INTRODUCTION: Within the last 50 years the management of patients with breast cancer has changed dramatically with a significant de-escalation of the role and magnitude of surgery, both for the management of the primary...INTRODUCTION: Within the last 50 years the management of patients with breast cancer has changed dramatically with a significant de-escalation of the role and magnitude of surgery, both for the management of the primary tumor and for the management of the axilla. In the management of the axilla of patients with early stage breast cancer (EBC) and clinically uninvolved axilla (cN0), axillary lymph node dissection (ALND) was gradually replaced by sentinel lymph node biopsy (SLNB) saving more than 60-70% of patients from an unnecessary dissection. Further studies confirmed that isolated tumor cells or micrometastases found on the SLN had no further benefit from ALND sparing even more patients from an unnecessary ALND. Eventually, the Z0011 and other studies showed that even patients with 1-2 positive SLN can be spared from ALND provided they fulfill certain criteria. Still though there were many flaws in these studies and further research was necessary to generalize the results of these studies to a wider target group. Meanwhile, there is a clear view that many low risk patients if they have their axilla evaluated via US and are not found to have suspicious nodes, it is highly unlikely to have involved axilla. This let to studies evaluating the non-surgical management of the axilla. Finally, in the post neoadjuvant setting 3 randomized controlled trials showed that under certain circumstances SLNB can be done after the NAC even in patients who initially had involved axilla and was converted to clinically uninvolved (cN1→cN0). EVIDENCE ACQUISITION: PubMed, Medline, the Cochrane Library Controlled Trials Register as well as National Institutes of Health ClinicalTrials.Gov database have been consulted up to May 2020. EVIDENCE SYNTHESIS: We studied and described the ongoing trials on patients not undergoing neoadjuvant chemotherapy and we discussed the eligibility criteria, the comparison arms and the expected outcomes. We further examined the ongoing trials on patients undergoing neoadjuvant chemotherapy in the same manner. CONCLUSIONS: Although we have covered a long way in the journey of eliminating axillary surgery, there are still lots of questions to be answered and trials to be conducted. We anticipate the results of the ongoing trials to provide the necessary evidence to safely de-escalate more the axillary surgery, both in the non-neoadjuvant as well as in the neoadjuvant setting, hoping that in the not so far future the axillary surgery will eventually perish.
Since its introduction nearly 30 years ago, sentinel lymph node biopsy (SLNB) has become the standard technique to stage the axilla for the great majority of patients with early breast cancer. While the accuracy of SLNB...Since its introduction nearly 30 years ago, sentinel lymph node biopsy (SLNB) has become the standard technique to stage the axilla for the great majority of patients with early breast cancer. While the accuracy of SLNB in clinically node-negative patients who undergo neoadjuvant chemotherapy (NAC) is similar to the upfront surgery setting, modifications of the technique to improve the false negative rate are necessary in node-positive patients at presentation. Currently, patients who present with matted nodes, cN1 patients who fail to downstage to cN0 with NAC and those with pathological residual disease have an indication to undergo axillary lymph node dissection. Ongoing trials will confirm if extensive nodal irradiation can replace surgery in patients with residual nodal disease after NAC and if nodal radiotherapy can be omitted in patients who achieve nodal pathological complete response. The aim of this review was to focus on the open questions on the management of the axilla after NAC.
The evolution of axillary surgery in breast cancer has led from complete axillary dissection (AD) to sentinel node biopsy (SNB). It has not stopped yet but continues with a progressive de-escalation of surgical procedure...The evolution of axillary surgery in breast cancer has led from complete axillary dissection (AD) to sentinel node biopsy (SNB). It has not stopped yet but continues with a progressive de-escalation of surgical procedures aiming at axillary conservation. In parallel, the meaning of axillary surgery has changed as well. Over time, the dual role of both a therapeutic and a staging procedure has decreased leaving room to other modalities to treat and stage breast cancer. Although, the gold standard for axillary staging in early breast cancer remains SNB, the idea that axillary surgery could be even omitted has been proposed. The concept of abandoning axillary surgery is revolutionary but not new. Historical literature provides interesting data on patients who did not receive any axillary treatment at all with no impact on their survival. Starting from this, several ongoing trials are working to demonstrate that in selected breast cancer cohorts the information deriving from axillary surgery is superfluous and "axillary observation" alone is as effective as SNB. Whilst surgery has been de-escalated to less invasive procedures, systemic treatment, radiotherapy, multigene assays and advanced imaging modalities have gained ground in the management of breast cancer. New research is expected to help select the subgroups of patients for whom axillary surgery is not necessary anymore. This is a qualitative review reporting the most relevant literature data from historical trials on the omission of axillary surgery to the most recent and ongoing ones.
Subjects undergoing ostomy are increasing and share a reduced quality of life. The patient flow (PF) is the pathway of a patient from hospital admission to discharge and should provide care appropriateness to the patient...Subjects undergoing ostomy are increasing and share a reduced quality of life. The patient flow (PF) is the pathway of a patient from hospital admission to discharge and should provide care appropriateness to the patient himself. In the recent literature no paper exists regarding the PF of the patient undergoing (intestinal or urinary) ostomy, which is the objective of the present article. This paper stems from the work done during the Educational Camp entitled "The Patient Flow in Stoma Care," which took place on three separate days (27 May, 18 September, and 21 November 2019) at B. Braun Milano S.p.A. and regarded 33 stomatherapy nurses from all over Italy supervised by the authors. The participants, divided into heterogeneous groups, developed the PF by means of three specific work methodologies: mental maps, timeline and appreciative inquiry. The elaborated PF was inspired to the International Charter of the Ostomates' Rights. The efficacious and empathic communication and the role of the patient and/or the caregiver as the main characters are transversal to every step and must be always pursued. The PF is developed in eight macro-areas: diagnosis; pre-admission; admission and preoperative phase; surgical operation; awakening; postoperative phase; discharge; follow-up. In agreement with the recent literature, this systematic approach will give benefits to the patients in terms of outcome and perception of taking charge before, during and after the ostomy. At the same time the performances, the therapeutic appropriateness, the optimization of technology and healthcare resources and the staff satisfaction will equally be guaranteed.
BACKGROUND: During Coronavirus disease (COVID-19) pandemic entire countries rapidly ran out of intensive care beds, occupied by critically ill infected patients. Elective surgery was initially halted and acute non-deferr...BACKGROUND: During Coronavirus disease (COVID-19) pandemic entire countries rapidly ran out of intensive care beds, occupied by critically ill infected patients. Elective surgery was initially halted and acute non-deferrable surgical care drastically limited. The presence of COVID-19 patients into intensive care units (ICU) is currently decreasing but their congestion have restricted our therapeutic strategies during the last months. METHODS: In the COVID-19 era eighteen patients (8 men, 10 women) with a mean age of 80 years, needing undelayable abdominal surgery underwent awake open surgery at our Department. Prior to surgery, all patients underwent COVID-19 investigation. In all cases locoregional anesthesia (LA) was performed. Intraoperative and postoperative pain has been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. RESULTS: Mean operative time was 104 minutes. In only one case conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. Only one perioperative complication occurred. Early readmissions after surgery were never observed. CONCLUSIONS: On the basis of our experience awake laparotomy under LA resulted feasible, safe, painless and, in specific cases, the only viable option. For patients presenting fragile cardiovascular and respiratory, reserves and in whom general anesthesia (GA) would presumably increase morbidity and mortality we encourage LA as an alternative to GA. In the COVID-19 era, it has become part of our ICU-preserving strategy allowing us to carry out undeferrable surgeries.
Parastomal hernia is not a rare event. Being by definition a complication of ostomy creation, a parastomal hernia also carries the risk of becoming symptomatic and complicated. At present, there are not enough solid data...Parastomal hernia is not a rare event. Being by definition a complication of ostomy creation, a parastomal hernia also carries the risk of becoming symptomatic and complicated. At present, there are not enough solid data in literature to allow an evidence-based approach to this condition and to its possible complications, especially in the emergency setting. The aim of this paper is to describe through a narrative review of the literature the different surgical approaches concerning parastomal hernias. In order to exemplify the emergency complications we also present two cases in which the watchful waiting approach eventually led to the necessity of urgent surgical treatment, due to bowel incarceration into the parastomal hernia. We chose to tailor the surgical plan on the patient's anatomic and clinical condition, pursuing the laparoscopic approach with two different surgical technique (Sugarbaker and keyhole), each time estimated by the operating surgeon to be the more suitable option for the patient. We acknowledge that laparoscopy can be an optimal choice for the emergency and elective treatment of parastomal hernias, whenever an appropriate know-how is present.
Abdominal rectus diastasis (RD) is characterized by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This condition is associated with bulging of abdominal content, and...Abdominal rectus diastasis (RD) is characterized by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This condition is associated with bulging of abdominal content, and it is mostly acquired during pregnancy or obesity. Symptoms include pain and discomfort in the abdomen, musculoskeletal and uro-gynecological problems in addition to negative body image and impaired quality of life. In this review we present current knowledge on the novel surgical mini-invasive techniques for treatment of RD. The aim of our study is to discuss the use of a standard classification to define pathological RD and possible indications for a minimally invasive repair, considering complications, patients' satisfaction and recurrence rate. A PubMed search of the literature has been conducted in January 2020 including the most recent articles using the following criteria among the interventions for RD: mini-invasive surgery, laparoscopic, endoscopy and robotic procedures. Minimally invasive surgical treatment options for rectus diastasis are poorly investigated and indications for repair are still debated. Guidelines are mandatory to standardize surgical management of RD.
BACKGROUND: Morgagni hernias present technical challenges. The laparoscopic approach for repair was first described in 1992; however, as these hernias are uncommon in adult life, few data exist on the optimal method for...BACKGROUND: Morgagni hernias present technical challenges. The laparoscopic approach for repair was first described in 1992; however, as these hernias are uncommon in adult life, few data exist on the optimal method for surgical management. The purpose of this study was to analyze a method for laparoscopic repair of Morgagni giant hernias using laparoscopic primary closure with V lock (Medtronic, Covidien). METHODS: This case series describes a method of laparoscopic Morgagni hernia repair using primary closure. In all patients, a laparoscopic transabdominal approach was used. The content of the hernia was reduced into the abdomen, and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. Clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. Demographic data such as BMI and operative and postoperative data were collected. RESULTS: Retrospectively collected data for 9 patients were analyzed. There were 1 (11.1%) males and 8 (88.8%) females. The median BMI was 29.14±52 kg/m. The median operative time was 80±25 minutes. There were no intraoperative complications or conversions to open surgery. Patients began a fluid diet on the first postoperative day and were discharged after a median hospital stay of 3±1.87 days. In a median follow-up of 36 months, we did not observe any recurrences. CONCLUSIONS: Transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for the repair of Morgagni hernia. In our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs.
BACKGROUND: Aim of this study was to assess whether the reduction in the number of tackers maintains a similar recurrence rate and to subsequently evaluate whether this reduction associated with fibrin adhesive (FA) infl...BACKGROUND: Aim of this study was to assess whether the reduction in the number of tackers maintains a similar recurrence rate and to subsequently evaluate whether this reduction associated with fibrin adhesive (FA) influences postsurgical pain after laparoscopic ventral hernia repair (LVHR) at 5 years follow-up. METHODS: Fifty patients with ventral hernia (intervention group) underwent to LVHR with the double crown (DC) technique with a decrease in the number of tackers, each tacker being separated by about 3 cm associated with FA to seal the spaces between them. Data obtained from intervention group were compared to data obtained from a historical series of 50 patients (control group) undergoing LVHR using DC technique with tackers at 1 cm each other. RESULTS: No statistically significant differences were found between groups about patients' characteristics. Mean hospital stay was 2 days. Statistically significant differences were observed about hospital stay between both groups U-Mann-Whitney ([UMW] =345, P=0) being higher in the control group. Statistically significant difference was observed in the postoperative pain evaluated by the visual analogical scale (VAS) score, having 95% of patients in the control group with VAS less than or equal to 7 compared to 4.55 in the intervention group. Recurrence rate was 4.1% for the control group versus 4.2% in the intervention group. CONCLUSIONS: The reduction of metallic tackers associated with FA does not present statistically significant differences in the recurrence rate in comparison to conventional DC technique. In the intervention group a reduction in postoperative pain and hospital stay were observed.
BACKGROUND: Incisional hernia still represents the most frequent late complication of abdominal surgery. After a direct repair, in literature is reported a recurrence rate ranging from 31 to 49%, meanwhile after a prosth...BACKGROUND: Incisional hernia still represents the most frequent late complication of abdominal surgery. After a direct repair, in literature is reported a recurrence rate ranging from 31 to 49%, meanwhile after a prosthetic repair such values were much lower, with a recurrence rate up to 10%. The sites of prosthetic placement in the abdominal wall are premusculo-aponeurotic (onlay, or Chevrel technique), retromuscular-prefascial and preperitoneal (Rives technique, Stoppa technique), whereas intraperitoneal insertion can be done with open or laparoscopic surgery. The aim of this study was to evaluate the immediate and late postoperative results in patients treated with a Chevrel technique for ventral incisional hernia. METHODS: A retrospective review was conducted on the medical records of patients undergoing ventral hernia repair between January 2008 and December 2018 at the Emergency Surgery Unit of the Careggi University Hospital in Florence. RESULTS: Between January 2008 and December 2018 at the Emergency Surgery Unit of the Careggi University Hospital in Florence, 461 patients (245 male, 216 female) with a mean age of 61,52 years were submitted to ventral incisional hernia repair with a Chevrel technique. The mean operatory time was 95.29 min (±50.48) and in 72 patients (15.61%) human fibrin glue was vaporized under the mesh using a spray device. Mean postoperative hospital stay was 5 days and all drain tubes were removed after 7.1 days as mean (±4.3). No intraoperative mortality nor postoperative mortality was reported. In our experience the Chevrel technique for ventral incisional hernia show a recurrence rate (3.2%). Parietal complications observed were seroma in 7.1% of patients, hematoma in 4.7%, localized skin necrosis in 5.2%, surgical site infection in 6.7%, data comparable with the results reported in the other studies. CONCLUSIONS: Most of the objections to the Chevrel procedure focus on the parietal complications and risk of infection. Chevrel procedure cannot be considered an obsolete intervention, in our series, results were very satisfactory in both immediate and late follow-up; moreover this technique is safe and easy to perform.
BACKGROUND: The technical evolution of hernia repair has brought to the introduction of laparoscopy in this field. The most common laparoscopic techniques are transabdominal preperitoneal (TAPP) repair and totally extrap...BACKGROUND: The technical evolution of hernia repair has brought to the introduction of laparoscopy in this field. The most common laparoscopic techniques are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. Indirect comparisons between TAPP and TEP have raised questions as to which is the superior approach in improving patient outcomes; however, there is still a scarcity of data directly comparing these laparoscopic approaches. The aim of this report is to offer a retrospective comparison between the two techniques with a long-term follow-up. METHODS: This study is a retrospective comparative study, comparing TEP and TAPP in the treatment of groin hernias. All patients undergoing laparoscopic hernia repair from 2015 and 2020 at a large UK Hospital Trust with tertiary referral center, were considered as eligible for inclusion. The primary endpoint was rate of successful surgery defined as absence of recurrence and chronic pain at the end of the follow-up. Secondary endpoints were conversion rate (the switch from TEP to TAPP was considered as a conversion for the index procedure), need for admission, readmission rate, serious adverse events (including visceral injuries and vascular injuries), rate of persisting pain at the end of follow-up, operative time and overall complications rate (hematoma, seroma, wound/superficial infection, mesh/deep infection, port site hernia). RESULTS: Of the patients included in the study who underwent laparoscopic repair of inguinal hernia between 2015 and 2020, 140 (55.1%) underwent TEP and 114 (44.9%) had TAPP repair. The mean operative time did not differ between the two groups (P=0.202). The conversion rate was nil. The two procedures did not differ for intraoperative and postoperative complications. The length of hospital stay was significantly longer in the TAPP group (P<0.0001). The overall recurrence rate was 2.4%. and did not differ between the two groups. Costs were acquired from the clinical coding department. Mean costs were measured in pounds sterling and a significant difference was noted between the two groups (P=0.083). In the short term, the most common complication was seroma formation and was significantly more frequent in the TAPP group (P<0.001). In the long term, chronic pain was the most frequent complication in both groups and significant correlated when the operation performed for recurrent hernia, whereas the hernia Type 3 was a factor that which influenced recurrence. CONCLUSIONS: In conclusion, TAPP and TEP have similar, overall complication risks, postoperative acute and chronic pain incidence and recurrence rates. Since TAPP and TEP have comparable outcomes it is recommended that the choice of the technique should be based on the surgeon's skills, education, and experience.
Recent studies have demonstrated that the extent of surgical treatment in both breast and axilla can be minimized through a multimodal and personalized management, based on assessment of breast cancer (BC) molecular subt...Recent studies have demonstrated that the extent of surgical treatment in both breast and axilla can be minimized through a multimodal and personalized management, based on assessment of breast cancer (BC) molecular subtypes, genetics and on the prevailing relevance of systemic therapies. Axillary lymph-nodes dissection (ALND) represents the older surgical modality for appropriate staging and for adjuvant systemic and radiation therapies planning. Thanks to findings from extensive and crucial clinical trials, sentinel lymph node biopsy (SLNB) replaced this approach, obviating the need for ALND in node-negative disease patients, both in mastectomy and conservative surgery, and becoming a crucial turning point in BC managing. Furthermore, recent clinical trials have established that ALND can be avoided in those patients with low axillary disease burden in the sentinel nodes who are undergoing breast-conserving surgery (BCS) with radiotherapy. Several studies also proved that neoadjuvant chemotherapy (NAC) increases the BCS rates, as well reducing the extent of axillary surgery. The potential oncological safety of axillary observation choice in early BC patients undergoing BCS, in the recent perspective of the prevailing value of BC biology, is also under scientific evaluation. This study explores the current role of SLNB in BC patients eligible for BCS, providing a view into future directions in BC care.
The spread of COVID-19 pandemic has determined a huge imbalance between real clinical needs of the population and effective resources availability. The aim of this study was to report how this situation forces surgeons t...The spread of COVID-19 pandemic has determined a huge imbalance between real clinical needs of the population and effective resources availability. The aim of this study was to report how this situation forces surgeons to consider a non-operative management as an alternative. This is a retrospective monocentric study and we collected data from 60 patients, split in two groups: info from Group A, 28 patients (11 March to 11 April 2020) were compared with info from group B, 32 patients (11 March to 11 April 2019). The most relevant difference between the groups is related to patient's clinical management. The two groups had a considerably different number of cases that were treated with an operative management: 18 cases (64,7%) in group A vs. 28 cases (87,5%) in group B. Otherwise, non-operative approach occurred in 10 cases (35,7%) in group A and only in 4 patients (12,5%) in group B. These data suggest that the drastic reduction of means narrows the range of therapeutic choices. Indeed, in this emergency scenario, the rationing of healthcare resources was the propelling for surgeons to consider alternative therapeutic pathways.
INTRODUCTION: The objective of this study is to compare the effectiveness of Limberg flap (LF) versus Karydakis and Bascom procedure to reduce the recurrence of pilonidal sinus disease. EVIDENCE ACQUISITION: The data ret...INTRODUCTION: The objective of this study is to compare the effectiveness of Limberg flap (LF) versus Karydakis and Bascom procedure to reduce the recurrence of pilonidal sinus disease. EVIDENCE ACQUISITION: The data retrieved from the published randomized controlled trials (RCT) comparing the effectiveness of LF versus Karydakis and Bascom procedure was analyzed using the principles of meta-analysis. The summated outcome of the dichotomous data was presented in risk ratio (RR). EVIDENCE SYNTHESIS: Eighteen RCTs on 2073 patients comparing the effectiveness of LF versus Karydakis and or Bascom procedure for the surgical excision of pilonidal sinus disease were analyzed. In the random effects model analysis using the statistical software Review Manager 5.3, the LF was associated with the reduced risk (RR, 0.52; 95% CI: 0.29, 0.93; z=2.19; P=0.03) of disease recurrence after pilonidal sinus excision compared to Karydakis and Bascom procedure. On subgroup analysis the LF was still superior to Karidakys procedure (RR, 0.52; 95% CI: 0.23, 1.17; z=1.57; P=0.12) and Bascom procedure (RR, 0.49; 95% CI: 0.19, 1.29; z=1.44; P=0.15) but statistically it was not significant. CONCLUSIONS: LF seems to have clinical advantage over Karydakis and Bascom procedure in terms of reduced recurrence rate following surgical excision of pilonidal sinus. Although, this advantage was clinically persisted on subgroup analysis but failed to achieve statistical significance.