Cystic Echinococcosis of the Breast - Diagnostic Dilemma or just a Rare Primary Localization

Introduction: Although the liver and lung are the most frequently affected organs in cystic echinococcosis, the cysts may develop in any viscera and tissues. Breast is a rare primary localization with few cases described in the literature. We present an updated and systematic review and discuss the possible mechanisms of spreading, diagnostic and treatment options.Materials and methods: We performed a literature search in PUBMED using the key words ‘hydatid disease’, ‘cystic echinococcosis’ and ‘breast echinococcosis’ without time limitation. Only studies reporting breast cystic echinococcosis were included.Results: Overall, 121 cases with cystic echinococcosis and 2 with alveolar echinococcosis were reported. A total of 52 cases were included in the analysis. The mean size of cysts was 5.5 cm (range 1.7-12). The most common clinical presentation was painless lump presented from 4 months to 19 years before the final diagnosis. Most cases had isolated breast CE, few cases had synchronous localizations – femoral, thigh and lung, and previous liver CE. Most were active CL and CE1-2 cysts (72%). Ultrasound was used in 83%, followed by mammography (35%). Fine needle aspiration was reported in 27 cases with positive finding in 59%.Conclusions: In cases with cystic breast lesions from endemic regions we recommend the US as a gold standard. CT and MRT are more accurate but expensive tools without the potential to change the surgical tactic. In contrast to the other localizations of CE, complete excision of the cysts is the best diagnostic and treatment approach

Laparoscopic Distal Subtotal Gastrectomy with D2 Lymphadenectomy Dissection for Early-Stage Gastric Cancer

Aim: Since 1991, laparoscopic surgery has been adopted as part of the treatment of gastric cancer, and it is now performed worldwide. The aim of this video presentation was to present our experience, operative technique and surgical skills with laparoscopic gastric resection for distal, early-stage gastric cancer.Materials and Methods: A 62-year-old female was admitted to our Department of Surgery with anamnesis of epigastric pain. A gastric endoscopy with biopsy and CT scan of the abdomen and pelvis, were performed. An adenocarcinoma located in the lower third of the stomach with suspicion for perigastric lymph node metastasis was diagnosed. Laparoscopic distal subtotal gastrectomy with D2 lymphadenectomy was performed. Results: The duration of the surgery was 205 min, and blood loss was 130 ml. All resected margins were tumor-free and the number of retrieved lymph nodes was 24 (free of metastatic involvement). The postoperative course was without complications and the patient was discharged on the 6th postoperative day.Conclusions: This case demonstrated that the total laparoscopic distal subtotal gastric resection for early-stage gastric cancer had good results. The laparoscopic approach for gastric cancer follows all oncologic principles

What is the effectiveness of the negative pressure wound therapy (NPWT) in patients treated with open abdomen technique? A systematic review and meta-analysis

BACKGROUND The open abdomen technique may be used in critically ill patients to manage abdominal injury, reduce the septic complications, and prevent the abdominal compartment syndrome. Many different techniques have been proposed and multiple studies have been conducted, but the best method of temporary abdominal closure has not been determined yet. Recently, new randomized and nonrandomized controlled trials have been published on this topic. We aimed to perform an up-to-date systematic review on the management of open abdomen, including the most recent published randomized and nonrandomized controlled trials, to compare negative pressure wound therapy (NPWT) with no NPWT and define if one technique has better outcomes than the other with regard to primary fascial closure, postoperative 30-day mortality and morbidity, enteroatmospheric fistulae, abdominal abscess, bleeding, and length of stay. METHODS According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions, an online literature research (until July 1, 2015) was performed on MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Library databases. The MeSH terms and free words used "vacuum assisted closure" "vac;", "open abdomen", "damage control surgery", and "temporary abdominal closure". No language restriction was made. RESULTS The initial systematic literature search yielded 452 studies. After a careful assessment of the titles and of the full text was obtained, eight articles fulfilled inclusion criteria. We analyzed 1,225 patients, of whom 723 (59%) underwent NPWT and 502 (41%) did not undergo NPWT, and performed four subgroups: VAC versus Bogota bag technique (two studies, 106 participants), VAC versus mesh-foil laparostomy (two studies, 159 participants), VAC versus laparostomy (adhesive impermeable with midline zip) (one study, 106 participants), and NPWT versus no NPWT techniques (three studies, 854 participants) in which it is not possible to perform an analysis of the different types of treatment. Comparing the NPWT group and the group without NPWT, there was no statistically significant difference in fascial closure (63.5% vs 69.5%; odds ratio [OR], 0.74; 95% confidence interval [CI], 0.27-2.06; p = 0.57), postoperative 30-day overall morbidity (p = 0.19), postoperative enteroatmospheric fistulae rate (2.1% vs 5.8%; OR, 0.63; 95% CIs, 0.12-3.15; p = 0.57), in the postoperative bleeding rate (5.7% vs 14.9%; OR, 0.58; 95% CIs, 0.05-6.84; p = 0.87), and postoperative abdominal abscess rate (2.4% vs 5.6%; OR, 0.42; 95% CI, 0.13-1.34; p = 0.14). On the other hand, statistical significance was found between the NPWT group and the group without NPWT in the postoperative mortality rate (28.5% vs 41.4%; OR, 0.46; 95% CI, 0.23-0.91; p = 0.03) and in the length of stay in the intensive care unit (mean difference, -4.53; 95% CI, -5.46 to 3.60; p < 0.00001). CONCLUSION The limitations of the present analysis might be related to the lack of randomized controlled trials, so there is a risk of selection bias favoring NPWT. For several outcomes, there were few studies, confidence intervals were wide, and inconsistency was high, suggesting that although there were no statistically significant differences between the groups, there was insufficient evidence to show that the outcomes were similar. We can conclude from the current available data that NPWT seems to be associated with a trend toward better outcomes compared to the use of no NPWT. It does reflect the evidence presented in the current systematic review; however, the data should be interpreted with substantial caution given a number of weaknesses (in particular, the lack of statistical significance and heterogeneity between studies, i.e., small sample size of the included studies, high variability between studies). We highlight the need for randomized controlled trials having homogeneous inclusion criteria to assess the use of NPWT for the management of open abdomen

Laparoscopic Repair of Parastomal Hernia

Aim: Open repair of parastomal hernias is associated with high rates of morbidity and recurrence. A basic principle is the necessity of mesh-based techniques. The aim of this report was to review our department`s experience and evaluate a laparoscopic repair of parastomal hernia, primarily based on the intraperitoneal onlay mesh technique.Materials and Methods: A 77-year-old female was admitted to our institution with a two-year history of parastomal hernia. She had undergone abdominoperineal rectal extirpation for rectal cancer seven years before. CT scan of the abdomen and pelvis was performed before surgery and there was no evidence of cancer recurrence. Laparoscopic repair of the hernia with mesh was performed in this case.Results: A piece of COVIDIEN Parietex Composite Parastomal Mesh with a central keyhole and a radial incision was fastened laparoscopically over the colostomy and the hernia defect with a wide overlap, without dissecting out the sac. The mesh was secured to the margins of the hernia with circumferential tacking. The postoperative course was benign, without complications and she was dismissed from the hospital on the 4th postoperative day. Six months after surgery, there was no recurrence of the hernia.Conclusions: This case demonstrated that laparoscopic repair of parastomal hernia had good results and was a feasible and safe procedure for repairing this difficult problem

Minimally Invasive or Open Inguinal Hernia Repairs - Immunological Results

Introduction: The minimally invasive technique has replaced the open approach in many surgical procedures. The advantages and disadvantages of open and minimally invasive hernia surgery are still being discussed. This study compared postoperative immune changes after minimally invasive and open repair in patients with inguinal hernias (H-patients).Materials and Methods: The study included 36 male patients with inguinal hernias. Eighteen underwent minimally invasive hernia repair (Hm-patients). The mean age of the Hm- group was 52.4 years (18-73). The remaining 18 patients underwent open hernia repair (Ho- patients). Their mean age was 56.7 years (29-81). Blood tests were performed 24 hours prior to surgery, and 24 hours and 7 days after surgery. The analysis included full blood count and markers of inflammation (CRP, ESR, Fibrinogen). T- (CD3+), B- (CD19+) and NK-cell lymphocyte populations were studied by means of flow cytometry, as well as activation of leukocytes, according to the expression of HLA-DR, CD38, CD279, CD163. All data were analyzed using SPSS version 21.Results: 24 hours after surgery, there was a significant decrease in the monocytes and the NK- cells and an increase in the number of leukocytes, lymphocytes and granulocytes in the minimally invasive group compared with the open group. This difference between the two groups didn`t exist on the 7th postoperative day. Activated granulocytes (CD64+), monocytes (CD64/CD163+), T- lymphocytes (CD3+) and B-lymphocytes (CD19+) had a significant decrease in the open group compared with the minimally invasive group on the first postoperative day. On the 7th postoperative day, there was a significant increase in the markers of inflammation (CRP, ESR, Fibrinogen) and a decrease in the erythrocytes, the hematocrit and hemoglobin levels, NKT-cells, CD3+ and %HLA-DR in CD19+ in the open group.Conclusions: Minimally invasive inguinal hernia repair is a technically feasible option with lesser degrees of immunosuppressive response to open repair. Postoperative immune and blood parameters under investigation, are better preserved in the minimally invasive group

Carbon Dioxide Embolism Associated with Transanal Total Mesorectal Excision Surgery: A Report From the International Registries

BACKGROUND: Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision. OBJECTIVE: This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique. DESIGN: Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event. SETTINGS: The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries. MAIN OUTCOME MEASURES: Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured. RESULTS: Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be 480.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15mm Hg (12\u201320mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30\ub0 and 45\ub0. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths. LIMITATIONS: This is a retrospective study surveying reported outcomes by surgeons and anesthetists. CONCLUSIONS: Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links. lww.com/DCR/A961

Predictive Factors and Risk Model for Positive Circumferential Resection Margin Rate after Transanal Total Mesorectal Excision in 2653 Patients with Rectal Cancer

The aim of this study was to determine the incidence of, and preoperative risk factors for, positive circumferential resection margin (CRM) after transanal total mesorectal excision (TaTME). Background: TaTME has the potential to further reduce the rate of positive CRM for patients with low rectal cancer, thereby improving oncological outcome. Methods: A prospective registry-based study including all cases recorded on the international TaTME registry between July 2014 and January 2018 was performed. Endpoints were the incidence of, and predictive factors for, positive CRM. Univariate and multivariate logistic regressions were performed, and factors for positive CRM were then assessed by formulating a predictive model. Results: In total, 2653 patients undergoing TaTME for rectal cancer were included. The incidence of positive CRM was 107 (4.0%). In multivariate logistic regression analysis, a positive CRM after TaTME was significantly associated with tumors located up to 1 cm from the anorectal junction, anterior tumors, cT4 tumors, extra-mural venous invasion (EMVI), and threatened or involved CRM on baseline MRI (odds ratios 2.09, 1.66, 1.93, 1.94, and 1.72, respectively). The predictive model showed adequate discrimination (area under the receiver-operating characteristic curve >0.70), and predicted a 28% risk of positive CRM if all risk factors were present. Conclusion: Five preoperative tumor-related characteristics had an adverse effect on CRM involvement after TaTME. The predicted risk of positive CRM after TaTME for a specific patient can be calculated preoperatively with the proposed model and may help guide patient selection for optimal treatment and enhance a tailored treatment approach to further optimize oncological outcomes