Annali italiani di chirurgia最新文献

Aim: To document the first known case of internal hernia following the Ceriani Procedure (CP) and evaluate its clinical and surgical management.

Case presentation: A 57-year-old female with a history of biliopancreatic diversion (BPD) underwent CP for inadequate weight loss. She presented one year later with acute abdominal pain and fever. Diagnostic imaging and laparoscopy confirmed an internal hernia. Treatment involved lysis of adhesions, hernia reduction, and closure of mesenteric defects. The patient had an uneventful recovery and remained symptom-free during follow-up.

Results: The patient presented with acute abdominal pain and fever one year after undergoing the CP. Laboratory tests revealed elevated white blood cell count (11,780/mm³) and lactate levels (3.6 mmol/L), with normal inflammatory markers. CT imaging showed signs of small bowel obstruction and a swirl sign consistent with internal hernia. Emergency laparoscopy confirmed herniation through an inframesenteric defect. The procedure was converted to open laparotomy for safe hernia reduction and mesenteric defect closure. The patient recovered without complications and was discharged on postoperative day three. At follow-up, she remained symptom-free.

Conclusions: Internal hernia is a potential complication after CP, similar to Roux-en-Y reconstructions. Prompt diagnosis and surgical intervention are critical to avoiding severe complications like bowel infarction.

Aim: This study aims to evaluate physicians' approaches to dyspepsia management, with a focus on the use of gastroscopy and Helicobacter pylori testing.

Methods: This cross-sectional survey study was conducted among physicians from different specialties, including general practitioners, internal medicine specialists, and surgeons. The questionnaire assessed approaches to diagnosing, management strategies, and adherence to clinical guidelines.

Results: A survey of 262 physicians revealed that 22.9% of them recommended gastroscopy for all dyspeptic patients, with the proportion increasing with patient age. The study also found that Helicobacter pylori testing was conducted in only 16.4% of new dyspeptic cases, suggesting a potential gap in clinical practice guidelines. Furthermore, general surgery specialists were found to be less likely to adhere to clinical guidelines, favoring a broader use of gastroscopy. The survey also revealed that most physicians (67.6%) prescribed proton pump inhibitors as an initial treatment, with varying treatment durations.

Conclusions: This study highlights significant variability in dyspepsia management among physicians, which may stem from the lack of regional guidelines and insufficient postgraduate education. While surgeons' more frequent use of endoscopy reflects a heightened focus on diagnostic accuracy, it may inadvertently contribute to appointment system congestion, delaying gastric cancer diagnosis. Implementing region-specific guidelines alongside comprehensive postgraduate training presents a promising strategy for enhancing system efficiency.

Aim: Diverticular disease (DD) is one of the most common benign gastrointestinal conditions in the Western world, with a range of clinical manifestations from uncomplicated symptoms to acute complications requiring surgery. Elective sigmoidectomy is indicated in cases of Complicated Diverticular Disease (CDD) after recovery, Symptomatic Uncomplicated Diverticular Disease (SUDD), and Recurrent Diverticulitis (RD). This study aims to assess the short- and long-term outcomes of a standardized surgical approach for DD.

Methods: A retrospective analysis was conducted on 442 patients who underwent elective sigmoidectomy or left hemicolectomy for DD disease between January 2012 and March 2020. Different DD scenarios were included: 128 patients with SUDD (29%), 170 with RD (38.5%), 144 with CDD (34.0%). All patients had nearly 5 years of follow-up. Preoperative evaluations included computed tomography (CT) scans and colonoscopy. Surgical procedures followed a standardized protocol, including medial to lateral approach, inferior mesenteric artery preservation, distal resection at the level of the upper rectum with a 60 mm blue Endo Gia cartridge, an end-to-end Knight-Griffen anastomosis with a 29 mm circular stapler and Indocyanine Green (ICG) testing. Demographic data, type of DD, surgical technique, and postoperative outcomes were recorded. The primary outcome measures included intraoperative details, complication rates, recurrence rates, and quality of life (GastroIntestinal Quality of Life Index [GIQLI] scores) at 1 and 5 years post-surgery.

Results: The cohort included 240 males and 202 females with a median age of 50 years. The surgical procedure was standardized across all patients. The mean operative time was 121 ± 28 minutes, with a conversion rate of 5.2% and an overall complication rate of 16.1%. Major complications, including anastomotic leaks, were observed in 4.9% of patients. The mean hospital stay was 4 days. Diverticulitis recurrence occurred in 5.2% of patients, more frequently in those with a disease duration of more than 5 years (p = 0.028). Cox regression analysis revealed that the duration of DD greater than 5 years was the only significant risk factor for diverticulitis recurrence (Hazard Ratio [HR] 2.42, 95% CI 1.12 to 4.62, p = 0.028). GIQLI scores significantly improved 1 year after surgery (92.7 ± 9.5 vs 97.8 ± 8.5, p < 0.001) and continued to improve at 5 years (92.7 ± 9.5 vs 118.1 ± 10.6, p < 0.001).

Conclusions: Elective sigmoidectomy for DD, using a standardized laparoscopic technique, is safe and effective, with low complication rates and significant long-term improvement in quality of life. The recurrence rate of diverticulitis is low, and surgery provides lasting relief, especially for patients with recurrent or complicated forms of the disease. Standardization appears essential to optimize safety and efficacy in DD management.

Aim: Climate change is a major global health threat, and healthcare contributes 4-5% of global greenhouse gas emissions. Operating rooms (ORs) are particularly resource-intensive, producing high levels of waste and emissions. Sustainable surgical practices are essential to reduce the environmental impact of healthcare. This review aims to summarise and compare key international initiatives that promote sustainability in the OR.

Methods: A narrative review was conducted between January and March 2025. Resources were identified through searches of PubMed, Google Scholar, and professional society websites. Inclusion criteria included publication or endorsement by recognised academic or professional bodies, availability in English, and provision of practical guidance on surgical sustainability. No formal quality assessment was performed due to the heterogeneity of sources.

Results: Four major frameworks were identified: the Intercollegiate Green Theatre Checklist, which offers actionable perioperative recommendations including reusable equipment, waste reduction, and energy savings; the European Association for Endoscopic Surgery (EAES)/the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Taskforce, which focuses on leadership, education, and international collaboration; the Harvard Climate in Obstetrics, Anaesthesia and Surgery Team (COAST) Group, which promotes equity-focused, low-cost, and scalable solutions suitable for varied healthcare settings; the World Federation of Societies of Anaesthesiologists (WFSA) Global Consensus, which outlines sustainable anaesthetic practices and education. These frameworks align with the "5R" model-Reduce, Reuse, Recycle, Rethink, and Research-and highlight the OR as a key area for intervention.

Conclusions: Despite implementation barriers, these frameworks provide practical, scalable strategies for surgical teams to reduce emissions. Embedding sustainability in surgical practice is critical for achieving healthcare decarbonisation and improving planetary health.

Aim: Differentiating complicated appendicitis (CA) from uncomplicated appendicitis (UA) is a critical aspect of preoperative evaluation that influences surgical planning and patient outcomes. This study explored the role of the immature granulocyte count (IG#) and percentage (IG%) as accessible and reliable biomarkers to enhance the diagnostic precision of CA.

Methods: This retrospective observational study analyzed 482 emergency appendectomies performed at a single tertiary hospital between January 2020 and June 2023. After excluding 23 cases due to haematological disorders, malignancies, additional procedures, or incomplete data, 459 patients were included in the final analysis. Patients were categorized into the UA and CA groups based on histopathological examination. CA was defined as a perforation or gangrene. Laboratory parameters, including IG#, IG%, and inflammatory markers, were compared between groups.

Results: Among the 459 patients, 386 (84.1%) had UA and 73 (15.9%) had CA. The median age of CA patients was significantly higher than that of UA patients (36 vs. 33 years, p = 0.016). CA patients also demonstrated significantly elevated levels of C-reactive protein (CRP), direct bilirubin, white blood cell count (WBC), IG#, IG%, and neutrophil-to-lymphocyte ratio (NLR) compared to UA patients (p < 0.001). Receiver operating characteristic (ROC) analysis identified an IG# cut-off of 0.06 (area under the ROC curve [AUROC] = 0.699, sensitivity = 68.5%, specificity = 65.2%) and an IG% cut-off of 0.35 (AUROC = 0.663, sensitivity = 75.3%, specificity = 49.6%). In the multivariable logistic regression analysis, none of the evaluated laboratory parameters, including WBC count (Odds ratio (OR): 1.133, 95% Confidence interval (CI): 0.979-1.313, p = 0.095), IG# (OR: 0.000, 95% CI: 0.000-1.595, p = 0.056), IG% (OR: 6.740, 95% CI: 0.873-52.064, p = 0.067), and NLR (OR: 1.070, 95% CI: 0.980-1.169, p = 0.131), remained significant independent predictors of CA.

Conclusions: Elevated IG# and IG% levels were associated with CA in univariate analysis; however, they did not remain significant independent predictors in the multivariable model. Although the potential of these markers may still provide complementary information in certain clinical scenarios, further large-scale prospective studies are needed to better define their role in clinical practice.

Aim: Lumbar tuberculosis can cause spinal instability and neurological deficits, often requiring surgery. Traditional anterior-posterior surgery is effective but highly invasive, leading to greater trauma and longer recovery. Minimally invasive techniques, such as oblique lumbar debridement with posterior percutaneous fixation, may reduce surgical damage and improve recovery. However, their efficacy remains unclear. This study compares this minimally invasive approach with conventional surgery to assess its feasibility as an alternative treatment.

Methods: A retrospective analysis was conducted on 156 patients diagnosed with single-segment lumbar tuberculosis between July 2016 and October 2019. Patients were divided into a minimally invasive group (Min group, n = 76), treated with the oblique lumbar approach combined with Posterior Percutaneous Pedicle Screw Fixation (PPPSF), and a conventional Open group (n = 80). All patients received standard anti-tuberculosis therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) for at least two weeks preoperatively and continued for 10-12 months postoperatively, adjusted based on drug sensitivity testing. Nutritional support and bracing for three months post-surgery were also provided. Surgical and postoperative metrics were evaluated, including operative time, intraoperative blood loss, length of abdominal incision, postoperative drainage volume and postoperative hospital stay. Functional outcomes were assessed using the visual analogue scale (VAS) and oswestry disability index (ODI), while serology markers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and creatine phosphokinase (CPK) levels were measured. Radiographic parameters, including the Cobb angle and sagittal vertical axis (SVA), were also evaluated. Postoperative complications were also documented.

Results: The Min group demonstrated significantly shorter operation time, smaller incisions, reduced blood loss, shorter hospital stays, and lower postoperative drainage and CPK levels compared to the conventional Open group (p < 0.05). There was no significant difference in VAS, ODI, ESR and CRP levels between the two groups at different times after surgery (p > 0.05). Radiographic assessments revealed no significant differences in the Cobb angle or SVA at any postoperative time point (p > 0.05). However, the Min group exhibited a significantly higher rate of Grade 1 spinal fusion (59 vs. 38 cases, p < 0.05). Although postoperative complications were lower in the Min group (14.5% vs. 18.8%), the difference was not statistically significant (p = 0.474).

Conclusions: Oblique lumbar debridement with PPPSF represents a viable alternative to traditional anterior-posterior surgery for single-segment lumbar tuberculosis, offering reduced surgical trauma and accelerated postoperative recovery.

Aim: To explore the differences in clinical features between patients with pituitary apoplexy and those without, analyze the risk factors for pituitary apoplexy, evaluate the incidence of postoperative complications between patients with pituitary apoplexy and those without, and investigate the risk factors for postoperative complications to provide clinical guidance for diagnosis and treatment.

Methods: In this retrospective analysis, clinical data of 108 pituitary tumor patients admitted between January 2020 and July 2024 were collected. The patients were divided into two groups: the pituitary apoplexy group (n = 50) and the pituitary non-apoplexy group (n = 58). Baseline data, surgical outcomes, and postoperative complications were compared between the two groups. Multivariate logistic regression analysis was performed to identify the risk factors for pituitary apoplexy and postoperative complications.

Results: Multivariate logistic regression analysis revealed that tumor size (odds ratio [OR] = 1.064, 95% confidence interval [CI]: 1.010-1.120, p < 0.05) and hypertension (OR = 5.552, 95% CI: 1.660-18.572, p < 0.05) were independent risk factors for pituitary apoplexy. The incidence of postoperative pituitary dysfunction and the average length of hospital stay were higher in the apoplexy group than in the non-apoplexy group (p < 0.05). Multivariate logistic regression analysis showed that tumor size (OR = 1.142, 95% CI: 1.061-1.229, p < 0.05) and preoperative hypothyroidism (OR = 12.002, 95% CI: 1.129-127.648, p < 0.05) were identified as independent risk factors for postoperative complications in pituitary tumor patients.

Conclusions: The occurrence of pituitary apoplexy is closely related to tumor size and hypertension. Patients with apoplexy face a higher risk of postoperative pituitary dysfunction and experience a longer hospital stay compared to the non-apoplexy patients. Postoperative complications are associated with tumor size and preoperative hypothyroidism.

Cerebral arteriovenous malformations (AVMs) are rare vascular anomalies associated with a risk of devastating intracerebral hemorrhage. They are often diagnosed following the appearance of seizures, focal neurological signs, or bleeding. In such cases endovascular embolization, which aims to occlude the AVM nidus and reduce risk of hemorrhage, has become a crucial therapeutic approach. Herein, we describe the case of a 62-year-old patient with a history of bleeding caused by cerebral AVM. During urgent endovascular embolization of the patient's AVM, a combination of large-caliber platinum coils and Onyx™ liquid embolic agent was used to achieve hemostasis after catheterizing a primary feeder. However, when the catheter was being pulled back, the proximal part of the coil migrated and became entangled with the catheter, thus remaining partially in the AVM and partially elongated in the access vessel thereby impeding the catheter from being completely removed from the percutaneous access. Surgical access with repair of the axillary artery was necessary to remove the catheter trapped in the coil. The successful outcome of this case demonstrates the importance of early recognition, timely intervention, and multidisciplinary team collaboration in managing AVM complications during neurovascular procedures to optimize patient outcomes.

Aim: This study aimed to evaluate the relationship between colonic diverticular disease (CD) and colonic polyps (CP) in Turkiye, considering age and gender distribution.

Methods: This retrospective cross-sectional study analyzed patients who underwent total colonoscopy between 1 January 2021, and 1 January 2022. Patients with a history of colon resection, inflammatory bowel disease, or prior polypectomy were excluded. The presence of CD and CP was assessed according to age, gender, and colonic localization [right (R), left (L), bilateral (B)].

Results: A total of 452 patients were included, with 248 (54.9%) males and 204 (45.1%) females. The mean age was 57.7 ± 13.0 years. Among them, 235 were in the patient group [CD (+) and/or CP (+)], and 217 were in the control group. The study found a significant association between CD and CP, particularly among older patients, with rates of CD (+) and CP (+) increasing with age (p = 0.001). Interestingly, CD (+) patients had a lower risk of CP compared to CD (-) patients (p = 0.003). Additionally, male patients exhibited significantly higher CP rates than females.

Conclusions: Our findings indicate that CD (+) patients have a significantly lower risk of CP (+) compared to CD (-) patients. These results provide valuable insights into the relationship between CD and CP, which may help guide future research.

Aim: This study aims to explore the impact of perioperative comfort nursing combined with targeted operating room nursing on the stress response and nursing satisfaction in colorectal cancer patients, emphasizing the importance of precision nursing in enhancing postoperative recovery.

Methods: This retrospective study analyzed clinical data of colorectal cancer patients (n = 165) who underwent laparoscopic colorectal surgery at our hospital between February 2022 and February 2024. Grouped according to different perioperative nursing methods, and the patients were divided into two groups: the experimental group (n = 85) and the control group (n = 80). The control group received routine operating room nursing, while the experimental group received comfort nursing in addition to targeted operating room care. The differences in the impact of the two nursing models on patients' surgical-related indicators, stress response measured by Serum Amyloid A (SAA), Interleukin-6 (IL-6), and C-reactive protein (CRP) levels, pain scores, as well as nursing satisfaction, postoperative follow-up status, were evaluated and compared between the two groups.

Results: The experimental group demonstrated significantly shorter postoperative times to first flatus, first out-of-bed activity, first oral intake, length of hospital stay, anastomotic healing time, and postoperative infection rate compared to the control group (p < 0.05). On days 1 and 2 after surgery, SAA, IL-6, and CRP levels were elevated in both groups compared to their preoperative levels, with the experimental group showing significantly lower levels than the control group (p < 0.05). Furthermore, on postoperative days 1, 3, and 7, the Visual Analog Scale (VAS) scores were significantly lower in the experimental group (p < 0.05). In contrast, nursing satisfaction was significantly higher in the experimental group than in the control group (p < 0.05). Six months and one year after surgery, the experimental group showed significantly higher scores on the Barthel index and the Quality-of-Life Questionnaire Core 30 (QLQ-C30) compared to the control group, while their Hamilton Anxiety Scale (HAMA) and Self-Rating Depression Scale (SDS) scores were significantly lower (p < 0.05).

Conclusions: Integrating comfort nursing with a targeted operating room nursing approach during laparoscopic colorectal cancer surgery helps promote early recovery, alleviate postoperative pain and stress response, improve nursing satisfaction, and promote patient recovery. The effectiveness of nursing interventions may partly depend on the stability of surgical techniques; further verification is needed through multi-center, large-sample studies. The synergistic effect of both factors contributes to the patient's recovery.