1,721,191 research outputs found
Impact of Diagnostic laparoscopy on the managment of gastic cancer: prospective study of 120 consecutive patients with primary gastric adenocarcinoma
No full textLe risque de plaies biliaires au cours de la cholécystectomie par laparoscopie
No full textThe incidence of iatrogenic injuries of the bile ducts has increased significantly since laparascopic cholecystectomy became the "gold standard" in the treatment of cholelithiasis. The incidence of major biliary ductal injury ranges from 0.25% to 0.74%, and of minor injury from 0.28% to 1.7%. The cause of the injury is not always clearly identifiable. In more than half the cases, the injury occurs during maneuvers to isolate the cystic duct or to free the gallbladder from the common bile duct. These maneuvers may be more difficult and consequently more dangerous when there is significant inflammation as may be seen in acute cholecystitis, or in case of obesity, cirrhosis with portal hypertension, previous surgery with peritoneal adhesions, or anatomic variations of the hepatic pedicle. Pre-operative evaluation of clinical risk factors should be coupled with intra-operative caution and instrumental evaluation. The increase in frequency of iatrogenic biliary injuries can not be attributed simply to the inexperience of the surgeon or the learning curve as was initially suggested. Many injuries are due, rather, to the surgeon's failure to respect basic technical rules, long established for open cholecystectomy and which should not be modified for the laparoscopic technique. While routine cholangiography does not offer complete protection from iatrogenic ductal injuries, it is essential to visualize the biliary tract whenever a lesion of the ductal system is clearly identified or even suspected. In such cases, facility with the technique of intraoperative cholangiography and a knowledge of the radiological anatomy of the biliary tree are essential for an accurate and complete intraoperative evaluation of the biliary injury. Finally, in the presence of acute or chronic inflammation or other factors for technical difficulty (obesity, cirrhosis, previous surgery, anatomic variations, intraoperative bleeding), the surgeon must not hesitate to consider conversion to an open surgical approach. In such complicated cases, even the open approach is not a guarantee against biliary injury; there is no substitute for experience and caution in biliary surgery
Acute pancreatitis associated with primary hyperparathyroidism
No full text: Coexistence of primary hyperparathyroidism and acute pancreatitis has widely been reported in literature, but a causal relationship remains controversial. A case of acute pancreatitis as a first symptom of primary hyperparathyroidism with severe hypercalcemia is reported. In this patient a reduction of serum calcium level was obtained with medical therapy and resulted in the resolution of acute pancreatitis symptoms within 10 days. At the same time a parathyroid adenoma was clinically identified and elective parathyroidectomy was performed with complete normalization of intact parathyroid hormone and serum calcium level. At three-year follow-up, no recurrence or complications of pancreatitis were documented. The presented case suggests a cause and effect relationship between acute pancreatitis and severe hypercalcemia which should be kept in mind in the differential diagnosis of non-biliary, non-alcoholic acute pancreatitis. Reduction of hypercalcemia with medical treatment can represent a good chance for elective surgical neck exploration
Safety of hospital discharge before return of bowel function after elective colorectal surgery
No full textBackground: Ileus is common after colorectal surgery and is associated with an increased risk of postoperative complications. Identifying features of normal bowel recovery and the appropriateness for hospital discharge is challenging. This study explored the safety of hospital discharge before the return of bowel function. Methods: A prospective, multicentre cohort study was undertaken across an international collaborative network. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The main outcome of interest was readmission to hospital within 30 days of surgery. The impact of discharge timing according to the return of bowel function was explored using multivariable regression analysis. Other outcomes were postoperative complications within 30 days of surgery, measured using the Clavien–Dindo classification system. Results: A total of 3288 patients were included in the analysis, of whom 301 (9·2 per cent) were discharged before the return of bowel function. The median duration of hospital stay for patients discharged before and after return of bowel function was 5 (i.q.r. 4–7) and 7 (6–8) days respectively (P < 0·001). There were no significant differences in rates of readmission between these groups (6·6 versus 8·0 per cent; P = 0·499), and this remained the case after multivariable adjustment for baseline differences (odds ratio 0·90, 95 per cent c.i. 0·55 to 1·46; P = 0·659). Rates of postoperative complications were also similar in those discharged before versus after return of bowel function (minor: 34·7 versus 39·5 per cent; major 3·3 versus 3·4 per cent; P = 0·110). Conclusion: Discharge before return of bowel function after elective colorectal surgery appears to be safe in appropriately selected patients
Surgical Training for Transanal Total Mesorectal Excision in a Live Animal Model: A Preliminary Experience
No full textBackground: In this preliminary experience, the feasibility and effectiveness of surgical training with an animal model for transanal total mesorectal excision (TaTME) were evaluated.Methods: The training was conducted in two experimental animal laboratories in Italy authorized by the Italian Ministry of Health, using female Danish Landrace pigs under the supervision of surgeons with extensive experience in TaTME, animal laboratory training and cadaver laboratory training. The procedure was divided into separate steps, and all the participants were guided step-by-step throughout the entirety of the procedure.Results: During all the editions of the animal laboratory, all the procedures were completed with no major damage to the anatomical structures or intraoperative death of the animals. Live animal tissue is very similar to human tissue, helping trainees improve their tactile feedback. The bleeding effect improved the value of the training and taught the participants how to address this complication. The lack of mesorectal tissue in pigs compared with humans was the main difference. Animal laboratories should not be considered alternatives to cadaver laboratories but as complementary training activities due to their effectiveness and lower costs.Conclusions: Surgical training in animal models for TaTME seems to be effective and could be an opportunity to improve training alongside the use of a cadaver laboratory and proctoring
Long-term outcomes of elective surgery for diverticular disease: A call for standardization
No full textTo date, the appropriate management of diverticular disease is still controversial. The American Society of Colon and Rectal Surgeons declared that the decision between conservative or surgical approach should be taken by a case-by-case evaluation. There is still lack of evidence in literature about long-term outcomes after elective sigmoid resection for diverticular disease. Considering the potentially key role of the surgical technique in long-term outcomes, there is the need for surgeons to define strict rules to standardize the surgical technique. Currently there are 5 areas of debate in elective surgery for diverticular disease: laparoscopic versus open approach, the site of the proximal and distal colonic division, the vascular approach and the mobilization of the splenic flexure. The purpose of this paper is to review existing knowledge about technical aspects, which represent how the surgeon is able to affect the long-term results
Perioperative chemotherapy for gastric cancer: how should we measure the efficacy?
No full textNo abstrac
Towards the goal of r0 resection in locally advanced gastriccancer through the path of neoadjuvant chemotherapy e impact of tumour downstaging on survival in a single series.
No full textBackground: Long term survival after R0 resection in locally advanced gastric cancer
(LAGC) remains poor, suggesting that a true curative treatment is seldom performed. Preoperative treatment protocols have been proven to be effective in LAGC by large-scale
randomized trials; this theoretically happens through an increased control on both distant
and loco-regional recurrencies. Aim of this study is the evaluation of the effects on the
primary tumour, along with its lymphatic basin, induced by preoperative chemotherapy
and the survival impact on a single series of locally advanced gastric carcinomas.
Methods: 47 patients with LAGC, staged by laparoscopy, underwent D2-gastrectomy after
preoperative chemotherapy. The effects of preoperative treatment were evaluated by a quantitative analysis , which determined the percentage of residual vital tumour cells in the surgical specimens, and by a qualitative analysis , which evaluated the achievement of
8 ABSTRACTStumour-downstaging (T/dwn) induced by any grade of pathologic response. T/dwn after preoperative chemotherapy was assessed comparing pre-treatment clinical and laparoscopic
staging with post-operative pathologic staging. The c2 test was used to evaluate the significance of statistical differences among sub-groups. Survival was calculated by Kaplane
Meier method and the prognostic significance of prognostic factors was determined by
means of univariate analysis (log-rank test). Multivariate analysis was performed using the
Cox proportional hazard model in backward stepwise regression.
Results: "Quantitative analysis" of pathologic response was unable to show a clear
prognostic significance. T/dwn was obtained in 25 out of 47 patients. T/dwn was
associated with a smaller tumour diameter (34 mm. mean-diameter in T/dwn group
versus 55 mm.mean-diameter in non-T/dwn group, p1⁄40.002) and a higher R0-resection rate (96% in T/dwn group versus 72% in no-T/dwn group, p1⁄40.04). Overall survival at 5 years was 55%. In those patients who benefited from a R0-resection (40/47
patients: R0-resection rate 1⁄4 85%) overall survival reached up to 63%. At univariate
and multivariate analysis, R0-resection was found to be an independent prognostic
factor (R1-2/R0: HR 6.250/1, p1⁄40.002).
Conclusions: In this study, R0-resection was the most important prognostic factor for
LAGC selected to be treated by preoperative chemotherapy.
Patients who obtained T/dwn had a definitely better chance of cure, mainly through
the achievement of a true R0-resection
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