Serafino Vanella

Severe acute pancreatitis: advances and insights in assessment of severity and management.

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

End-to-end versus end-to-side stapled anastomoses after anterior resection for rectal cancer.

Sphincter‐saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end‐to‐end and end‐to‐side anastomosis after anterior resection for T1–T2 rectal cancer.

Botulinum toxin for recurrent anal fissure following lateral internal sphincterotomy.

The aim of the study was to evaluate the efficacy of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy.

Complications in thyroid surgery. Harmonic Scalpel, Harmonic Focus versus Conventional Hemostasis: A meta-analysis

BACKGROUND To evaluate the incidence of postoperative complications, hemostatic effects and safety of Total Thyroidectomy (TT) performed using the Harmonic Scalpel (HS), the Harmonic Focus (HF) or Conventional Hemostasis (CH). METHODS The meta-analysis was performed according to PRISMA guidelines. A literature search was conducted from 2003 to 2014 and stringent criteria were required for inclusion. Thirteen studies concerning an overall population of 1458 compared HS versus CH, whilst 8 studies with 1667 patients compared HF versus CH. RESULTS There was a significant reduction of operative time (Mean Difference [MD] = -25.49 min.; 95% CI -32.43 to -18.55), intraoperative blood loss (MD = -30.49 mL; 95% CI -53.01 to -7.97), postoperative drainage volume (MD = -12.90 mL; 95% CI -22.83 to -2.98) and postoperative pain (MD = -0.87; 95% CI -1.27 to -0.46) in patients underwent TT with HS. Regarding HF group, a significant reduction of operative time (MD = -25.99 min., 95% CI -34.56 to -17.41), length of hospital stay (MD = -0.57; 95% CI -0.97 to -0.17), transient hypocalcemia (OR = 0.56; 95% CI 0.39 to 0.81) and postoperative pain (MD = -1.33 days; 95% CI -2.49 to -0.17) resulted. CONCLUSIONS HS TT can be a safe, useful and fast alternative to conventional TT. The newer HF can reduce the rate of hypocalcemia. Future RCTs of larger patient cohorts with more detailed data of postoperative complications, cost-effectiveness and cosmetic results, randomization procedures, intention-to-treat analyses and blinding of outcome assessors are needed to draw more meaningful conclusions.

Botulinum toxin for chronic anal fissure after biliopancreatic diversion for morbid obesity

AIM To study the effect of botulinum toxin in patients with chronic anal fissure after biliopancreatic diversion (BPD) for severe obesity. METHODS Fifty-nine symptomatic adults with chronic anal fissure developed after BPD were enrolled in an open label study. The outcome was evaluated clinically and by comparing the pressure of the anal sphincters before and after treatment. All data were analyzed in univariate and multivariate analysis. RESULTS Two months after treatment, 65.4% of the patients had a healing scar. Only one patient had mild incontinence to flatus that lasted 3 wk after treatment, but this disappeared spontaneously. In the multivariate analysis of the data, two registered months after the treatment, sex (P = 0.01), baseline resting anal pressure (P = 0.02) and resting anal pressure 2 mo after treatment (P < 0.0001) were significantly related to healing rate. CONCLUSION Botulinum toxin, despite worse results than in non-obese individuals, appears the best alternative to surgery for this group of patients with a high risk of incontinence.

Extended or limited lymph node dissection? A gastric cancer surgical dilemma

W e read with great interest the article by Memon and coworkers1 reporting the outcome of a meta-analysis of randomized controlled trial evaluating the efficacy and drawbacks of limited (D1) versus extended (D2) lymphadenectomy for proven gastric carcinoma. This is a very excellent article; the basic organization of this report is clear and convincing, and the associated conclusions and recommendations are based on a review by investigators with long-standing interest in gastric disorders.2–4 Worldwide, gastric cancer is one of the top-3 leading causes of cancer mortality, but their incidence and presentation vary geographically. Currently, surgery is the only possible cure. Nodal status is an important prognostic indicator for gastric cancer, and despite results of randomized controlled trials, debate continues over the importance of aggressive lymphadenectomy. On the basis of the results of the meta-analysis, the authors conclude that D1 gastrectomy is associated with significant fewer anastomotic leaks, postoperative complication rate, and reoperation rate, decreased length of hospital stay, and 30-day mortality rate. Finally, the 5-year survival in patients who underwent D1 gastrectomy was similar to the D2 cohort.1 Similar results have been founded in recent meta-analysis.5 Overall, 14 randomized controlled trials (3432 patients) were included in the meta-analysis. Of the D1 and D2 surgery groups, the operative mortality and postoperative morbidity were higher in the D2 group than in the D1 group, but the 3and 5-year survival rates were not statistically different. Also, the operative time was shorter in the D1 group than in the D2 group. In the D2 versus D3 surgical group, the operative mortality, percentage of postoperative complications, operative time, and hospital stay were not significantly different. The results suggest that D2 and D3 surgical

Anastomotic leak and local recurrence in colorectal cancer

W e read with interest the systematic review and meta-analysis by Mirnezami et al.1 The aim of the study is to investigate the long-term oncological influence of anastomotic leak (AL) after restorative surgery for colorectal cancer (CRC) using meta-analysis methods. Principal outcomes evaluated were local recurrence, distant recurrence, and longterm survival. We agree with the authors that the study is subject to a number of limitations. Adjuvant therapy may have a confusing effect on the results of the paper, and also fewer patients with advanced CRC who develop an AL receive adjuvant therapy, when compared with stage-matched groups of patients without an AL.2 It seems conceivable that failure to receive adjuvant treatment, or delays to the start of therapy due to development of an AL, may facilitate recurrence of CRC. Therefore, we agree with the authors that caution must also be exerted in overinterpretation of the reported findings; a statistical association between AL and increased local recurrence and reduced cancer specific survival does not imply a causative association. The impact of AL on the immediate postoperative morbidity and mortality is well known.3–5 However, it is controversial whether the AL itself is a prognostic factor for local recurrence and/or survival of patients with CRC. Although some investigators report that AL is an independent prognostic factor associated with local recurrence or survival, others do not support this point of view.5 One problem with this type of analysis is that usually the proportion of patients with AL is so small that it is difficult to identify it as a factor in long-term survival.3 Meta-analysis uses statistical methods to obtain a quantitative estimate of the effect of a particular intervention from the effects reported in many studies. Compared with traditional reviews and expert opinion, meta-analysis provides a more objective and quantitative summary of the evidence that is

Treating Benign Prostatic Hyperplasia with Botulinum Neurotoxin

Botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several disorders; the use of this agent has extended to a plethora of conditions including focal dystonia, spasticity, inappropriate contraction in most gastrointestinal sphincters, eye movement disorders, hyperhidrosis, genitourinary disorders and aesthetically undesirable hyperfunctional facial lines. In addition, BoNT is being investigated for the control of pain, and for the management of tension or migraine headaches and myofascial pain syndrome. Benign prostatic hyperplasia (BPH) is a common condition in ageing men; the goal of therapy is to reduce the lower urinary tract symptoms (LUTS) associated with BPH and to improve the quality of life. However, medical treatment, including drugs that relax smooth muscle within the prostate and drugs that shrink the gland are not totally effective or without complications. The standard surgical treatment for BPH is progressively changing to minimally invasive therapies, but none of them has provided clear results. The use of BoNT-A to inhibit the autonomic efferent effects on prostate growth and contraction, and inhibit the abnormal afferent effects on prostate sensation, might be an alternative treatment for BPH. BoNT injections have several advantages over drugs and surgical therapies in the management of intractable or chronic disease; systemic pharmacologic effects are rare, permanent destruction of tissue does not occur, and graded degrees of relaxation may be achieved by varying the dose injected. In this paper, clinical experience over the last years with BoNT in BPH impaired patients will be illustrated.

Evaluation of multiple prognostic scores in patients with acute pancreatitis.

REFERENCES 1 . Papachristou GI , Muddana V , Yadav D et al. Comparison of BISAP, Ranson’s, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis . Am J Gastroenterol 2010 ; 105 : 435 – 41 . 2 . Windsor JA . Th ere is no room for complacency in the assessment of the severity of acute pancreatitis . Pancreatology 2008 ; 8 : 105 – 9 . 3 . Windsor JA . Search for prognostic markers for acute pancreatitis . Lancet 2000 ; 355 : 1924 – 5 . 4 . Mofi di R , Duff M , Madhavan K et al. Identifi cation of severe acute pancreatitis using an artifi cial neural network . Surgery 2007 ; 141 : 59 – 66 .

Chronic anal fissure: Surgical or reversible neurochemical sphincterotomy?

The management of chronic anal fissure has received renewed interest and has been re-evaluated over the past 20 years. The use of botulinum toxin seems to be a promising and safe approach, particularly in patients at high risk for incontinence. A recent meta-analysis investigated the efficacy of botulinum toxin injection compared with lateral internal sphincterotomy for the management of this condition.