Consequences of the spilled gallstones during laparoscopic cholecystectomy: a systematic review

Complications secondary to spilled gallstones can be classified in the category of disease of medical progress because prior to advent of laparoscopic cholecystectomy very few reports published on the topic. The aim of the present study was to investigate the predisposing factors and the complication rate of spilled gallstones during laparoscopic cholecystectomy over the past 21 years

Epatectomia totale con shunt porto-cava in emergenza come strategia ponte in attesa di trapianto di fegato. L'esperienza ventennale del King's College Hospital di Londra.

Il trapianto epatico (Liver Transplantation, LT) è il gold standard nel trattamento di pazienti affetti da malattia epatica acuta e cronica allo stadio terminale. Inoltre, il trapianto epatico super-urgente rappresenta l’unica procedura salva vita nel malato affetto da insufficienza epatica acuta (Acute Liver Failure, ALF). A causa dell’attuale scarsità di donatori, non sempre è possibile, a fronte dell’esigenza, una pronta disponibilità di un organo da trapiantare. La necrosi epatica massiva che si sviluppa in corso di ALF comporta l’esacerbarsi di gravi sintomi sistemici, noti come Toxic Liver Syndrome (TLS), che includono: instabilità emodinamica, acidosi metabolica, insufficienza renale e respiratoria, scompenso multi-organo fino all’exitus del paziente. In pazienti in attesa di LT ed affetti da ALF, o rigetto acuto di organo trapiantato (Primary Non Function, PNF) o trauma epatico maggiore, l’epatectomia totale con derivazione venosa Porto-Cava (Total Hepatectomy and Porto-Caval Shunt, HpcS) può essere considerata come l’ultima risorsa disponibile per stabilizzare il loro quadro clinico. La HpcS permette di creare una finestra temporale, chiamata anhepatic time (AT), in attesa che un organo si renda disponibile per eseguire un LT mediante una procedura chirurgica “two-stage”. In letteratura però non sono ancora chiari e definiti i parametri entro i quali si può decidere di intraprendere questa difficile strada terapeutica ed inoltre rimane aperto l’interrogativo su quale sia la durata temporale massima a cui un uomo può sopravvivere in assenza di fegato. Questo lavoro di tesi descrive una delle prime e più numerose serie mondiali comprendente 17 pazienti trapiantati in seguito ad un periodo di AT (fino a un massimo di 72 h) presso la “Liver Unit” del King’s College Hospital di Londra tra il 1989 ed il 2011. Di questi, 14 pazienti hanno potuto beneficiare del trapianto di fegato e 9 sono sopravvissuti alla procedura completa. La nostra esperienza clinica e gli importantissimi progressi fatti nel campo della terapia rianimatoria attribuiscono alla HpcS un ruolo salva vita pur rimanendo una procedura chirurgica “estrema” in cui è imprescindibile la multidisciplinarietà tra le parti chirurgiche e mediche del team di specialisti che prende in carico il paziente affetto da ALF

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients’ morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship

Case report of a familial triple: a syndrome and review of the literature

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Case report of a familial triple: a syndrome and review of the literature

RATIONALE: Triple-A syndrome, or Allgrove syndrome (AS), is a rare autosomal recessive disorder characterized by the alacrimia, achalasia, and adrenal insufficiency triad. Alacrimia usually starts at early infancy, while achalasia and adrenal insufficiency appear later during childhood or adulthood. Some patients may also present with the so-called Double-A syndrome (i.e., alacrimia and achalasia, or alacrimia and adrenal insufficiency); adrenal insufficiency usually represents a life-threatening event due to severe hypoglycemia. Many patients may also present other associated manifestations, such as neurological disorders. We describe, here, 2 sisters of non-consanguineous parents. PATIENT CONCERNS: An 8-year-old girl was admitted to the Pediatric Care Unit of Parma after an episode characterized by seizure with loss of consciousness and generalized hypertonia lasting a few minutes. Her sister, a 6-year-old girl, presented with recurrent episodes of vomiting and failure to thrive. DIAGNOSES: Both children were investigated by laboratory tests, esophagogastroduodenoscopy, and imaging. The first patient had the complete triad of AS (alacrimia, achalasia, adrenal insufficiency), while the second one presented only alacrimia and achalasia. Both resulted from a mutation in the achalasia, addisonianism, alacrimia syndrome gene. INTERVENTIONS: Both patients were treated with oral hydrocortisone for Addison disease, and with artificial tears in the first case. After many pneumatic endoscopic dilations and therapy with nifedipine, both patients underwent surgical Heller myotomy for achalasia. OUTCOMES: A rapid and favorable recovery to normal diet and with improvement of growth parameters was obtained. These cases are also compared with the literature data, reported in a brief review. LESSONS: AS is a rare multisystemic disorder. The longer diagnosis is delayed, the greater extent to which this syndrome may be life-threatening, mainly because of hypoglycemia due to adrenal insufficiency. In AS, the red-flag symptom of alacrimia should instigate investigation for achalasia, Addison disease, and achalasia, addisonianism, alacrimia syndrome gene mutation

Robotic multiquadrant colorectal procedures: A single-center experience and a systematic review of the literature

Purpose: Robotic surgery has been progressively implemented for colorectal procedures but is still limited for multiquadrant abdominal resections. The present study aims to describe our experience in robotic multiquadrant colorectal surgeries and provide a systematic review and meta-analysis of the literature investigating the outcomes of robotic total proctocolectomy (TPC), total colectomy (TC), subtotal colectomy (STC), or completion proctectomy (CP) compared to laparoscopy. Methods: At our institution 16 consecutive patients underwent a 2- or 3-stage totally robotic total proctocolectomy (TPC) with ileal pouch-anal anastomosis. A systematic review of the literature was performed to select studies on robotic and laparoscopic multiquadrant colorectal procedures. Meta-analyses were used to compare the two approaches. Results: In our case series, 14/16 patients underwent a 2-stage robotic TPC for ulcerative colitis with a mean operative time of 271.42 (SD:37.95) minutes. No conversion occurred. Two patients developed postoperative complications. The mean hospital stay was 8.28 (SD:1.47) days with no readmissions. Mortality was nil. All patients underwent loop-ileostomy closure, and functional outcomes were satisfactory. The literature appraisal was based on 23 retrospective studies, including 736 robotic and 9,904 laparoscopic multiquadrant surgeries. In the robotic group, 36 patients underwent STC, 371 TC, 166 TPC, and 163 CP. Pooled data analysis showed that robotic TC and STC had a lower conversion rate (OR = 0.17;95% CI, 0.04–0.82; p = 0.03) than laparoscopic TC and STC. The robotic approach was associated with longer operative time for TC and STC (MD = 104.64;95% CI, 18.42–190.87; p = 0.02) and TPC and CP (MD = 38.8;95% CI, 18.7–59.06; p = 0.0002), with no differences for postoperative complications and hospital stay. Reports on urological outcomes, sexual dysfunction, and quality of life were missing. Conclusions: Our experience and the literature suggest that robotic multiquadrant colorectal surgery is safe and effective, with low morbidity and mortality rates. Nevertheless, the overall level of evidence is low, and functional outcomes of robotic approach remain largely unknown. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42022303016

Total extraperitoneal endoscopic hernioplasty (TEP) versus Lichtenstein hernioplasty: a systematic review by updated traditional and cumulative meta-analysis of randomised-controlled trials.

BACKGROUND-PURPOSE: Totally extraperitoneal (TEP) endoscopic hernioplasty and Lichtenstein hernioplasty are the most commonly used approaches for inguinal hernia repair. However, current evidence on which is the preferred approach is inconclusive. This updated meta-analysis was conducted to track the accumulation of evidence over time. METHODS: Studies were identified by a systematic literature search of the EMBASE, PubMed, Cochrane Library, and Google Scholar databases. Fixed- and random-effects models were used to cumulatively assess the accumulation of evidence over time. RESULTS: The TEP cohort showed significantly higher rates of recurrences and vascular injuries compared to the Lichtenstein cohort; [Peto Odds ratio (OR) = 1.58 (1.22, 2.04), p = 0.005], [Peto OR = 2.49 (1.05, 5.88), p = 0.04], respectively. In contrast, haematoma formation rate, time to return to usual activities, and local paraesthesia were significantly lower in the TEP cohort compared to the Lichtenstein cohort; [Peto OR = 0.26 (0.16, 0.41), p ≤ 0.001], [mean difference = - 6.32 (- 8.17, - 4.48), p ≤ 0.001], [Peto OR = 0.26 (0.17, 0.40), p ≤ 0.001], respectively. CONCLUSIONS: This study, which is based on randomised-controlled trials (RCTs) of high quality, showed significantly higher rates of recurrences and vascular injuries in the TEP cohort than in the Lichtenstein cohort. In contrast, rate of postoperative haematoma formation, local paraesthesia, and time to return to usual activities were significantly lower in the TEP cohort than in the Lichtenstein cohort. Future multicentre RCTs with strict adherence to the standards recommended in the Consolidated Standards of Reporting Trials guidelines will shed further light on the topic

PEG reimplantation after Buried Bumper Syndrome: a case report

Percutaneous endoscopic gastrostomy (PEG) is the method of choice to provide long-term enteral nutrition for patients with impossibility to be fed orally. Although it is considered a routine and safe procedure, potential complications exist, which are generally classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use, such as buried bumper syndrome (BBS). BBS is a potentially life-threatening complication, occurring in 0.3% to 2.5% of cases. Additional complications related to BBS may present, such as wound infection, peritonitis, and necrotizing fasciitis. Once resolved the acute complication, an adequate feeding method should be prompted for the patient, among whom PEG remains of choice. After tissue inflammation, fibrosis may prevent a standard endoscopic procedure for the new implantation, therefore endoscopists should modulate procedures to obtain successful and safe results. A combined surgical-and endoscopic strategy could resolve implantation difficulties ensuring a safe and simple procedure. We present here a case of BBS complicated with abdominal wall cellulitis in a paraplegic 35-year-old-man who was admitted to our hospital. (www.actabiomedica.it)

Bouveret syndrome in a cholecystoduodenal fistula

The treatment of Bouveret syndrome lacks specific guidelines and is strictly interdisciplinary. Especially, if electrohydraulic lithotripsy is not available and endoscopic removal fails, a timely surgical approach is advised