Stefano Reggio

Open vs totally laparoscopic right colectomy: technique and results

BackgroundRight colectomy is the surgical treatment for malignantpathologies involving the intestinal tract between theileocecal Bahuino valve and the colic hepatic flexure.Laparoscopic resection must respect the same oncologi-cal criteria as the open approach including:‘’no-touchisolation technique’’, isolation and ligation of the vascularpedicles at the origin, oncological lymphadenectomy and‘’distal and radial clearance’’ of the neoplasm from resec-tion margins.Two major procedures have been described for thetreatment of right colon tumors: Open right colectomy(ORC) and Totally Laparoscopic resection (TL) in whichvascular ligations, intestinal resection and anastomosis areperformed by laparoscopy (Figure 1).In ORC technique, there is an abdominal right sidelaparotomy; in TL there is a minilaparotomy used only forendobag colon extraction and it is located in parapubicregion.MethodsFrom May 2004 to march 2013, we performed in HighSpecialistic Surgical Centers (Aosta “Parini” Hospital andNaples “Federico II” University) 132 laparoscopic rightcolectomies and 127 open right colectomies of which wehave selected 75 laparoscopic cases of these 11 for benignpathologies and 64 for neoplastic diseases and 75 OpenCases. The M/F rate was 1/1. The mean age was 64.7 ± 7.2.Colonic preoperative washout was performed to allpatients with 2 L for a day of polyethylene glycol (PEG) inthe two days before the operation, associated with a fiber-free diet. The day before operation, we positioned in allpatient antalgic peridural catheter with 0.5% levobupiva-caine (4 ml/h); on the following day, in the operatingroom, after anesthetic induction, we also positioned naso-gastric tube (NG tube) and urinary catheter (UC) and nodrain according to Kehlet protocols (in the last 23 cases).In the TL colectomy, the sovrapubic minilaparotomy of6 ± 2 cm is necessary only for the specimen extractionfrom the parapubic minilaparotomy performed by a 15-mm Endocatch, preventing the peritoneal spreading ofneoplastic cells.The procedures were considered curative only whenthere was no intraoperative evidence of secondarylocations.NG tube was removed after the operation and UC in themorning after surgery. The patients were allowed to drinkliquids with oral assumption of medicines the evening ofthe operation (Table 1) [1]. All the patients underwent acycle of postoperative physiokinesis therapy. Patients weredischarged when they became autonomous in movementsand walking with a restored bowel function without feverand pain.They were followed-up at least 1 year, starting on the30

Clinical efficacy of HBOT(hyperbaric oxygen therapy) in the treatment of foot ulcers in elderly diabetic patient: our experience

Background The development of foot ulcers is a serious complication in elderly diabetic patients. Its treatment is based on the use of different techniques, but when they fail that often lead to limb amputation. The efficacy of treatment with HBOT in diabetic foot ulcer has been evaluated for more than 20 years, but its use has never become routine, its use is a reality that in recent years is increasingly consolidating, especially as an adjuvant to conventional therapies and the NPWT (Negative Pressure Wound Therapy ) and dermal substitutes. Many studies prove its validity, experimentally the beneficial effects consist in the improvement of tissue perfusion, inflammatory cytokines down-regulation, fibroblasts proliferation, edema reduction , angiogenesis promotion and collagen production, it is also proven by the years the favorable effect against infectious component of the lesion [1,2]. In particular, the hyperbaric oxygen increases the bactericidal activity and is particularly toxic to anaerobes [3]. In addition, many studies, including some meta-analyzes, documenting the positive role of HBOT in reducing the risk of amputation, although a recent meta-analysis it is clear the shortterm benefit, but for the long-term studies would be needed to be so designated such as to minimize any bias [4]5. In our center, we evaluated the use of hyperbaric oxygen therapy to reduce limb amputation risk. Methods This observational study, open-label short-term evaluated the clinical efficacy of this method integrated medical therapy, treatment of wound cleansing and debridement, and topical applications of hydrocolloids, alginates, polyacrylates and foams. After obtaining informed consents, 7 diabetic patients with foot ulcers (n = 7) were enrolled and treated with cycles of hyperbaric oxygen therapy (2.4 ATA) for a period of about 85 minutes for 5 days a week, during the period between January and September 2012, with follow-up until May 2013.Among the exclusion criteria we considered: patients with compromised bone and / or Charcot’s foot, Wagner class greater than III, non elegible patients for HBOT (AP chest X-ray, visit ENT, cardiological examination with ECG, laboratory tests to assess feasibility), then patients with severe impairment of arterial district in the affected arm. All patients have done foot X-ray and ECO Color Doppler of lower limb as preliminary study, which showed: four patients Wagner class II, Winsor index between 0.9 and 1, three patients Wagner Class III, with winsor pathological index. The treatment was carried out in two stages: at first, the patients were treated with medical therapy, surgical debridement, exudate management and stimulation of granulation and epithelialization with advanced wound dressings, wound swabs and orthotics , in a second time were matched HBOT cycles. The follow-up was done by clinical and biochemical controls with particular attention to the glycemic profile and obtaining optimal levels of glycated hemoglobin, and taking cilostazol tablets 100 mg, possibly associated with antiplatelets (cardioaspirin, clopidogrel). We established two outcome measures : 1) surgical healing of the lesions, 2) amputation (short-term assessment by the end of treatment until May 2013). * Correspondence: luciano.grimaldi@unina.it Department of Specialized Surgery, Division of Gastrointestinal Surgery Rehabilitation of Election and Emergency. “Federico II” University, Naples, Italy Full list of author information is available at the end of the article Grimaldi et al. BMC Surgery 2013, 13(Suppl 1):A26 http://www.biomedcentral.com/1471-2482/13/S1/A26

Classification of Inguinal and Abdominal Wall Hernia

Since 1840, when Hesselbach used the inferior epigastrics vessels as the defining boundary between indirect and direct hernias, surgeons have always tried to classify the inguinal hernias. This first classification resisted for years; nowadays the interest in a more accurate and scientific classification of groin hernias is increasing. The general opinion is that one standardized system must be adopted, and since 2009 the EHS recommended that its classification system should be used [1]. The primary objective of any classification system is to stratify the pathology in study (groin hernia) for severity in order to allow reasonable comparisons between treatment strategies [2]. Moreover, a classification must be simple and easy to use. Several operative techniques with their variations for herniorrhaphy have been described, but no one classification system can satisfy all presently. The EHS overpass this problem, developing a brand new classification system by consensus [2–9]: in effect an expert panel analyzed the known systems to date and proposed classification that resembles largely the Aachen classification [10]. This latter makes a distinction between the anatomical localization (indirect or lateral vs. direct or medial) and the size of the hernia orifice defect in cm ( 3 cm) (Table 4.1). Moreover Miserez et al. [2] decided to modify to some minor aspects this classification, proposing the “index finger” rule as the reference in open surgery (normally the size of the tip of the index finger is mostly around 1.5–2 cm). This size is also identical to the length of the branches of a pair of most laparoscopic graspers, dissector, allowing the surgeon to use the same standardized classification during mini-invasive procedures [11, 12]. For recurrent hernias, a detailed description could be used as proposed by Campanelli et al. [13]. The recurrent hernias are divided into three types: Type R1: first recurrence “high,” oblique external, reducible hernia with small (<2 cm) defect in nonobese patients, after pure tissue or mesh repair Type R2: first recurrence “low,” direct, reducible hernia with small (<2 cm) defect in nonobese patients, after pure tissue or mesh repair Type R3: all other recurrences or anyway not easily included in R1 or R2, after pure tissue or mesh repair (femoral, big defects, multirecurrent, non-reducible, obese patient)

Laparoscopic near-total splenectomy: a single-center experience of a standardized procedure

Abstract Background: Near-total splenectomy (NTS) represents an innovative and effective surgery technique for spleen disease, reducing the risk of severe infections and thromboembolic events after total splenectomy. The authors reported a laparoscopic near-total splenectomy (LNTS) surgical experience following the optimal results of the open approach, describing a standardized and effective minimally invasive technique with the purpose of preserving a minimal residual spleen. Material and methods: From November 2006 to September 2016, 15 patients with splenic and hematologic disease underwent LNTS, according to a laparoscopic procedure developed by the authors. The end criterion was to conserve a remanent spleen of 10–15 cm3 in size. Results: Patient age ranged between 18 and 59 years. Mean operative time was 70 ± 20 min. Mean hospital stay was 3.46 (range 3–7) days. One complication occurred during the surgery for a lesion of the inferior polar artery with need of a total splenectomy. No conversion to open surgery was necessary. Conclusions: LNTS is a safe and effective technique for the management of splenic and hematologic disease with a low intra- and post-operative complication rate, and it can minimize the late sequelae of secondary splenectomy. However, it requires further studies with more cases to evaluate its role.

Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant.

BackgroundLaparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication.MethodsFrom January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction.ResultsAmong the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect.ConclusionIn our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.

Three-Dimensional High-Definition Laparoscopic Treatment of DunbarSyndrome (Celiac Axis Compression by Median Arcuate LigamentHypertrophy) With Intra-Operative Laparoscopic Duplex UltrasoundEvaluation: Report of Two Cases

Introduction: Dunbar syndrome consists in a rare vascular disorder characterized by extrinsic compression of the celiac artery. This mechanic compression results in symptoms related to intermittent mesenteric ischemia. The goal of treatment is to release celiac artery compression and to restore vessel patency. Here we report two cases treated in our Surgical Department over the last four years. Case Report: A young female of 28 years-old, L.P., and 57-year-old men, E.G., both affected by recurrent post-prandial diffuse abdominal pain, diarrhea and weight loss came to our observation. A complete abdominal evaluation associated to radiologic exams made the diagnosis of CAC syndrome. Both patients were referred to a 3D laparoscopic surgical treatment of CACS with release of the median arcuate ligament. Vessels patency was checked intra-operatively using ecolaparoscopy. Conclusion: Median arcuate ligament section is the treatment of choice in Dunbar Syndrome, a rare vascular syndrome caused by extrinsic compression of the celiac trunk by a lower-inserted muscular bridge that connects the two crura of the diaphragm and crosses over the abdominal aorta. Minimally invasive 3D laparoscopic approach is ideal to treat Dunbar syndrome for the high definition and magnification of the 3D visualization. We perform an intraoperative laparoscopic duplex ultrasound investigation in the initial phase of the operation and at the conclusion of the procedure to assess the effectiveness of the treatment.

Laparoscopic 3D high-definition Deloyers procedure: when, how, why?

After extensive mobilization and resection of the left colon, colorectal anastomosis may result impossible due to the distance between the remaining colon and the rectal stump. The Deloyers procedure represents an interesting alternative to total colectomy with ileorectal anastomosis. In this manuscript, we describe when and how to perform this technique with a mini-invasive approach. We also report the case of a patient who underwent Deloyers procedure, due to early ischemia of the descending colon after left colectomy.

Analysis of early postoperative complications in patients with resectable rectal cancer after neo-adjuvant chemo-radiotherapy

Background Surgery is presently playing a leading role in rectal cancer treatment, but the natural history of the disease, featured by a high local recurrence rate (30-40% until the 8090 years), suggested the possibility of using multimodal treatment regimen : radiotherapy (before, during and after surgery) possibly associated with chemotherapy [1,2]. This approach is recommended for the maority of patients with stage II (negative lymph nodes with tumor invading the muscularis) or with stage III (positive lymph nodes but without metastases after a time span). The neoadjuvant radio and chemo therapy, though having no impact on global survival rate, associated to TME reduce the local recurrence rate, provide a higher control level of systemic disease (micro metastases eradication), increase the rate of complete pathological responses, and allow a higher rate of “sphincter sparing” surgery [3,4].

Male breast cancer: a rare case of neoplasia in elderly; our experience and review of the literature

Background Male breast cancer (MBC) is a rare tumor and accounts for <1 % of all breast cancers, but its incidence is increasing. The majority of breast lesions in men are benign and the causes, optimal treatments, and medical/ psychosocial sequelae of breast cancer in men are poorly understood. [1] The natural history and prognostic factors do not differ from the female form, this tumor is characterized by a higher mortality rate because the presenting symptoms are often underestimated, and it comes to diagnosis when the disease is already advanced [2].

Outcome of surgical resection of localized gastrointestinal stromal tumors: our experience

Background Gastrointestinal stromal tumors (GISTs) constitute the most common non epithelial neoplasm that occur within the gastrointestinal tract with a world wide annual incidence of 8-14/million. They are usually located in the upper gastrointestinal tract particularly in the stomach (60%), in the small bowel (30%), esophagus (5%) and rectum (5%). Gist(s) origin from sporadic mutations within the tyrosine-kinase receptors of the interstitial Cajal cells. The clinical presentation of Gist (s) is quite heterogeneous [1]. The most common associated symptoms are abdominal pain, bleeding, gastroenteric outlet obstruction. Modern cross-sectional imaging studies include TC and/or magnetic resonance imaging in combination with upper endoscopy. Upper endoscopy with ultrasonography (EUS) is an useful tool to pick tissue for diagnosis for cytology (FNA) or trucut biopsy. In addition EUS can show the depth of penetration through the layers of the gastro-enteric wall and origin of these neoplasm . Routinary biopsies increase the risk of tumor spillage or hemorrhage with consequent higher rate of recurrence or disseminated sarcomatosis therefore only selective biopsies are recommended [2]. Complete surgical resection is the only curative therapy of Gist without metastasis. Surgery of large Gists may result technically difficult. However debulking before molecular therapy or reducing the size with neoadjuvant therapy by imatinib can give longer survival and better results [3]. In this study we report our experience on surgical treatment of 16 patients with localized gastrointestinal stromal tumors.