotherapy and/or radiotherapy (surgical group) versus 383 who were treated with chemotherapy and/or radiotherapy (medical group).Despite the OS at 10 years between surgical and medical groups did not show relevant differences, the DFS was significantly better in the medical group (P = 0.00001). Accordingly a trend was noticed in the recurrence rate, which was lower in the medical group (6.06 vs. 8.57%); and an higher mortality was revealed in the surgical group (4.51% vs. 1.50%).The chemotherapy confirms its primary role in the management of PGIL as part of systemic treatment in the medical group. Surgery remains the treatment of choice in case of PGIL acutely complicated, although there is no evidence in literature regarding the utility of preventive surgery.

Bronchogenic cyst of the ileal mesentery: a case report and a review of literature

IntroductionBronchogenic cyst is a rare clinical entity that occurs due to abnormal development of the foregut; the majority of bronchogenic cysts have been described in the mediastinum and they are rarely found in an extrathoracic location.Case presentationWe describe the case of an intra-abdominal bronchogenic cyst of the mesentery, incidentally discovered during an emergency laparotomy for a perforated gastric ulcer in a 33-year-old Caucasian man.ConclusionsBronchogenic cyst should be considered in the differential diagnosis of subdiaphragmatic masses, even in an intraperitoneal location.

Incidental finding of carcinoid tumor on Meckel's diverticulum: case report and literature review, should prophylactic resection be recommended?

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and is caused by incomplete obliteration of the vitelline duct during intrauterine life. MD affects less than 2% of the population. In most cases, MD is asymptomatic and the estimated average complication risk of MD carriers, which is inversely proportional to age, ranges between 2% and 4%. The most common MD-related complications are gastrointestinal bleeding, intestinal obstruction and acute phlogosis. Excision is mandatory in the case of symptomatic diverticula regardless of age, while surgical treatment for asymptomatic diverticula remains controversial. According to the majority of studies, the incidental finding of MD in children is an indication for surgical resection, while the management of adults is not yet unanimous. In this case report, we describe the prophylactic resection of an incidentally detected MD, which led to the removal of an occult mucosal carcinoid tumor. In literature, the association of MD and carcinoid tumor is reported as a rare finding. Even though the strategy for adult patients of an incidental finding of MD during surgery performed for other reasons divides the experts, we recommend prophylactic excision in order to avoid any further risk.

Spontaneous splenic rupture in patient with metastatic melanoma treated with vemurafenib

BackgroundBRAF inhibitors such as vemurafenib are a new family of biological drugs, recently available to treat metastatic malignant melanoma.MethodsWe present the case of a 38-year-old man affected by metastatic melanoma who had been under treatment with vemurafenib for a few days. The patient suffered from sudden onset of abdominal pain due to intra-abdominal hemorrhage with profuse hemoperitoneum. An emergency abdominal sonography confirmed the clinical suspicion of a splenic rupture.ResultsThe intraoperative finding was hemoperitoneum due to splenic two-step rupture and splenectomy was therefore performed. Histopathology confirmed splenic hematoma and capsule laceration, in the absence of metastasis.ConclusionsThis report describes the occurrence of a previously unreported adverse event in a patient with stage IV melanoma receiving vemurafenib.

Recurrent differentiated thyroid cancer: to cut or burn

The term “relapse carcinoma” is used improperly to indicate either a local or loco-regional relapse or a systematic metastatsis [1]. Local relapse (LR) after thyroidectomy for cancer is “the repetition of the neoplastic lesion in proximity of the previous intervention of excision” [2]. According to Duren [3] relapses of thyroidal carcinoma need to be classified as: local (LR): that may present itself in the residual thyroid lobe or in the thyroid bed where surgery was performed; loco-regional (RLR): that may present in the cervical lymph nodes of the central compartment or lateral-cervical nodes; and metastasis in distance (MD). The MD are frequently synchronous with LR or RLR; they have haematogenous genesis and concern most frequently the lungs and skeleton. There is controversy over how to catergorize the relapse in the thyroidal bed with infiltrations of neighbouring organs (periodontal structures muscles, thyroidal cartilage, cricoid, laryngeal nerves, etc. and the neighbouring organs oesophagus, trachea, larynx). As per the classification proposed by Duren [3] these should be considered as LR, whereas according to Mozzillo and Pezzullo [1] they are categorised as RLR. The RLR at the level of the cervical lymphnodal stations represents an ulterior problem: are these true relapses, residual cancer, or recurrence in progression? Caraco [4], in his report to the ninety-fourth Congress of the Italian Society of Surgery, specified that local recurrences are only those recurrences that are characterized by the appearance of neoplastic tissue in the thyroidal lodge, in the residual parenchyma, and in the adjacent structures, excluding the lymph nodes [5,6]. In nearly 53% of cases the relapse is reported in RLR, in 28% in LR, and in 13% the MD is present of these 6% of cases have mixed relapses [7]; the prognosis of LR is however, better than that of the others [8]. The differentiated tumors of the thyroid are slow growing and due to this rarely reach notable dimensions or result in metastasis in lymph and/or haematic systems [2]. Only 10% of patients die from differentiated thyroid cancer [9]. Most of the local relapses occur within the first five years of the excision of the primary cancer [5,6,10-12], however, the recurrence can occur as late as 20 years after the initial diagnosis and treatment [13]. An accurate evaluation of incidence of LR is possible solely with a considerable number of treated patients and lengthy follow-up that is not available at most centres and hence this kind of information can be obtained from the date from centres that have high volume of thyroid carcinoma and good follow-up like Mayo Clinic or Lahey Clinic [5,6,13] or through observational studies at several other medical centres [14]. Currently relapses represent a rare event in patients who undergo removal of thyroidal carcinoma (3-13%) [5,6,10-12,15-17]. This is due to the ever increasing frequency of total thyroidectomy for management of cancer [18]. The complete excision of the thyroidal parenchyma prevents local recurrence. Giovanni Razzaboni in “Treatise on Prognostic Surgery” (1938) stated that “The most rational operating method, so long as not free from grave consequences of another kind, remains the total extra-capsular thyroidectomy, so as is used, when possible, for the surgical removal of whatever other tumour” [19]. he further emphasized in his work published after his death in 1956 entitled “Treatise on Clinical Therapeutic Surgery” that “Only an removal of this capacity justifies, in the face of a proven malignant tumour, surgical intervention, any other incomplete or partial demolition does nothing but accelerate the ready reoccurrences, even in a very short time” [20]. * Correspondence: cirocchiroberto@yahoo.it General and Emergency Surgical Unit. Department of Surgical Sciences, Radiology and Dentistry. University of Perugia, Perugia, Italy Full list of author information is available at the end of the article Cirocchi et al. World Journal of Surgical Oncology 2011, 9:89 http://www.wjso.com/content/9/1/89 WORLD JOURNAL OF SURGICAL ONCOLOGY

Emergency treatment of complicated incisional hernias: a case study

BackgroundThe emergency treatment of incisional hernias is infrequent but it can be complicated with strangulation or obstruction and in some cases the surgical approach may also include an intestinal resection with the possibility of peritoneal contamination. Our study aims at reporting our experience in the emergency treatment of complicated incisional hernias.MethodsSince January 1999 till July 2008, 89 patients (55 males and 34 females) were treated for complicated incisional hernias in emergency. The patients were divided in two groups: Group I consisting of 33 patients that were treated with prosthesis apposition and Group II, consisting of 56 patients that were treated by performing a direct abdominal wall muscles suture.ResultsAll the patients underwent a 6-month follow up; we noticed 9 recurrences (9/56, 16%) in the patients treated with direct abdominal wall muscles suture and 1 recurrence (1/33, 3%) in the group of patients treated with the prosthesis apposition.ConclusionsAccording to our experience, the emergency treatment of complicated incisional hernias through prosthesis apposition is always feasible and ensures less post-operative complications (16% vs 21,2%) and recurrences (3% vs 16%) compared to the patients treated with direct muscular suture.