Updates in Surgery

Single-incision laparoscopic surgery (SILS) is currently regarded as the next major advance in the progress of minimally invasive techniques in colorectal surgery. We describe our initial experience using SILS for the management of colorectal disease and present preliminary short-term results. Between February 2010 and April 2011, 7 patients (4 females and 3 males, mean age 55 years, range 32–74) underwent SILS for either benign or malignant colorectal disease. Preoperative diagnosis was diverticular disease of the sigmoid colon in two patients, malignant polyps of the sigmoid colon in two other patients and large villous tumor of the right colon in three patients. Surgical procedures, 4 anterior resections of the rectum and 3 right hemicolectomies, were performed through a 3 cm single umbilical incision using a SILS multi port device with conventional or articulated laparoscopic instruments. There were no intraoperative complications or conversions in the standard laparoscopic procedure. The mean operative time for anterior resections was 160.0 ± 10.6 min, whereas it was 160.6 ± 20 for right hemicolectomies. Blood loss was minimal. No postoperative complications were reported in any of the patients. The overall mean hospital stay was 4.8 ± 0.2 days (range 4–5). For the subset of patients with malignant or pre-malignant disease, the mean number of retrieved lymph nodes was 15.6 ± 4.4 (range 6–31). Cosmetic results were considered excellent by all the patients after 15 days. In conclusion, our preliminary experience shows that SILS for colorectal disease is feasible and safe with potential reproducible oncologic results.

In the last three decades surgeons have begun to perform outpatient thyroid surgery (OTS). Important outcome measures of a day-hospital procedure are the patient’s quality of life (QoL) and satisfaction, but information on these issues in the OTS setting is scanty. The aim of this pilot study was to explore how early discharge after thyroidectomy affects patients’ QoL and satisfaction. Postoperative QoL and satisfaction were assessed retrospectively by giving each patient a self-report questionnaire specifically created in our center for OTS and derived from the post-discharge surgical recovery (PSR) scale to assess physical and mental well-being. Twenty-three of 24 patients (96%), 16 women and 7 men with a median age of 48 years (range 16–72), completed the questionnaire, answering 92% of the questions. QoL based on this scale gave a median score of 81.8% (range 62–98.8%). No major or minor complications occurred in the study group. Regarding QoL eight patients (35%) reported feeling “tired all the time” and six patients (26%) reported mild pain, which in two cases resolved spontaneously. Regarding patient satisfaction two-thirds of patients judged OTS positively while the remaining one-third would not recommend it. Our study showed very good uptake by patients of a new questionnaire dedicated to OTS as a possible aid in the identification of areas for improvement of OTS management. However, to be considered a safe procedure with maximum patient compliance and satisfaction, OTS was found to require considerable effort by hospital staff and patients’ caregivers compared to inpatient thyroid surgery.

Good perfusion of the bowel and a tension-free anastomosis are the two main prerequisites for an uneventful anastomotic healing in rectal surgery. This prospective cohort study investigates the noninvasive intraoperative spectrophotometric assessment of the bowel perfusion using a device called “Oxygen to See” (O2C®). Forty patients, planned for low anterior resection, were prospectively enrolled in this study to undergo an intraoperative spectrophotometric assessment of the bowel. Three different O2C® parameters were collected from the colonic and the rectal stumps before fashioning the anastomosis: SO2 (capillary venous oxygen saturation), rHb (relative hemoglobin amount), and flow (blood flow velocity). Bowel perfusion was also assessed with the cold-steel-test (CST), which involves severing the colic marginal artery of Drummond at the tip of the colon stump. The data collected from the spectrophotometric measurement and the CST were analyzed for correlation of both methods with respect to each other and to the outcome of the anastomosis. Nine patients were excluded due to different reasons, thus leaving 31 patients for statistical analysis. Three flow parameters collected at the colonic stump significantly predicted an anastomotic leak (p: 0.0057; p: 0.0250; p: 0.0404). One rHb parameter collected at the rectal stump correlated weakly with the anastomotic outcome (p: 0.0768). The CST did not correlate significantly with anastomotic leak (p: 0.1195), but showed significant correlations to some rHb values. Intraoperative noninvasive spectrophotometric measurement is feasible and could be a useful method in assessing bowel perfusion before fashioning a colorectal anastomosis.

This study was performed to retrospectively analyze and compare the related clinical indicators between extralevator abdominoperineal excision (ELAPE) and non-ELAPE under laparoscopic for low rectal cancer. From June 2018 to September 2021, a total of 80 patients with low rectal cancer who underwent either of the above two types of surgeries at our Hospital were enrolled. Patients were divided into the ELAPE group and non-ELAPE group based on the different surgical methods. Preoperative general indicators, intraoperative indicators, postoperative complications, positive circumferential resection margin rate, local recurrence rate, hospital stay length, hospital expenses, and other related indicators were compared between the two groups. There were no significant differences in the comparison of preoperative indexes between the ELAPE group and non-ELAPE group, including age, preoperative BMI, and gender. Similarly, there were no significant differences in abdominal operation time, total operation time, and the number of intraoperative lymph nodes dissected between the two groups. However, the perineal operation time, intraoperative blood loss, intraoperative perforation rate, and positive circumferential resection margin rate were significantly different between the two groups. In the comparison of postoperative indexes, perineal complications, postoperative hospital stay length, and IPSS score were significantly different between the two groups. The use of ELAPE in treating T3-4NxM0 phase low rectal cancer was superior to non-ELAPE in reducing intraoperative perforation rate, positive circumferential resection margin rate, local recurrence rate, etc.

Patients with gastroesophageal reflux disease (GERD) may present with a variety of symptoms, including heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. Therefore, the clinical presentation of GERD varies among individuals and conversely symptoms not always correspond to the presence of actual reflux. For that reason, the diagnosis poses certain challenges to the physician. To overcome these challenges, a thorough clinical examination followed by objective functional testing could improve diagnostic accuracy. In addition, a proper evaluation of patients with GERD can help in identifying those who will likely benefit the most from an antireflux procedure. The diagnostic work-up of these patients should include: symptomatic evaluation, upper endoscopy, barium swallow, high-resolution manometry, and ambulatory pH monitoring. Once a proper diagnosis of GERD is achieved, antireflux surgery is an excellent option for patients with partial control of symptoms with medication, for patients who do not want to be on long-term medical treatment (compliance/cost), or when complications of medical treatment occur.

The incidence of hip dislocation after primary total hip arthroplasty (THA) has been reported to range from 1 to 25% in THA revision. Here, we explore the hypothesis that there is a correlation between postoperative ileus (POI) and THA dislocation, with POI after THA possibly representing a sentinel event. We retrospectively identified a cohort of 529 consecutive patients who underwent hip arthroplasty from 2008 to 2010. Of them, 251 were male and 278 were female, and a mean average for age of 71.5 (range 65–76). In particular, 19 THA patients showed signs of gastrointestinal complications, and therapeutic consultation was performed with the onset of the first intestinal symptom. Of these 19 patients, 3 THA patients developed POI within 1 week after surgical treatment. A conservative treatment was practised and it seemed to improve the condition: canalization returned and all patients were discharged from the hospital. Unfortunately, two of these patients were readmitted after 2 weeks due to THA dislocation and they underwent THA revision and were discharged from the hospital 7 days later. Follow-up revealed no further problems at 6 months. Our clinical experience with these post-THA primary ileus patients raises the possibility that intra-abdominal symptoms represent a sentinel event in THA dislocation. THA dislocation using neuronal pathway of immunomodulation may modulate POI. Since the risk of THA dislocation is the greatest in the first 3 months after hip arthroplasty, the surgeon should be familiar with the relationship between THA and various pelvic and visceral complications to ensure that POI remains only a rare complication.

To determine if preoperative-intraoperative factors such as age, comorbidities, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and severity of peritonitis affect the rate of morbidity and mortality in patients undergoing a primary anastomosis (PA) or Hartmann Procedure (HP) for perforated diverticulitis. This is a systematic review and meta-analysis, conducted according to PRISMA, with an electronic search of the PubMed, Medline, Cochrane Library, and Google Scholar databases. The search retrieved 614 studies, of which 11 were included. Preoperative-Intraoperative factors including age, ASA classification, BMI, severity of peritonitis, and comorbidities were collected. Primary endpoints were mortality and postoperative complications including sepsis, surgical site infection, wound dehiscence, hemorrhage, postoperative ileus, stoma complications, anastomotic leak, and stump leakage. 133,304 patients were included, of whom 126,504 (94.9%) underwent a HP and 6800 (5.1%) underwent a PA. There was no difference between the groups with regards to comorbidities (p = 0.32), BMI (p = 0.28), or severity of peritonitis (p = 0.09). There was no difference in mortality [RR 0.76 (0.44–1.33); p = 0.33]; [RR 0.66 (0.33–1.35); p = 0.25]. More non-surgical postoperative complications occurred in the HP group (p = 0.02). There was a significant association in the HP group between the severity of peritonitis and mortality (p = 0.01), and surgical site infection (p = 0.01). In patients with perforated diverticulitis, PA can be chosen. Age, comorbidities, and BMI do not influence postoperative outcomes. The severity of peritonitis should be taken into account as a predictor of postoperative morbidity and mortality.

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann–Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann–Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.