La splenectomia con tecnica mini-invasiva. Stato dell'arte

La tecnica della splenectomia laparoscopica è piuttosto recente, nasce nel 1991 con Bernard Delaitre in Francia; da allora la casistica in letteratura è aumentata progressivamente e da procedura sperimentale è diventata il gold standard nell’approccio chirurgico a questo organo. Rappresenta, tuttavia, una procedura di chirurgia mini-invasiva avanzata, e in quanto tale richiede, oltre ad una completa conoscenza dell’anatomia splenica da parte del chirurgo che la esegue,anche una adeguata abilità. Le tecniche mini-invasive hanno prodotto procedure sicure e gravate da minori complicanze, sia in caso di patologia benigna che maligna della milza, sia nel trattamento delle malattie che si accompagnano a marcata splenomegali

Colorectal neoplastic emergencies in immunocompromised patients: preliminary result from the Web-based International Register of Emergency Surgery and Trauma (WIRES-T trial)

Association of advanced age, neoplastic disease and immunocompromission (IC) may lead to surgical emergencies. Few data exist about this topic. Present study reports the preliminary data from the WIRES-T trial about patients managed for colorectal neoplastic emergencies in immunocompromised patients. The required data were taken from a prospective observational international register. The study was approved by the Ethical Committee with approval n. 17575; ClinicalTrials.gov Identifier: NCT03643718. 839 patients were collected; 753 (80.7%) with mild-moderate IC and 86 (10.3%) with severe. Median age was 71.9 years and 73 years, respectively, in the two groups. The causes of mild-moderate IC were reported such malignancy (753-100%), diabetes (103-13.7%), malnutrition (26-3.5%) and uremia (1-0.1%), while severe IC causes were steroids treatment (14-16.3%); neutropenia (7-8.1%), malignancy on chemotherapy (71-82.6%). Preoperative risk classification were reported as follow: mild-moderate: ASA 1-14 (1.9%); ASA 2-202 (26.8%); ASA 3-341 (45.3%); ASA 4-84 (11.2%); ASA 5-7 (0.9%); severe group: ASA 1-1 patient (1.2%); ASA 2-16 patients (18.6%); ASA 3-41 patients (47.7%); ASA 4-19 patients (22.1%); ASA 5-3 patients (3.5%); lastly, ASA score was unavailable for 105 cases (13.9%) in mild-moderate group and in 6 cases (6.9%) in severe group. All the patients enrolled underwent urgent/emergency surgery Damage control approach with open abdomen was adopted in 18 patients. Mortality was 5.1% and 12.8%, respectively, in mild-moderate and severe groups. Long-term survival data: in mild-moderate disease-free survival (median, IQR) is 28 (10-91) and in severe IC, it is 21 (10-94). Overall survival (median, IQR) is 44 (18-99) and 26 (20-90) in mild-moderate and severe, respectively; the same is for post-progression survival (median, IQR) 29 (16-81) and 28, respectively. Univariate and multivariate analyses showed as the only factor influencing mortality in mild-moderate and severe IC is the ASA score. Colorectal neoplastic emergencies in immunocompromised patients are more frequent in elderly. Sigmoid and right colon are the most involved. Emergency surgery is at higher risk of complication and mortality; however, management in dedicated emergency surgery units is necessary to reduce disease burden and to optimize results by combining oncological and acute care principles. This approach may improve outcomes to obtain clinical advantages for patients like those observed in elective scenario. Lastly, damage control approach seems feasible and safe in selected patients

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study : a WSES observational study

BackgroundTiming and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.MethodsThis worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.ResultsA total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate >= 22 breaths/min, systolic blood pressure 4mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8.ConclusionsThe simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.Peer reviewe

The impact of inflammatory response on cell cancer endocavitary spread in colonic and ovarian malignancies

The term “peritoneal carcinomatosis” (PC), usually indicating the shedding, implantation and dissemination of a tumor to the peritoneal coating that covers the abdominal cavity and the viscera within it, is the result of a complex sequence of molecular events by which tumor cells disseminate from their primary organ to establish independent metastatic deposits on the visceral and parietal lining of the abdominal cavity. Several studies in the last decade have shown as inflammatory mediators promote not only carcinogenesis, but also tumor progression. The systemic inflammatory response, usually made of composite ratios or cumulative scores of different circulating white blood cells or acute phase proteins, has shown some prognostic significance; the production of these mediators participates in the up-regulating of adhesion molecules on the peritoneal surface, thus enhancing the metastatic potential of tumor cells. In this view, an intriguing topic concerns the relationship between carcinosis and the ATP-sensitive P2X7 receptor (P2X7R), a powerful and multifaceted inflammatory mediator. In most tumors, P2X7R is constantly and tonically active, thus stimulating cell growth, proliferation and migration, and influencing tumor microenvironment. Fifty-two female adult patients aging 40-80 years, with clinical indication for primary surgical treatment for intraperitoneal CC or EOC in the section of General Surgery and Gynecologic Oncology of the University Hospital in Pisa, Italy, between January 2016 and June 2018 were consecutively enrolled on a volunteer basis. The final population consisted of 15 patients with histological diagnosis of EOC and 18 patients with intraperitoneal CC. Causes of patient exclusion were the mismatch between the histological inclusion criteria and the tumoral staging (parameter T) on anatomo-pathological examination, and the scarce amount of RNA extracted from tissue samples, insufficient to perform a molecular analysis. At the beginning of the surgical procedure two samples of disease-free parietal and omental peritoneum were collected in each patient. A partially differential expression pattern was observed, with a significantly higher expression of CD68, FGFR1 and IL-6 in adipocytes from CRC patients and enhanced VEGF expression in adipocytes from EOC. The expression of other generic markers of tissue inflammation, matrix deposition and cell migration, like TNFα, TGFβ or MCP-1 did not differ between the two cancers. Similarly, the inflammatory platform P2X7R-NLRP3 did not differ, with P2X7R barely expressed in both and NLRP3 showing an ample variability. P2X7R and NLRP3 were the only inflammatory factors significantly more expressed in patients carrying both types of carcinosis. The presence of extra-abdomen metastases was associated with a higher adipocyte expression of FGFR1 and TGFβ. The presence of extra-abdomen metastases was associated with a higher adipocyte expression of FGFR1 and TGFβ. We confirm here the role of TGFβ as marker of invasion and potential epithelial-mesenchimal transition in both CRC and EOC. These preliminary results suggest a putative role of the adipocyte P2X7R-NLRP3 inflammasome in modulating chemotaxis and metastatic spread in CC and EOC; further studies on larger groups of patients are required to better characterize the role of such pathwa

Chi, quando e come operare in urgenza per occlusione aderenziale del tenue: validazione di un nuovo algoritmo decisionale

OBIETTIVI L’occlusione aderenziale dell’intestino tenue (ASBO) rappresenta una frequente causa di ricovero nei dipartimenti di emergenza e accettazione. Il management dei pazienti con ASBO appare estremamente complesso. Come emerge dalla letteratura, la presenza di segni di ischemia intestinale è indicata la chirurgia nel più breve tempo possibile. In assenza di segni di strangolamento, il Gastrografin Test (GT) rappresenta un utile strumento nel trattamento conservativo. Lo scopo di questo studio è quello di validare un nuovo algoritmo decisionale sul management dell’ASBO, sviluppato sulla base delle raccomandazioni fornite dalle linee guida di recente pubblicazione. Lo studio ha analizzato i risultati del ricorso sistematico e standardizzato al GT, identificando la presenza di fattori predittivi del suo fallimento, e l’attività laparoscopica svolta nel nostro centro nel trattamento chirurgico dell’ASBO . MATERIALI E METODI Dal Gennaio 2015 al Marzo 2016 un nuovo algoritmo decisionale è stato applicato nella gestione diagnostica e terapeutica di una serie consecutiva di 90 pazienti con 92 episodi di ASBO. In tutti i casi è stata eseguita una TC con mdc per via endovenosa all’ammissione. In 12 casi (13%) si è reso necessario intervento chirurgico in urgenza. In 80 casi (87%) di ASBO si è invece utilizzato trattamento conservativo implementato dal GT. Da un database prospettico sono stati raccolti ed analizzati i dati relativi a caratteristiche demografiche (sesso, età, BMI), anamnestiche (pregressi episodi di ASBO, pregressi interventi chirurgici) e radiologiche TC (spessore parietale > 5 mm, calibro massimo medio del tenue, versamento libero e pneumatosi parietale). Per i pazienti sottoposti ad intervento chirurgico sono stati analizzati i dati operatori e di outcome. È stata effettuata un’analisi di tipo univariato per confrontare i gruppi di pazienti e di regressione logistica multivariata per identificare eventuali fattori correlati al fallimento del GT. RISULTATI Degli 80 episodi di ASBO sottoposti ad iniziale trattamento conservativo, 31 (39%) hanno risposto entro 24 ore dalla somministrazione del Gastrografin (gruppo A). I restanti 49 episodi (61%) hanno richiesto un trattamento chirurgico dopo fallimento del GT (gruppo B) nonostante in 5 di questi (6%) il GT avesse dato esito positivo con opacizzazione del colon a 24 ore dalla sua somministrazione. La presenza di spessore parietale > 5 mm è risultata in maniera statisticamente significativa maggiore nei pazienti del gruppo B rispetto al gruppo A (49% vs 19,4%, p = 0,015), così come il calibro massimo medio del tenue (4,35 cm vs 3,7 cm, p = 0,002). I fattori significativamente associati al fallimento del GT sono stati il calibro massimo dell’ansa intestinale (p = 0,011; OR 2,6; IC 95%) e la presenza di ispessimento parietale (p = 0,026; OR: 3,88; IC 95%). 61 casi di ASBO (66% dell’intera casistica) sono stati sottoposti a trattamento chirurgico nel periodo esaminato, di cui 23 con approccio open (38% - gruppo OPEN) e i restanti 38 con approccio laparoscopico (62% - gruppo LAP). Il tasso di conversione è risultato del 39,5% con un’incidenza di lesioni iatrogene intestinali del 2,6% nel gruppo LAP e del 13% nel gruppo OPEN. I pazienti del gruppo LAP hanno mostrato un’ASA score medio statisticamente inferiore, un numero di pregressi chirurgici addominali e un calibro massimo medio del tenue significativamente maggiori rispetto al gruppo OPEN. Fra i dati post-operatori, solo il tempo di canalizzazione è risultato significativamente più breve nel gruppo LAP. CONCLUSIONI L’applicazione nel nostro centro di un algoritmo decisionale per il management dell’ASBO ha comportato miglioramenti soggettivi, difficilmente quantificabili, quali una riduzione dell’incertezza per il chirurgo, una maggiore frequenza nella rivalutazione clinica del paziente e minore controversia riguardo il timing della chirurgia dopo fallimento di un NOM. Il GT si è dimostrato uno strumento sicuro e valido nel management conservativo dei pazienti con ASBO in assenza di segni suggestivi di ischemia intestinale. Ha un ruolo fortemente predittivo nei confronti della chirurgia differita che trova indicazione e timing ideali nel paziente nel quale il Gastrografin non raggiunga il colon nelle 24 ore dalla sua somministrazione. Il calibro massimo del tenue e la presenza di ispessimento parietale alla TC sono emersi come fattori indicativi di fallimento del trattamento con il GT. La laparoscopia trova maggiore applicazione nei casi meno severi e nei pazienti con minori comorbidità. L’esperienza del chirurgo ne rappresenta il più importante fattore in fase decisionale. Nel setting di un quadro di ASBO non risolto dopo GT, la laparoscopia dovrebbe essere presa in considerazione come prima scelta di trattamento. Il miglior parametro per misurare la sicurezza della procedura laparoscopica è rappresentato dal rapporto fra conversione precoce e tardiva, in relazione all’insorgenza di una possibile complicanza intraoperatoria

Acute appendicitis complicating De Garengeot's hernia treated with combined laparoscopic-open technique: a case series and literature review

An acute appendicitis in the context of a De Garengeot's hernia is a very rare event and represents a hard challenge for surgeons. As only few cases have been reported in literature, there is no consensus about its optimal surgical strategy of treatment. Here we present two consecutive cases of female patients presenting an uncommon acute appendicitis in a femoral hernia treated with a combined laparoscopic/open technique

LAPAROSCOPIC MANAGEMENT OF VENTRAL HERNIA IN ACUTE PRESENTATION

Although laparoscopic repair of incisional hernia is a well established practice, little is known about the role of laparoscopy when incisional hernia is complicated by acute bowel obstruction. Based on literature, no evidence for this topic can be drawn. However data from a few case series suggest that this approach does not seem to be associated with increased complication and recurrence rates compared to the same procedure performed electively. Facing emergency hernia repair, the use of minimally invasive surgery is strongly influenced by surgeon’s laparoscopic skill to carefully perform adhesiolysis, to safety reduce the herniated bowel into the peritoneal cavity, and to repair the wall defect in the presence of distended bowel loops. Main critical factors in decision-making process for a laparoscopic approach are: degree of bowel obstruction, intestinal viability, size and location of hernia defect and defect/hernia sac ratio. Keeping an uncontaminated abdomen is the key for a laparoscopic mesh repair and a successful outcome. Herein we present our experience about the laparoscopic management of incarcerated ventral hernia by highlighting tips and tricks to safety and effectively perform this top-challenging approach

Laparoscopic resection of multiple aneurysms of the gastroepiploic arterial arcade

Gastroepiploic arterial aneurysms (GEAA) represent a very rare disorder [1, 2]. The risk of GEAA rupture is high, and it is associated with a high mortality rate [3]. GEAAs are usually identified following rupture or are incidentally diagnosed. In emergency, an open surgical approach to treat GEAAs has been most frequently reported [4]. Alternatively, if the patient is hemodynamically stable, an angiography and embolization can be attempted. Herein we report the case of a patient presenting with two fissurated GEAAs that were successfully excised laparoscopically after failure of the endovascular approach

An unusual case of repeated splenectomy: traumatic rupture of an accessory spleen in a previously splenectomized patient

The traumatic rupture of an accessory spleen is a very rare condition and only few cases have been reported in the literature. We describe the case of a 51-year-old man undergone splenectomy for trauma several years before, who developed hemoperitoneum due to a laceration of a voluminous accessory spleen, following an accidental two-meter fall. As a conservative management of the injury was not possible, an accessory splenectomy was then required. Thus, a briefly review of the literature about this uncommon topic was perfomed

Laparoscopic armamentarium for common bile duct stones clearance: tricks and tips

The laparoscopic common bile duct exploration with cholecystectomy (LCBDE + LC) has been shown to be safe and effective for the treatment of choledocolithiasis. However, the use of LCBDE + LC is in decline, as almost replaced by the endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy. Should this trend continue, the laparoscopic approach to choledocholithiasis is at risk of disappearing from the armamentarium of the general surgeons. The aim of this video presentation is to explain the different types of LCBD exploration (transcystic vs transcholedochotomy), when to use them and how to perform them safely and efficiently. Furthermore, the authors explain the intraoperative situations in which a biliary tutor should be placed and how they can be properly managed