Retroperitoneal fibrosis: a case of a patient (63y/o) treated with low-dose methotrexate (MTX) and 6-methylprednisolone (6-MP)

Retroperitoneal fibrosis (RPF), is a rare fibroinflammatory disease. The pathogenesis of RPF is still unclear and numerous theories have been reported such as environmental factors, immunologic process, genetic component, local inflammation and advanced atherosclerosis. RPF is characterized by the presence of a particular retroperitoneal fibrotic tissue which is white, woody and involving retroperitoneal structures such as the great vessels, ureters and psoas muscle. The main complication of RPF is the obstruction of local structures such as the ureters due to the fibrosis and the treatment of this aspect represents the main challenge for this pathology. RPF medical treatment consists of corticosteroids or/and immunosuppressive therapy. We report a case of a patient (63y/o) affected by idiopathic RPF treated with low-dose methotrexate (MTX) and 6-methylprednisolone (6-MP) for two years, describing and confirming the effectiveness and safety of a long-term low-dose MTX and 6-MP treatment

Robotic versus laparoscopic approach in colonic resections for cancer and Benign diseases. Systematic review and meta-analysis

Objectives The aim of this systematic review and meta-Analysis is to compare robotic colectomy (RC) with laparoscopic colectomy (LC) in terms of intraoperative and postoperative outcomes. Materials and Methods A systematic literature search was performed to retrieve comparative studies of robotic and laparoscopic colectomy. The databases searched were PubMed, Embase and the Cochrane Central Register of Controlled Trials from January 2000 to October 2014. The Odds ratio, Risk difference and Mean difference were used as the summary statistics. Results A total of 12 studies, which included a total of 4,148 patients who had undergone robotic or laparoscopic colectomy, were included and analyzed. RC demonstrated a longer operative time (MD 41.52, P<0.00001) and higher cost (MD 2.42, P<0.00001) than did LC. The time to first flatus passage (MD-0.51, P = 0.003) and the length of hospital stay (MD-0.68, P = 0.01) were significantly shorter after RC. Additionally, the intraoperative blood loss (MD-16.82, P<0.00001) was significantly less in RC. There was also a significantly lower incidence of overall postoperative complications (OR 0.74, P = 0.02) and wound infections (RD-0.02, P = 0.03) after RC. No differences in the postoperative ileus, in the anastomotic leak, or in the conversion to open surgery rate and in the number of harvested lymph nodes outcomes were found between the approaches. Conclusions The present meta-Analysis, mainly based on observational studies, suggests that RC is more time-consuming and expensive than laparoscopy but that it results in faster recovery of bowel function, a shorter hospital stay, less blood loss and lower rates of both overall postoperative complications and wound infections. Copyright: © 2015 Trastulli et al.OBJECTIVES: The aim of this systematic review and meta-analysis is to compare robotic colectomy (RC) with laparoscopic colectomy (LC) in terms of intraoperative and postoperative outcomes. MATERIALS AND METHODS: A systematic literature search was performed to retrieve comparative studies of robotic and laparoscopic colectomy. The databases searched were PubMed, Embase and the Cochrane Central Register of Controlled Trials from January 2000 to October 2014. The Odds ratio, Risk difference and Mean difference were used as the summary statistics. RESULTS: A total of 12 studies, which included a total of 4,148 patients who had undergone robotic or laparoscopic colectomy, were included and analyzed. RC demonstrated a longer operative time (MD 41.52, P<0.00001) and higher cost (MD 2.42, P<0.00001) than did LC. The time to first flatus passage (MD -0.51, P = 0.003) and the length of hospital stay (MD -0.68, P = 0.01) were significantly shorter after RC. Additionally, the intraoperative blood loss (MD -16.82, P<0.00001) was significantly less in RC. There was also a significantly lower incidence of overall postoperative complications (OR 0.74, P = 0.02) and wound infections (RD -0.02, P = 0.03) after RC. No differences in the postoperative ileus, in the anastomotic leak, or in the conversion to open surgery rate and in the number of harvested lymph nodes outcomes were found between the approaches. CONCLUSIONS: The present meta-analysis, mainly based on observational studies, suggests that RC is more time-consuming and expensive than laparoscopy but that it results in faster recovery of bowel function, a shorter hospital stay, less blood loss and lower rates of both overall postoperative complications and wound infections

Male breast cancer, clinical presentation, diagnosis and treatment: Twenty years of experience in our Breast Unit

BACKGROUND: The male breast cancer (MBC) is a rare and represents less than 1% of all malignancies in men and only 1% of all breast cancers incident. We illustrate the experience of our team about the clinico-pathological characteristics, treatment and prognostic factors of patients treated over a period of twenty years . RESULTS: Forty-seven patients were collected 1995-2014 at the Breast Unit of the Hospital of Terni, Italy. The average age was 67 years and the median time to diagnosis from the onset of symptoms was 16 months. The main clinical complaint was sub areolar swelling in 36, 76% of cases. Most patients have come to our attention with advanced disease. The histology of about ninety percent of the tumors were invasive ductal carcinoma. Management consisted mainly of radical mastectomy; followed by adjuvant radiotherapy and hormonal therapy with or without chemotherapy. The median follow-up was 38 months. The evolution has been characterized by local recurrences; in eight cases (17% of all patients). Metastasis occurred in 15 cases (32% of all patients). The site of bone metastases was in eight cases; lung in four cases; liver in three cases; liver and skin in one case and pleura and skin in one case. CONCLUSION: The male breast cancer has many similarities to breast cancer in women, but there are distinct functions that need to be appreciated. Future research for a better understanding of the disease should provide a better account of genetic and epigenetic characteristics of these forms; but, above all, epidemiological and biological cohorts numerically more consistent

Management of perforated diverticulitis with generalized peritonitis. a multidisciplinary review and position paper

La diverticolite perforata è una condizione clinica emergente e la sua gestione è impegnativa e ancora dibattuta. Lo scopo di questo documento di posizione era di rivedere criticamente le prove disponibili sulla gestione della diverticolite perforata e della peritonite generalizzata al fine di fornire suggerimenti basati sull'evidenza per una strategia di gestione. Quattro società scientifiche italiane (SICCR, SICUT, SIRM, AIGO), esperti selezionati che hanno identificato 5 temi clinicamente rilevanti nella gestione della diverticolite perforata con peritonite generalizzata che trarrebbero beneficio da una revisione multidisciplinare. Sono state affrontate le seguenti 5 problematiche: 1) Criteri per decidere tra trattamento conservativo e chirurgico in caso di diverticolite perforata con peritonite; 2) Criteri o sistema di punteggio per scegliere l'opzione chirurgica più appropriata quando è confermata la peritonite diffusa 3); La procedura chirurgica appropriata in pazienti emodinamicamente stabili o stabilizzati con peritonite diffusa; 4) La procedura chirurgica appropriata per i pazienti con peritonite generalizzata e shock settico e 5) Terapia medica ottimale in pazienti con peritonite generalizzata da perforazione diverticolare prima e dopo l'intervento chirurgico. Nella diverticolite perforata la chirurgia è indicata in caso di peritonite diffusa o fallimento della gestione conservativa e la decisione di operare non è basata sulla presenza di aria extraluminale. Se la peritonite diffusa è confermata, la scelta della tecnica chirurgica si basa sui risultati intraoperatori e sulla presenza o il rischio di shock settico grave. Ulteriori fattori prognostici da considerare sono lo squilibrio fisiologico, l'età, le comorbidità e lo stato immunitario. Nei pazienti emodinamicamente stabili, la laparoscopia di emergenza presenta vantaggi rispetto alla chirurgia a cielo aperto. Le opzioni includono resezione e anastomosi, procedura di Hartmann o lavaggio laparoscopico. Nella peritonite generalizzata con shock settico, è preferibile un approccio chirurgico aperto. La resezione non restaurativa e / o la chirurgia per il controllo del danno sembrano essere le uniche opzioni praticabili, a seconda della gravità dell'instabilità emodinamica. La gestione medica multidisciplinare dovrebbe essere applicata con gli obiettivi principali di controllare l'infezione, alleviare il dolore postoperatorio e prevenire e / o trattare ileo postoperatorio. In conclusione, la complessità e la diversità dei pazienti con perforazione diverticolare e peritonite diffusa richiede una strategia personalizzata, che preveda un'accurata classificazione dello squilibrio fisiologico, la stadiazione dell'infezione intra-addominale e la scelta della procedura chirurgica più appropriata.Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure

Effect of antithrombotic therapy on postoperative outcome of 538 consecutive emergency laparoscopic cholecystectomies for acute cholecystitis. Two Italian center’s study

The risk of developing hemorrhagic complications during or after emergency cholecystectomy (EC) for acute cholecystitis (AC) in patients with antithrombotic therapy (ATT) remains uncertain. In this double-center study, we evaluated post-operative outcomes in patients with ATT undergoing EC. We retrospectively evaluated 538 patients who underwent laparoscopic EC for AC between May 2015 and December 2019 at two referral centers. 89 of them (17%) were on ATT. We defined postoperative complication rates, including bleeding, as our primary outcome. Mortality was higher in the ATT group. Morbidity was higher in the ATT group as well; however, the difference was not statistically significant. 12 patients (2%) experienced intraoperative blood loss over 500&nbsp;ml and ten (2%) had postoperative bleeding complications. Two patients (&lt; 1%) experienced both intraoperative and postoperative bleeding. On multivariate analysis, ATT was not significantly associated with worse postoperative outcomes. Antithrombotic therapy is not an independently associated factor of severe postoperative complications (including bleeding) or mortality. However, these patients still represent a challenging group and must be carefully managed to avoid postoperative bleeding complications

Open Surgery for Sportsman’s Hernia a Retrospective Study

Sportsman’s hernia is a painful syndrome in the inguinal area occurring in patients who play sports at an amatorial or professional level. Pain arises during sport, and sometimes persists after activity, representing an obstacle to sport resumption. A laparoscopic/endoscopic approach is proposed by many authors for treatment of the inguinal wall defect. Aim of this study is to assess the open technique in terms of safety and effectiveness, in order to obtain the benefit of an open treatment in an outpatient management. From October 2017 to July 2019, 34 patients underwent surgery for groin pain syndrome. All cases exhibited a bulging of the inguinal posterior wall. 14 patients were treated with Lichtenstein technique with transversalis fascia plication and placement of a polypropylene mesh fixed with fibrin glue. In 20 cases, a polypropylene mesh was placed in the preperitoneal space. The procedure was performed in day surgery facilities. Early or late postoperative complications did not occur in both groups. All patients returned to sport, in 32 cases with complete pain relief, whereas 2 patients experienced mild residual pain. The average value of return to sport was 34.11 ± 8.44 days. The average value of return to play was 53.82 ± 11.69 days. With regard to postoperative pain, no substantial differences between the two techniques were detected, and good results in terms of the resumption of sport were ensured in both groups. Surgical treatment for sportsman’s hernia should be considered only after the failure of conservative treatment. The open technique is safe and allows a rapid postoperative recovery

Reconnection surgery in adult post-operative short bowel syndrome < 100 cm: is colonic continuity sufficient to achieve enteral autonomy without autologous gastrointestinal reconstruction? Report from a single center and systematic review of literature

A systematic bibliographic research concerning patients operated on for SBS was performed: inclusion criteria were adult age, reconnection surgery and SBS &lt; 100 cm. Autologous gastrointestinal reconstruction represented an exclusion criteria. The outcomes of interest were the rate of total parenteral nutrition (TPN) independence and the length of follow-up (minimum 1 year) after surgery. We reviewed our experience from 2003 to 2013 with minimum 1-year follow-up, dealing with reconnection surgery in 13 adults affected by &lt; 100 cm SBS after massive small bowel resection: autologous gastrointestinal reconstruction was not feasible. Three (out of 5168 screened papers) non randomized controlled trials with 116 adult patients were analysed showing weaning from TPN (40%, 50% and 90% respectively) after reconnection surgery without autologous gastrointestinal reconstruction. Among our 13 adults, mean age was 54.1 years (53.8 % ASA III): 69.2 % had a high stomal output (&gt; 500 cc/day) and TPN dependence was 100%. We performed a jejuno-colonic anastomosis (SBS type II) in 53.8%, in 46.1% of cases without ileo-cecal valve, leaving a mean residual small bowel length of 75.7 cm. In-hospital mortality was 0%. After a minimum period of 1 year of intestinal rehabilitation, all our patients (100%) went back to oral intake and 69.2% were off TPN (9 patients). No one was listed for transplantation. A residual small bowel length of minimum 75 cm, even if reconnected to part of the colon, seems able to produce a TPN independence without autologous gastrointestinal reconstruction after a minimum period of 1 year of intestinal rehabilitation

Colovesical fistulae in the sigmoid diverticulitis

Nella maggior parte dei casi le fistole colovescicali rappresentano una complicanza della malattia diverticolare e sono la tipologia più comune di fistola colodigestiva; meno comuni sono le fistole colovaginali, colocutanee, coloenteriche e colouterine. Nel presente lavoro abbiamo effettuato una review della letteratura riguardante le fistole colovescicali in chirurgia colorettale per diverticolite del sigma. Decriviamo anche due casi che hanno richiesto un trattamento chirurgico, in uno in elezione e nell’altro in urgenza. In entrambi i casi abbiamo eseguito una resezione colica con anastomosi primaria e minimaresezione vesvicale con posizionamento di catetere di Foley in media per 10 giorni

Is the outpatient management of acute diverticulitis safe and effective? A systematic review and meta-analysis

Background: In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting. Methods: A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment. Results: This systematic review included 21 studies including 1781 patients who had outpatient management of AD including 11&nbsp;prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered&nbsp;protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data. Conclusions: The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure