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Background: Ulcerative colitis may impair anorectal function, causing disabling symp-toms such as incontinence and/or increase in the stool frequency, urgency and tenesmus. Data on anorectal function in these patients evaluated by conventional anorectal manometry are conflicting. Objectives: The aim of this prospective study was to assess by means of high resolution anorectal manometry the anorectal function in patients with mild-to-moderate ulcerative colitis at presentation and after remission. Anorectal function of ulcerative colitis patients was compared to that observed in healthy volunteers. Methods: 20 patients with mild to moderate left-sided ulcerative colitis or proctitis and 20 healthy volunteers were prospectively enrolled. All ulcerative colitis patients underwent high resolution ano-rectal manometry before treatment and after clinical remission. Results: Ulcerative colitis patients showed similar values for anal sphincter function as healthy vol-unteers, whereas rectal threshold volume for the first sensation, desire to defecate, urgency to defecate and maximum discomfort were significantly lower than in healthy volunteers (p Conclusions: Ulcerative colitis patients show altered rectal function, with increased rectal sensitivity and lower compliance, compared to controls. This altered function is restored after successful treat-ment of the underlying inflammatory process. Finally high resolution anorectal manometry provides useful information on anorectal functionality and, in our opinion, should be preferred over conven-tional manometry.

Eosinophilic oesophagitis (EoE) may lead to severe complications if not promptly recognised.To assess the diagnostic delay in patients with EoE and to explore its risk factors.EoE patients followed-up at eight clinics were included via retrospective chart review. Diagnostic delay was estimated as the time lapse occurring between the appearance of the first likely symptoms indicative of EoE and the final diagnosis. Patient-dependent and physician-dependent diagnostic delays were assessed. Multivariable regression models were computed.261 patients with EoE (mean age 34±14 years; M:F ratio=3:1) were included. The median overall diagnostic delay was 36 months (IQR 12-88), while patient- and physician-dependent diagnostic delays were 18 months (IQR 5-49) and 6 months (IQR 1-24). Patient-dependent delay was greater compared to physician-dependent delay (95% CI 5.1-19.3, p0.001). A previous misdiagnosis was formulated in 109 cases (41.8%; gastro-oesophageal reflux disease in 67 patients, 25.7%). The variables significantly associated with greater overall diagnostic delay were being a non-smoker,1 episode of food impaction, previous endoscopy with no biopsies, regurgitation, and ≥2 assessing physicians. Being single was significantly associated with lower overall and patient-dependent diagnostic delay.EoE is burdened by substantial diagnostic delay, depending on both patient-related and physician-related factors.

Purpose Postoperative non-invasive ventilation (NIV) has been proposed as an attractive strategy to reduce morbidity in obese subjects undergoing general anesthesia. The increased body mass index (BMI) correlates with loss of perioperative functional residual capacity, expiratory reserve volume, and total lung capacity. The aim of the current study is to evaluate the efficacy of NIV in post-anaesthesia care unit (PACU) in reducing post-extubation acute respiratory failure (ARF) after biliointestinal by-pass (BIBP) in obese patients.Methods A retrospective analysis was conducted from January 2019 to December 2020 to compare acute respiratory failure within the first 72 postoperative hours and oximetry values of obese patients undergone BIBP after postoperative NIV adoption or conventional Venturi mask. Results 50 patients received NIV postoperative protocol and 57 patients received conventional Venturi Mask ventilation were included in the study. After 120 min in PACU pH, pCO2, pO2 and SpO2 resulted better in NIV Group vs Control Group (pConclusion After bariatric surgery, the short term NIV during PACU observation promotes a more rapid recovery of postoperative lung function and oxygenation in obese patients, reducing the critical care necessity in the days following surgery. Therefore, as day case surgery becomes more advocated even for the morbid obesity, it might be considered a necessary procedure.

Background: Schwannomas, also called neurinomas, are rare benign tumors of the neural cells that can develop from the sheaths of nervous structures of several districts, although the most frequent sites are the cranial nerves (25%–45%). Rarely, cases show neck schwannomas in the thyroid parenchyma, while the cases of thyroid-bed schwannomas mimicking a thyroid-gland lesions are anecdotal. Methods: We report the case of a 70-year-old man with a preoperative-imaging diagnosis of a thyroid neoplasm, confirmed as Thyr 4 by fine-needle cytology. Results: During surgery, an extra-thyroidal lesion was discovered, determined to be a neck schwannoma through definitive pathology. A literature review of cases of thyroid-bed-lesion schwannomas misinterpreted as thyroid neoplasms was carried out. Conclusions: In the case of suspicious extra-thyroidal lesions, we advocate for a close routine cooperation between the cytologist, the radiologist, and the surgeon in the attempt to reach an accurate preoperative diagnosis.

Background: Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure. Methods: From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152). Conclusions: In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles’ procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.

Background: Obesity represents a critical health issue and it is also a risk factor for pelvic floor disorders (PFD). It is important to screen patients for obesity to assess their quality of life (QOL) and reduce health care costs. Methods: We evaluated the prevalence of PFD, such as urinary incontinence (UI), fecal incontinence (FI), constipation, rectal and female pelvic organ prolapse, and also the QOL of obese patients referred to our center. Results: The most prevalent PFD was constipation, affecting 18% (n = 71) of the patients, 11% for FI (n = 43), and 17% for UI (n = 67). The QOL, according to the Short Form-36 results, was worse in the obese group with PFD than the obese patients without PFD (p < 0.01). In only one subscale, mental health, the difference was not statistically different. Conclusions: The prevalence of PFD was almost similar between the obese and the control group. However, obese patients with PFD present a lower QOL than obese patients without PFD. This aspect is essential to investigate on embarrassing health problems, often hidden by patients, to improve QOL.

Stapler-less laparoscopic sleeve gastrectomy (LSG) is emerging as a new potential affordable cost-effective alternative procedure. However, no pre-clinical data are currently available on human tissue. We aimed to evaluate whether traditionally suturing without the use of surgical stapling may produce a comparable bursting pressure on human gastric tissue. A prospective cohort of consecutive patients undergoing LSG was divided in two groups to compare a barbed extra-mucosal running suture (stapler-less) versus a standard stapler line. A burst pressure test was applied to the gastric specimen employing high-resolution manometric catheter. Type, location and features of the leak were described. We enrolled a total of 40 obese patients, 20 patients for each group. Median burst pressures of the stapler-less group resulted statistically significant increased (p p = N.S.), more often at the proximal stomach (p

Background: Verneuil’s disease is a rare suppurative pathology of apocrine glands and pilosebaceous system of the inguinal-pelvis and perianal region with a multifactorial aetiology. The disease produces skin fistulas, draining a serum-purulent material on the skin, and finally with spontaneous healing. Verneuil’s disease can be complicated by recurrence, and unfortunately, by squamous carcinoma. We have found in literature, just 2 cases of Hidradenitis Suppurativa, complicated by Verrucous Carcinoma. Main Observation: we describe a patient F, 34-year-old, comes to our observation at 4th gestational month, with suppurative sinus pilonidalis diagnosis and with the absolute indication of the gynaecologist to the abortion. We decided to continue the pregnancy. The patient gives birth with C. to 9 months; the new-born baby was perfectly healthy and after the maternal milk analysis, the baby also nursed for about 2 months. Finally, we decided to perform a wide excision biopsy and after a controversial histology (first Warty Carcinoma, then after a “second view” Suppurative Hidradenitis), we started a series of medical treatments, including biological therapy with Infliximab, but unfortunately with fleeting results. The patient did not answer substantially. Therefore, the last chance appears a combined demolitive and plastic surgical treatment. The histology described a Verrucous squamous cell carcinoma maximum diameter of 38 x 26 cm, with lateral deep margins free of neoplastic involvement. Conclusion: This very advanced clinical behaviour of the Hidradenitis Suppurativa can present in pregnancy, therefore, motivating the interruption of the same one. Our experience contributes to underlining the possibility to bring to term the pregnancy. This case report shows how the hormonal activity can anyway influence the development of the hidradenitis and an interesting hypothesis could consider the hormonal activity of the pregnancy and the HPV promoting gene regulation (RB) from inflammatory pathology to neoplastic pathology in VC like a model to study.

Background. We aim to evaluate morphofunctional changes of the sphincter complex after GateKeeper (GK) and SphinKeeper (SK) procedures and correlate these with symptom improvement. Methods. Ten consecutive females undergoing SK implant were age-matched with a cohort of 10 females who previously underwent the GK procedure. Patients in the SK and GK groups underwent implantation of 10 and 6 prostheses, respectively. Muscle tension ( Tm), expressed in millinewtons per centimetre squared, mN (cm2)−1, was calculated using the equation Tm = P( r i)( tm)−1, where P is the average maximum squeeze pressure and r i and tm the inner radius and thickness of the external anal sphincter, respectively. The pre- and postimplant changes in Tm and Cleveland Clinic Fecal Incontinence Score (CCFIS) were tested by linear and Poisson regression models, respectively. Results. The CCFIS significantly improved in both groups at 12-month postimplantation. Although not reaching statistical significance, symptom improvement after SK was 33% above that observed after GK ( P = .088). Compared to the baseline, a significant increase in Tm was observed in both groups at 12 months (GK, 508.1 [478.8-568.0] vs 864.4 [827.0-885.8] mN (cm2)−1; SK, 528.0 [472.7-564.0] vs 858.6 [828.0-919.6] mN (cm2)−1, P = .005). Compared to the GK group, Tm was significantly higher in patients after SK implant (158.3 mN (cm2)−1 [95% confidence interval, 109.6-207.0]; P < .001), after controlling for baseline values, at 12-month postimplantation. Conclusions. GK and SK are safe and effective treatments for FI with good short-term clinical outcomes. Comparative analysis showed superiority of SK over GK in terms of gain in Tm, with borderline significantly better improvement in symptoms. Larger studies are needed to confirm these findings.

The use of one anastomosis gastric bypass (OAGB) is rapidly spreading. Concerns about biliary reflux and malabsorption with consequent nutritional deficits exist, so studies on biliopancreatic limb (BPL) adequate length in OAGB are required to balance excess weight loss in percentage (% EWL), resolution of comorbidities, and nutritional deficit. The purpose was to evaluate, at 2 years after OAGB, the effects of BPL length on weight loss, resolution of comorbidity, and nutritional deficiencies in patients. From January 2015 to January 2017, 180 patients were collected into three groups based BPL length: group A, 150 cm; group B, 180 cm; and group C, 200 cm. Aims were to compare %EWL, co-morbidity resolution rates, nutritional parameters, and morbidity/mortality in the three groups. The total number of patients was 180: 60 for each group. One hundred seventy-two (95%) patients attended the 1-year follow-up (group A = 58; group B = 58, group C = 56). One hundred fifty-seven (87%) patients attended the 2-year follow-up (group A = 52 (87%); group B = 53 (88%); group C = 52 (87%)). There was no statistically significant difference in %EWL, %TWL, T2DM, and hypertension resolution rates among the groups. About vitamin deficiency, differences were not statistically significant. Iron and ferritin deficiency rate were statistically significant only between A and C groups. According to our evidence, standardization of BPL length shorter than 200 cm is suggested, potentially minimizing malnutrition-related outcomes. Our study seems to show that a BPL of 150–180 cm is safe and effective in terms of EWL and comorbidity improvement with low malnutrition effects even in BMI > 50.

Background: A worrying increase of gastroesophageal reflux disease (GERD) and Barrett esophagus has been reported after sleeve gastrectomy (SG). Recent reports on combined fundoplication and SG seem to accomplish initial favorable results. However, no study included manometry or pH monitoring to evaluate the impact of fundoplication in SG on esophageal physiology. Method: In this study, 32 consecutive bariatric patients with GERD and/or esophagitis had high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) before and after laparoscopic sleeve gastrectomy associated to anterior fundoplication (D-SLEEVE). The following parameters were calculated at HRiM: lower esophageal sphincter pressure and relaxation, peristalsis, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH, symptom index association (SI), and symptom-association probability (SAP) were also analyzed. Results: At a median follow-up of 14months, HRiM showed an increased LES function, and MII-pH showed an excellent control of both acid exposure of the esophagus and number of reflux events. Bariatric outcomes (BMI and EWL%) were also comparable to regular SG (p = NS). Conclusion: D-SLEEVE is an effective restrictive procedure, which recreates a functional LES pressure able to control and/or prevent mild GERD at 1-year follow-up.

Highlights • Percutaneous dilatation tracheotomy enables non-surgeons to perform tracheotomies at patients bedside. • Bleeding is a common complication of percutaneous dilatation tracheotomies. • Performing a pre-operative neck ultrasound can help identifying aberrant vessels and reduce the risk of periprocedural bleeding., Introduction Percutaneous dilatation tracheotomy (PDT) is a relatively recent technique that enables non surgeons to perform tracheotomies at bedside reducing operation rooms schedules. It is burdened by a moderate risk of postoperative bleeding. Presentation of case The patient was a 57 years old with a temporal intraparenchymal hematoma, submitted to percutaneous dilatation tracheotomy. Despite the favorable anatomical features, a pre-procedural US was performed, identifying a pulsating vessel with an arterial pattern, 2 cm above the hollow. The procedure was then considered at high risk, an operation room was required for the technique and an on-call surgeon was alerted. The procedure was ended safely and any bleeding was avoided because the technique was practiced with the best precautions. Discussion PDT strength is the possibility for non surgeons to perform tracheotomies in selected patients at bedside, reducing operation rooms congestion. Such technique though is a “blind” technique, and postoperative bleedings can occur and represent a feared complication. Conversely, the surgical tracheotomy permits a better control of hemorrhages, but needs the involvement of a surgeon and availability of an operation room. Performing a PDT guided by a neck ultrasound is useful to identify eventual aberrant vessel whose course could complicate the tracheotomy, it is part of PDT guidelines of some States. Conclusion US-PDT could help reducing procedure related complications selecting those high risk patients still in need of operating room and surgical assistance. US-PDT feasibility combined to its easy availability and low costs encourage its introduction into everyday practice.

Obstructed defecation syndrome is a common multifactorial disease whose treatment is based primarily on clinic presentation for the lack of reliable instrumental and anatomopathological criteria.We analyzed the pathological findings of the resected rectal specimens after stapled transanal rectal resection in patients affected by outlet obstruction.This was a retrospective cohort study.The setting was a university hospital.Patients who underwent rectal resection for obstructed defecation syndrome due to internal rectal prolapse.Specimens of obstructed defecation syndrome patients were analyzed through conventional histology and morphometric image analysis and compared to the ones of rectal specimens excised for oncological diseases.The primary outcome was to investigate the anatomopathological impairments underlying rectal prolapse.From January 2017 to December 2020, 46 specimens from the stapled transanal rectal resection group were compared with 40 specimens from the control group. At conventional histology in stapled transanal rectal resection group, 34 samples (73.9%) presented a moderate-severe fibrosis grade with a moderate grade of nerve degeneration in 33 cases (71.7%). In the control group, conventional histology revealed fibrosis absence in 31 specimens (77.5%), while the absence of nerve degeneration was detected in 37 controls (92.5%). In the stapled transanal rectal resection group, morphometric image analysis showed moderate fibrosis and severe fibrosis in 19 (41.3%) and 25 (54.4%) cases, respectively. In the control group, morphometric image analysis showed only low grade of fibrosis in 11 cases (27.5%). A significant difference in all fibrosis and nerve dysplasia grades between groups was found in conventional histology and morphometric image analysis evaluations (p0.001).The small sample size and the retrospective design of the study. Moreover, there is no chance to use as control group specimens from healthy volunteers.Stapled transanal rectal resection specimens showed a higher fibrosis and nerve dysplasia rate, an important parameter that nowadays is preoperatively completely unconsidered and in a near future could address patients with rectal prolapse to the best treatment approach. See Video Abstract at http://links.lww.com/DCR/B928.

Indeterminate follicular thyroid lesions (Thyr 3A and 3B) account for 10% to 30% of all cytopathologic diagnoses, and their unpredictable behavior represents a hard clinical challenge. The possibility to preoperatively predict malignancy is largely advocated to establish a tailored surgery, preventing diagnostic thyroidectomy. We analyzed the role of the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR) and the lymphocyte-to-monocyte ratio (LMR) as prognostic factors of malignancy for indeterminate thyroid nodules. In patients affected by cytological Thyr 3A/3B nodules, NLR, PLR and LMR were retrospectively compared and correlated with definitive pathology malignancy, utilizing student’s t-test, ROC analysis and logistic regression. One-hundred and thirty-eight patients presented a Thyr 3A and 215 patients presented a Thyr 3B. After the logistic regression, in Thyr 3A, none of the variables were able to predict malignancy. In Thyr 3B, NLR prognosticated thyroid cancer with an AUC value of 0.685 (p < 0.0001) and a cut-off of 2.202. The NLR results were also similar when considering the overall cohort. The use of cytological risk stratification in addressing the management of indeterminate thyroid nodules in patients is not always reliable. NLR is an easy and reproducible inflammatory biomarker capable of improving the accuracy of preoperative prognostication of malignancy.

Chronic kidney disease (CKD) is a major clinical sign of patients with Bardet-Biedl syndrome (BBS), especially in those carrying BBS10 mutations. Twenty-nine patients with BBS and 30 controls underwent a serum-targeted metabolomic analysis. In vitro studies were conducted in two kidney-derived epithelial cell lines, where Bbs10 was stably deleted (IMCD3-Bbs10-/-cells) and over-expressed. The CKD status affected plasmatic metabolite fingerprinting in both patients with BBS and controls. Specific phosphatidylcholine and acylcarnitines discriminated eGFR decline only in patients with BBS. IMCD3-Bbs10-/ cells displayed intracellular lipidaccumulation, reduced mitochondrial potential membrane and citrate synthase staining. Mass-Spectrometry-based analysis revealed that human BBS10 interacted with six mitochondrial proteins, in vitro. In conclusion, renal dysfunction correlated with abnormal phosphatidylcholine and acylcarnitines plasma levels in patients with BBS; in vitro, Bbs10 depletion caused mitochondrial defects while human BBS10 interacted with several mitochondria-related proteins, suggesting an unexplored role of this protein.

Sacrococcigeal pilonidalis disease (SPD) recurrence is a major factor influencing surgical outcomes. Several different surgical treatments have been reported, however, there is a lack of long-term data on reoperation. Aim of this study was to analyze outcomes of a single center adopting a standardized off-midline asymmetric procedure (D-shape). Analytic longitudinal assessment of 83 patients (median age 35years, range 23–59years) with recurrent SPD that completed the 5-year study design following D-shape reoperation. Among a cohort of 607 patients, we enrolled 83 recurrent SPD. After D-shape reoperation, second recurrence rate was 9.6% (8/83). Second recurrence rate was not statistically significantly different among patients undergone D-shape as first surgery compared to patients of symmetric excision group (11.8% vs. 7.4%, p = 0.57). Similarly, there was no statistical difference among patients who underwent D-shape as first surgery compared to patients who underwent symmetric excision elsewhere (11.8% vs. 9.1%, p =.75). D-shape is a safe and effective when adopted as revisional surgery at a long-term follow-up. Comparative evaluation is warranted to establish the potential superiority over different surgical surgery in case of recurrence.

The aim of this retrospective study is to evaluate the preliminary results of a mini-invasive procedure for the treatment of supralevator abscesses (SLA) of cryptoglandular origin by extrasphincteric extension. In this clinical study, an innovative two-stage procedure was tested for the surgical treatment of SLA. As first step and as a preparation for surgery, the interventional radiologist positioned a CT-guided percutaneous perianal guidewire inside the abscess cavity under local anesthesia. As second step, the surgeon performed an abscess incision and drainage around the guidewire, with a complete debridement of all the necrotic tissue. If a complex anal fistula was identified, a loose seton was placed in situ. Nine patients, comprising 5 men (55%) and 4 women (45%), underwent the above-mentioned two-stage procedure to treat SLA of cryptoglandular origin. Median age was 32 years (range, 25–42 years). A silicone draining seton was placed during the surgical procedure in 5 patients (55%), since a coexisting fistula was also revealed by surgery. A repeat surgery, along with a new drainage procedure, was required in one patient out of nine (11.1%) for a complete wound healing. The complete wound healing was achieved after a median of 30 days (range, 26–38). At the 1-year follow-up, the healing rate was 89%. The treatment of SLA of cryptoglandular origin by using this innovative two-stage procedure may be a safe and convenient surgical option to effectively decrease the risk of recurrence and anal sphincteric injuries.

UNSTRUCTURED As in any other fields, the healthcare industry is prone to cyber threats. Every day, hospitals need to ensure that the informations about patients are adequately secure. Currently, CIOs and CISOs are trying to protect their departments from security matters. It is crucial to adopt appropriate measures to deal with risk management and business continuity. Focus of this paper is to review some of the common standards and frameworks used by healthcare organizations to face challenges of a Cyber Security. Furthermore, we highlight advantages and disadvantages of information security standards as ISO/IEC 27799, HIPAA, HITRUST, NIST CSF and GDPR comparing with each other.

Introduction Considering the multitude of bariatric procedures performed all over the world, the necessity of revisional surgery increased accordingly. Several authors argued that with the great diffusion of sleeve gastrectomy (SG), the number of patients who experienced a weight regain at long follow-up was congruous and physiologic, even if not negligible. Recent studies showed that one anastomosis gastric bypass (OAGB) was an effective and safe option also as redo surgery. The aim of the study was to evaluate effectiveness of OAGB as redo surgery after SG in term of anthropometric features and remission of comorbidities. Methods Bariatric patients experiencing weight regain and insufficient weight loss after SG and undergoing OAGB as redo surgery were retrospectively analyzed. During post-OAGB outpatient visit weight, %EWL, BMI, comorbidities, and vitamin deficiencies were evaluated. A further visit was scheduled for the evaluation of postoperative esophagitis/gastritis at upper endoscopy. Results Fifty-nine (Reviewer #3-1) patients underwent OAGB as redo-surgery consequently to the worsening of the bariatric outcomes at 29.42 +/- 7.29 months from SG (mean weight, BMI and %EWL were 120.89 +/- 16.79 kg, 43 +/- 4.39 and 19.84 +/- 30.29, respectively). Conversely, at a mean follow-up of 34.32 +/- 1.71 months (Reviewer #3-3) after OAGB, no weight regain or insufficient weight loss cases were recorded (mean weight 71.25 +/- 10.22 kg, mean BMI 24.46 +/- 2.06 kg/m2, mean %EWL 69.49 +/- 14.4, p < 0.0001) (Reviewer #3-2). Conclusion OAGB is a safe and effective bariatric procedure in terms of morbidity, mortality, and %EWL also as revision surgery after SG. Further larger studies are needed to address this issue.

Introduction: Bariatric surgery leads to rapid weight loss, a well-known risk factor for gallstone formation. Postoperative biliary complication rate requiring cholecystectomy is between 0.9 and 7.5% after laparoscopic sleeve gastrectomy and between 6 and 50% after laparoscopic gastric bypass. Several authors recommended ursodeoxycholic acid (UDCA) administration to reduce gallstone formation after diet-induced weight reduction. The aim of this randomized monocentric study is to evaluate gallstone incidence after prophylactic administration of UDCA in patients undergoing one anastomosis gastric bypass (OAGB). Methods: Patients undergoing OAGB were prospectively randomized into 2 groups: the UDCA group receiving oral UDCA 600mg/days for 6months in the immediate postoperative days, and the control group not administered with UDCA. Each group included 95 patients. Abdominal ultrasound, clinical evaluation, and quality of life scoring with Gastrointestinal Quality of Life Index (GIQLI) were performed postoperatively in all patients at 3, 6, and 12months. Results: At 12months of postoperative follow-up, 4 (4.2%) and 24 patients (25.2%) showed gallstones in the UDCA group and control group, respectively (p < 0.05). Among those who developed gallstones, 8 (28.6%) cases were symptomatic whereas 20 (71.4%) did not show any symptom. No statistically significant difference in GIQLI score between the two groups was found. Conclusion: OAGB, as other malabsorbent procedures, appears to have higher rate of cholelithiasis than purely restrictive procedures. In our prospective randomized controlled study, a regular postoperative UDCA intake during the first 6months seems to significantly reduce cholelithiasis incidence after OAGB, with no case of intolerance reported. Further studies are needed to assess this issue.

Adult adipose tissue-derived mesenchymal stem cells (ASCs) constitute a vital population of multipotent cells capable of differentiating into numerous end-organ phenotypes. However, scientific and translational endeavors to harness the regenerative potential of ASCs are currently limited by an incomplete understanding of the mechanisms that determine cell-lineage commitment and stemness. In the current study, we used reduced representation bisulfite sequencing (RRBS) analysis to identify epigenetic gene targets and cellular processes that are responsive to 5′-azacitidine (5′-AZA). We describe specific changes to DNA methylation of ASCs, uncovering pathways likely associated with the enhancement of their proliferative capacity. We identified 4,797 differentially methylated regions (FDR < 0.05) associated with 3,625 genes, of which 1,584 DMRs annotated to the promoter region. Gene set enrichment of differentially methylated promoters identified “phagocytosis,” “type 2 diabetes,” and “metabolic pathways” as disproportionately hypomethylated, whereas “adipocyte differentiation” was the most-enriched pathway among hyper-methylated gene promoters. Weighted coexpression network analysis of DMRs identified clusters associated with cellular proliferation and other developmental programs. Furthermore, the ELK4 binding site was disproportionately hyper-methylated within the promoters of genes associated with AKT signaling. Overall, this study offers numerous preliminary insights into the epigenetic landscape that influences the regenerative capacity of human ASCs.

The pelvic floor is a complex anatomical entity and its neuromuscular assessment is evaluated through debated neurophysiological tests. An innovative approach is the study of pelvic floor through dynamic transperineal ultrasound (DTU). The aim of this study is to evaluate DTU sensitivity in recognizing patients with fecal incontinence and to evaluate its concordance with the results of the motor latency studied via pudendal nerve terminal motor latency (PNTML). Female patients affected by FI addressed to our center of coloproctology were prospectively assessed. After a coloproctological evaluation, comprising the PNTML assessment to identify pudendal neuropathy, patients were addressed to DTU to determine anterior and posterior displacement of puborectalis muscle by a blinded coloproctologist. In order to compare the data, a cohort of female healthy volunteers was enrolled. Sixty-eight subjects (34 patients and 34 healthy volunteers) were enrolled. The sensitivities of anterior displacement, posterior displacement and either anterior or posterior displacement in determining the fecal incontinence were 82%, 67% and 91%, respectively. A further high correlation of either anterior or posterior displacement with PTNML was also noted (88%). DTU is an indirect, painless and reproducible method for the identification of the pelvic floor neuromuscular integrity. Its findings seem to highly correlate with FI symptoms and with PNTML results. In the near future, after larger comparative studies, DTU would be considered a potential reliable non-invasive and feasible indirect procedure in the identification of fecal incontinence by pudendal neuropathy. Trial registration number is NCT03933683.

Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist’s scrupulous hard work, especially as regards the patient’s emotional and psychic state, and finally the patient’s compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from “real” success to illusion “myth”. RESUMO A reabilitação do assoalho pélvico visa abordar alterações funcionais e anatômicas perineais, bem como disfunções mecânicas torácicas-abdominais que levam a doenças procto-urológicas como prisão de ventre, incontinência fecal e urinária e dor pélvica. Requerem uma abordagem multidimensional, com impacto significativo na qualidade de vida dos pacientes. Um protocolo clínico e instrumental exaustivo para avaliar os transtornos de defecação deve incluir avaliação clínica e instrumental, bem como diversos parâmetros clínicos/fisiátricos. Todos esses parâmetros devem ser considerados para reconhecer e definir qualquer fator potencial desempenhando um papel nos aspectos funcionais da incontinência, prisão de ventre e dor pélvica. Após tal avaliação, tendo identificado com precisão quaisquer alterações anatômicas e funcionais tóraco-abdomino-perineais, um programa de reabilitação pelvi-perineal pode ser realizado para corrigir as alterações acima mencionadas e obter melhora clínica. O sucesso do processo de reabilitação está ligado a diversos fatores, como uma avaliação cuidadosa do paciente, visando selecionar a terapia de reabilitação direcionada mais adequada e específica, além do trabalho árduo e escrupuloso do terapeuta, especialmente no que diz respeito ao estado emocional e psíquico do paciente e, finalmente, a conformidade do paciente em realizar a terapia em si, especialmente em casa. Esses fatores podem influenciar profundamente os resultados globais das terapias de reabilitação, que vão desde o sucesso “real” até o “mito” ilusório.

Backgrounds. One of the major complications after laparoscopic sleeve gastrectomy (LSG) is represented by leaks along the staple line. Several reinforcement techniques have been proposed, but scarce data about the real strengthening offered are present. Thus, we aimed to evaluate if different reinforcements produced different bursting pressures after LSG, and then to verify if the clinical application of the stronger reinforcement produced a reduction in leakage rate. Methods. We prospectively enrolled all consecutive obese patients that underwent LSG. We tested 3 different types of staple lines, as follows: group 1, no reinforcement; group 2, bioabsorbable buttress reinforcement; group 3, invaginating overrunning barbed suture. A burst pressure test was applied to the gastric specimen by means of high-resolution manometric catheter. After burst pressure tests, a subsequent consecutive series of patients were treated with the most effective reinforcement, and rate of leaks was recorded. Results. We enrolled in total 110 obese patients; 20 patients for each group of staple line reinforcement and then other 50 consecutive patients underwent LSG with the higher burst pressure staple line reinforcement. Median burst pressures were similar in group 1 and group 2; group 3 showed a statistically significant pressure increase ( P < .0001) than group 1 and group 2, with a 5.2-fold value. Other consecutive 50 obese patients underwent LSG with overrunning reinforcement. In none of them a leak was detected. Conclusions. Reinforcement of the SG staple line, with overrunning suture, seems to drastically increase bursting pressures in an ex vivo model and it is promising when reproduced in vivo.

In the last 20 years, there has been an increase in claims after surgery worldwide. Due to the rise in bariatric surgery utilization, this increasing trend was also recorded in this surgical specialty. The available published data regarding lawsuits after bariatric surgery is summarized in this chapter. Even though claims are increasing, only around 20% of them are successful for plaintiffs. The most common reason for successful claims was a delay in the diagnosis/treatment of complications.

Total thyroidectomy is very common in endocrine surgery and the haemostasis can be obtained in different ways across surgery; recently, some devices have been developed to support this surgical phase. In this paper, a health technology assessment is conducted through the define, measure, analyse, improve, and control cycle of the Six Sigma methodology to compare traditional total thyroidectomy with the surgical operation performed through a new device in an overall population of 104 patients. Length of hospital stay, drain output, and time for surgery were considered the critical to qualities in order to compare the surgical approaches which can be considered equal regarding the organizational, ethical, and security impact. Statistical tests (Kolmogorov–Smirnov, t test, ANOVA, Mann–Whitney, and Kruskal–Wallis tests) and visual management diagrams were employed to compare the approaches, but no statistically significant difference was found between them. Considering these results, this study shows that the introduction of the device to perform total thyroidectomy does not guarantee appreciable clinical advantages. A cost analysis to quantify the economic impact of the device into the practice could be a future development. Healthy policy leaders and clinicians who are requested to make decisions regarding the supply of biomedical technologies could benefit from this research.

Undifferentiated connective tissue disease at risk for systemic sclerosis (UCTD-risk-SSc), otherwise referred to as very early-early SSc, is a condition characterized by Raynaud's phenomenon with serum SSc marker autoantibodies and/or typical capillaroscopic findings and unsatisfying classification criteria for the disease. The aim of the present study was to assess the prevalence of right (RV) or left ventricular (LV) systolic and/or diastolic dysfunction by standard echocardiography and tissue Doppler imaging (TDI). Thirty patients with UCTD-risk-SSc (28 female, mean age 47 ± 13 years, range 21-70) and 30 age- and sex-matched controls underwent cardiac assessment by standard echocardiography and TDI. UCTD-risk-SSc patients and controls did not show any difference at standard echocardiography. Despite results falling within the respective normal ranges, TDI pointed out a mild impairment of LV and RV diastolic (E m 15 ± 4 vs. 19 ± 5, p = 0.0004; E/E m 6.1 ± 1.7 vs. 4.8 ± 1.2, p = 0.001; E t 14 ± 3 vs. 16 ± 2, p = 0.02; E t/A t 0.9 ± 0.4 vs. 1.3 ± 0.3, p = 0.002; E/E t 3.5 ± 1.2 vs. 4.2 ± 0.9, p = 0.02) and systolic function (S m 13 ± 3 vs. 15 ± 2 cm/s, p

No studies have examined scars and quality of life after different treatments of wound dehiscence in patients undergoing post-bariatric abdominoplasty. Scars and quality of life of patients with postoperative wound dehiscence managed with negative pressure wound therapy (group A) and conventional wound therapy (group B) were reviewed 6 months after wound healing. Of 38 patients undergoing treatment for wound dehiscence after 203 abdominoplasty, 35 (group A = 14 versus group B = 21) entered the study. Wound healing in group A was significantly faster than group B (P = 0·001). Patients (P = 0·0001) and observers (P = 0·0001) reported better overall opinions on a scar assessment scale for group A. Better overall quality of life and general health satisfaction were observed in group A (P < 0·05). A significant correlation was observed between the World Health Organization Quality of Life scores and Patient and Observer Scar Assessment Scale scores (r=-0·68, P < 0·0001) in all 35 patients. Negative pressure wound therapy is feasible and effective in patients with wound dehiscence following post-bariatric abdominoplasty. An adequate post-treatment outcome is achieved compared with conventional wound therapy in light of a strong association found between worse patient scar self-assessment and poor overall quality of life, regardless of the received treatment.

Hemorrhoidal disease (HD) treatment still remains controversial. In fact, despite many surgical progresses, postoperative pain, and discomfort remain the major weaknesses. Laser hemorrhoidoplasty (LHP) is a minimal invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser. The aim of the current study is to analyze the feasibility and efficacy of LHP in patients with II–III degrees hemorrhoids. Consecutive patients with II–III degree hemorrhoids were enrolled in the study and underwent an LHP treatment using a 1470-nm diode laser. Operative time, postoperative pain and complications, resolution of symptoms, and length of return to daily activity were prospectively evaluated. Recurrence of prolapsed hemorrhoid or symptoms at a minimum follow-up of 6months was evaluated. Fifty patients (28 males and 22 females) were enrolled in the study. No significant intraoperative complications occurred. Postoperative pain score (at 12, 18, and 24h postoperatively), evaluated through visual analogue scale, was extremely low (mean value 2). No postoperative spontaneous bleeding occurred. The 100% of our population came back to daily activity 2 days after surgery. At a mean follow-up period of 8.6months, we reported a recurrence rate of 0%. LHP demonstrated a large efficacy in selected patients. The greatest strength points were low postoperative pain, the presence of slightly significant peri-anal wounds, no special anal hygienic measures and low surgical time. Thus, resulting in a negligible postoperative discomfort, LHP could be considered a painless and minimal invasive technique in the treatment of HD.

Background Fecal incontinence (FI) is a common condition that has devastating consequences for patients’ QOL. In some patients, the conventional functional pelvic floor electrical stimulation has been effective but is an invasive and embarrassing treatment. The object of the study was to evaluate the feasibility of functional extracorporeal magnetic stimulation (FMS) in strengthening the pelvic floor muscles without an anal plug and the embarrassment of undressing. Materials and Methods Thirty patients (26 female and 4 males) with FI were enrolled. All patients were assessed during a specialized coloproctology evaluation followed by endoanal ultrasonography and anorectal manometry. All patients underwent an FMS treatment once weekly for 8 weeks. Patients’ outcome was assessed by the Cleveland Clinic Fecal Incontinence Score (CCFIS) and by the fecal incontinence QOL questionnaire (FIQL). Results After 8 weeks, the number of solid and liquid stool leakage per week was significantly reduced (p Conclusion FMS is a safe, non-invasive and painless treatment for FI. It could be recommended for selected patients with non-surgical FI to ensure a rapid clinical improvement.

Introduction Hemostasis during thyroidectomy is essential; however the most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with the combination of harmonic scalpel (HS) and an advanced hemostatic pad (Hemopatch). Methods Patient undergone TT were divided into two groups: HS + hemopatch and HS + traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates. Results Between September 2014 and March 2015, 60 patients were enrolled (30 to Hs + Hemopatch, 30 to Hs and standard hemostasis); 71.4% female; mean age 48.5 years. The 24-h drain output was lower in the HS + hemopatch group compared with standard TT. HS and hemopatch also had a shorter mean surgery time (p Conclusion combination of hemopatch plus HS is effective and safe for TT with a complementary hemostatic approach.

Background To evaluate the use of a double loop reconstruction following pylorus preserving proximal pancreaticoduodenectomy (PPPPD). Methods Morbidity and mortality were evaluated in 55 patients undergoing PPPPD for malignant tumors, followed by a double loop reconstruction. Results The mean intra-operative blood loss was 908 mL ± 531. In-hospital mortality was 5.4% (3/55 pts). The mean length of hospital stay was 17 ± 5 days (range 12-45 days). Postoperative complications occurred in 25 patients (46.2%). Five patients developed an anastomotic leak, one biliary and four pancreatic (4/55; 7%). Delayed gastric emptying occurred in 8 patients (14.5%). Reoperation was required in two patients for hemorrhage. Conclusions A double loop alimentary reconstruction following PPPPD led to a low incidence of DGE and pancreatic fistula. Although mortality rate was higher than that reported by referral centres, this technique has been performed in a not specialized unit attaining acceptable results.

Obstructive sleep apnea syndrome (OSAS) is prevalent among morbidly obese patients. Evaluation of the specific effects of sleeve gastrectomy (SG) on upper airway function has not been reported. Given the possibility that some patients will not respond despite weight loss, no studies have investigated whether other mechanisms may be responsible for persistent OSAS after bariatric surgery.To evaluate by subjective and objective assessment the impact of SG on upper respiratory physiology in the long-term.University Hospital, Division of Bariatric and ENT Surgery, in Italy.Thirty-six consecutive patients with OSAS who underwent laparoscopic SG were prospectively enrolled. The effect of SG on respiratory function and OSAS was followed for 5 years.All patients completed the 5-year follow-up. A significant (P.001) improvement in modified Epworth Sleepiness Scale questionnaire (ESS) was obtained in 91.6% (33/36) of patients. The Apnea/Hypopnea index (AHI) improved in 80.6% (29/36) of patients after surgery (from 32.8 ± 1.7 to 5.8 ± 1.2 (P.001), 4.9 ± 1.7). The remaining 19.4% (7/36) of patients with a positive ESS and/or AHI all had an associated respiratory resistance due to nasal obstructive diseases.SG improved OSAS overall, but patients who did not improve or only partially improved despite weight loss were found to have an associated nasal responsible pathology. How these patients will respond to nasal surgery and whether a 2-step procedure should be recommended for OSAS patients requires further study.