Minimally invasive laparoscopic and robot-assisted emergency treatment of strangulated giant hiatal hernias: report of five cases and literature review

Background Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature. Methods During 10 years (December 2009–December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review. Results The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences. Conclusion Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations

Chemioipertermia intraperitoneale laparoscopica nel trattamento dell’ascite maligna. Case report

Malignant ascites is a pathological condition, due to several abdominal and extra-abdominal neoplasms, representing a difficult challenge in treatment. Different medical and surgical options have been proposed, but none of them have shown efficacy, leading only to partial and temporary relief of symptoms. Laparoscopic intraperitoneal chemotherapy may be a valid therapeutic option in patients in whom medical therapies have failed and peritoneovenous shunting is contraindicatd. A 49-years old woman with malignant ascites, secondary to peritoneal localization of right pleural mesothelioma, underwent, after failure of medical therapy, laparoscopic intraperitoneal chemotherapy (with Cisplatin 25 mg/m2/L and Doxorubicin 7 mg/m2/L). An important and lasting reduction of ascites and abdominal symptoms was documented till the exitus, due to pulmonary embolism after 11 months.Laparoscopic intraperitoneal chemotherapy may be a good therapeutic option to palliative malignant ascites in patient not eligible for a radical cytoreductive treatment, but further investigations are needed to standardized dosage and perfusion procedur

Small bowel metastasis from lung cancer: a possible cause of acute abdomen. Case report and literature review

Obiettivo. Il cancro del polmone è la principale causa di morte per neoplasia al mondo e il 50% dei pazienti presentano già alla diagnosi malattia metastatica. Le metastasi al tratto gastroenterico da neoplasia polmonare sono ritenute piuttosto rare, ma un’incidenza considerevole è riportata in alcune serie autoptiche. La rilevanza clinica delle metastasi gastroenteriche (GE) è piuttosto bassa, ma può aumentare se si considera l’alto numero di nuove diagnosi e l’efficacia della chemioterapia negli stadi avanzati. La prognosi delle complicanze da metastasi GE da cancro del polmone è peggiore del decorso naturale della neoplasia e il sanguinamento o la perforazione del sito metastatico possono essere accelerati dall’effetto della chemioterapia sistemica. Caso clinico. Descriviamo il caso di un paziente con addome acuto da perforazione di ansa digiunale per metastasi da cancro del polmone. Segue la revisione della più recente letteratura sulle metastasi GE da neoplasia polmonare. Discussione. Le metastasi GE da cancro del polmone possono manifestarsi nel decorso clinico della malattia e richiedono una terapia chirurgia gravata da prognosi infausta. La percentuale dei pazienti affetti da neoplasia polmonare che sviluppano metastasi GE può raggiungere il 14%. Il carcinoma a grandi cellule, che metastatizza ai surreni e ai reni, è più spesso associato anche alla localizzazione gastroenterica. Conclusioni. Le complicazioni di metastasi GE, sebbene rare, devono essere considerate come possibile causa di addome acuto nei pazienti affetti da neoplasia polmonare. L’identificazione dei possibili segni clinici, anche predittivi, di metastasi GE può aiutare nella diagnosi e nella strategia terapeutica

Esperienza preliminare di chemioterapia perioperatoria nel cancro gastrico localmente avanzato

Obiettivo. Il cancro gastrico (gastric cancer, GC) è una neoplasia dalla prognosi infausta ed è spesso diagnosticato in stadio avanzato. La chemioterapia neoadiuvante (neoadjuvant chemotherapy, NAC) si propone di aumentare la possibilità di ottenere una resezione chirurgica completa e di incrementare la sopravvivenza globale (overall survival, OS). Pazienti e metodi. Dal novembre 2006, sei pazienti affetti da adenocarcinoma gastrico, diagnosticato e studiato mediante endoscopia, ecoendoscopia e 18FDG-PET-TC total body, sono stati arruolati nel protocollo di chemioterapia perioperatoria, secondo i seguenti criteri di inclusione: cT2N+M0 o cT3-4NxM0, età 60%, assenza di insufficienza epatica, renale e midollare. I pazienti vengono sottoposti a tre cicli di chemioterapia preoperatoria e post-operatoria con Epirubicina, Cisplatino e 5-Fluorouracile (ECF), come proposto dal MAGIC trial. A quindici giorni dalla fine della chemioterapia pre-operatoria il paziente viene sottoposto a ecoendoscopia e 18FDG-PET-TC total body per valutare la risposta al trattamento; successivamente viene indirizzato alla chirurgia. Trenta giorni dopo l’intervento chirurgico ha inizio la chemioterapia postoperatoria. Risultati. Tutti i pazienti arruolati hanno completato la chemioterapia preoperatoria. Cinque pazienti sono stati sottoposti a gastrectomia subtotale D2, un paziente a gastrectomia totale D1. Non sono state osservate né morbidità né mortalità peri- e post-operatorie. Durante la chemioterapia postoperatoria due pazienti hanno sviluppato trombosi della vena succlavia destra ed un paziente insufficienza renale. Conclusioni. Sebbene la chirurgia rimanga il trattamento principale per il GC, è evidente che un miglioramento della prognosi è coadiuvato da un trattamento multidisciplinare. Come dimostrato dal MAGIC Trial, la NAC ha una tossicità accettabile e può aumentare la OS, permettendo il down-staging della neoplasia primitiva e incrementandone quindi la resecabilità

Necrotizing pancreatitis: A review of the interventions

Acute pancreatitis may have a wide range of severity, from a clinically self-limiting to a quickly fatal course. Necrotizing pancreatitis (NP) is the most dreadful evolution associated to a poor prognosis: mortality is approximately 15% and up to 30-39% in case of infected necrosis, which is the major cause of death. Intervention is generally required for infected pancreatic necrosis and less commonly in patients with sterile necrosis who are symptomatic (gastric or duodenal outlet or biliary obstruction). Traditionally the most widely used approach to infected necrosis has been open surgical necrosectomy, but it is burdened by high morbidity (34-95%) and mortality (11-39%) rates. In the last two decades the treatment of NP has significantly evolved from open surgery towards minimally invasive techniques (percutaneous catheter drainage, per-oral endoscopic, laparoscopy and rigid retroperitoneal videoscopy). The objective of this review is to summarize the current state of the art of the management of NP and to clarify some aspects about its diagnosis and treatment

Purse-string closure versus conventional primary closure of wound following stoma reversal: Meta-analysis of randomized controlled trials

Purpose: Surgical site infection (SSI) is one of the most frequent complications after stoma closure and the optimal skin closure technique is still not clear. The goal of this review was to compare outcomes with purse-string closure technique (PSC) versus conventional closure technique (CCT) for skin closure after stoma reversal. Methods: We performed a systematic review and meta-analysis of available randomized controlled trials (RCTs) to compare SSI rate within 30 days, operative time, hospital stay, incisional hernia and intestinal obstruction rates between PSC and CCT. Results: The pooled analysis of 5 studies showed a statically significant lower rate of SSI in favor of PSC compared to CCT (OR -0.24; 95% CI -0.32, - 0.15; p < 0.00001). No statistically significant differences were observed in the operative time (OR -0.05; 95% CI -3.95, 3.84; p = 0.98) and in the length of hospital stay (OR -0.20; 95% CI -0.76, 0.36; p = 0.48), between the two techniques. Additionally, two out of the five studies provided data on incisional hernia and intestinal obstruction and the pooled analysis revealed no statistically significant differences between PSC and CCT techniques: incisional hernia (OR 0.81, 95% CI 0.27–2.47; p = 0.71) and intestinal obstruction (OR 1.07, 95% CI 0.41–2.84; p = 0.88). Conclusions: The analysis of 5 RCTs showed that SSI rate is statistically significant lower when PSC is performed, compared to CCT. Whereas, no significant differences were found between the two techniques with regards to operative time, length of hospital stay, incisional hernia and intestinal obstruction rates

Un caso di neoplasia gastrica metastatica trattato con successo con chirurgia e chemioterapia

A case of long-term survivor 50-year-old man treated for advanced gastric cancer with two liver metastases is described. Patient underwent a total gastrectomy with D2 lymphadenectomy and atipic liver resection. After surgery, chemotherapy with PELF achieved a complete clinical response; six month from the fourth cycle, Ca19.9 levels slowly increased until 185 U/mL and a retro-peritoneal lymphadenopathy was detected by US. Three different chemoterapic combinations (FOLFOX, FOLFIRI, FOLFOX4) was administrated but two new liver recurrences spread out. From November 2007 until now, patient received 8 CDF cycles and he obtained a complete clinical response supported by persistent negativity of TC-PET scans. The radiological investigations performed after last admission in our Department for jaundice, revealed multiple liver lesions with Ca19.9 levels of 6.766 U/mL. The patient required placement of metallic biliary endoprosthesis. He is still alive 41 month after primary surgery. We consider this case a successful example of survival increasing by integrated surgery-chemotherapy treatment but also an expression of the failure of current available therapy in the definitive cure for gastric cancer. Metastatic gastric cancer should be considered a disease treatable but not curable

Robot-assisted Toupet fundoplication and associated cholecystectomy in symptomatic giant hiatal hernia with situs viscerum inversus—A case report and literature review

Introduction:Giant hiatus hernia is defined as migration of &gt;30% of the stomach with or without other intra- abdominal organs into the chest. Situs Viscerum Inversus is a rare congenital condition in which the major visceral organs are reversed from their normal arrangement; they are translated (completely or partially) on the opposite side of the body. Diagnosis is often incidental. We report a Robot-assisted Toupet fundoplication for a giant hiatal hernia with gastro oesophageal reflux disease and cholelithiasis, in a 63-years-old woman with situs viscerum inversus.Presentation of case:A 63-year-old woman with Situs Viscerum Inversus was diagnosed with giant sliding hiatus hernia. We performed a Robot-assisted procedure of reduction of hiatal hernia in abdomen and Toupet fundoplication with Bio A mesh placement and gastropexy procedure associated to cholecystectomy. The operation time was of 190 minutes. The patient was discharged on third postoperative day after X-ray check and he tolerated a solid food.Discussion: Minimally invasive surgery represents , nowadays, the standard approach for hiatal hernia and cholelithiasis. Conclusion:In challenging cases as the giant hernias ad rare anomaly as situs viscerum inversus, the surgical treatment can be facilitated by the use of robotic technology

Transanal total mesorectal excision (TaTME): single-centre early experience in a selected population

Total mesorectal excision (TME) represents the key principle in the surgical treatment of rectal cancer. Transanal mesorectal excision was introduced as a complement to conventional surgery to overcome its technical difficulties. The aim of this study was to evaluate the early surgical results following the introduction of this novel technique at our Unit. Between January and May 2016, 12 patients diagnosed with mid-low rectal adenocarcinoma were enrolled into this study and evaluated with regards demography, histopathology, peri-operative data and postoperative complications. The tumor was located in the middle rectum in 6 patients (50%), in the lower rectum in 6 patients (50%). Mean operative time was 356.5 ± 76.2 min (range 240-494). Eleven out 12 patients (91.6%) had less than 200 mL of intraoperative blood loss. Mean hospital stay was 10.9 ± 4.6 days (range 5-19). No mortality was recorded. Intraoperative complications were recorded in 1, while early post-operative complications (< 30 days) were observed in 5 patients (41.6%). Histopathology showed in all cases an intact mesorectum. Mean number of lymphnodes harvested was 13.6 ± 6.6 (range 4-29). Distal and circumferential margin was, respectively, of 20.8 ± 14.2 mm (range 2-45 mm) and 16.1 ± 7.6 mm (range 3-30 mm). The comparative analysis showed significant differences concerning mean operative time (p = 0.0473) and estimated blood loss (p = 0.0367). This study confirms this technique is safe and feasible, but more evidence to support its use over conventional laparoscopic surgery is needed

Complete Remission of Unresectable Hepatocellular Carcinoma after Combined Sorafenib and Adjuvant Yttrium-90 Radioembolization

Sorafenib has improved the median overall survival of unresectable or otherwise untreatable hepatocellular carcinoma (HCC) of 3c3 months, compared to supportive cares. Complete response, although rare, has been reported. The authors reported herein a case of complete biochemical and radiological remission of advanced unresectable HCC with lymph node metastasis and tumoral portal vein thrombosis treated by 5 months therapy with sorafenib followed by adjuvant Yttrium-90 radioembolization. At 12 months follow-up, there is no evidence of HCC recurrenc