Updates in Surgery最新文献

Functional pancreatic neuroendocrine tumors (pNET) necessitate surgical resection. Enucleation is the preferred surgical method for well-differentiated pNETs that measure less than 2 cm in diameter, as it offers a greater likelihood of enhancing post-operative recovery and decreasing morbidity and mortality. Insulinomas are particularly suitable for enucleation when such a procedure is viable. However, enucleating tumors within the uncinate process of the pancreas, especially on its posterior aspect, can present substantial challenges. The accompanying video illustrates a robotic-assisted enucleation of an insulinoma in the uncinate process, performed on a 41-year-old male with recurrent hypoglycemia. This intervention led to the resolution of symptoms and incurred minimal post-operative morbidity.

We, herein, describe a case of complex parenchyma-sparing hepatectomy for multiple bilobar colorectal liver metastases (CRLMs). A 61-year-old woman, previously operated for an occlusive adenocarcinoma of the transverse colon and undergoing adjuvant chemotherapy, developed metachronous bilobar CRLMs. After administration of a II line chemotherapy with partial response, she was referred to our hospital. The pre- and post-treatment imaging recognized seven liver lesions, with a bilobar distribution involving segments 3, 4, 5, 8, and 7. After multidisciplinary team evaluation, the surgical strategy was planned by means of three-dimensional reconstruction and simulation software. The planned and executed procedure consisted of a unique transection plane comprising partial resection of segments 3-4-5-8-7, thus removing the central transversal portion of the liver. Accurate preoperative planning and intraoperative ultrasound for resection guidance allowed us to achieve a complex parenchymal sparing procedure in an advanced disease that would be usually candidate for major resection and staged hepatectomy.

Biliary complications remain a real issue in liver transplantation (LT). Despite meta-analyses, the anastomosis technique, especially the use of biliary drain as T-Tube drain (TT) or transcystic drain, remains controversial. This study conducted by the ARCHET research group examine the incidence and types of biliary complications (BC) after LT according to the presence or absence of a biliary drain. 1485 patients with LT surgery between 2009 to 2015 in 4 LT centers were included, divided into 3 groups: no drain (ND n = 442), transcystic drain (TCD, n = 169) and TT(n = 874).The T-Tube group includes 3 techniques: transanastomotic, subanastomotic and tunneled retroperitoneal. Fistula and biliary stricture (AS) rates were studied. The risk factors of BC were investigated by multivariate analysis. The BC rate was lower in the TT group (17% TT, 25% TCD, 31% ND, p < 0.05), the complication rate Dindo-Clavien grade ≥ III is higher in the ND group (24% vs. 10% TT p < 0.05). Arterial complication has been found as a risk factor of BC with the multivariate analysis (p < 0.01, OR 1.86 [1.20-2.84]). In addition, the TT decreased by 5 the risk of AS (p < 0.05, OR 0.19 [0.12-0.28]). The fistula rate does not differ regardless of the reconstruction mode. In this study, biliary drain decreases the rate of BC. The findings confirmed the role of T-tube insertion in prevention of AS regardless of the way it is set up.

Situs viscerum inversus totalis (SIT) is a rare congenital anomaly. Deceased donors with this condition are often declined because of the technical issues in both the organ's procurement and its transplant. Only eight cases of deceased donor organs with SIT were reported to be used for liver transplantation (LT). We herein present a case of LT using a graft from an SIT donor: a modified retroversus piggyback technique was used. A 15 year-old female was referred to our institution as a potential donor. An SIT condition was discovered during standard donor evaluation together with the presence of a complex triple arterial pedicle. Procurement operative time was 125 min, from skin incision to cross-clamp. Liver extraction occurred 32 min after cold flush. The recipient was a 56 year-old male affected by recurrent hepatocellular carcinoma (HCC) on hepatitis C related liver cirrhosis. Position and orientation trials of the graft were made and it was decided to implant it with the retroversus technique. Direct duct-to-duct biliary reconstruction was achieved. The postoperative course was uneventful. To our knowledge, this is the first implant with retroversus technique combined to direct biliary reconstruction and the first repetition of that technique. Cases like this highlight how technical complexity can be overcome leading to successful management of difficult scenarios in a safe manner.

Laparoscopic cholecystectomy (LC) remains the gold standard procedure for the management of benign gallbladder disease. Recognizing the need to mitigate complications, mainly bile duct injury (BDI), various techniques for ductal identification during LC have emerged, including the "Critical View of Safety" (CVS) and the infundibular technique (IT). In this systematic review and meta-analysis, we assess and compare the outcomes of both techniques, with a primary focus on evaluating their impact on BDIs. A comprehensive search was conducted using PubMed and Scopus databases. The search focused on the surgical technique, incidences of minor and major BDIs, operative time, conversion rate, and length of stay, among patients undergoing LC for benign gallbladder disease. Our initial search retrieved 264 studies. After screening the unique studies against our predefined inclusion/exclusion criteria, only five met our criteria and were included. Additionally, a manual search identified eight more relevant studies, bringing the total number of included studies to 13. The total number of included patients was 4,837. Approximately two-thirds underwent LC using the CVS approach (61.1%), and 66.3% were female, with a mean age of 44.4 ± 11.2 years. The CVS approach was associated with a significant reduction in overall BDIs (RR = 0.36; 95% CI 0.18-0.71) and major BDIs (RR = 0.28; 95% CI 0.13-0.63). However, there were no significant differences in terms of minor BDIs, operative time, conversion rates, or length of stay. Our study demonstrated the superiority of the CVS approach in terms of reducing the incidence of overall and major BDIs compared to IT. However, our study revealed no other significant differences between the two techniques. Further research, including multicentric randomized controlled trials, will be necessary to further evaluate the efficacy of these techniques.

Gout is the most common form of inflammatory arthritis, and it is due to the deposition of monosodium urate crystals in the articular and extra-articular tissues. Body mass index is strongly correlated with elevated serum uric acid levels and gout is often associated with obesity and metabolic syndrome. Recommended nonpharmacological treatments for hyperuricemia and gout include dietary modifications and weight loss. Many studies have demonstrated that weight loss could reduce serum urate in patients with obesity and it is a commonly recommended treatment for gout. Bariatric surgery-induced weight loss exerts beneficial effects on hyperuricemia and gout, even if a possible raise of gout flares can be observed in patients with hyperuricemia early after surgery. The aim of this review is to systematically analyze all the studies published so far reporting a link between hyperuricemia and/or gout and bariatric surgery to obtain reliable figures on the incidence of this disease and describe the mechanisms underlying this association. Eleven studies accounting for 11,256 patients were included in the review. Mean preoperative prevalence of gout was 4.1%, while the preoperative prevalence of hyperuricemia ranged from 30.6% to 58%. After a mean follow-up of 8.5 months, postoperative prevalence of gout significantly decreased to 2.9% (p < .007). The incidence of gout flares after bariatric surgery was higher in the early postoperative phase and progressively decreased over time. Similarly, serum uric acid concentrations showed an increase within the first postoperative month, which was followed by a progressive decrease below the preoperative value.

Compared to standardized minimally invasive colorectal procedures, there is considerable perioperative heterogeneity in loop ileostomy reversal. This study aimed to investigate the current perioperative practice and technical variations of loop ileostomy reversal following rectal cancer surgery. A nationwide online survey was conducted among members of the Italian Society of ColoRectal Surgery (SICCR). A link to the questionnaire was sent via mail. The survey consisted of 31 questions concerning the main procedural steps and application of the ERAS protocol after loop ileostomy reversal. Overall, 219 participants completed the survey. One respondent in four used a combination of water-soluble contrast studies (WSCS) and digital rectal examination to assess the integrity of the anastomosis before ileostomy closure. Conversely, 17.8% of them used either only WSCS or only endoscopy. Surgeons routinely perform hand-sewn or stapled anastomoses in 45.2% and 54.8% of the cases, respectively. Side-to-side antiperistaltic stapled anastomosis was the most performed anastomosis (36%). Most surgeons declared that they have never used prostheses for abdominal wall closure (64%), whereas 35% preferred retromuscular mesh placement in selected cases only. Forty-six respondents (66.7%) reported using interrupted stitches for skin closure, while 65 (29.7%) a purse-string suture. Furthermore, skin approximation at the stoma site using open methods was significantly more common among surgeons with greater experience in ileostomy reversal (p = 0.031). Overall, a good compliance with the ERAS protocol was found. However, colorectal surgeons were significantly more likely to follow the ERAS pathway than general surgeons (p < 0.05). Surgeons use different anastomotic techniques for ileostomy reversal after rectal cancer surgery. Based on current evidence, purse-string skin closure and ERAS pathway should be implemented, while the role of mesh prophylactic strategy needs to be explored further.