Minerva Chirurgica[JOURNAL]
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200 papers
Endoscopic treatment of early esophageal squamous neoplasia.
Fleischmann C, Messmann H
Minerva Chir · 2018 Aug · PMID 29843499 · Publisher ↗
Esophageal squamous cell carcinoma (ESCC) remains the most common esophageal cancer in the world, though a rising incidence of esophageal adenocarcinoma could be seen during the last decade in the western world. There ar...
Esophageal squamous cell carcinoma (ESCC) remains the most common esophageal cancer in the world, though a rising incidence of esophageal adenocarcinoma could be seen during the last decade in the western world. There are several known risk factors for ESCC, such as smoking, alcohol consumption, radiation or others. As there is a risk of lymph node metastasis already in early stages, early endoscopic detection is crucial for curative endoscopic treatment options. Therefore, newest technical improvements such as enhancement techniques or virtual chromoendoscopy are helpful for the diagnosis of mucosal carcinoma. Lugol's iodine remains the gold standard to detect early esophageal cancer, however, it should be combined with these newer techniques. For the prediction of invasion depth, a new classification was developed by the Japan Esophageal society. By using magnifying endoscopy and Narrow Band Imaging, the microvascular morphology allows a prediction of invasion depth of early squamous cell carcinoma. Endoscopic resection is suitable for patients with early-stage ESCC (m1-m2), because of the low risk of lymph node metastasis. EMR should be performed if the lesion is smaller than 15 mm, because a R0 resection can be achieved. Larger lesions (>15 mm) should be resected via endoscopic submucosal dissection to reach an en bloc resection, a lower recurrence rate and a R0 situation.
Operative technique in robotic rectal resection.
Mangano A, Valle V, Fernandes E … +3 more , Bustos R, Gheza F, Giulianotti PC
Minerva Chir · 2019 Dec · PMID 29806763 · Publisher ↗
A still too high percentage of the colorectal resections are currently performed by open technique. This in part because laparoscopy has some technical hurdles: not ideal ergonomics, poor control on the traction exerted...
A still too high percentage of the colorectal resections are currently performed by open technique. This in part because laparoscopy has some technical hurdles: not ideal ergonomics, poor control on the traction exerted by the Assistant, long/steep learning curve, confined dexterity, low tactile feedback, hand-tremor and 2D vision with a not completely stable camera. The robotic approach, given the increased surgical dexterity and the better surgical view, may be used to solve the laparoscopic downsides (in particular in the most complex cases). In the present work, after an extensive robotic experience and a robotic program started by Giulianotti et al. in October 2000, we show our operative steps for the robotic rectal resection. The aim is to propose a model to standardize the surgical technique and potentially pave the way for the acquisition of more reproducible data among different centers. This proposal may be also a technical guide to learn the robotic way and also for the expert surgeons as an adjunct in the teaching strategy.
Operative technique in robotic left colonic resection.
Mangano A, Valle V, Fernandes E … +3 more , Bustos R, Gheza F, Giulianotti PC
Minerva Chir · 2019 Oct · PMID 29806762 · Publisher ↗
Minimally invasive techniques have changed the clinical practice in general surgery and provided an improvement of outcomes. Laparoscopic and open surgery have similar oncological outcomes in the colorectal field. Those...
Minimally invasive techniques have changed the clinical practice in general surgery and provided an improvement of outcomes. Laparoscopic and open surgery have similar oncological outcomes in the colorectal field. Those findings have been proven by prospective randomized multicenter trials and systematic reviews. However, some colorectal operations are still being performed by the open approach. This is partially related to the technical hurdles of the laparoscopic approach (particularly for more complex cases). Robotic surgery can be beneficial in overcoming the laparoscopic hurdles and limitations. Indeed, given the improved dexterity, the 3D stereotactic magnified view (with the camera controlled directly by the surgeon), the tremor filtering technology and the 7 degrees of liberty of the surgical instruments can guarantee a more accurate surgical dissection and tissue manipulation. Herein, after a large robotic experience in this field connected to a robotic program started by Giulianotti et al. in October 2000, we present our approach to robotic left colonic resection with routine splenic flexure mobilization. This approach may be helpful to get more reproducible results, it may be a technical guide and also an additional training tool for surgical residents.
Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study.
Mangano A, Fernandes E, Valle V … +3 more , Bustos R, Gheza F, Giulianotti PC
Minerva Chir · 2018 Oct · PMID 29806761 · Publisher ↗
BACKGROUND: The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, th...
BACKGROUND: The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, this maneuver may increase the risk of iatrogenic spleen damage; for others this does not change the odds. Ligaments over-traction is the most frequent injury mechanism. Some documented risk factors are reported: laparotomic approach, male gender, vascular disease, cancer, diverticulitis, surgery performed in emergency-setting. The type of procedure influences the associated risk: transverse colectomy is the riskiest, followed by left colonic resection and pancolectomy. METHODS: Retrospective original paper. Sample size - a total of 125 patients have been considered. 75 robotic left colonic resections (60%), 40 robotic rectal resections (32%) and 10 robotic pancolectomy (8%). Primary outcomes - 1) percentage of iatrogenic splenic injuries; 2) conversion rate. Secondary outcomes - 1) intra-/postoperative complications; 2) anastomotic leakage rate; 3) mortality. In order to avoid potential confounding factors and technical/expertise heterogeneity, all the procedures included have been performed using the same standardized operative technique and by the same experienced surgeon (P.C.G.). RESULTS: We retrospectively analyzed 125 procedures. Primary outcomes - 1) iatrogenic splenic injuries: 0%; 2) conversion rate: 1.6%. Secondary outcomes - 1) intraoperative complications: 0%; 2) anastomotic leakage rate: 1 case of leakage out of 125 cases (1.3% of the left colectomy sub-sample); in this case the leakage was probably due to an infectious process rather than a vascular deficit; 3) mortality: 0%; 4) miscellanea postoperatory complications (small bowel obstructions, wound infection, pelvic collections, pneumonia and acute kidney injury) are detailed in the manuscript. CONCLUSIONS: In our experience, and according to some of the literature data as well, during robotic left colonic/rectal resections the routine mobilization of the left flexure as a standard procedure is not a risk factor in terms of iatrogenic spleen injury rate. Conversely, this technique may be beneficial as it does not excessively extend the operative time, increases the surgical skills acquirement, and reduces the tension-related anastomotic ischemia. It also allows a better oncological dissection. Standard laparoscopic approach reduces the rate of spleen by almost 3.5 times in comparison to open surgery. The improved technical accuracy provided by the robotic platform may decrease the rate of splenic injury. More studies are needed on the topic to confirm our findings.
Oligometastatic prostate cancer and salvage lymph node dissection: systematic review.
Brassetti A, Proietti F, Pansadoro V
Minerva Chir · 2019 Feb · PMID 29806760 · Publisher ↗
INTRODUCTION: We provide a comprehensive description of the physio-pathological theories behind oligometastatic prostate cancer (PCa) and analyze modern imaging techniques, presenting a systematic review of the available...
INTRODUCTION: We provide a comprehensive description of the physio-pathological theories behind oligometastatic prostate cancer (PCa) and analyze modern imaging techniques, presenting a systematic review of the available evidences regarding salvage lymph node dissection (sLND). EVIDENCE ACQUISITION: A systematic review was attempted. The PubMed/Medline database was searched for "salvage" AND ("lymph node dissection" OR "lymphadenectomy") AND "prostate" AND "cancer." Only English publications were targeted. Relevant original articles addressing the role of sLND in PCa were selected. EVIDENCE SYNTHESIS: Biochemical response (BR) was reported in 10-79.5% of the cases overall. These results were not durable and biochemical recurrence occurred in 54.5-93.8% of the cases, within 5 years. Furthermore, 50-80% of patients received some kind of adjuvant treatment right after sLND, regardless post-operative prostate-specific antigen levels. Surgery-related morbidity was low, with a 0-27% incidence of Clavien-Dindo III complications. No sLND-related deaths were observed. CONCLUSIONS: sLND is not associated with a durable response over time but may postpone HT and its related complications, in selected patients. Although a limited morbidity was reported, sLND remains technically demanding and a careful selection of patients is advisable.
Role of confocal laser endomicroscopy in patients with early esophageal neoplasia.
Kollar M, Spicak J, Honsova E … +3 more , Krajciova J, Vackova Z, Martinek J
Minerva Chir · 2018 Aug · PMID 29806759 · Publisher ↗
Probe-based confocal laser endomicroscopy (pCLE) enables real-time histopathological assessment during endoscopic procedures to evaluate epithelial and subepithelial structures with a 1000x magnification. It may be used...
Probe-based confocal laser endomicroscopy (pCLE) enables real-time histopathological assessment during endoscopic procedures to evaluate epithelial and subepithelial structures with a 1000x magnification. It may be used in various localizations not only in the digestive tract, but its role in clinical practice is still a matter of discussion. The main advantages of pCLE compared to standard biopsies may be: 1) real-time diagnosis; 2) which may be done by the endoscopist; and 3) a larger evaluated area compared to standard biopsies. In theory, pCLE has the potential to eliminate the need for biopsy. However, pCLE cannot replace standard biopsies at this time, among others, standard forceps biopsies are presently more cost-effective. pCLE may be used to enhance the diagnostic arsenal and improve mucosal visualization and evaluation in patients with Barrett's esophagus (BE), with visible esophageal lesions and in patients undergoing surveillance endoscopy after endoscopic treatment of BE related neoplasia. pCLE requires sufficient training and use of validated classifications systems. At present, the majority of endoscopic centers do not use pCLE routinely and no guidelines recommend its routine use for patients with different esophageal diseases, although pCLE is (in selected indications) reimbursed in some countries. This article describes the principle and performance of pCLE and reviews its use in patients with BE and early esophageal neoplasia.
Selective use of radiation for locally advanced rectal cancer: one size does not fit all.
Roxburgh CS, Weiser MR
Minerva Chir · 2018 Dec · PMID 29806758 · Full text
The last three decades have seen several major advances in the multidisciplinary management of locally advanced rectal cancer (LARC). Although rectal cancer management varies globally, the standard of care for clinical s...
The last three decades have seen several major advances in the multidisciplinary management of locally advanced rectal cancer (LARC). Although rectal cancer management varies globally, the standard of care for clinical stage II/III rectal cancer in North America remains chemoradiation followed by total mesorectal excision and adjuvant therapy. In this review we evaluate the evidence for neoadjuvant therapy in LARC and the variety of treatment options available. We identify heterogeneity of outcomes in stage II/III rectal cancer, leading to the potential for overtreatment. The PROSPECT Trial is a multicenter, international effort to determine whether a selective approach to provision of radiotherapy in stage II/III LARC is a viable treatment option. Unlike many other studies, the aim of PROSPECT is to reduce treatment rather than increase the intensity of preoperative therapy. LARC is a heterogeneous disease with varying risk of relapse. Studies are underway to attempt to individualize care to avoid overtreatment while maintaining excellent oncologic outcomes.
Radiofrequency ablation for Barrett's esophagus-related neoplasia.
Krajciova J, Vackova Z, Spicak J … +1 more , Martinek J
Minerva Chir · 2018 Aug · PMID 29806757 · Publisher ↗
Barrett's esophagus (BE) is a premalignant condition associated with increased risk of developing esophageal adenocarcinoma. In the past, BE patients with high-grade intraepithelial neoplasia (IEN) or early adenocarcinom...
Barrett's esophagus (BE) is a premalignant condition associated with increased risk of developing esophageal adenocarcinoma. In the past, BE patients with high-grade intraepithelial neoplasia (IEN) or early adenocarcinoma (EAC) were indicated for esophagectomy. With the recent advance in endoscopy, endoscopic techniques have surpassed esophagectomy in the treatment of Barrett's esophagus-related neoplasia and minimized the treatment-related morbidity. Patients with IEN are candidates for endoscopic treatment - endoscopic mucosal resection (ER) of visible lesions and/or ablation therapy of flat Barrett's mucosa. ER combined with radiofrequency ablation (RFA) is now considered as a gold standard for treatment of patients with early Barrett's cancer. RFA is currently the most effective method of ablation used in the treatment of low-grade intraepithelial neoplasia/high-grade intraepithelial neoplasia without visible lesions and for ablation of residual Barrett's mucosa following ER/ESD of EAC or HGIN aiming to achieve complete eradication of Barrett's surface and thus, decreasing the risk of recurrent dysplasia or cancer. The rates of complete remission of neoplasia and metaplasia after completion of endoscopic treatment are 81-92.6% and 75-88.2%, respectively. The aim of this article is to review the principles, techniques, indications, efficacy and safety of this ablative method and surveillance of patients after successful treatment with RFA.
The evolution of pelvic dissection for rectal cancer from blunt dissection to total mesorectal excision.
Krizzuk D, Rickles AS, Wexner SD
Minerva Chir · 2018 Dec · PMID 29806756 · Publisher ↗
"Modern" rectal cancer treatment began in the 18th century. However, initial results of the pioneer surgeons were very poor. During the next several decades, significant progress was made towards the cure of rectal cance...
"Modern" rectal cancer treatment began in the 18th century. However, initial results of the pioneer surgeons were very poor. During the next several decades, significant progress was made towards the cure of rectal cancer. Improvements have included lowering mortality, reducing recurrence, and optimizing functional outcomes. This article reviews the individuals and their advancements in rectal cancer treatment. It describes the changes in the surgical approach for tumor resection, the study of the lymphatic spread of rectal cancer and the advances in sphincter preservation procedures from the era of blunt dissection until the paradigm changing revolution of total mesorectal excision.
Robotic surgery for rectal cancer: the future?
Sammour T, Chang GJ
Minerva Chir · 2018 Dec · PMID 29806755 · Publisher ↗
Robotic technology currently offers some technical advantages in pelvic dissection compared with competing minimally invasive techniques, and adoption for the surgical treatment of rectal cancer is rapidly increasing wor...
Robotic technology currently offers some technical advantages in pelvic dissection compared with competing minimally invasive techniques, and adoption for the surgical treatment of rectal cancer is rapidly increasing worldwide. While there are some early data demonstrating modest improvement in patient outcomes, benefits in terms of long-term oncological outcomes, as well as potential improvements in surgeon-centered outcomes such as fatigue and repetitive stress injury are actively being investigated. Rapid innovation, with the impending release of several new robotic platforms, is likely to further expand the application of these technologies, improve on current limitations, and reduce capital and consumable costs. It is imperative that, as the technology develops and adoption increases further, clinician and research led programs drive safe implementation with a patient-first approach.
Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review.
Amato B, Fugetto F, Compagna R … +8 more , Zurlo V, Barbetta A, Petrella G, Aprea G, Danzi M, Rocca A, de Franciscis S, Serra R
Minerva Chir · 2019 Dec · PMID 29806754 · Publisher ↗
INTRODUCTION: Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The...
INTRODUCTION: Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions. EVIDENCE ACQUISITION: A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data. EVIDENCE SYNTHESIS: Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts. CONCLUSIONS: The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.
Emergent treatment of carotid stenosis: an evidence-based systematic review.
Serra R, Barbetta A, Fugetto F … +8 more , Licastro N, Aprea G, Petrella G, Danzi M, Rocca A, Compagna R, De Franciscis S, Amato B
Minerva Chir · 2018 Oct · PMID 29806753 · Publisher ↗
INTRODUCTION: Stroke is one of the major causes of death in the world, but above all is the condition most associated with severe long-term disabilities. It is clear that this condition therefore requires the best therap...
INTRODUCTION: Stroke is one of the major causes of death in the world, but above all is the condition most associated with severe long-term disabilities. It is clear that this condition therefore requires the best therapeutic approach possible to minimize the consequences that this can lead to. The major issues concern the type of treatment to be used for revascularization (carotid endarterectomy [CEA] or stenting of the carotid artery [CAS]) and the timing of the treatment itself. Many studies have been conducted on this issue, but a definitive and unanimous verdict has not yet been reached on account of the great variety of results obtained from the various study group. The aim of this review is to analyze the latest scientific findings focused on revascularization following a symptomatic carotid stenosis (SCS). EVIDENCE ACQUISITION: We searched all publications addressing treatments and timing of approach to SCS. Randomized trials, cohort studies and reviews were contemplated in order to give a breadth of clinical data. Medline and Science Direct were searched from January 2013 to April 2017. EVIDENCE SYNTHESIS: Of the 819 records found, 76 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 54 manuscripts because of the following reasons: 1) no innovative or important content; 2) insufficient data; 3) no clear potential biases or strategies to solve them; 4) no clear endpoints; and 5) inconsistent or arbitrary conclusions. The final set included 22 articles. CONCLUSIONS: CEA is considered a less problematic method than CAS, especially for patients over the age of 75; CAS remains recommended in patients with a favorable anatomy or high surgical risks. Studies that showed more solid results seem to lead to the conclusion that optimal timing may be between 2 days and the end of the first week from the onset of symptoms in patients who are appropriate candidates for surgery.
Endoscopic treatment of early esophageal adenocarcinoma.
Milano RV, Bergman JJ, Pouw RE
Minerva Chir · 2018 Aug · PMID 29795070 · Publisher ↗
The incidence of esophageal adenocarcinoma is on the rise. With advances in endoscopic techniques and imaging technology, early neoplastic lesions are being increasingly detected and treated. Managing early esophageal ad...
The incidence of esophageal adenocarcinoma is on the rise. With advances in endoscopic techniques and imaging technology, early neoplastic lesions are being increasingly detected and treated. Managing early esophageal adenocarcinoma with endoscopic techniques is now considered the cornerstone of therapy, offering an alternative to surgery. The available endoscopic techniques can be broadly categorized into resection and ablation techniques that may be combined to increase the effectiveness of therapy. However, endoscopic treatments are highly specialized and patients with early adenocarcinoma should be referred to centers with expertise in advanced endoscopy of the esophagus. We review the proper method for conducting a thorough evaluation of early neoplastic lesions, staging details, the available endoscopic resection and ablation techniques, and the efficacy and safety of different endoscopic treatments.
Can the depth of invasion of early esophageal cancer be predicted based on endoscopic evidence?
Maes S, Haidry R, Bisschops R
Minerva Chir · 2018 Aug · PMID 29795069 · Publisher ↗
INTRODUCTION: Esophageal cancer is one of the leading causes of cancer-related death worldwide. Its poor prognosis is related to an often late diagnosis. An earlier diagnosis and treatment however, is related to a better...
INTRODUCTION: Esophageal cancer is one of the leading causes of cancer-related death worldwide. Its poor prognosis is related to an often late diagnosis. An earlier diagnosis and treatment however, is related to a better outcome. Early stage esophageal cancer can be diagnosed and treated endoscopically with minimally invasive techniques, which is associated with lower mortality and morbidity than surgery. Whether esophageal carcinoma can be treated endoscopically depends mainly on the risk of lymph node metastasis, which itself correlates to the invasion depth of the tumor. The question is whether endoscopy can accurately determine the invasion depth and thus the treatment modality. EVIDENCE ACQUISITION: Articles used for this review were identified by searches of PubMed and references of relevant articles. EVIDENCE SYNTHESIS: Lesion morphology has some predictive value for the depth of invasion for squamous cell carcinoma (SCC) and esophageal adenocarcinoma (EAC). An intramucosal cancer generally has a flat appearance (Paris 0-IIa, 0-IIb,). By contrast, a submucosally invasive cancer often has an excavated (0-IIc, 0-III) and sometimes a polypoid morphology (0-I). In SCC, classification of surface vessels and intrapapillary capillary loops (IPCLs) allows accurate assessment of invasion depth. Generally, mucosal lesions are an indication for endoscopic treatment. However recent studies have shown that tumors with submucosal infiltration and low risk profile for metastasis can also be treated safely by endoscopic resection. CONCLUSIONS: Endoscopic assessment allows a rather accurate estimation of invasion depth of early esophageal cancer. To determine the final treatment modality however the final histological staging obtained by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is crucial.
Prevention of esophageal strictures after circumferential endoscopic submucosal dissection.
Martínek J, Juhas S, Dolezel R … +5 more , Walterová B, Juhasova J, Klima J, Rabekova Z, Vacková Z
Minerva Chir · 2018 Aug · PMID 29795068 · Publisher ↗
Endoscopic submucosal dissection or widespread endoscopic resection allow the radical removal of circumferential or near-circumferential neoplastic esophageal lesions. The advantage of these endoscopic methods is mini-in...
Endoscopic submucosal dissection or widespread endoscopic resection allow the radical removal of circumferential or near-circumferential neoplastic esophageal lesions. The advantage of these endoscopic methods is mini-invasivity and low risk of major adverse events compared to traditional esophagectomy. The major drawback of these extensive resections is the development of stricture - the risk is 70-80% if more than 75% of the circumference is removed and almost 100% if the whole circumference is removed. Thus, an effective method to prevent post-ER/ESD esophageal stricture would be of major benefit, because treatment of strictures requires multiple sessions of endoscopic dilatation and may carry a risk of perforation. Moreover, not all strictures are easy to treat and some patients may develop refractory strictures. There are several techniques and methods, which have been tested in both experimental and/or clinical studies but no one has received general acceptance based on results of high-quality evidence. The studies are usually small with a limited number of patients, there is a lack of randomized controlled trials and some techniques have been described only in experimental studies. Thus, prevention of post-ESD strictures remains an unresolved issue. On the other hand, because of the high risk of stricture and partially proven effectiveness of some preventive techniques, a preventive strategy should be considered in patients undergoing extensive ER/ESD in the esophagus. There is, however, no evidence about the superiority or inferiority of a particular preventive strategy compared to other techniques, moreover, there is paucity of data assessing the effectiveness of the combination of different preventive methods. The best preventive strategies known so far include 1) oral or local administration of corticosteroids; and 2) preventive stenting. Other strategies (preventive sessions of endoscopic dilatation or tissue engineering methods) have unproven efficacy or are too demanding for practical use. Nevertheless, the use of (any) preventive strategy after extensive ER/ESD of the esophagus probably reduces the risk of stricture and the number of endoscopic dilatations, therefore, it should be considered in these patients. However, there is a need for high quality evidence as well as for new ideas and approaches to resolve this important clinical problem.
Not all diverticulites are colonic: small bowel diverticulitis - A systematic review.
De Simone B, Alberici L, Ansaloni L … +3 more , Sartelli M, Coccolini F, Catena F
Minerva Chir · 2019 Apr · PMID 29795067 · Publisher ↗
INTRODUCTION: Small bowel non-Meckelian diverticulitis (SBNMD) is not so an uncommon cause of admission in departments of emergency surgery. Our aim is to highlight signs and symptoms for early diagnosis and report prope...
INTRODUCTION: Small bowel non-Meckelian diverticulitis (SBNMD) is not so an uncommon cause of admission in departments of emergency surgery. Our aim is to highlight signs and symptoms for early diagnosis and report proper surgical treatments. EVIDENCE ACQUISITION: The systematic review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P). EVIDENCE SYNTHESIS: Twelve studies met our inclusion criteria. A total of 527 patients diagnosed with SBNMD were analyzed: there were 159 (30%) cases of diverticular bleeding, 125 (23%) cases of perforated SBNMD, 91 (17.26%) cases of intestinal obstruction, 79 (14.9%) cases of non-complicated diverticulitis, and 36 (6.8%) cases of ileal diverticulosis. Among bleeding patients, endoscopy procedures were performed in 51 (32%) cases. Surgery was necessary in 77/159 (48.4%) cases. Medical treatment was sufficient in 15/159 (9.4%) cases. In case of perforation, 93/125 (74.4%) patients were submitted to surgery, with open technique in 78/93 (83.8%) patients, by laparoscopy in 2/93 (2.1%) with conversion rate of 1.07%. Eight of 125 (6.4%) cases received medical treatment. In case of obstruction, non-operative management was effective in 3/91 (3.2%) cases. Surgery was performed in 74/91 (78%) cases, with open technique in 64/91 (86.4%) cases, by laparoscopy in 3/74 (4%), with one patient converted in laparotomy. CONCLUSIONS: Diagnosis of SBNMD is often made at emergency surgical exploration with high morbidity and mortality rate. SBNMD must be considered in elderly patients presenting with abdominal pain. A multidisciplinary approach to the patient (involving a radiologist, a surgeon, and a gastroenterologist) is necessary to make an early diagnosis. In case of complicated SBNMD, the emergency surgeon must choose the right surgical treatment.
Non-operative management of rectal cancer: understanding tumor biology.
Wei IH, Garcia-Aguilar J
Minerva Chir · 2018 Dec · PMID 29795066 · Full text
The management of locally-advanced rectal cancer involves a combination of chemotherapy, chemoradiation, and surgical resection to provide excellent local tumor control and overall survival. However, aspects of this mult...
The management of locally-advanced rectal cancer involves a combination of chemotherapy, chemoradiation, and surgical resection to provide excellent local tumor control and overall survival. However, aspects of this multimodality approach are associated with significant morbidity and long-term sequelae. In addition, there is growing evidence that patients with a clinical complete response to chemotherapy and chemoradiation treatments may be safely offered initial non-operative management in a rigorous surveillance program. Weighed against the morbidity and significant sequelae of rectal resection, recognizing how to best optimize non-operative strategies without compromising oncologic outcomes is critical to our understanding and treatment of this disease.
Early surgical management of acute cholecystitis in ultra-octogenarian patients: our 5-year experience.
Oldani A, Calabrò M, Maroso F … +6 more , Deiro G, Ravizzini L, Gentile V, Magaton C, Amato M, Gentilli S
Minerva Chir · 2019 Jun · PMID 29795065 · Publisher ↗
BACKGROUND: Acute calculous cholecystitis is a leading cause for hospital admission especially in developed countries. As older age population increases, medical research should consider the efficacy of all therapeutic o...
BACKGROUND: Acute calculous cholecystitis is a leading cause for hospital admission especially in developed countries. As older age population increases, medical research should consider the efficacy of all therapeutic options, including early surgical procedure in an emergency context, for the treatment of acute cholecystitis in elderly high-risk patients. METHODS: From 01/01/2012 to 31/12/2016, 245 patients were admitted to our Institution with diagnosis of acute cholecystitis and managed with cholecystectomy within the same hospitalization. The study population was divided into 2 subgroups: group A (patients aged more than 80 years) and group B (patients within the limit of 80 years of age); the objective of the study was to evaluate and compare the surgical outcomes of the 2 groups in terms of conversion rate, mortality rate, overall morbidity and procedure-related complication rates. RESULTS: Statistical analysis did not show significant differences between ultra octogenarian and younger patients in terms of conversion to open procedure, iatrogenic bile duct lesions, postoperative peritoneal bleeding, bile leakage and peritoneal collection; no differences in terms of hospital stay have been demonstrated. Mortality and overall morbidity rates, even if similar to what observed in Literature and within acceptable values, were significantly higher in elderly patients, due to the presence of severe comorbidities leading to potentially fatal postoperative events. CONCLUSIONS: Minimally invasive approach in an emergency setting for acute cholecystitis seems to be a feasible and adequate therapeutic approach for extremely aged high-risk patients.
Gallstone ileus in elderly patients.
Erdas E, Medas F, Salaris C … +5 more , Canu GL, Sanna S, Gordini L, Pisano G, Calò PG
Minerva Chir · 2018 Dec · PMID 29795064 · Publisher ↗
Abstract loading — click title to view on PubMed.
Modified Paul-Mikulicz jejunostomy in frail geriatric patients undergoing emergency small bowel resection.
Ruscelli P, Popivanov G, Tabola R … +7 more , Polistena A, Sanguinetti A, Avenia N, Renzi C, Cirocchi R, Ursi P, Fingerhut A
Minerva Chir · 2019 Apr · PMID 29795063 · Publisher ↗
BACKGROUND: Proximal or extended bowel resections are sometimes necessary during emergency surgery of the small bowel and call for creating a high small bowel stomy as a part of damage control surgery. Secondary restorat...
BACKGROUND: Proximal or extended bowel resections are sometimes necessary during emergency surgery of the small bowel and call for creating a high small bowel stomy as a part of damage control surgery. Secondary restoration of intestinal continuity in the frail geriatric patient, further weakened by subsequent severe malabsorption may be prohibitive. METHODS: Six patients underwent emergency small bowel resection for proximal jejunal disease (83.3% high-grade adhesive SBO and 16.7% jejunal diverticulitis complicated with perforation). With the intention to avoid end jejunostomy and the need for repeat laparotomy for bowel continuity restoration we modified the classic Paul-Mikulicz jejunostomy. RESULTS: The postoperative course was uneventful in four patients whose general condition improved considerably. At six-month follow-up, neither patients required parenteral nutrition. CONCLUSIONS: This modified stoma can have the advantage of allowing a partial passage of the enteric contents, reducing the degree of malabsorption, and rendering jejunostomy reversal easy to perform later.
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