Umile Michele Cosenza

Laparoscopic cholecystectomy in day surgery: Feasibility and outcomes of the first 400 patients

BACKGROUND The aim of this study was to evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in a day surgery setting in Italy. MATERIAL AND METHODS Between March 2003 and June 2011, in our institution 439 patients were selected for day surgery LC. To evaluate the efficacy and safety of the procedure, postoperative complications, pain, nausea and vomiting were monitored at 4, 8, and 24 h after surgery. Patients admitted for an overnight stay or readmitted after discharging were also monitored. RESULTS Over 8 years we performed 400 LC in day surgery setting and no conversion or major intraoperative complication were detected. A total of 387 patients (96.7%) were successfully discharged after 8-10 h of observation. Postoperative monitoring showed good pain control (mean VAS score 1.5) and only 3 (0.7%) of the 7 patients who experienced major pain were admitted. Twenty-seven patients (6.7%) experienced PONV and 9 (2.2%) of these required admission. None of the patients needed to be readmitted after discharging. The satisfaction questionnaire administered at 1 month office visit showed that 380 patients (95%) were satisfied with day surgery LC. CONCLUSIONS Our success rate of 96.7% can be attributed to strict adherence to the patient selection criteria. The main reasons for hospital admission were pain and PONV; adequate control of these represents the key of success for day surgery LC. This study confirms the feasibility and safety of LC performed in day surgery setting.

Is desmoplasia a protective factor for survival in patients with colorectal carcinoma

BACKGROUND & AIMS The role of desmoplasia in colorectal carcinoma progression is unclear and the presence of collagen stroma may represent a barrier against cancer diffusion and vascular invasion or a stroma to build up and support the tumor. The aim of this study was to evaluate the effect of desmoplastic response on long-term survival of patients who underwent radical resection for colorectal carcinoma. METHODS The study included 429 patients who underwent radical colorectal resection for cancer with a median follow-up period of 72.8 months. RESULTS At univariate analysis significant associations were observed between desmoplasia and histologic type, parietal infiltration, growth pattern, and staging. No associations were found between desmoplasia and the other clinical and histologic parameters. The multivariate analysis stratified for tumor stage revealed that the factor showing the most favorable influence on time to death was desmoplasia. The presence of desmoplasia was likely to decrease the failure rate to a third of the rate experienced by patients without desmoplasia. Parietal infiltration was associated with an increased risk for a shortened time to death. CONCLUSIONS Our results favor the view that desmoplasia is a protective factor for survival in patients with colorectal carcinoma. This finding is consistent with the hypothesis that desmoplasia may prevent cancer invasiveness by building a barrier against tumor diffusion.

Topical glyceryl trinitrate ointment for pain related to anal hypertonia after stapled hemorrhoidopexy: a randomized controlled trial.

BACKGROUND: Postoperative pain after stapled hemorrhoidopexy is cause for considerable concern and may be related to contracture of continence muscles. OBJECTIVE: We compared glyceryl trinitrate 0.4% ointment with lidocaine chlorohydrate 2.5% gel as topical therapy to relieve the pain of anorectal muscular spasm after stapled hemorrhoidopexy. DESIGN: This was a single-blind, parallel-group, randomized controlled trial. SETTING: The study was conducted at a university teaching hospital in Rome, Italy. PATIENTS: Patients with severe postoperative anal pain after stapled hemorrhoidopexy, clinical evidence of anal hypertonia, and elevated anal resting pressure on manometric assessment were enrolled. Patients treated for concomitant anorectal disease were excluded. INTERVENTIONS: Participants were randomly assigned to receive twice-daily, local topical application of glyceryl trinitrate or lidocaine for a total of 14 days. MAIN OUTCOME MEASURES: Pain intensity was measured on a visual analog scale at baseline and after 2, 7, and 14 days of therapy. Anal resting pressure was measured pre- and postoperatively and after 14 days of therapy. RESULTS: Of 480 patients undergoing stapled hemorrhoidopexy, 121 had severe postoperative pain (score >3) and underwent clinical examination; 45 patients (13 women, 28 men) had clinically evident anal hypertonia and underwent anorectal manometry; 41 patients had elevated anal resting pressure and entered the study. Mean pain scores were significantly lower with glyceryl trinitrate than with lidocaine on day 2 (2.5±1.0 vs 4.0±1.1, p < 0.0001); day 7 (1.4 vs 2.8, p < 0.0001); and day 14 (0.4 vs 1.4, p = 0.003). Anal resting pressure was significantly lower with glyceryl trinitrate than with lidocaine on day 14 (75.4±7.4 mmHg vs 85.6±7.9 mmHg, p < 0.0001). LIMITATIONS: GTN-induced reduction in sphincter tone could not be evaluated during the initial period, when pain was most intense. Because anorectal manometry was performed only in patients with severe pain and clinical evidence of anal hypertonia, firm conclusions cannot be drawn as to frequency of hypertonia after SH. Bias may have been introduced because the surgical team could not be blinded. CONCLUSION: Topical 0.4% glyceryl trinitrate is effective in relieving pain and reducing anal resting pressure in patients with anal hypertonia after stapled hemorrhoidopexy.

True aneurysm of the ulnar artery in a soccer goalkeeper: A case report and surgical considerations

An aneurysm of the ulnar artery was first described by Guattani in 1772. It is a rare lesion, usually caused by blunt or penetrating trauma, often the result of occupational or athletic activity. Aneurysms of the ulnar artery have been found in manual laborers who repetitively use a hammer, a screwdriver, or other tool against fixed objects and in athletes who receive repetitive blunt injury to the hand. Smokers are particularly at high risk because tobacco may have deleterious effects on the arterial vasculature when superimposed on an aneurysmal defect. Aneurysms are generally located in the superficial segment of the ulnar artery at the level of the carpal hamate bone and may be true or false. A false aneurysm has a fibrous wall vessel, whereas a true aneurysm shows a marked change of the three vascular layers. The true aneurysm often follows a blunt injury of the hand, whereas a false aneurysm generally results from a penetrating artery injury. We report a case of a sports-related true ulnar artery aneurysm.

Leiomyosarcoma of the rectum after pelvic radiation therapy for endometrial carcinoma.

during the same examination. In this respect, it is noteworthy that, out of 163 CD patients newly diagnosed by Dickey and Hughes, 33 (20%) were suspected of having the disease and biopsied only because of the presence of endoscopic signs. Celiac sprue is a disease with a wide spectrum of clinical manifestations, varying from overt malabsorbtion to subclinical or even silent forms (4); the golden standard for the diagnosis relies on histological abnormalities that improve under a gluten-free diet (5). Although initially considered to be relatively uncommon, it has now been found to be one of the most frequent genetically based diseases in the general population (6–8). The real problem is deciding which patients should be submitted to duodenal biopsies: at present, clinical history and symptoms, biochemical findings suggestive of malabsorbtion, and/or positive serological markers (antigliadin, antiendomysium, and antitransglutaminase antibodies) are considered indications for obtaining an intestinal biopsy; the presence of duodenal markers is a very important adjunctive tool that must strongly induce endoscopists to perform duodenal biopsies.

Feasibility and safety study of day-case Transtar™ procedure.

BACKGROUND Short hospitalization surgery is cost effective and convenient for both patients and healthcare system. Stapled transanal rectal resection (STARR) conducted with the new curved device, Contour Transtar, has proved an effective and safe procedure for treatment of obstructed defecation syndrome. The aim of this study was to determine the safety and feasibility of STARR, performed as a day-case procedure. MATERIAL AND METHODS Retrospective review was performed of all STARR performed as day-case surgery between September 2009 and February 2011. The entire study (intervention, data collection and data analysis) was conducted at the One-day Surgery Unit of the St. Andrea Hospital, Rome, Italy. All patients with surgical indication to STARR for the presence of an obstructed defecation syndrome were included in the study. We excluded from day-case protocol, patients over 65 years old, with an ASA score of III-IV or with a BMI over 35. The surgical technique reflects the original technique proposed by Antonio Longo with the exception of the longitudinal prolapse opening, which was created with the use of an electric scalpel between two Kocher clamps and not by an application of Transtar stapler. To evaluate the feasibility and safety of performing this procedure with short hospitalization, we investigated the presence and the time of presentation of post-operative complications. RESULTS Eighty-nine patients underwent STARR as a day-case regimen, and none presented major complications or required an extension of hospital stay or readmission. CONCLUSIONS STARR performed with Contour Transtar, in selected patients, is safe and feasible in day-case regimen if performed by expert surgeons and in a structure that allows the physician to keep the patient hospitalized or to re-admit and promptly treat those patients who present major surgical complication.

Surgical Management of Nonparasitic Cysts of the Liver: Report of 17 Cases

A retrospective study of 17 patients with symptomatic nonparasitic liver cysts, surgically treated over a 19-year period at the First Surgical Clinic, University of Rome ‘La Sapienza’, was carried out to evaluate the incidence, symptoms and management of this condition. The incidence of liver cysts was 4.28/1,000 with respect to the number of abdominal surgical procedures performed between 1987 and 1990, and 1.75/1,000 with respect to the number of ambulatory liver ultrasonographies carried out in the same time period as the last 12 cases. The critical diameter at which the cyst becomes symptomatic was found to be 5 cm (p