Impact of office-based surgery for hemorrhoids on clinical outcomes and institutional costs: a prospective controlled study

Aim: Transanal hemorrhoidal artery ligation with mucopexy (THAL-m) is a treatment option for symptomatic hemorrhoidal disease (HD). Open hemorrhoidectomy (OH) has stood the test of time in terms of radical cure for HD. Both techniques can be performed under local anesthesia. The aim of this study was to determine the impact on postoperative outcome and cost-effectiveness of performing these techniques in ambulatory setting in an Italian academic centre. Method: A prospective series of grade II /III HD. 100 consecutive patients undergoing ambulatory surgical treatment of hemorrhoids in 2015–2017 (group A) were compared to 100 patients operated at the same institution in the same period (Group H) by hospitalization. The primary outcome was sick leave used as a proxy of clinical outcome. Secondary outcomes included postoperative complications, cost-effectiveness, and patient satisfaction. Results: Sick leave was significantly reduced in Group A patients (8 days versus 15) with no increase in postoperative complications, and patient satisfaction was high. Total mean direct costs per patient were significantly lower in office-based setting versus the hospital stay group (431 euros versus 1320). Conclusion: Implementing ambulatory surgery for hemorrhoids is feasible, efficient, safe, and cost-effective but correct selection of patients is necessary

Late Epiphrenic-Retroperitoneal Fistula of an Esophageal Diverticulum Ten Years after Surgical Excision: Report of the First Case

Background: Esophageal fistula is a rare complication of an epiphrenic diverticulum and represents a difficult diagnostic challenge. In the majority of cases in the English literature, the fistula is secondary to the spontaneous perforation of the epiphrenic diverticulum and in only one case an esophagobronchial fistula occurs after resection of an epiphrenic diverticulum. No case of esophageal fistula communicating with the retroperitoneum tissues was found. Case Report: We present a case of 84 years old male admitted in 2017 in our Hospital for the appearance of epigastralgia and cough with traces of blood to sputum, asthenia and night sweats. Ten years before he underwent to a hiatal hernia plastic sec. Nissen and subsequently was reoperated for exeresis of diverticulum of the distal third of the esophagus by thoracotomy. In August 2008, because of esophageal substenosis an operation of posterior gastropexy sec. Hill with the demolition of the previous hiatoplasty was performed. In 2017, a computerized tomography shows a voluminous abscess in the right paravertebral region with development along the muscular plane of the ipsilateral psoas and a fistular path of about 4 cm between the posterior wall of the esophagus and the retroperitoneal collection of the abdomen. Conclusions: Esophageal fistula represents a complex problem of epiphrenic diverticulum and rarely a hidden complication of surgery. Surgery is the treatment of choice in suitable patients

Adverse events in thyroid surgery: observational study in three surgical units with high volume/year

Background: Thyroid surgery, performed for benign or malignant pathologies, is one of the most frequently performed procedures and its frequency has even been increasing in recent years. Postoperative bleeding, recurrent laryngeal nerve (RLN) palsy, associated to dysphonia, dysphagia, dyspnea, and hypoparathyroidism represent the most fearful and common complications. We conducted a multicenter, observational study of retrospectively collected data in three high-volume referral centers, enrolling all patients undergone to thyroid surgery between January 2016 and December 2017 in Parma University Hospital, Cagliari University Hospital and Ferrara University Hospital. Materials: Patients were divided into five groups, differentiated thyroid carcinoma, medullary thyroid carcinoma, non-toxic benign pathology, hyperfunctioning benign pathology and NIFTP (Non-invasive Follicular Thyroid neoplasm with Papillary-like nuclear features). A follow up at 7 and 30 days was executed, evaluating the onset of paresthesia, dysphonia and dysphagia. A 6-month follow-up was conducted in cases of early complications. Results: Totally, 1252 patients were eligible for the study: 907 female and 345 male, with a female to male ratio of 2.6:1 and an average age of 53.428. Total thyroidectomy was performed in 1022 cases, lobectomy in 230. After 6 months we recorded paresthesia in 0.5%, dysphonia in 1.8% and dysphagia in 0.5%. Conclusion: Our study confirms once again that a share of morbidity escapes the possibilities of prediction and control by the operator, depending on patient anamnestic, pathological or anatomical factors

Micro-Fragmented Adipose Tissue: A New Minimally Invasive Method for Treatment of Anal Fistula? A Pilot Study

The treatment of Anal fistula continues to be one of the most challenging clinical problems in anorectal surgery. Many sphincter-preserving procedures for the treatment of anal fistula have been recently introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Micro-fragmented adipose tissue injection associated closure of the internal opening with Lipogems® technique is one of them. The properties of autologous adipose-derived stem cells for regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of the present article is to evaluate the safety and efficacy of autologous, micro-fragmented and minimally manipulated adipose tissue injection associated with closure of the internal opening in promoting anal fistula healing

Management of the pelvic floor disfunctions: combined versus single surgical procedure in a multidisciplinary approach: a retrospective study

The objective of this study was to compare the outcome of combined surgical treatment of multicompartmental pelvic floor defects versus single procedures within a multidisciplinary path in order to try to clarify what is the most effective surgical approach

Do I Need to Operate on That in the Middle of the Night? Development of a Nomogram for the Diagnosis of Severe Acute Cholecystitis

Background Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis. Methods This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created. Results Age as a continuous variable, WBC count ≥ 12.4 × 103/μl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points. Conclusions Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes

Do I Need to Operate on That in the Middle of the Night? Development of a Nomogram for the Diagnosis of Severe Acute Cholecystitis

Background Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis. Methods This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created. Results Age as a continuous variable, WBC count ≥ 12.4 × 103/μl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points. Conclusions Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes

Trans-anal irrigation in patients with multiple sclerosis: Efficacy in treating disease-related bowel dysfunctions and impact on the gut microbiota: A monocentric prospective study

Background: Constipation and faecal incontinence are not so uncommon in patients with multiple sclerosis, impairing quality of life. The gut microbiota is altered in multiple sclerosis patients and likely contributes to disease pathogenesis. Trans-anal irrigation has been proven to allow treatment of neurogenic bowel dysfunction and may affect gut microbiota. Objectives: The primary outcome was trans-anal irrigation effectiveness on constipation and faecal incontinence. The secondary outcome was gut microbiota profiling compared to healthy subjects and during trans-anal irrigation adoption. Methods: We conducted a prospective cohort study on multiple sclerosis patients, screened with Patient Assessment of Constipation Quality of Life questionnaire before undergoing constipation and faecal incontinence scoring, abdomen X-ray for intestinal transit time, compilation of food and evacuation diaries and faecal sample collection for gut microbiota analysis before and after 4 weeks of trans-anal irrigation. Results and Conclusions: Eighty patients were screened of which nearly half had intestinal symptoms. The included population (n = 37) was predominantly composed of women with significantly longer disease duration, higher mean age and disability than the excluded one (p < 0.05). Twelve patients completed the trans-anal irrigation phase, which led to significant improvement of bowel dysfunction symptom-related quality of life, increase in gut microbiota diversity and reduction of the proportions of pro-inflammatory taxa (p < 0.05). Trans-anal irrigation was safe, satisfactory and could help counteract multiple sclerosis-related dysbiosis

Diagnostic and prognostic microRNAs in the serum of breast cancer patients measured by droplet digital PCR

Background: Breast cancer circulating biomarkers include carcinoembryonic antigen and carbohydrate antigen 15-3, which are used for patient follow-up. Since sensitivity and specificity are low, novel and more useful biomarkers are needed. The presence of stable circulating microRNAs (miRNAs) in serum or plasma suggested a promising role for these tiny RNAs as cancer biomarkers. To acquire an absolute concentration of circulating miRNAs and reduce the impact of preanalytical and analytical variables, we used the droplet digital PCR (ddPCR) technique. Results: We investigated a panel of five miRNAs in the sera of two independent cohorts of breast cancer patients and disease-free controls. The study showed that miR-148b-3p and miR-652-3p levels were significantly lower in the serum of breast cancer patients than that in controls in both cohorts. For these two miRNAs, the stratification of breast cancer patients versus controls was confirmed by receiver operating characteristic curve analyses. In addition, we showed that higher levels of serum miR-10b-5p were associated with clinicobiological markers of poor prognosis. Conclusions: The study revealed the usefulness of the ddPCR approach for the quantification of circulating miRNAs. The use of the ddPCR quantitative approach revealed very good agreement between two independent cohorts in terms of comparable absolute miRNA concentrations and consistent trends of dysregulation in breast cancer patients versus controls. Overall, this study supports the use of the quantitative ddPCR approach for monitoring the absolute levels of diagnostic and prognostic tumor-specific circulating miRNAs