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Body image is a multidimensional construct that encompasses perceptions about body size, emotions, and cognition about physical appearance. Obese identity is related to body image in the lifetime, and according to scientific literature body image dissatisfaction among obese patient persist after bariatric surgery. The objective of this review is to examine the body image changes in patients with obesity pre-and post-bariatric surgery. We have carried out a systematic review of literature on PubMed. Initially, 169 publications have been identified, but in total, in compliance with inclusion and exclusion criteria, 15 studies have been analyzed. According to the examined literature, body image does not change after bariatric surgery. These patients will be difficult to adapt for a new body, because there is a persistent obese view of self. Furthermore, ex-obese patients are dissatisfied with the excessive skin after bariatric surgery. Excessive body weight, and negative self-image are replaced with dissatisfaction with excessive skin, and the factors associated with body image stability are still unknown. Literature examination raises the issue of body image dissatisfaction, but does not explain why it varies so widely across bariatric patients. Obese identity is related to body image across the lifetime and is an important factor of post-surgical outcomes. Longitudinal studies based on ideal body image pre- and post- bariatric surgery and evidence-based controlled studies on psychotherapeutic treatment for body image dissatisfaction are strongly recommended. Psychotherapy could improve body image quality and wellbeing. Evidence obtained from: systematic reviews of experimental studies.

Background Since its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery. Case presentation A 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination. Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder. The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4) against gallbladder vessels. All these findings define a histological diagnosis of vasculitis of the gallbladder. Conclusions Ischemic gangrenous cholecystitis can be a tardive complication of COVID-19, and it is characterized by a dysregulated host inflammatory response and thrombosis of medium-size vessels.

Tumor recurrences or metastases remain a major hurdle in improving overall cancer survival. In the perioperative period, the balance between the ability of the cancer to seed and grow at the metastatic site and the ability of the patient to fight against the tumor (i.e. the host antitumor immunity) may determine the development of clinically evident metastases and influence the patient outcome. Up to 80% of oncological patients receive anesthesia and/or analgesia for diagnostic, therapeutic or palliative interventions. Therefore, anesthesiologists are asked to administer drugs such as opiates and volatile or intravenous anesthetics, which may determine different effects on immunomodulation and cancer recurrence. For instance, some studies suggest that intravenous drugs, such as propofol, may inhibit the host immunity to a lower extent as compared to volatile anesthetics. Similarly, some studies suggest that analgesia assured by local anesthetics may provide a reduction of cancer recurrence rate; whilst on the opposite side, opioids may exert negative consequences in patients undergoing cancer surgery, by interacting with the immune system response via the modulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, or directly through the opioid receptors on the surface of immune cells. In this review, we summarize the main findings on the effects induced by different drugs on immunomodulation and cancer recurrence.

Background: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry. Methods: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications. Results: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013–0.89mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not. Conclusion: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.

Tumor-associated macrophages (TAMs) may be noticed in gastric carcinomas (GC), but their clinicopathological significance has not been yet explored. From a histological review of 400 cases of tubular/papillary adenocarcinomas, 24 cases of stage I–II gastric adenocarcinomas with intraglandular and stromal TAMs were identified. Their clinicopathological features were compared with 72 pT-matched as well as stage-matched control cases of adenocarcinomas without TAMs. TAMs present in GC cases were present either in glands or in neoplastic stroma, showing an immunoreactivity for CD68 and CD80, sometimes, they were organized in mature granulomas with occasional giant cells. Therefore, the stained TAMs were reminiscent of a specific polarized macrophage M1 phenotype, however, in any case of our cohort, no M2 phenotype macrophages were documented by CD 163 and CD 204 immunostainings. Statistically, no significant differences in age, gender, tumor location, size, and lymphovascular and perineural invasion between the case group with TAMs and pT- as well as stage-matched controls were reported, furthermore, the case group showed lower frequency of lymph node metastasis (p = 0.02). In addition, a significantly different clinical course and overall survival rate were also observed in gastric adenocarcinomas with M1 TAMs (p = 0.02) in comparison to controls. These results suggest that tumor-associated M1 macrophages are related to a quite indolent growth and a better prognosis of patients with this peculiar variant of gastric adenocarcinomas.

Background: Tumor recurrences or metastases remain a major hurdle in improving overall cancer survival. In anticancer therapy, some patients inevitably develop chemo-/radiotherapy resistance at some point. Cancer stem cells are the driving force of tumorigenesis, recurrences, and metastases, contributing also to the failure of some cancer treatments. Summary: Emergent evidence suggests that stem cell diseases are at the base of human cancers, and tumor progression and chemo-/radiotherapy resistance may be dependent on just a small subpopulation of cancer stem cells. Hyperthermia can be a strong cancer treatment, especially when combined with radio- or chemotherapy. It is a relatively safe therapy, may kill or weaken tumor cells, and significantly increases the effectiveness of other treatments. However, these mechanisms remain largely unknown. A literature search was performed using PubMed including cited English publications. The search was last conducted in December 2019. Search phrases included “stem cells,” “hyperthermia,” “cancer,” and “therapy.” Abstracts, letters, editorials, and expert opinions were not considered for the drafting of the study. Key Message: Our goal was to focus on and to summarize different biological features of cancer stem cells and new therapeutic approaches using hyperthermia and its potential translation to human clinical trials.

The value of the routine histopathologic examination of resected gastric remnants following laparoscopic sleeve gastrectomy (LSG) remains to be controversial. This study aimed to determine whether the routine histopathologic examination of gastric specimens is necessary for all patients undergoing LSG if upper gastrointestinal endoscopy (UGIE) plus multiple biopsies are performed routinely during the preoperative work-up. Clinicopathologic data of 474 patients who underwent LSG were analysed. Types of histopathologic findings in LSG specimens and the prevalence of these and Helicobacter pylori (HP) infection were estimated. Comparisons were conducted to assess the association of risk factors with the most frequent abnormal and premalignant histopathologic findings. Chronic gastritis was the most common gastric pathology (63.5%) and premalignant lesions were present in 7.8% of the specimens. The prevalence of HP infection was 36.9%. A statistically significant association was observed between HP infection and chronic gastritis (P = .000), and premalignant lesions (P = .000). Similarly, a statistically significant association was noted between age and premalignant gastric lesions (P = .000). Histopathologic examination of LSG specimens may not be routinely needed and can be performed on selected patients. While we recommend routine preoperative UGIE in all LSG-treated patients, we suggest that histopathologic assessment of the LSG specimens should be mandatory when UGIE biopsies demonstrate HP infection and/or premalignant lesions, in all patients older than 42 years, and in cases of intraoperative detection of incidental tumours or suspicious lesions.

Schwannoma is a peripheral nerve tumor that arises from the neural sheath, generally solitary and benign. Retroperitoneal location is rare, less than 6%, and often asymptomatic until the tumor reaches a large size and causes compressive symptoms. Schwannoma is difficult to diagnose by conventional imaging features alone, and so diagnosis is commonly confirmed with surgical resection. Endoscopic ultrasound (EUS) fine-needle aspiration (FNA) is useful for the preoperative diagnosis and the following treatment plan, although the diagnostic accuracy rate is rather low. EUS fine needle biopsy (FNB), with improved needle designs, has shown increasingly better diagnostic accuracy even in extrapancreatic solid lesions. We report a case of a retroperitoneal schwannoma successfully diagnosed before surgery by EUS-guided FNB.

Objective: Up to 30% of pediatric patients with Crohn's disease (CD) require surgery. The aim of the study was to evaluate long-term health-related quality of life (HRQoL) outcome in children with CD who have had ileocolonic resection.Materials and methods: This was a retrospective cross-sectional study on all pediatric patients who had undergone surgery for CD between January 2015 and December 2017 in the Pediatric Surgery and Gastroenterology Units of the University Hospital of Messina. Surgical treatment was represented by laparoscopic ileocecal resection with latero-lateral anastomosis. Patients were asked to fill in a modified version of the IMPACT III questionnaire made up of 15 closed questions before and after surgery. The questionnaire was scored on a five-point scale with 5 reporting “not a problem” and 1 “a very severe problem.” The total score ranged from 15 (worst HRQoL) to 75 (best HRQoL). Frequency of relapses, reoperations, complications during follow-up, and postoperative bowel function were also studied.Results: Data were obtained in 10 patients (9 males), who underwent surgery at a median age of 13.5 years (range 13–18), after a median post-diagnosis period of 2.5 years (range 0–8). Preoperative scores were low in all 4 domains of the questionnaire. Postoperatively, HRQoL measures improved significantly (p < 0.05) about symptoms, school attendance, social and emotional functioning. Overall, nearly all patients were completely satisfied with the surgical outcome.Conclusions: HRQoL is low in CD children referred for possible operation, and surgery may positively affect the overall HRQoL. Collecting HRQoL data provides insight into the impact of treatment on children health status.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), has been rapidly spreading all over the world and is responsible for the current pandemic. The current pandemic has found the Italian national health system unprepared to provide an appropriate and prompt response, heavily affecting surgical activities. Based on the limited data available in the literature and personal experiences, the Società Italiana di Chirurgia dell’OBesità e Malattie Metaboliche (SICOB) provides recommendations regarding the triage of bariatric surgical procedures during the COVID-19 pandemic defining a dedicated path for surgery in morbidly obese patients with known or suspected COVID-19 who may require emergency operations. Finally, the current paper delineates a strategy to resume outpatient visits and elective bariatric surgery once the acute phase of the pandemic is over. Models developed during the COVID-19 crisis should be integrated into hospital practices for future use in similar scenarios. Surgeons are presented with a golden opportunity to embrace systemic change and to drive their professional future.

Background The restrictions adopted in Italy during the phase I COVID-19 pandemics with a nationwide lockdown period, represented a challenge in the management of Patients with Inflammatory Bowel Disease (IBD) patients. The aim of the present study was to assess if, and how, a limited course of telemedicine did influence the clinical outcome in patients with Crohn’s disease (CD) and Ulcerative Colitis (UC). Methods IBD patients followed before March 8th, 2020 were included and divided into 3 groups (Fig.1): group 1, patients on endovenous biologics (EV); group 2, patients on biologics administered subcutaneously (SC); and group 3, patients on conventional treatments (CT) at the start of lockdown. The primary outcome was to assess the occurrence of disease flare in the three groups since only the EV group received face-to-face visits during lockdown. As secondary outcome we assessed the number of control endoscopies performed and the start of new biologic therapies, compared with a reference period in 2019. Results A total of 689 patients (CD: 369, UC 320) were included in the study (247 IV, 217 SC and 225 CT, respectively). Telemedicine was more frequently adopted in SC and CS, (p

This study aimed to assess the best achievable outcomes in laparoscopic liver resection (LLR) after risk adjustment based on surgical technical difficulty using a national registry.LLRs registered in the Italian Group of Minimally Invasive Liver Surgery registry from November 2014 to March 2018 were considered. Benchmarks were calculated according to the Achievable Benchmark of Care (ABC™). LLRs at each centre were divided into three clusters (groups I, II and III) based on the Kawaguchi classification. ABCs for overall and major morbidity were calculated in each cluster. Multivariable analysis was used to identify independent risk factors for overall and major morbidity. Significant variables were used in further risk adjustment.A total of 1752 of 2263 patients fulfilled the inclusion criteria: 1096 (62·6 per cent) in group I, 435 (24·8 per cent) in group II and 221 (12·6 per cent) in group III. The ABCs for overall morbidity (7·8, 14·2 and 26·4 per cent for grades I, II and II respectively) and major morbidity (1·4, 2·2 and 5·7 per cent) increased with the difficulty of LLR. Multivariable analysis showed an increased risk of overall morbidity associated with multiple LLRs (odds ratio (OR) 1·35), simultaneous intestinal resection (OR 3·76) and cirrhosis (OR 1·83), and an increased risk of major morbidity with intestinal resection (OR 4·61). ABCs for overall and major morbidity were 14·4 and 3·2 per cent respectively for multiple LLRs, 30 and 11·1 per cent for intestinal resection, and 14·9 and 4·8 per cent for cirrhosis.Overall morbidity benchmarks for LLR ranged from 7·8 to 26·4 per cent, and those for major morbidity from 1·4 to 5·7 per cent, depending on complexity. Benchmark values should be adjusted according to multiple LLRs or simultaneous intestinal resection and cirrhosis.Este estudio tuvo como objetivo evaluar los mejores resultados que se pueden conseguir en la resección hepática laparoscópica (laparoscopic liver resection, LLR) después del ajuste por riesgos basado en la dificultad de la técnica quirúrgica utilizando un registro nacional. MÉTODOS: Se consideraron las LLRs incluidas en el Registro del Grupo Italiano de Cirugía Hepática Mínimamente Invasiva desde 11/2014 a 03/2018. Los resultados de referencia (benchmarks) se calcularon de acuerdo con el Achievable Benchmark of Care (ABC™). Las LLRs de cada uno de los centros se dividieron en 3 grupos (Grupo I, II y III) en base a la clasificación de Kawaguchi. Se calculó el ABC de la morbilidad global y de la morbilidad mayor para cada grupo. Se realizó un análisis multivariable para identificar los factores independientes de riesgos para la morbilidad global y morbilidad mayor. Se utilizaron variables significativas para realizar ajustes de riesgo adicionales.Un total de 1.752 pacientes de los 2.263 cumplían los criterios de inclusión, de los cuales 1.096 (62,6%) se incluyeron en el Grupo I, 435 (24,8%) en el Grupo II y 221 (12,6%) en el Grupo III. El ABC de la morbilidad global (7,8%, 14,2%, 26,4%) y de la morbilidad mayor (1,4%, 2,2%, 5,7%) aumentó del Grupo I al Grupo III. El análisis multivariable mostró un incremento del riesgo para la morbilidad global asociada con múltiples LLRs (razón de oportunidades, odds ratio, OR 1,349), resección intestinal simultánea (OR 3,760) y cirrosis (OR 1,825), y para la morbilidad mayor con la resección intestinal (OR 4,606). Los ABC de la morbilidad global y morbilidad mayor fueron 14,4% y 3,2% para las LLR múltiples, 30% y 11% para la resección intestinal, y 14,9% y 4,8% para la cirrosis, respectivamente. CONCLUSIÓN: Los resultados de referencia (benchmark) para la morbilidad global y morbilidad mayor en la LLR variaron entre un 8% y un 26% y entre un 1,4% y un 5,7%, dependiendo de la complejidad. Los valores de referencia deberían ajustarse de acuerdo con la práctica de LLRs múltiples o resección intestinal simultánea y cirrosis.

BackgroundColorectal cancer (CRC) is the most common tumor of the gastrointestinal tract. Anastomotic leak (AL) and prolonged postoperative ileus (PPOI) are two important complications of colorectal surgery. In this observational retrospective study, we evaluated the positive effects of transanal tube No Coil®in patients with CRC undergoing low anterior resection (LAR) and left hemicolectomy (LC).MethodsThirty-eight cases and forty controls resulted eligible for the final sample. No Coil®placement (SapiMed Spa, Alessandria, Italy) was considered an inclusion criteria for the case group. No Coil®was placed immediately after the end of surgical treatment.ResultsPPOI was significantly more frequent in the control group. AL was evident in 1 patient (2.6%) of cases and 3 patients (7.5%) of controls. No statistical difference was found in AL occurrence between groups. POI days and AL resulted associated with hospital stay. POI days were negatively associated with No Coil placement and positively with AL.ConclusionWith our preliminary data, we suggest that No Coil®placement can be considered as a valuable procedure assisting colorectal surgery, but further studies are required to confirm and enlarge actual evidence.

BACKGROUND Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is the recommended elective surgery for children with ulcerative colitis (UC). The aim of this study was to evaluate functional and long-term health-related quality of life (HRQoL) outcomes of surgery in paediatric patients with UC. METHODS We reviewed the hospital records of all paediatric patients who had undergone surgery for UC between January 2009 and December 2016 in the Units of Paediatric Gastroenterology and Surgery, of both the University Hospital of Messina, and the Gaslini Children's Hospital of Genoa. Surgical treatment was represented by restorative proctocolectomy and laparoscopic IPAA. Patients and parents were interviewed by telephone before and after surgery and responded to the modified IMPACT III questionnaire about health outcomes and HRQoL. The questionnaire was scored on a five-point scale with higher scores indicating a better HRQoL. The total score ranged from 35 (worst HRQoL) to 175 (best HRQoL). RESULTS Data were obtained in 30 patients (16 males), with a median age of 12 (range 3- 16). The median amount of time elapsed after the operation was 3 years (range 1-4.5). Preoperative scores were very low in all 4 domains of the questionnaire. Postoperatively, HRQoL measures improved significantly (p

The continuous rise in the incidence and prevalence of obesity along with its associated devastating economic burden has been a serious threat to global public health. Over the last few decades, unsatisfactory results with conservative treatment of obesity such as diets, behavior modification, pharmacologic therapy, alone or in combination, have left bariatric surgery as the only, most effective option for treatment of obesity and its related comorbid diseases. Surgeons have been constantly looking for safer, more effective, and more persistent bariatric procedures, to aid in the rapid growth and advancement of this relatively young surgical branch. The introduction of minimally invasive techniques in the bariatric field can be regarded as the turning point in the history of this practice. The advantages offered by laparoscopic bariatric procedures compared to open surgeries were so pronounced that a massive increase in patient demand and number of surgeries performed worldwide ensued.

Background & aims Obesity is associated with non-alcoholic fatty liver (NAFL), which may progress towards non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC). Occult hepatitis B virus infection (OBI) may contribute to hepatic damage in patients with chronic liver disease of different aetiologies (eg HCV, alcohol). However, information on the prevalence and clinical impact of OBI in obese individuals is lacking. The aims of this study were to investigate NASH prevalence and risk factors in obese people who underwent bariatric surgery. Methods Two-hundred and twenty-six subjects (160 females; mean age 42.9 years ±10.8 SD) without evidence of any further cause of liver disease consecutively underwent bariatric surgery in two Italian liver centers. During surgery, all patients underwent liver biopsy for histological evaluation and molecular studies. Liver DNA extracts were tested for PNPLA3, TM6SF2, MBOAT7, IRGM polymorphisms and for OBI. Univariate and multivariate analyses were used to identify predictors of NASH. Results Histology showed NASH in 115 (50.9%) and NAFL in 111 cases (49.1%). Twenty-nine/226 (12.8%) cases had OBI, 24 (82.8%) of whom had NASH and 5 (17.2%) NAFL, whereas among the 197 OBI-negative cases, 91 (46.2%) had NASH and 106 (53.8%) NAFL (P = .0002). Multivariate analysis showed that older age (P = .03, OR 1.034), alanine aminotransferase values (P = .005, OR 1.023), insulin resistance/diabetes (P = .02, OR 2.257), TM6SF2 polymorphism (P = .04, OR 3.168) and OBI (P = .004, OR 5.503) were independent predictors of NASH. Conclusion NASH is highly prevalent in obese individuals undergoing bariatric surgery. OBI is one of the strongest risk factors of NASH in these patients.

The surname and given name of author Riccardo Brachet Contul was incorrectly published.

One Anastomosis Gastric Bypass–Mini Gastric Bypass (OAGB-MGB) is rapidly gaining popularity and is currently being performed by an increasing number of bariatric surgeons worldwide. However, excessive postoperative weight loss and malnutrition still remain a major concern regarding this procedure. The aim of this observational retrospective study was to investigate whether a tailored biliopancreatic limb (BPL) length relative to small bowel length (SBL) is superior to a fixed BPL length of 200 cm in terms of weight loss results and nutritional deficiencies in morbidly obese patients 1 year following OAGB-MGB. Sixty-four patients who underwent OAGB-MGB were divided into two consecutive groups depending on the BPL length used: fixed 200-cm BPL and tailored BPL groups. Anthropometric measurements (%EWL, TWL, %TWL) and nutritional parameters (vitamin A, vitamin D3, vitamin B12, serum iron, serum albumin, total protein) were compared between the two groups at 1-year follow-up. No statistically significant differences were observed between the patients in two groups in terms of %EWL, TWL, %TWL. The number of patients with deficiencies of vitamin A (p = 0.030), vitamin D3 (p = 0.020), and albumin (p = 0.030) was significantly higher in fixed 200-cm BPL group as compared with tailored BPL group, 1 year following OAGB-MGB. No statistically significant differences were seen between the patients in two groups in terms of vitamin B12, iron, and total protein deficiencies. Tailoring BPL length by bypassing about 40% of the SBL seems to be safe and effective. According to preliminary results of this study, a tailored BPL length relative to SBL is even likely to be superior to the fixed 200-cm BPL as it is associated with less nutritional deficiencies while providing similar weight loss results. Further randomized studies with larger sample sizes and longer follow-up periods are necessary to confirm the primary results of this study.

To address the issue whether three dimensional (3D) offers real operative time advantages to the surgical procedure (primary endpoint) and significant reduction of surgeon's physical strain (secondary endpoint), we have retrospectively analyzed two consecutive series of laparoscopic right hemicolectomy (LRH) performed by a single experienced laparoscopic colorectal surgeon with two different imaging systems (two dimensional [2D] and 3D).Since January 2014, 25 consecutive patients with right colon cancer underwent 3D LRH and other 25 consecutive ones received a 2D LRH by a single experienced surgeon. After the insertion of the access ports, the surgical procedure has been divided in component tasks and the execution times were compared. Upon completion of each procedure, the consultant surgeon was asked to complete a nonvalidated subjective questionnaire to evaluate quality of depth perception and surgical strain.The execution times for the entire procedure and the single tasks were not significantly different between the 2D and 3D groups, except for the second task "side-to-side ileotransverse anastomosis" (P .05). The surgeon experienced better depth perception with the 3D system and subjectively reported less strain using the 3D vision system rather than the 2D system, particularly during longer procedures.Three-dimensional imaging seems not to influence the performance time of laparoscopic right colon cancer surgery when the surgeon is experienced in 2D laparoscopy, although the 3D system seems to offer better depth perception and to subjectively determine less physical strain compared to 2D vision. Further comparative studies are necessary to address the issue whether novice surgeons could benefit from a reduced learning curve using 3D vision and to verify with greater numbers if 3D, even with a similar operative time, can reduce perioperative complications.

Background Insulin resistance in visceral adipose tissue (VAT), skeletal muscle and liver is a prominent feature of most patients with obesity. How this association arises remains poorly understood. The objective of this study was to demonstrate that the decrease in insulin receptor (INSR) expression and insulin signaling in VAT from obese individuals is an early molecular manifestation that might play a crucial role in the cascade of events leading to systemic insulin resistance. Methods To clarify the role of INSR and insulin signaling in adipose tissue dysfunction in obesity, we first measured INSR expression in VAT samples from normal-weight subjects and patients with different degrees of obesity. We complemented these studies with experiments on high-fat diet (HFD)-induced obese mice, and in human and murine adipocyte cultures, in both normoxic and hypoxic conditions. Findings An inverse correlation was observed between increasing body mass index and decreasing INSR expression in VAT of obese humans. Our results indicate that VAT-specific downregulation of INSR is an early event in obesity-related adipose cell dysfunction, which increases systemic insulin resistance in both obese humans and mice. We also provide evidence that obesity-related hypoxia in VAT plays a determinant role in this scenario by decreasing INSR mRNA stability. This decreased stability is through the activation of a miRNA (miR-128) that downregulates INSR expression in adipocytes. Interpretation We present a novel pathogenic mechanism of reduced INSR expression and insulin signaling in adipocytes. Our data provide a new explanation linking obesity with systemic insulin resistance. Funding This work was partly supported by a grant from Nutramed (PON 03PE000_78_1) and by the European Commission (FESR FSE 2014-2020 and Regione Calabria).

Objective: Laparoscopic liver resection (LLR) for Hepatocellular Carcinoma (HCC) is one of the most important indications for the minimally invasive approach. Our study aims to analyze the experience of the Italian Group of Minimally Invasive Liver Surgery with laparoscopic surgical treatment of HCC, with a focus on tumor location and how it affects morbidity and mortality. Methods: 38 centers participated in this study; 372 cases of LLR for HCC were prospectively enrolled. Patients were divided into two groups according to the HCC nodule location. Group 1 favorable location and group 2 unfavorable location. Perioperative outcomes were compared between the two groups before and after a propensity score match (PS) 1:1. Results: Before PS in group 2 surgical time was longer; conversion rate was higher; postoperative transfusion and comprehensive complication index were also higher. PS was performed with a cohort of 298 patients (from 18 centers), with 66 and 232 patients with HCC in unfavorable and favorable locations, respectively. After PS matching, 62 patients from group 1 and group 2 each were compared. Operative and postoperative course were similar in patients with HCC in favorable and unfavorable LLR locations. Surgical margins were found to be identical before and after PS. Conclusions: These results show that LLR in patients with HCC can be safely performed in all segments because of the extensive experience of all surgeons from multiple centers in performing traditional open liver surgery as well as laparoscopic surgery.

Due to an error in production the members of SICE CoDIG (Colon Dx Italian Group) listed in the Acknowledgments were not tagged correctly as authors in the XML of this article. This listing is presented again here:.

Introduction The paraumbilical hernia sac often contains the omentum, the small bowel, and less commonly the colon. The herniation of the pancreas through a paraumbilical hernia is extremely rare and has been reported only by two cases in the literature; moreover, acute pancreatitis secondary to this condition is a particularly unusual event. Case report We present a very unusual case of a 67-year-old female patient with a voluminous paraumbilical hernia containing the pancreas, complicated by acute pancreatitis. Laboratory data revealed an elevation of the pancreatic enzymes. An intravenous contrast-enhanced computed tomography (CT) scan of the abdomen demonstrated a large hernia sac containing multiple viscera, including the pancreas. The patient underwent emergency laparotomy with a diagnosis of intestinal obstruction. Conclusion The clinicians should consider this rare condition in the differential diagnosis of patients presenting with large paraumbilical hernias associated with classical symptoms of acute pancreatitis, particularly in the absence of typical risk factors for pancreatitis. An intravenous contrast-enhanced abdominal CT scan should be performed immediately in these patients. We recommend the patients and the surgeons to consider prompt surgical repair for paraumbilical hernias to avoid further complications and the higher incidence of morbidity and mortality associated with emergency surgeries.

A technical error led to incorrect rendering of the author group in this article. The correct authorship is as follows.

Several studies in the last years demonstrated the better surgical outcome of laparoscopic approach to adrenal gland. Laparoscopic surgery is more difficult to learn and requires different psychomotor skills than open surgery, especially with regard to complex maneuvers requiring precision and dexterity. The development of robotic platform with three-dimensional vision and increased degrees of freedom of the surgical instruments has the aim to overcome these problems. We performed a systematic literature review with meta-analysis to evaluate preoperative data and surgical outcomes of robotic adrenalectomy compared with laparoscopic technique. In September 2016 we performed a systematic literature review using the Pubmed, Scopus and ISI web of knowledge database with search term "robotic adrenalectomy". We identified 13 studies with eligible criteria that compared surgical outcomes. This present systematic review with meta-analysis includes 798 patients: 379 underwent to robotic adrenalectomy (cases group) and 419 to laparoscopic adrenalectomy (controls group). There were no significant differences between the two groups of patients respect to age, gender, laterality and tumor size. BMI instead was significant lower in the robotic group. In this group we found also patients with higher incidence of previous abdominal surgery. The results from operative time demonstrated lower operative time for laparoscopic group but there were no significant differences with robotic group. Robotic adrenalectomy showed a significant lower blood loss. Robotic adrenalectomy is a safe and feasible technique with reduced blood loss and shorter hospital stay than laparoscopic adrenalectomy. Laparoscopic approach seems to be a more rapid technique when comparing to robotic technique, although recent studies demonstrate a significant operative time reduction in robotic group with the learning curve improvement and the development of new surgical technology.

Background Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is the recommended elective surgery for children with ulcerative colitis (UC). The aim of the present study was to evaluate health outcomes of children with UC and undergone restorative proctocolectomy with IPAA and to compare preoperative and postoperative health-related quality of life (HRQoL). Methods We reviewed the hospital records of all paediatric patients who had undergone surgery for UC between January 2009 and December 2016 in the Units of Paediatric Surgery and Gastroenterology of the University Hospitals of Messina and Genoa. Surgical treatment was represented by restorative proctocolectomy and laparoscopic IPAA. Patients and parents were interviewed by telephone before and after surgery, and responded to the modified IMPACT III questionnaire about health outcomes and HRQoL. The final version was made up of 15 closed questions of functional outcomes and HRQoL. All of the issues were grouped into 5 domains, such as gastrointestinal functional aspects (7 questions), school functioning (2 questions), social functioning (3 questions), emotional functioning (3 questions). The questionnaire was scored on a five-point scale with higher scores indicating a better HRQoL. The total score ranged from 35 (worst HRQoL) to 175 (best HRQoL). Results Data were obtained in 30 patients (16 males), who underwent surgery after a median post-diagnosis period of 3 years (range 1–4.5), at a median age of 12 (range 3–16). The most common indication for colectomy was acute severe colitis (63%, n = 19). Table 1 shows all the functioning total scores before and after IPAA. HRQoL scores showed a statistically significant improvement after IPAA. This difference was observed in all dimensions of HRQoL (symptoms, school attendance, social activities, and emotional functioning). Overall, nearly all were completely satisfied with the outcome of colectomy. No operation-related mortality was reported. By the end of the follow-up, one patient developed pouchitis 1 month after colectomy, and responded well to antibiotic therapy. Conclusion Our data confirmed that HRQoL is low in children with UC referred for possible operation, and showed that surgical treatment may positively affect the overall HRQoL.

Drug malabsorption is one of the potential troubles after bariatric surgery. Evidence for diminished levothyroxine (L-T4) absorption has been reported in patients after bariatric surgery.This study reports 17 cases of hypothyroid patients [who were well replaced with thyroxine tablets (for1 year) to euthyroid thyrotropin (TSH) levels before surgery (13 Roux-en-Y gastric bypasses (RYGB); 4 biliary pancreatic diversions (BPD))]. From 3 to 8 months after surgery, these patients had elevated TSH levels. Patients were then switched from oral tablets to a liquid L-T4 formulation (with the same dosage, 30 min before breakfast).Two-three months after the switch, TSH was significantly reduced both in patients treated with RYGB, as in those treated with BPD, while FT4 and FT3 levels were not significantly changed (RYGB group, TSH μIU/mL: 7.58 ± 3.07 vs 3.808 ± 1.83, P 0.001; BPD group, TSH μIU/mL: 8.82 ± 2.76 vs 3.12 ± 1.33, P 0.01).These results first show that liquid L-T4 could prevent the problem of malabsorption in patients with BPD and confirm those of previous studies in patients submitted to RYGB, suggesting that the L-T4 oral liquid formulation could circumvent malabsorption after bariatric surgery.

BACKGROUND AND AIMS Bleeding and staple line leak are the most common postoperative complications of LSG. To prevent and/or to promptly identify such complications, conventional peri-operative protocols imply post-operative gastric decompression (NGT) and staple line drain (IAD). Our aim was to evaluate the role of naso-gastric tube (NGT) and intra-abdominal drain (IAD) in preventing and/or facilitating identification and treatment of post-operative complications after sleeve gastrectomy. PATIENTS AND METHODS A retrospective observational study on two consecutive series has been undertaken to evaluate the real utility of routine placement of NGT and IAD at the end of a LSG to prevent (primary end-point), promptly identify (secondary end-point) and manage (tertiary end-point) bleeding and staple line leakage. Collected outcome data of all consecutive cases, which underwent primary LSG at our Department, were analyzed. The first 100 consecutive patients (group A) received the standard perioperative protocol and the other consecutive 100 (group B) received a fast track protocol (no NGT neither IAD). RESULTS The two groups were not different in their outcome. Two bleeding occurred in Group A and were conservatively treated. One abscess developed in group B soon after surgery. It was diagnosed by an abdominal CT performed because patients presented fever, leucocitosis and tachycardia. It was successfully treated by percutaneous ultrasound-guided drainage. One fistula occurred in group B after discharge on 30th post-operative day. Fistula was suspected based on fever and tachycardia in absence of any abdominal discomfort and was confirmed by an abdominal CT. The patient was successfully treated in 40 days by endoscopic positioning of a gastric tube-prosthesis and percutaneous ultrasound-guided drainage of abdominal collection. A third patient in group B experienced bleeding suspected due to hemoglobin drop and confirmed by abdominal CT. He also was conservatively treated. CONCLUSIONS In conclusion, placement of drains does not facilitate detection of leak, abscess, or bleeding after primary LSG.

Background: Single-port laparoscopic surgery as an alternative to conventional laparoscopic cholecystectomy for benign disease has not yet been accepted as a standard procedure. The aim of the multi-port versus single-port cholecystectomy trial was to compare morbidity rates after single-access (SPC) and standard laparoscopy (MPC). Methods: This non-inferiority phase 3 trial was conducted at 20 hospital surgical departments in six countries. At each centre, patients were randomly assigned to undergo either SPC or MPC. The primary outcome was overall morbidity within 60 days after surgery. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov (NCT01104727). Results: The study was conducted between April 2011 and May 2015. A total of 600 patients were randomly assigned to receive either SPC (n = 297) or MPC (n = 303) and were eligible for data analysis. Postsurgical complications within 60 days were recorded in 13 patients (4.7 %) in the SPC group and in 16 (6.1 %) in the MPC group (P = 0.468); however, single-access procedures took longer [70 min (range 25–265) vs. 55 min (range 22–185); PÂ

In the last decades, the three-dimensional (3D) imaging systems have been introduced in an attempt to improve depth perception and image quality during laparoscopic cholecystectomy interventions. The goal of our systematic review was to provide enough convincing evidences on superiority and benefits of 3D over two-dimensional (2D) imaging systems, from both surgeon's and patient's point of view, justifying the cost-effectiveness of newly developed 3D systems.Two authors separately performed a full literature search aiming to find randomized controlled trials evaluating the advantages and disadvantages of 3D versus 2D laparoscopic cholecystectomy procedures. The patients who underwent elective laparoscopic cholecystectomy were included in this study irrespective of their age and sex. Differing opinions between the two authors were reviewed by the third author.A total of 912 articles were initially reviewed by their titles and abstracts for eligibility. After being filtered through predetermined inclusion and exclusion criteria, and excluding the duplicates, only 10 studies underwent the final evaluation by the full text assessment. Eventually, only five randomized controlled studies were included in this study. Operative time and depth perception/image quality were set as the primary and secondary outcomes, respectively. The operative time was significantly shorter in 60% of the studies. Of five studies that evaluated the depth perception and image quality, all five (100%) reported a better depth perception and image quality.3D imaging systems tend to shorten the operative time compared to 2D systems and result in a better depth perception. More studies and investigations with bigger cohort sizes and using unique 3D visual systems are necessary to justify the cost-effectiveness of the new, more expensive 3D systems.

We describe a case of a 76-year-old man with a giant ileal gastrointestinal stromal tumour (GIST) causing an intestinal subocclusion and a subsequent haemoperitoneum. During his hospital stay for a sudden hypovolemic shock, the patient underwent an urgent laparotomy and a 20 cm × 15 cm ruptured ileal GIST causing haemoperitoneum was found. Only 13 cases of ileal GIST causing peritoneal bleeding have been described since 2000, the one we presented is the largest. Although rare this pathological entity should be kept in mind in case of sudden abdominal pain and hypovolemic shock in patients with a large intraabdominal mass.

Endoscopic thyroidectomy (ET) allows surgeons to remove a thyroid tumor from a remote site, while providing excellent results from a cosmetic viewpoint. Minimally invasive surgery is widely employed for the treatment of thyroid diseases. Several minimal access approaches to the thyroid gland have been described. The commonly performed surgeries have been endoscopic lobectomies. We have performed ET trans orally by the inferior vestibular approach. Our preliminary results indicate that ET performed via transoral is a technically feasible and safe procedure with excellent cosmetic results for patients with benign thyroid tumors. In this report, we have summarized a focused on the pre- and post-operative patient care of this procedure.

Background: In the US, the thermal ablation workload for cancer involving the liver is predicted to more than double in the next 5 years, emphasising the need to develop and improve the current technology. Study Design: A multicentre nonrandomised prospective clinical trial (NCT00514930) was undertaken, to assess the efficacy and safety of a new bipolar radiofrequency ablation/aspirator device, in the treatment of primary and secondary cancers of the liver. Results: A total of 34 lesions in 16 patients were ablated at laparotomy and followed up at 4 weeks. The mean diameter of lesion before ablation was 3.2±2.22 (range 1–10) cm, the mean volume aspirated during ablation was 9.25±7.3 (range 0–25) ml and the mean operative time was 145.95±40.7 (range 60–215) min. There was one major complication of a pleural effusion, which required drainage. The mean length of stay was 8±3.2 (range 3–14) days. In 11 patients, the ablated tumour was resected. On histological assessment, there was no evidence of viable cancer at the tumour edge. On follow-up computed tomography, the ablation zone fully encompassed the targeted tumour and there were no local complications related to ablation. Conclusion: Initial analysis of the data from this small cohort, with only a short-term follow-up, shows this device to be safe and effective.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) allows cholecystectomy to be performed by means of a flexible scope introduced through the stomach, rectus, bladder, or vagina. However, available endoscopes have several limitations if used in the peritoneal cavity. The hybrid technique reported overcomes these limitations by using conventional 5-mm laparoscopic instruments through the umbilical scar and transabdominal sutures for retraction. After creating the pneumoperitoneum with a Veress needle, a 5-mm port is introduced into the umbilicus followed by a 5-mm, 30 degrees scope. A culdotomy then is performed under direct and laparoscopic views. The flexible endoscope is inserted into the pelvis through the vagina and advanced to expose the gallbladder. Three or more transabdominal sutures are placed through the gallbladder wall for retraction. Cholecystectomy then is performed using conventional 5-mm laparoscopic instruments through the 5-mm umbilical port. Finally, stay sutures are removed and the specimen is retrieved through the vagina. Six patients successfully have undergone this new procedure. In our opinion this hybrid approach increases safety, overcomes the limitation of the current instrumentation, and maintains most of the advantages of Natural Orifice Transluminal Endoscopic Surgery.

BACKGROUND: The potential applications of radiofrequency (RF) energy in medicine are an expanding field. This paper describes the development and early results of the application of four novel radiofrequency devices in surgery, endoscopy and interventional radiology. METHODS: The four devices that were designed and have been assessed were 1) Endoblate: a bipolar RF catheter for endoscopic use which was assessed in patients with rectal tumors, 2) Hexablate: a bipolar RF ablation/aspiration device which was used to treat liver cancers, 3) VesCoag: a bipolar RF catheter for endovascular ablation which was used by interventional radiologists to seal the blood vessels of tumors within the liver and 4) EndoHPB: an endoscopic bipolar RF catheter for endobiliary ablation which so far has been assessed in a porcine model. RESULTS: In the pilot clinical studies on Endoblate, Hexablate and VesCoag, all the devices could be used in the clinical situation for which they had been designed. There were no technical problems and no serious adverse events associated with their use. All were used in bipolar mode apart from VesCoag, where it was found that a monopolar current was required for effective vessel sealing. For EndoHPB in the porcine model, it was determined that the ideal power setting was 5–10 watts for 2 min. A clinical trial is to be undertaken to determine whether this power setting is applicable for when EndoHPB is used in the management of malignant obstructive jaundice. CONCLUSIONS: It is an exciting time in the development of new RF instruments, and as they become more sophisticated their clinical applications will expand. These early data from the animal and pilot clinical studies are promising and larger studies with longer term follow-up needs to be undertaken to establish their true clinical worth.

Background. In recent years the progress of laparoscopic procedures and the development of new and dedicated technologies have made laproscopic hepatic surgery feasible and safe. In spite of this laparoscopic liver resection remains a surgical procedure of great challenge because of the risk of massive bleeding during liver transection and the complicated biliary and vascular anatomy in the liver. A new laparoscopic device is reported here to assist liver resection laparoscopically. Methods. The laparoscopic Habib™ 4X is a bipolar radiofrequency device consisting of a 2x2 array of needles arranged in a rectangle. It is introduced perpendicularly into the liver, along the intended transection line. It produces coagulative necrosis of the liver parenchyma sealing biliary radicals and blood vessels and enables bloodless transection of the liver parenchyma. Results. Twenty-four Laparoscopic liver resections were performed with LH4X out of a total of 28 attempted resections over 12 months. Pringle manoeuvre was not used in any of the patients. None of the patients required intraoperative transfusion of red cells or blood products. Conclusion. Laparoscopic liver resection can be safely performed with laparoscopic Habib™ 4X with a significantly low risk of intraoperative bleeding or postoperative complications.

To address the issue whether three-dimensional (3D) offers real operative time advantages to the laparoscopic surgical procedure, we have designed a single-surgeon prospective randomized comparison of 3D versus two-dimensional (2D) imaging during two different bariatric procedures. Forty morbidly obese patients were randomized on the day of surgery by a random computer-generated allocation list to receive either a 3D high-definition (HD) display or 2D HD imaging system laparoscopic bariatric procedure by a single experienced surgeon. Forty operations were performed with either a 3D HD display or 2D HD imaging system. After the insertion of the access ports, both surgical procedures were divided in component tasks, and the execution times were compared. The execution times for the entire procedure and the single tasks were not significantly different between the 2D and 3D groups during sleeve gastrectomy. The execution times for the entire procedure and the single tasks, except for the first one, were significantly different between the 2D and 3D groups during mini-gastric bypass (p

This survey provides an overview about current spread of Minimally Invasive Liver Resection (MILR) in Italy. Primary endpoint was to assess evolution of MILR in recent years and its degree of application among centres with different experience in laparoscopic and hepatic surgery. A questionnaire with items describing activity MILR was sent to Italian surgical centers. Diagnosis, technical approaches, resection extent, devices and vascular control, reasons for conversion, morbidity and mortality were recorded. Level of expertise per centre was analysed in terms of learning curve acquisition and relationship with hepatobiliary background. 1497 MILRs from 39 centers (median 27 patients/center, range 1–145, period 1995–2012) were collected. Conversion rate was 10.7% (180 patients out of 1677, excluded from subsequent analysis), with bleeding representing most frequent cause of conversion (34.4%). Eleven centers completed learning curve, performing >60 MILR. Benign lesions were 27.5% and malignant 72.5%, with hepatocellular carcinoma being the most frequent indication. 92.6% of cases were performed with a totally laparoscopic technique (1.3% were hand-assisted, 1.9% single-port and 4.2% robotic). Minor resections accounted for 92.9% (left lateral sectionectomy resulted the most frequent procedure; 23.8%), while major resections represented 7.1%. Overall mortality was 0.2% (3 of 1497 patients) and morbidity 22.8%. Mean length of stay was 5days. Correlation between MILR activity and a hepatobiliary background was not clear comparing MILR cases and liver resection volumes per center. MILR has been significantly widespread in Italy in recent years, with several centers having definitely completed the learning curve as attested by clinical results consistent with major series from the Western and Eastern countries. MILR programs in Italy seem to arise from both centers with specific hepatobiliary expertise and centers performing advanced general laparoscopic surgery.

Key Clinical Message Ingestion of foreign bodies is a common clinical problem, but intrahepatic migration is an exceptional occurrence. Clinical history is not helpful. Abdominal ultrasonography and CT are fundamental to exclude surgical causes of fever of unknown origin. Laparoscopic segmental liver resection is recommendable to avoid generalized peritonitis.

Aims and background Intraoperative blood loss during liver resection remains a major concern due to its association with higher postoperative complications and shorter long-term survival. The aim of this study was to assess the feasibility and safety of a novel concept for liver resection using a radiofrequency energy-assisted technique. Methods From January 2001 to July 2002, 42 patients were operated on using radiofrequency energy-assisted liver resection. Radiofrequency energy was applied along the resection edge to create a ‘zone of desiccation’ prior to resection with a scalpel. Results Median resection time was 50 mins (range, 30–110). The median blood loss during resection was 30 mL (range, 15–992). Mean preoperative and postoperative hemoglobin values were 13.7 g/dL (SD ± 1.6) and 11.8 g/dL (SD ± 1.4), respectively. No blood transfusion was registered, nor was any mortality observed. There were 3 postoperative complications, one subphrenic abscess, one chest infection and one biliary leak from a hepatico-jejunostomy. Median postoperative stay was 8 days (range, 5–86). Conclusions Liver resection assisted by radiofrequency energy is feasible, easy and safe. This novel technique offers a new method for ‘transfusion-free’ resection without the need for sutures, ties, staples, tissue glue or admission to an intensive care unit.

Axillary lymph node dissection for staging and local control of nodal disease is an integral part of breast cancer therapy. Lymphorrea is a serious and disabling complication of axillary lymphadenectomy, but no effective therapy is currently available. Octreotide is a hormone with general antisecretory effects that has been used to control lymphorrhea in thoracic duct injury and after radical neck dissection. The aim of the study we describe in this article was to determine whether octreotide has a role in the treatment of post axillary lymphadenectomy lymphorrhea.This is a prospective randomized controlled trial. Two hundred sixty-one consecutive patients with various stages of breast cancer who underwent axillary lymph node dissection were randomized and followed for 7 years. The treatment group received 0.1 mg octreotide subcutaneously three times a day for 5 days, starting on the first postoperative day, while the control group received no treatment. Of the 261 patients undergoing axillary node dissection, 136 were assigned to the control group and 125 composed the treatment group. The control group and the treatment group were evaluated for amount and duration of lymphorrhea as well as inflammatory and infectious complications.In the control group, the mean quantity (+/- standard deviation) of lymphorrhea was 94.6 +/- 19 cc per day and the average duration was 16.7 +/- 3.0 days. In comparison, the mean quantity of lymphorrhea in the treatment group was 65.4 +/- 21.1 cc (p0.0001) per day and the average duration was 7.1 +/- 2.9 days (p0.0001). We did not find an important difference in the number of infectious complication or hematomas formation between the study groups.Octreotide can be used successfully for the treatment of post-axillary dissection lymphorrea, and potentially, in the prevention of post-axillary lymph node dissection lymphosarcoma, since the amount and duration of lymphorrhea in this setting are known to be important risk factors for its development. Potentially, octreotide might be used in similar situations where lymphorrhea is detrimental, such as peripheral vascular surgery and regional lymph node dissection for melanoma.

This retrospective study compares the clinical and nutritional outcomes of 100 morbidly obese patients who underwent biliopancreatic diversion (BPD) with common (CC) and alimentary channel (AC) length, respectively, 50/250 and 80/200 cm. One hundred patients who received BPD from October 2006 to November 2011 were identified from a database of bariatric procedures performed at the University Hospital of Messina, and the outcomes in terms of weight loss and morbidity were compared. Forty morbidly obese patients underwent BPD with CC 80 cm and AC 200 cm (group 1) and 60 morbidly obese patients underwent BPD with CC 50 cm and AC 250 cm (group 2). A gradual weight loss was observed in both groups during the first 3 years after the operation without any significant difference between the two groups. Two cases of protein malnutrition occurred in the group 2 (3 %) due to poor patient compliance in terms of adequate dietary protein intake. Sideropenic anemia was found in 42 % of obese patients in group 2 versus 22.5 % in group 1 at third-year follow-up despite adequate supplementation (p = 0.047). Diarrhea occurred more frequently with a shorter CC. Lipophilic vitamin deficiencies occurred more frequently with a shorter CC despite adequate oral supplementation. In the medium term, our series showed that shorter CC was associated with no weight loss advantage but with higher morbidity rate, especially in young and fertile women. We recommend a longer CC (80 cm) to be performed especially in this sub-population of obese patients.