Simona Gili

Effectiveness of fibrin glue in conjunction with collagen patches to reduce seroma formation after axillary lymphadenectomy for breast cancer

BACKGROUND Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15% to 85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies, with controversial results. METHODS Fifty patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray and a collagen patch were applied to the axillary fossa in 25 patients; the other 25 patients were treated conventionally. RESULTS Suction drainage was removed between postoperative days 3 and 4. Seroma magnitude and duration were significantly reduced (P = .004 and .02, respectively) and there were fewer evacuative punctures in patients receiving fibrin glue and collagen patches compared with the conventional treatment group. CONCLUSIONS Use of fibrin glue with collagen patches does not always prevent seroma formation, but it does reduce seroma magnitude and duration, as well as necessary evacuative punctures.

Gastroesophageal reflux disease and obesity: do we need to perform reflux testing in all candidates to bariatric surgery?

INTRODUCTION Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and esophageal erosions. However the relationship between obesity and GERD is still a subject of debate. In fact, if in most cases bariatric surgery can diminish reflux by losing a large amount of fat, on the other hand some restrictive procedure can worsen or cause the presence of GERD. Thus, it is unclear if patients candidate to bariatric surgery have to perform pre-operative reflux testing or not. AIM of the study was to verify the presence of GERD patterns in patients candidate to surgery and the need of pre-operative reflux testing. METHODS All patients underwent to a standardized questionnaire for symptoms severity (GERQ), upper endoscopy, high resolution manometry (HRiM) and impedance pH-monitoring (MII-pH). Patients were stratified into: group 1 (negative for both GERQ and endoscopy), group 2 (positive for GERQ and negative for endoscopy), group 3 (positive for both GERQ and endoscopy). A healthy-volunteers group (HV) was assessed. RESULTS One hundred thirty-nine subjects (obese, 124; HV normal weight, 15) were studied. Group 1 showed comparable mean LES pressure, peristaltic function, bolus transport and presence of hiatal hernia than HV. Group 2 showed a reduction of these parameters, while group 3 showed a statistical significant reduction in LES pressure, peristaltic function, bolus transport and increase in presence of hiatal hernia. At MII-pH, Group 1 showed a not significant increase in reflux patterns; group 2 and 3 showed a significant increase in esophageal acid exposure and in number of refluxes (both acid and weakly acid), with group 3 showing the higher grade of reflux pattern. CONCLUSIONS Obese subjects with pre-operative presence of GERD symptoms and endoscopical signs could be tested with HRM and MII-pH before undergoing bariatric surgery, especially for restrictive procedures. On the other hand, obese patients without any sign of GERD could not be tested for reflux, showing similar patterns to HV.

Axillary lymphadenectomy for breast cancer in elderly patients and fibrin glue

BackgroundAxillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results.MethodsThirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel.ResultsSuction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group.ConclusionsUse of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.

Esophagogastric junction morphology assessment by high resolution manometry in obese patients candidate to bariatric surgery

INTRODUCTION Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and hiatal hernia development. Pure restrictive bariatric surgery should not be indicated in case of hiatal hernia and GERD. However it is unclear what is the real incidence of disruption of esophagogastric junction (EGJ) in patients candidate to bariatric surgery. Actually, high resolution manometry (HRM) can provide accurate information about EGJ morphology. Aim of this study was to describe the EGJ morphology determined by HRM in obese patients candidate to bariatric surgery and to verify if different EGJ morphologies are associated to GERD-related symptoms presence. METHODS All patients underwent a standardized questionnaire for symptom presence and severity, upper endoscopy, high resolution manometry (HRM). EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and < 2 cm); Type III, >2 cm separation. RESULTS One hundred thirty-eight obese (BMI>35) subjects were studied. Ninety-eight obese patients referred at least one GERD-related symptom, whereas 40 subjects were symptom-free. According to HRM features, EGJ Type I morphology was documented in 51 (36.9%) patients, Type II in 48 (34.8%) and Type III in 39 (28.3%). EGJ Type III subjects were more frequently associated to Symptoms than EGJ Type I (38/39, 97.4%, vs. 21/59, 41.1% p < 0.001). CONCLUSIONS Obese subjects candidate to bariatric surgery have a high risk of disruption of EGJ morphology. In particular, obese patients with hiatal hernia often refer pre-operative presence of GERD symptoms. Testing obese patients with HRM before undergoing bariatric surgery, especially for restrictive procedures, can be useful for assessing presence of hiatal hernia.

Effectiveness of an advanced hemostatic pad combined with harmonic scalpel in thyroid surgery. A prospective study

INTRODUCTION Hemostasis during thyroidectomy is essential; however the most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with the combination of harmonic scalpel (HS) and an advanced hemostatic pad (Hemopatch). METHODS Patient undergone TT were divided into two groups: HS + hemopatch and HS + traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates. RESULTS Between September 2014 and March 2015, 60 patients were enrolled (30 to Hs + Hemopatch, 30 to Hs and standard hemostasis); 71.4% female; mean age 48.5 years. The 24-h drain output was lower in the HS + hemopatch group compared with standard TT. HS and hemopatch also had a shorter mean surgery time (p < 0.0001) vs standard TT. CONCLUSION combination of hemopatch plus HS is effective and safe for TT with a complementary hemostatic approach.

Long term quality of life after laparoscopic antireflux surgery for the elderly

BackgroundStudies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life.MethodsPatients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.ResultsForty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG).There were 114 (36.6%) patients who filled out the SF36 questionnaire (98 in the younger group, rate: 37.4%; 16 in the elderly group, rate: 32.6%) pre- and post-operatively. There was no significant difference between the two age groups regarding preoperative PCS ( 45.6 ± 7.8 in YG vs. 44.2 ± 8.2 in EG; P = 0.51) and MCS ( 48.1 ± 10.7 in YG vs. 46.9 ± 9.2 in EG; P = 0.67). There was no significant difference between the two age groups regarding postoperative PCS (49.8 ± 11.9 in YG and 48.2 ± 9.5 in EG ; P = 0.61 and MCS (48.4 ± 10.7 in YG vs. 50.1 ± 6.9 in EG; P = 0.54).ConclusionsIn conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.

Multimodal Treatment of Constipation: Surgery, Rehabilitation or Both?

Constipation accounts for 20% in western world population. In absence of any organic aetiology, this disorder may be related to bad alimentary habits based on inadequate introduction of the three components of stool (fibres, probiotics and water) that are essential for the physiologic activity of colon. Chronic constipation may be also associated with either colic or rectal anatomo-functional alterations. Colonic constipation (slow transit constipation) is usually related to a motility disorder (inertia coli) associated with a reduction of propagating contraction waves and decreased Cajal’ cells; on the other hand, rectal outlet dysfunction type constipation may be related to anatomical alterations (e.g. internal mucosal prolapse, rectocele) causing difficult rectal outlet and functional pelviperineal dyssynergia. The physiologic defaecatory act involves not only synchronism between rectum and anus, but even correct thoraco-abdominoperineal dynamics and vertebral position. This has to be carefully assessed by considering patient’s ability to accomplish adequate thoraco-abdominoperineal muscle movements needed for both adequate defaecatory dynamics and urine and stool retention. Therefore, the ideal treatment should not only address anatomical alterations such as mucosal prolapse, rectocele, rectorectal intussusception and sphincter defects, usually requiring a surgical approach, but even functional disorders, often insidious and difficult to detect. Surgery is mandatory to treat pathological findings, that physically represent an obstacle to fecal transit in the rectum. Many surgical techniques have been developed for the treatment of outlet obstruction with conflicting results. STARR (stapled transanal rectal resection) is a new surgical procedure that was launched by Longo in 2001. It is a minimally invasive transanal operation for rectocele and mucosal/rectal prolapse using a double circular stapler. This procedure is indicated when rectal mucosal prolapse is thought to be the cause of difficult defecation, and appears to be a rational treatment. This treatment aims to normalize the anatomical relationship of the anal mucosa with hemorrhoidal piles and anal sphincters by restoring the prolapse and improving venous perfusion. The procedure pulls the anal