Un nuovo approccio chirurgico combinato per la correzione del prolasso tricompartimentale del pavimento pelvico: risultati preliminari

Il passaggio nell’uomo dalla stazione orizzontale a quella verticale ha richiesto un pavimento pelvico robusto e resistente, atto a sopportare il peso degli organi addominali e pelvici. Gli orifizi per il passaggio attraverso il diaframma pelvico di organi provvisti di muscolatura propria (retto, uretra, e vagina nella femmina), insieme all’invecchiamento fisiologico del connettivo che compone i legamenti ed i muscoli pelvi-perineali, comportano il cedimento delle aree sottoposte a maggior pressione come la regione pelvica. Il prolasso pelvico (definito in letteratura come prolasso urogenitale) è una patologia dell’età adulta del sesso femminile molto frequente, dato che il rischio di subire un intervento chirurgico per il trattamento di un disordine della statica e della dinamica della pelvi è di circa il 10% per una donna con una vita media di 80 anni2,5-6. Tale patologia, oggi più facilmente diagnosticabile grazie allo sviluppo di nuove tecnologie radiologiche dinamiche, si presenta prevalentemente nelle donne di età superiore ai 40 anni e con un’incidenza di circa il 30-40%7,12. La strategia chirurgica adottata è fondata sul principio del sostegno dei 3 compartimenti. Le attuali tecniche prevedono approcci per via trans-vaginale o per via trans-addominale, con o senza l’utilizzo di rinforzi protesici. L’autore riporta nel presente lavoro i risultati preliminari di un nuovo tipo di trattamento chirurgico per la correzione del prolasso tricompartimentale frutto della combinazione di due differenti tecniche, valutandone fattibilità e risultati a breve e medio termine

Hemostasis in uncontrolled esophageal variceal bleeding by self-expanding metal stents. A systematic review

Aim: The aim of this systematic review was to evaluate the current reported efficacy and the mortality rate of SEMS treatment in uncontrolled bleeding patients. Background: Esophageal variceal bleeding (EVB) represents a life threatening pathology. Despite the adequate pharmacologic and endoscopic treatment, continuous or recurrent bleeding, named as uncontrolled bleeding, occurs in 10-20% of cases. A new removable, covered, and self-expanding metal stent (SEMS) was proposed to control the variceal bleeding. Materials and methods: The study was conducted according to the PRISMA statement. Studies were identified by searching MEDLINE (1989-present) and SCOPUS (1989-present) databases. The last search was run on 01 July 2015. Results: Nine studies (period range=2002-2015) met the inclusion criteria and were included in quantitative analysis. High rate of SEMS efficacy in controling acute bleeding was observed, with a reported percentage ranging from 77.7 to 100%. In 10% to 20% of patients, re-bleeding occurred with SEMS in situ. Stent deployment was successful in 77.8% to 100% of patients while 11 to 36.5% of patients experienced stent migration. Conclusion: SEMS could be effective and safe in control EVB and can be proposed as a reliable option to ballon tamponed for patient stabilization and as a bridging to other therapeutic approach. Keywords: Nonselective β-blockers, TIPSS, Endoscopic band ligation, Uncontrolled bleeding, Selfexpanding metal stent

Robotic double-loop reconstruction method following total gastrectomy

Minimally invasive surgery for gastric cancer is a challenge. The reconstructive time is a particular issue and researchers have adopted a large variety of solutions and produced heterogeneous data. The reconstructive phase can be divided into two major categories based on the approach adopted: the execution of extracorporeal versus intracorporeal anastomosis. In turn, the surgical team can perform the latter with laparoscopic or robotic assistance. However, the question is, how should a robotic esophagojejunal anastomosis be performed after total gastrectomy? Most articles in the literature have reported the execution of mechanical anastomoses [1] [2] [3] [4] [5] [6], especially with circular staplers via the creation of a manual purse-string around the anvil. Other solutions have described the use of the Orvil or the overlap technique. Only three authors have reported intracorporeal sutures with a completely robotic-sewn anastomosis [7] [8] [9]. A new robotic technique (the Parisi technique) was developed and adopted at St. Mary’s Hospital, Terni, Italy. A double-loop reconstruction method with an intracorporeal robot-sewn anastomosis is performe

Laparoscopic peritoneal lavage. Our experience and review of the literature

NTRODUCTION: Over the years various therapeutic techniques for diverticulitis have been developed. Laparoscopic peritoneal lavage (LPL) appears to be a safe and useful treatment, and it could be an effective alternative to colonic resection in emergency surgery. AIM: This prospective observational study aims to assess the safety and benefits of laparoscopic peritoneal lavage in perforated sigmoid diverticulitis. MATERIAL AND METHODS: We surgically treated 70 patients urgently for complicated sigmoid diverticulitis. Thirty-two (45.7%) patients underwent resection of the sigmoid colon and creation of a colostomy (Hartmann technique); 21 (30%) patients underwent peritoneal laparoscopic lavage; 4 (5.7%) patients underwent colostomy by the Mikulicz technique; and the remaining 13 (18.6%) patients underwent resection of the sigmoid colon and creation of a colorectal anastomosis with a protective ileostomy. RESULTS: The 66 patients examined were divided into 3 groups: 32 patients were treated with urgent surgery according to the Hartmann procedure; 13 patients were treated with resection and colorectal anastomosis; 21 patients were treated urgently with laparoscopic peritoneal lavage. We had no intraoperative complications. The overall mortality was 4.3% (3 patients). In the LPL group the morbidity rate was 33.3%. CONCLUSIONS: Currently it cannot be said that LPL is better in terms of mortality and morbidity than colonic resection. These data may, however, be proven wrong by greater attention in the selection of patients to undergo laparoscopic peritoneal lavage

Vitiligo and autoimmune thyroid disorders

Vitiligo represents the most common cause of acquired skin, hair and oral depigmentation, affecting 0.5-1% of the population worldwide. It is clinically characterized by the appearance of disfiguring circumscribed skin macules following melanocyte destruction by autoreactive cytotoxic T lymphocytes. Patients affected by vitiligo usually show a poorer quality of life and are more likely to suffer from depressive symptoms, particularly evident in dark-skinned individuals. Although vitiligo is a non-fatal disease, exposure of affected skin to UV light increases the chance of skin irritation and predisposes to skin cancer. In addition, vitiligo has been associated to other rare systemic disorders due to presence of melanocytes in other body districts, such as in the eyes, auditory, nervous and cardiac tissues, where melanocytes are thought to have roles different from that played in the skin. Several pathogenetic models have been proposed to explain vitiligo onset and progression, but clinical and experimental findings point mainly to the autoimmune hypothesis as the most qualified one. In this context, it is of relevance the strong association of vitiligo with other autoimmune diseases, in particular with autoimmune thyroid disorders, such as Hashimoto thyroiditis and Graves’ disease. In this review, after a brief overview of vitiligo and its pathogenesis, we will describe the clinical association between vitiligo and autoimmune thyroid disorders and discuss the possible underlying molecular mechanism(s)

Robotic total gastrectomy with intracorporeal robot-sewn anastomosis. A novel approach adopting the double-loop reconstruction method

Gastric cancer constitutes a major health problem. Robotic surgery has been progressively developed in this field. Although the feasibility of robotic procedures has been demonstrated, there are unresolved aspects being debated, including the reproducibility of intracorporeal in place of extracorporeal anastomosis. Difficulties of traditional laparoscopy have been described and there are well-known advantages of robotic systems, but few articles in literature describe a full robotic execution of the reconstructive phase while others do not give a thorough explanation how this phase was run. A new reconstructive approach, not yet described in literature, was recently adopted at our Center. Robotic total gastrectomy with D2 lymphadenectomy and a socalled ‘‘double-loop’’ reconstruction method with intracorporeal robotsewn anastomosis (Parisi’s technique) was performed in all reported cases. Preoperative, intraoperative, and postoperative data were collected and a technical note was documented. All tumors were located at the upper third of the stomach, and no conversions or intraoperative complications occurred. Histopathological analysis showed R0 resection obtained in all specimens. Hospital stay was regular in all patients and discharge was recommended starting from the 4th postoperative day. No major postoperative complications or reoperations occurred. Reconstruction of the digestive tract after total gastrectomy is one of the main areas of surgical research in the treatment of gastric cancer and in the field of minimally invasive surgery. The double-loop method is a valid simplification of the traditional technique of construction of the Roux-limb that could increase the feasibility and safety in performing a full hand-sewn intracorporeal reconstruction and it appears to fit the characteristics of the robotic system thus obtaining excellent postoperative clinical outcome

CTLA-4 and PD-1 ligand gene expression in epithelial thyroid cancers

The dysregulation of PD-1 ligands (PD-L1 and PD-L2) and CTLA-4 ligands (CD80 and CD86) represents a tumor strategy to escape the immune surveillance. Here, the expression of PD-L1, PD-L2, CD80 and CD86 was evaluated at mRNA level in 94 patients affected by papillary thyroid carcinoma (PTC) and 11 patients affected by anaplastic thyroid carcinoma (ATC). Variations in the mRNAs in PTC patients were then correlated with clinicopathological features. The expression of all genes was deregulated in PTC and ATC tissues compared to normal tissues. In particular, the down-regulation of CD80 was observed in above all ATC. In addition, the increased expression of CD80 associated to longer disease-free survival in PTC. Higher expression of PD-L1 associated with the classical histological variant and with the presence of BRAFV600E mutation in PTC. The increased PD-L2 expression correlated with BRAFV600E mutation and lymph node metastasis, while its lower expression correlated with the follicular PTC variant. The latter was also associated with the CD80 down-regulation, which was also related to the absence of lymph node metastasis. In conclusion, we documented the overall dysregulation of PD-1 and CTLA-4 ligands in PTC and ATC tissues and a possible prognostic value for CD80 gene expression in PTC

L’adenocarcinoma dell’appendice ileo-ciecale: presentazione di un caso clinico e revisione della letteratura

L’adenocarcinoma dell’appendice ileo-ciecale è una neoplasia di rara osservazione rappresentando meno dello 0,5% di tutti i tumori dell’apparato gastrointestinale. Nella maggior parte dei casi viene diagnosticato all’esame istologico definitivo di un’appendice asportata per flogosi, talora invece rappresenta un reperto del tutto inatteso, documentato da biopsie estemporanee, in corso di intervento chirurgico eseguito per sospetta appendicite acuta o altra patologia non appendicolare. La storia naturale di tale neoplasia è fortemente condizionata dalle peculiari caratteristiche anatomiche del viscere che ne favoriscono la precoce diffusione e una notevole tendenza alla perforazione. Si associa frequentemente ad altre neoplasie primitive, sincrone o metacrone, a localizzazione colo-rettale o extraintestinale. Il trattamento chirurgico oncologicamente corretto è l’emicolectomia destra che può essere eseguita come prima procedura, nei casi in cui la neoplasia venga diagnosticata pre- o intraoperatoriamente, o come seconda procedura, due-tre settimane dopo l’appendicectomia, qualora soltanto l’esame istologico dell’appendice asportata riveli la presenza dell’adenocarcinoma. L’emicolectomia destra è il trattamento chirurgico più idoneo in tutti gli istotipi (colico, mucinoso, adenocarcinoide), in presenza di perforazione ed anche nelle neoplasie allo stadio A di Dukes. Durante l’atto operatorio è necessario effettuare un’accurata esplorazione della cavità addominale per la ricerca di neoplasie sincrone, mentre dopo l’intervento i pazienti dovranno essere sottoposti ad un follow-up regolare e prolungato nel tempo onde diagnosticare precocemente eventuali neoplasie metacrone. Riportiamo il caso di una donna di 78 anni con adenocarcinoma dell’appendice scoperto casualmente in corso di intervento chirurgico eseguito per un quadro di occlusione intestinale da sospetta neoplasia del cieco

A Retrospective Case Series in Fournier’s Disease. And Its Emergency Management et Grafting Technique for Penis Coverage

Fournier’s gangrene is a necrotizing soft tissue infection of the genital, perineal, and perirectal areas. A primary isolated involvement of the penis is rare, but it can be elected in some circumstances. •epurpose ofthiscase series isto present the …ndings of our thirteen years’ experience in the reconstruction of the penis in Fournier’s gangrene and our full-thickness grafting technique to cover the penis rod. We retrospectively reviewed patient data who underwent a penis reconstruction following Fournier’s gangrene in 2018. •e data was analyzed to report the estimated percentage of complications, of patients with primary or secondary gangrene of the penis, the number of reinterventions, and …nally the percentage of deaths or recovery. 23 patients underwent reconstruction with our technique of full-thickness skin graft. In all cases, the skin graft was harvested from the upper armwith anarrow shapemark. Nofurther penile revision surgery was required, and neither patient complained about retraction, nor traction, or pain during erection. •e donor site healed without any complications. We believe that the coverage of the penis using our grafting technique is safe, easily reproducible, and demonstrates excellent esthetic and functional results