Pancreatic ductal adenocarcinoma is the fourth deadliest malignancy in developed countries and is predicted to become the second one within the 2030. The present work focuses on the state of the art of laparoscopic pancr...Pancreatic ductal adenocarcinoma is the fourth deadliest malignancy in developed countries and is predicted to become the second one within the 2030. The present work focuses on the state of the art of laparoscopic pancreaticoduodenectomy, including results of recent randomized trials, and discusses technical challenge and patients' interest of this technique.
Postoperative pancreatic fistula (POPF) is the most common and also the most threatening complication following distal pancreatectomy. For this reason, morbidity and mortality of this operation remain still high. Over th...Postoperative pancreatic fistula (POPF) is the most common and also the most threatening complication following distal pancreatectomy. For this reason, morbidity and mortality of this operation remain still high. Over the last two decades, many different studies have been performed aiming to reduce the rate and the severity of POPF. However, effective treatments to prevent or avoid clinically relevant pancreatic fistula are still unclear. In this review, we discuss the current evidence on such a relevant topic.
"Artery-first approach" encompasses different aspects for the surgical treatment of pancreatic cancer. It is a surgical technique or set of techniques which share in common the dissection of the main arterial vasculature..."Artery-first approach" encompasses different aspects for the surgical treatment of pancreatic cancer. It is a surgical technique or set of techniques which share in common the dissection of the main arterial vasculature involved in pancreatic cancer, before any irreversible surgical step is performed. On the other hand it represents the need for a meticulous dissection of the arterial planes and clearing of the retropancreatic tissue between the superior mesenteric artery, the common hepatic artery and portal vein in an attempt to achieve R0 resections. The recent expansion of this approach is based mainly on three factors: venous involvement should not be considered a contraindication for resection, most of the pancreatic resections performed with a standard procedure may be in fact non-oncological (R1) resections and the postero-medial or vascular margin is the most frequently invaded by the tumor. This review aimed to summarize and update the artery-first approach in pancreaticoduodenectomy.
Ablation treatments have been increasingly applied as an alternative treatment for unresectable locally advanced pancreatic cancer (LAPC). The goal of LAPC therapy is surgical resection with negative margins (R0); howeve...Ablation treatments have been increasingly applied as an alternative treatment for unresectable locally advanced pancreatic cancer (LAPC). The goal of LAPC therapy is surgical resection with negative margins (R0); however, that can be achieved only in a minority of patients and only following neoadjuvant treatment. Ablation might be useful for those patients with unresectable LAPC that do not progress towards metastatic stage and do not experience a true downstaging. Indeed, some LAPC that tend to grow locally, might be the subgroup of tumors that could benefit from ablation. Experience is necessary to select patients and the technique to adopt, since serious or fatal complications can occur. This review aims to discuss the role of ablation treatments in LAPC, with a unique focus on radiofrequency ablation and irreversible electroporation.
BACKGROUND: This study aims to investigate the impacts of preoperative maximum detrusor pressure (Pdet.max) on minimally invasive surgery effect on patients with benign prostatic hyperplasia. METHODS: The clinical data o...BACKGROUND: This study aims to investigate the impacts of preoperative maximum detrusor pressure (Pdet.max) on minimally invasive surgery effect on patients with benign prostatic hyperplasia. METHODS: The clinical data of a total of 156 patients receiving minimally invasive surgery for benign prostatic hyperplasia in Hospital of Nanchang Institute of Medical Sciences from August 2014 to June 2017 were retrospectively reviewed and summarized. The patients were divided into three groups according to different Pdet.max in the urodynamic examination results before the surgery, namely, group A (Pdet.max <50 cmH2O), group B (50≤ Pdet.max <90 cmH2O) and group C (Pdet.max ≥90 cmH2O). The International Prostate Symptom Score (IPSS) and Quality-of-Life score (QOLS) were compared. RESULTS: Compared with those in group A, the IPSS and QOLS of the patients in group B and group C at 1 month, 3 months and 12 months after the surgery were decreased notably (all P<0.05). Moreover, the IPSS and QOLS of the patients in group C were obviously lower than those in group B (all P<0.05). CONCLUSIONS: The results indicated that as the preoperative Pdet.max was increased, the symptoms of the patients receiving minimally invasive surgery for benign prostatic hyperplasia were ameliorated more significantly, and the patients had higher quality of life. The preoperative Pdet.max can judge the treatment effect of minimally invasive surgery on the patients with benign prostatic hyperplasia and help to guide the patients' prognosis. The greater the preoperative Pdet.max is, the better the treatment effect of the patients after the surgery will be, and the higher the quality of life will be.
BACKGROUND: To investigate the therapeutic effects of anterolateral thigh flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms and to discuss perioperative psychological care. MET...BACKGROUND: To investigate the therapeutic effects of anterolateral thigh flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms and to discuss perioperative psychological care. METHODS: A total of 80 patients who received oral and maxillofacial surgery for tumor resection in Nanfang Hospital from October 2014 to August 2016 were selected. Patients were randomly divided into control group and observation group, 40 patients in each group. Patients in control group received forearm flap transfer, while patients in observation group were treated with anterolateral thigh flap transfer. RESULTS: The survival rate of flap, food intake ability, quality of life and incidence of complication were compared between groups. There was no significant difference in survival rate of the flaps between two groups (P>0.05). No significant difference in food intake was found between groups at 3 months after operation (P>0.05). The UW-QOL scores of the two groups at 1 year after operation were significantly higher than those before operation (P<0.05), and no significant differences in UW-QOL scores were found between two groups at 1 year after operation (P>0.05). Incidence of temporary dysfunction, hyperplastic scar, permanent dysfunction, pigmentation and pruritus was significantly lower in observation group than in control group (P<0.05). There was no significant difference in the incidence of necrosis between two groups (P>0.05). CONCLUSIONS: The results showed that anterolateral thigh flap transfer has similar therapeutic effects to those of forearm flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms and improving food intake and quality of life. But Anterolateral thigh flap transfer can reduce the incidence of postoperative complications, so this treatment should be popularized.
BACKGROUND: External hemorrhoidal thrombosis is a common disease with an acute anal pain as the major symptom. It is astonishing the lack of studies which investigates the most effective treatment and there are not guide...BACKGROUND: External hemorrhoidal thrombosis is a common disease with an acute anal pain as the major symptom. It is astonishing the lack of studies which investigates the most effective treatment and there are not guidelines. Furthermore, nobody has ever evaluated this peculiar condition in an elderly population. METHODS: We have considered 87 patients aged >75 years who were visited and treated for this condition in our clinic, dividing them in three groups according the curative option chosen together with them after anamnesis and an interview: a conservative medical treatment (Group A), an immediate incision and evacuation of the thrombus (Group B) and the excision of hemorrhoid with the thrombus, with hemorrhoidectomy technique (Group C). The mean follow-up was 12.3 months. We analyzed immediate pain relief and time of remission of symptoms, bleeding, recurrences and major complications. RESULTS: The Group A presented a remission of symptoms in 11.8 days, Group B in 1.58 ad Group C in 7.8 days. The recurrence rate was very similar for the first two options (19.4% and 16.1%) and lower in the excision group (no recurrence during follow-up). Bleeding is the common adverse event observed with a high frequency in the immediate incision and evacuation of thrombus, less common in hemorrhoidectomy, that did not present major complication. Surgical option is often refused by elderly patient evaluating comorbidities in the fear of adverse events. CONCLUSIONS: The surgical treatment for EHT in elderly is safe and effective, but not the most common choice for fear of complications. Medical treatment or immediate incision of thrombus can be preferred and well accepted by elderly even if followed by a higher rate of recurrences.
BACKGROUND: One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young...BACKGROUND: One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young surgeons without prior experience in both open and laparoscopic colorectal surgery, who were autonomous in basic minimally-invasive surgical procedures. Right colectomy with intracorporeal anastomosis has been chosen as a model. METHODS: Between May 2015 and December 2017 two junior attending surgeons were trained through a STP. Right colectomy was divided into three main learning modules (colonic mobilization, vascular control, intracorporeal anastomosis) and each one was carried out by the trainees for at least two times under direct supervision of the senior surgeon. After the initial robotic cases completely performed under formal proctoring, they were privileged to perform robotic right colectomy independently without a mentor (20 procedures). Operative time, conversion rate, intra- and postoperative complications, length of stay and pathological outcomes were the variables analyzed to assess the effectiveness of the STP. RESULTS: The mean operative time was 200 minutes and no conversion was required. Neither intraoperative nor major postoperative complications were recorded and the mean length of hospital stay was 6 days. Mean nodal yield was 21. CONCLUSIONS: A STP in robotic colorectal surgery is feasible and effective. Right colectomy represents a good model as first step of the program in order to develop multiple technical skills. Previous experience in open or laparoscopic colorectal surgery may not be necessary.
BACKGROUND: Our aim is to propose the Video-Consulting Emergency (VCE) protocol as a tool to improve the decision-making process between an on-site emergency physician and a remote acute care surgeon using a smartphone,...BACKGROUND: Our aim is to propose the Video-Consulting Emergency (VCE) protocol as a tool to improve the decision-making process between an on-site emergency physician and a remote acute care surgeon using a smartphone, the FaceTime application, and the Acute Abdominal Decision Making (AADM®) model proposed by World Society of Emergency Surgeons members. METHODS: The VCE protocol involves the emergency physician and the on-call emergency surgeon. Both must be provided with a smartphone for 24-hour VC with FaceTime application. The AADM® model is a simple, systematic, diagnostic methodology developed by WSES to guide and support physicians throughout the management of acute abdominal pain in the emergency department (ED). FaceTime videoconsulting and the AADM® model con simply systematize the clinical reasoning of the emergency physician when evaluating acute non-traumatic abdomen. RESULTS: The VCE protocol in ED could be fundamental for an effective first surgical screening and it is an interesting clinical tool with the potential to improve clinical evaluation of patients admitted for acute abdomen. CONCLUSIONS: The videoconsulting application could decrease healthcare costs related to unnecessary exams, admissions, surgeries or transfers.
INTRODUCTION: Treatment of chronic calcifying pancreatitis is challenging and requires an interdisciplinary approach including endoscopist, surgeon and radiologist. With advances in endoscopic technology therapeutic inte...INTRODUCTION: Treatment of chronic calcifying pancreatitis is challenging and requires an interdisciplinary approach including endoscopist, surgeon and radiologist. With advances in endoscopic technology therapeutic interventions in the pancreatic duct became available. Extracorporeal shock wave lithotripsy (ESWL) is still recommended to be first line treatment, hence peroral pancreatoscopy- (POP) -guided intracorporal lithotripsy is a promising supplement in endoscopic therapy especially if ESWL is unsuccessful or not available. EVIDENCE AQUISITION: Evidence from published trials, abstracts and case reports on direct pancreatoscopic treatment of main pancreatic duct (MPD) stones was reviewed with focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline and Cochrane Database search for relevant studies was performed. EVIDENCE SYNTHESIS: Seventeen relevant publications meeting the inclusion criteria have been identified (two prospective series, seven retrospective trials, six case reports, two abstracts, for a total of 225 patients). Successful ductal clearance for POP-guided treatment was reported between 37.5% and 100%. Clinical success was reported between 74% and 100%. Adverse event (AE) rate for POP-guided therapy is reported with 0-30%. There is no reported mortality following POP treatment. Three ongoing trials found to be registered. CONCLUSIONS: POP-guided lithotripsy seems to be a promising alternative in a very selected patient cohort. Good powered randomized controlled trials are needed to prove efficiency and safety of the new technique also for large numbers of patients before it can be recommended as general practice. The focus of future studies should not only be on technical success, but also clinical success and patient-reported outcomes (quality of life).
Roux-en-Y gastric bypass surgery remains a popular surgical intervention worldwide to treat morbid obesity. It is effective and relatively safe. However, one of the results related to bariatric surgery-induced rapid weig...Roux-en-Y gastric bypass surgery remains a popular surgical intervention worldwide to treat morbid obesity. It is effective and relatively safe. However, one of the results related to bariatric surgery-induced rapid weight loss is the development of biliary stones. Endoscopic removal of common bile duct stones is challenging in patients with Roux-en-Y gastric bypass reconstruction. The current review highlights the different endoscopic approaches of the biliopancreatic system to perform endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y gastric bypass. A treatment algorithm is provided based on clinical indications.
BACKGROUND: Incarcerated groin hernias are a common presentation as surgical emergencies. Other surgical treatment modalities are becoming more widely accepted including the use of prosthetic mesh and laparoscopy for ass...BACKGROUND: Incarcerated groin hernias are a common presentation as surgical emergencies. Other surgical treatment modalities are becoming more widely accepted including the use of prosthetic mesh and laparoscopy for assessment of hernia content viability and for repair. The aim of this study was to report our current experience with the use of prosthetic mesh in the treatment of incarcerated hernias and to compare the effects of different operative approaches. METHODS: This retrospective study included 219 consecutive patients who underwent herniorrhaphy for incarcerated hernia between January 2013 and December 2017 in Beijing Chao-Yang Hospital. Twenty patients who were not used mesh were excluded. Patients who died in the postoperative period due to systemic complications, as well as those who were lost during the follow-up period, were excluded from the study. Demographics, surgical details, short term and long-term outcomes were collected. Mann-Whitney U-test and χ2 test were used for statistical analysis. RESULTS: A total of 156 patients (78.4%) presented with inguinal hernias, 42 with femoral hernia (21.1%), and one with mixed hernia (0.5%), respectively. Mesh was placed in 199 patients (100%), including 15 patients with concomitant bowel resection. Four patients (2.0%) developed surgical site infections (SSI), four patients (2.0%) had foreign body sensation, one patient (0.5%) had hernia recurrence, two patients (1.0%) had chronic pain, 22 patients (11.1%) had seroma, and the mortality was 2.0%. No significant difference was noted concerning the development of surgical site infection, postoperative recurrence, chronic pain, foreign body sensation, and mortality rates between the transabdominal preperitoneal (TAPP) repair and open mesh repair. There was statistically significant difference in the postoperative incidence of seroma between two groups (12 of 49 [24.5%] vs. 10 of 150 [6.7%]; P=0.001). CONCLUSIONS: Our experience demonstrates that acutely incarcerated or strangulated groin hernia in adults is a serious neglected problem. The use of mesh could become current practice even in case of bowel resection. There was no statistically significant difference in the postoperative complications between TAPP repair and open mesh repairs except seroma.
BACKGROUND: Peripheral lymphadenopathy can be caused by benign disease, or it could be a manifestation of underlying hematological disease or metastasis of a yet undiagnosed malignant condition. Fine-needle aspiration cy...BACKGROUND: Peripheral lymphadenopathy can be caused by benign disease, or it could be a manifestation of underlying hematological disease or metastasis of a yet undiagnosed malignant condition. Fine-needle aspiration cytology (FNAC) and image-guided core biopsy usually make up the first line of investigation. There are several disadvantages to these techniques: FNAC is an acellular aspirate that may provide non-diagnostic specimens, while core biopsy may fail in the presence of composite lymphoma, nodal necrosis, and insufficiency or fragmentation of the specimens. Our aim was to evaluate the safety and effectiveness of excisional biopsy (EB) in a large case series. METHODS: The study included 220 consecutive patients who underwent lymph node EB under local anesthesia. All patients underwent complete and systematic physical examination. Any palpable lymph node was evaluated for its location, size, consistency, fixation, and tenderness. All specimens were sent to the pathologist as fresh tissue. RESULTS: The EB materials demonstrated 89 (40.5%) benign lesions, 130 (59%) malignant diagnoses, and one (0.5%) unclear diagnosis. Mean operative time was 42.9 minutes (range 10-120 minutes). Harvested lymph nodes had a mean diameter of 3.3 x 2.3 cm. All patients were discharged within 8 hours. No major complications were reported, with a mean of 1.16 postoperative outpatient visits. Temporary seroma and/or minor lymph leak at the site of the incision occurred in 14 cases (6.4%), hematoma in 7 (3.2%), and dehiscence of the surgical incision in 4 (1.8%), and in 3 cases (1.4%) pain was reported up to 7 days postoperatively. CONCLUSIONS: Excisional biopsy is a diagnostic method that can be applied safely with minimal morbidity and mortality.
Although the true prevalence is unknown, colonic diverticulosis is one of the most common disease of the digestive tract in Western countries. Based on administrative data of hospitalized patients, the incidence of diver...Although the true prevalence is unknown, colonic diverticulosis is one of the most common disease of the digestive tract in Western countries. Based on administrative data of hospitalized patients, the incidence of diverticulitis has been increasing in last decades. In general, elderly patients undergo less frequently an elective colonic resection; but a substantial part of emergency surgeries is performed in elderly patients. In these older patients the choice of any clinical and surgical option is to be correlated not only to the severity of diverticulitis, but also to general status and the co-existing comorbidities. In this regard, it is mandatory that all patients undergo a multidimensional, comprehensive geriatric assessment to correctly identify those who are fit, vulnerable or frail. The analysis of data currently available highlights three relevant elements: type and severity of peritoneal contamination, hemodynamic conditions (stable or unstable), and concomitant comorbidities (fit or frail status). There is no single ideal surgical treatment that can be considered as gold standard for all clinical presentations; the final clinical decision-making should always be based on patient's general health status, severity of peritonitis and of sepsis. In a septic elderly patient who is hemodynamically unstable, treatment should be as prompt as possible independent of the Hinchey's stage, and could include either a Mickulicz stoma or a DCS strategy. In an elderly patient who is fit and hemodynamically stable, the surgical options are similar to those in a younger patient. If a patient is frail but hemodynamically stable, he should be treated with a Hartmann's procedures.
BACKGROUND: Acute appendicitis is a common acute surgical abdominal condition and despite the majority of cases are observed in children and young adults, its occurrence in the elderly seems to be increasing, with a high...BACKGROUND: Acute appendicitis is a common acute surgical abdominal condition and despite the majority of cases are observed in children and young adults, its occurrence in the elderly seems to be increasing, with a higher risk of perforation. The aim of this study was to evaluate the surgical outcomes following appendectomy for acute appendicitis in the elderly, making a comparison between perforated and nonperforated groups regarding operative time, hospital stay and postoperative complications. METHODS: The medical records of 48 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis from January 2011 to December 2016 were retrospectively reviewed. Patients were grouped into those with perforated and those with non-perforated appendicitis (NPA) and a comparison was made between both groups regarding demography, operative time, length of hospital stay and postoperative complications. RESULTS: From 48 patients over 60 years diagnosed with acute appendicitis, a PA was removed from 10 patients (20.8%). The PA group consisted of 3 males and 7 females, and their mean age was 71.6 years (range 65-84). The NPA group included 22 males and 16 females, and their mean age was 76.5 years (range 63-96). The mean operative time was 58±18.7 minutes and 43.3±9.9 minutes in the perforated and nonperforated groups respectively, with statistically significant difference (P=0.0013). The mean length of hospital stay was similar in the PA group and in the NPA group, being 6.5±1.8 days and 5.4±1.8 days respectively, but these differences were not statistically significant (P=0.093). The frequency of postoperative complications was similar in both groups as they were observed in 3 patients (30%) of the PA group and 10 patients (26%) of the NPA group (P=0.2488). No postoperative intraabdominal abscess was observed in both groups and there was no death after the surgery. CONCLUSIONS: PA, despite requiring a longer mean operative time, in our series is not producing a longer hospital stay or more postoperative complications compared to NPA. The non-operative management of uncomplicated appendicitis is a reasonable option in frail patients in order to avoid the burden of morbidity related to operation, nevertheless surgery remains the standard of care in all age groups.
INTRODUCTION: From 25% to 95% of those who have undergone radical prostatectomy (RP) report erectile dysfunction 12 months after surgery. We attempt a review of the available evidence regarding the anatomy of the caverno...INTRODUCTION: From 25% to 95% of those who have undergone radical prostatectomy (RP) report erectile dysfunction 12 months after surgery. We attempt a review of the available evidence regarding the anatomy of the cavernous nerves and the surgical refinements to enhance sexual function recovery after surgery. EVIDENCE ACQUISITION: The PubMed/Medline database was searched. Duplicates were removed. Studies were selected by the authors according to the aim of the present review. EVIDENCE SYNTHESIS: The cavernous nerves are deemed responsible for erections, but their exact function is still a matter of debate. They do not necessarily have the same distribution in all individuals: in most the cases, these nerves are located posterolaterally, however, it is not uncommon to find some fibers on the anterolateral aspects of the prostate, especially towards the apex. Several technical strategies were proposed in order to intraoperatively identify and spare the neurovascular bundles: despite all efforts, clinical results are still only partially satisfying. CONCLUSIONS: The recovery of potency is one of the most unpredictable outcomes after RP. The advent of the robotic surgical system seems to have brought a trend towards a faster recovery of erectile function.