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Introduction Duodenal rupture following blunt abdominal trauma is rare, and traumatic rupture of duodenal diverticula is exceptional. However, duodenum is the second most frequent location of intestinal diverticula following colon. Duodenal diverticula are common but only in few cases they are symptomatic due to the onset of complications such as inflammation, hemorrhage, or perforation. Perforation, although rare, especially post-trauma, is the most serious life threatening complication. Case presentation We report the case of a patient who, 24 hours after a blunt trauma secondary to a car accident, complained symptoms related to the perforation of a diverticulum of the fourth portion of the duodenum. A computed tomography was performed and extraluminal fluid-air collection was identified. During emergent laparotomy, a fourth portion perforated duodenal diverticulum was diagnosed, and resected. The recovery was uneventful. Discussion Diagnosis of perforated duodenal diverticulum represents a challenge in diagnosis and few guidelines exist about the management of this rare occurrence, especially in a traumatic setting. The present case is the first report of traumatic perforated diverticulum of the fourth duodenal portion. Conclusion Surgery still remain the most common approach in the treatment of this pathology, including diverticulectomy and primary repair., Highlights • Duodenal diverticula are a frequent, but they are usually asymptomatic until they develop complications, as perforation. • Traumatic perforation of duodenum is very infrequent and the traumatic rupture of duodenal diverticula is extremely rare. • Perforation, usually involves the second part of the duodenum. • The present case is the first report of traumatic perforated diverticulum of the fourth duodenal portion. • Surgery remain the most common approach in the treatment of complicated duodenal diverticula.

Diverticular disease affects ∼5–10% people worldwide, yet the indications for elective colectomy in uncomplicated diverticulitis are unclear. As there is no strong scientific evidence regarding histology in diverticular disease, the primary outcome of the study was to analyze the degree of inflammation of colonic wall in patients that underwent elective colectomy for uncomplicated diverticulitis and to retrospectively assess the correlation between patient clinical history and pathological features of surgical specimens in order to find some predictive factors that may be strictly correlated with histology. An observational retrospective study was conducted. Patients undergoing elective colectomy for uncomplicated diverticulitis between January 2014 and January 2016 in an academic medical center were collected. The majority of patients (46.2%) had previously encountered one episode of acute diverticulitis prior to colectomy, while 21.5% and 10.8% had experienced two and three or more prior episodes respectively. Most patients had recurrent or chronic abdominal pain in the left iliac fossa (66.2%) for diverticular disease and a large proportion also experienced constipation (40.0%). Diverticulitis was identified pathologically as being “mild” in 44.6% patients and “severe” in 55.4% patients. The mean age was significantly lower in patients with severe diverticulitis (56.7 years) than in patients with mild diverticulitis (67.0 years). 71.9% of males had severe diverticulitis compared to 39.4% of females. Males have a 3.9 times higher risk of histological severe diverticulitis than females (OR = 3.932; 1.390–11.122; p = 0.008). Multivariate logistic regression analysis confirmed that age and gender were independent factors associated with histological diagnosis. Single-institution data and retrospective design were main limitations of this study. Age and gender are independent factors associated with severity inflammation index derived at histological analysis and they could be translated to clinical practice to better categorize patients with uncomplicated diverticulitis at the bedside.

Complex abdominal wall defects (CAWDs) can be difficult to repair and using a conventional synthetic mesh is often unsuitable. A biological mesh might offer a solution for CAWD repair, but the clinical outcomes are unclear. Here, we evaluated the efficacy of a cross-linked, acellular porcine dermal collagen matrix implant (Permacol) for CAWD repair in a cohort of 60 patients. Here, 58.3% patients presented with a grade 3 hernia (according to the Ventral Hernia Working Group grading system) and a contaminated surgical field. Permacol was implanted as a bridge in 46.7%, as an underlay (intraperitoneal position) in 38.3% and as a sublay (retromuscolar position) in 15% of patients. Fascia closure was achieved in 53.3% of patients. The surgical site occurrence rate was 35% and the defect size significantly influenced the probability of post-operative complications. The long-term (2 year) hernia recurrence rate was 36.2%. This study represents the first large multi-centre Italian case series on Permacol implants in patients with a CAWD. Our data suggest that Permacol is a feasible strategy to repair a CAWD, with acceptable early complications and long-term (2 year) recurrence rates.

Traumatic limb wound management represents a common and challenging health problem. Conservative treatment can be a good option when surgery fails or surgical reconstruction is planned. Wound healing is a complex process that involves several factors and can be delayed if wound details are not noticed. So, expert healthcare professionals should take care of these delicate patients to obtain satisfactory outcomes in terms of cosmesis and functionality of the residual scar. Thanks to the description of three patients with traumatic limb injuries, this article emphasizes the importance of respecting what we call the three golden rules of wound management: correct cleaning of the wound, its accurate inspection and choose the appropriate dressing according to the wound aspect.

Background Portal vein thrombosis (PVT) occurs frequently in hepatocellular carcinoma (HCC) and is often diagnosed in the course of a routine patient evaluation and surveillance for liver cancer. The purpose of this study is to investigate the relationship between folate status and portal vein thrombosis. Methods HCC with PVT patients were 78, HCC without PVT were 60 and control subjects were 70 randomly selected. We evaluate serum and red blood cellular folate, homocysteine, alpha fetal protein cholesterol, triglycerides, prothrombin time. Results HCC patients with PVT showed lower levels of serum folate, respect HCC patients without PVT, with an average difference of 1.6 nmol/l p p p p p p Conclusion The low folate concentration and higher levels of homocysteine are associated with the loss of antithrombotic function, and with a more aggressive course of HCC and with a higher change of complications related to portal vein thrombosis

Introduction We report an extremely rare case of acute acalculous cholecystitis on a COVID-19 patient. In our knowledge, this is the first report of laparoscopic cholecystectomy performed on a COVID-19 patient. Presentation of case A COVID-19 patient was diagnosed with acute acalculous cholecystitis and a multidisciplinary team decided to perform a percutaneous transhepatic biliary drainage (PTBD) as the first treatment. SARS-CoV-2 RNA was not found in the bile fluid. Because of deterioration of the patient's clinical conditions, laparoscopic cholecystectomy had to be performed and since the gallbladder was gangrenous, the severe inflammation made surgery difficult to perform. Discussion Acalculous cholecystitis was related with mechanical ventilation and prolonged total parenteral nutrition, in this case the gangrenous histopathology pattern and the gallbladder wall ischemia was probably caused by vascular insufficiency secondary to severe acute respiratory distress syndrome of COVID-19 pneumonia. The percutaneous transhepatic gallbladder drainage (PTBD) was performed according to Tokyo Guidelines because of high surgical risk. Laparoscopic cholecystectomy was next performed due to no clinical improvement. The absence of viral RNA in the bile highlights that SARS-CoV-2 is not eliminated with the bile while it probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhoea. Conclusions Although the lack of evidence and guidelines about the management of patient with acute cholecystitis during COVID-19 pandemic, laparoscopic cholecystectomy, at most preceded by PTGBD on high surgical risk patients, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patients., Highlights • Coronavirus disease-19 (COVID-19) has spread to several countries around the world and has become an unprecedented pandemic. • Cholecystitis was probably caused by vascular insufficiency secondary to respiratory distress syndrome of COVID-19 pneumonia. • SARS-CoV-2 probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as diarrhoea. • Laparoscopic cholecystectomy, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patient.

Background Portal vein thrombosis (PVT) is reported in 10–40% of hepatocellular carcinoma (HCC) patients. The development of PVT is a multifactorial process, resulting from a reduction in portal blood flow and hypercoagulability. Methods We evaluated 44 HCC patients with PVT, 50 HCC patients without PVT and 50 healthy subjects. Homocysteine (Hcy), Vitamin B6, Vitamin B12 and folate were measured. Results Hcy in HCC patients with PVT is significant higher than the patients without PVT and controls subjects. Conclusion Total Hcy is a sensitive marker of PVT in patients with HCC.

Purpose/aim: The appropriate staging of colorectal cancer requires at least 12 lymph nodes to be sampled. We evaluated whether lymph node sampling (LNS) and lymph node ratio (LNR) can predict the prognosis of stage II-III patients.This is a retrospective study on 432 patients classified in LNS ≥12 and LNS12. Disease-free survival (DFS) was computed using the Kaplan-Meier method. We stratified stage III patients into 4 quartiles base on LNR values. To determine the optimal LNR cut-off, receiver operating characteristic (ROC) curve analysis was performed.There was a positive association between the number of lymph node sampled and the number of metastatic lymph nodes (p0.01). Among stage II patients, the DFS was 81% for LNS ≥ 12 and 72% for LNS12 (p = 0.158). Among stage III patients, the DFS was 58% (p0.001). We found a significant association between LNR quartiles and relapse in stage III patients but only in the LNS ≥ 12 group. ROC curve analysis indicated an ideal LNR cut-off value at 0.194 (sensitivity 65% and specificity 61%). The DFS of patients with LNR below 0.194 was 71%, and that of patients with LNR above 0.194 was 45% (log-rank test, p0.001). In the patients with LNS ≥ 12, the cut-off of 0.257 could predict recurrence (specificity 86%).Stage II patients with LNS12 tend to have shorter DFS than stage II patients with LNS ≥ 12. In stage III patients, an appropriate LNR cut-off is a better prognostic predictor than LNR quartile, especially in patients with LNS ≥ 12.

Lipoprotein (a) (Lp (a)) is a plasma lipoprotein consisting of a cholesterol rich LDL particle with one molecule of apolipoprotein B100 and one protein apolipoprotein (a) [apo(a)].

OBJECTIVE The simultaneous laparoendoscopic "rendezvous" (LERV) represents an alternative to sequential or totally laparoscopic approaches for patients affected by cholecystocholedocholithiasis. The aim of this study was to analyze the results in a large series of 210 consecutive patients. MATERIALS AND METHODS From 2002 to 2016 all patients affected by cholecystocholedocholithiasis were treated with a standardized "tailored" LERV. The relevant technical features of the procedure were recorded. An analysis of feasibility, effectiveness in stone clearance, and safety was performed. RESULTS Among 214 patients with common bile duct stones, 210 were treated with LERV and 4 with open rendezvous approach. Intraoperative cholangiography confirmed common bile duct stones in 179 patients (85.2%) or sludge in 18 (8.5%) and in 98.9% stone clearance was obtained endoscopically. Endoscopic papilla cannulation was feasible in 161 patients (76.7%), whereas in 49 (23.3%) a transcystic guidewire was needed. The overall LERV feasibility was 96.6%. The conversion rate to open surgery was 3.3%. Minor morbidity was observed in 1.9% of cases, mortality in 0.47%, and the mean hospital stay was 4.3 days. CONCLUSIONS These results confirm the high effectiveness of LERV. This approach to treat cholecystocholedocholithiasis should be preferred and therefore implemented where a strong collaboration between surgeons and endoscopists is possible.

Introduction Primary anorectal malignant melanoma is a rare and aggressive tumor that carries a poor prognosis. Anorectal melanoma (ARM) is often misdiagnosed as hemorrhoids adenocarcinoma polips and rectal cancer. ARM spreads along sub-mucosal planes and is often to wide-spread for complete resection at time of diagnosis and almost all patients die because of metastases. Presentation of the case A 77-year-old male patient presented a history of recurrent rectal bleeding and whose histopathological diagnosis was melanoma. Discussion The treatment of choice remains controversial. Surgery with complete resection represents the typical treatment. However standard operative procedures related to the area of resection and lymph dissection have yet to be established. Abdominal perineal resection (APR) with or without bilateral inguinal lymphadenectomy or wide local excision (WLE) have been used to manage patients with ARM. Conclusion The higher serum levels of LDH and YKL-40 are suggestive for Anorectal Melanoma diagnosis. The decrease of these findings may be associated with good prognosis. The review of both APR and WLE options suggests no significant difference in survival among patients., Highlights • Anorectal melanoma (ARM) is a systemic disease. • Regardless how aggressive is ARM, no surgical treatment will truly change the outcome. • If surgical teqchniques are available, patients should undergo to wide local excision. • In case of recurrence, the abdominal resection should be considered as the best surgical treatment.

Sublay mesh repair seems to be the most effective method for treating incisional hernias (IHs). The aim of this study was to report our experience with retromuscular repair and self-gripping mesh for the treatment of midline IHs. In addition, we provided a systematic review of the literature regarding the use of this novel combination. All patients undergoing elective IH repair from June 2016 to November 2018 were included. The self-gripping mesh was placed in the sublay position. Demographic data, defect sizes, postoperative complications and follow-up durations were collected. A systematic review of the available literature was conducted in January 2020 using main databases. A total of 37 patients (20/17M/F) were included in this study, and the mean age and body mass index (BMI) were 58 years and 27 kg/m2, respectively. Minor complications occurred in six patients. Long-term follow-up demonstrated recurrence in three patients. Regarding the review, five publications were considered relevant. The highest complication rate was 28.6%, and the recurrence rate varied from 0 to 5.1%. This is the first review of the literature regarding sublay IH repair using a self-gripping mesh. The low rates of postoperative complications and recurrence in our experience and those reported by most of the reviewed articles demonstrate that this is a safe and effective method for repairing IHs.

In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors’ approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.

The scientific interest (SI) for a given field can be ascertained by quantifying the volume of published research. We quantified the SI in surgical education to clarify the extent of worldwide efforts on this crucial factor required to improve health-care systems. A set of Medical Subject Headings (MeSH) was defined for the PubMed search. The number of Pubmed Indexed Papers (nPIP) relevant to the SI was extracted from database conception to December 2016 and their distribution and evolution by country were analyzed at 10-year intervals. Population Adjusted Index (PAI) and Medical School Adjusted Index (MSAI) analyses were performed for countries with the nPIP > 30. We identified 51,713 articles written in 33 different languages related to surgical education; 87.6% of these were written in English. General surgery was the leading surgical specialty. The overall nPIP doubled every 10 years from 1987 (from 6009 to 13,501, to 26,272) but stabilized at 3707, 3800 and 3433 in the past 3 years, respectively. The PAI and MSAI analyses showed that the USA, United Kingdom, New Zealand, Canada, Australia and Ireland are top producers of published research in surgical education, constituting a combined 62.88% of the nPIP. Our quantification of the change in SI in surgical education and training gives a clear picture of evolution, efforts and leadership worldwide over time. This picture mirrors an international academic society that should encourage all those involved in surgical education to improve efforts in educational research.

Background: Non-melanoma skin cancers (NMSC), despite having a favourable prognosis, present an increased risk of occult malignancies. The aim of this study was the evaluation of the usefulness of the mucinous marker carbohydrate 19-9 antigen (CA 19-9) in the diagnosis of occult cancers. (1) Patients and Methods: This is a case control study in which 480 patients with NMSC and 480 matched control subjects with dermatitis were enrolled, 208 patients with NMSC showed upper-normal CA 19-9 values, and 272 showed under-normal CA 19-9 values. (2) Results: The 208 patients positive for CA 19-9 included 87 with basal cell carcinoma (BCC) and 121 with squamous cell carcinoma (SCC). The 272 patients negative for CA 19-9 included 107 with BCC and 165 with SCC. For the SCC patients, CA 19-9 serum levels were significant in 121 of the patients (positive), 66 of which were affected by cancer, CA 19-9 was within the normal range in 165 patients, of which 30 were diagnosed with cancer. In the SCC patients, the CA 19-9 sensitivity was 68%, the specificity was 70%, the positive predictive value (PPV) was 54% (95%) and the negative predictive value (NPV) was 81%. In the BCC patients, the CA 19-9 sensitivity was 70%, the specificity was 66%, the PPV was 48% and the NPV was 83%. In the dermatitis patients (controls), we observed 121 patients that were CA 19-9 positive, with 15 malignancies, and 359 CA 19-9-negative patients, with three malignancies. (3) Conclusions: To confirm the association between CA 19-9 and an elevated risk of malignancies in NMSC, prospective cohort studies should be performed.

Background: Portal vein thrombosis (PVT) is a common complication of endstage hepatocellular carcinoma (HCC). : The aim of our study was to evaluate the role of Homocysteine (Hcy) in HCC patient with PVT. Hcy is a sulphur amino-acid involved in two pathways, trans-sulphuration and remethylation, that involve vitamins B6, B12 and folates. Methods: We recruited 54 patients with HCC and PVT, 60 patients with HCC and without PVT and 60 control subjects. We measured serum levels of Hcy, folate, vitamins B6 and B12. Results: The comparison between HCC patients with PVT versus HCC without PVT was shown that mean values of Hcy were 6.4 nmol/L (p Conclusion: High serum levels of Hcy are an established thrombotic risk factor in the general population. We found significantly higher levels of Hcy in HCC patients with PVT versus both HCC patients without PVT and controls.

Michele Malaguarnera,1,2 Saverio Latteri,3 Gaetano Bertino,4 Roberto Madeddu,5 Vito Emanuele Catania,3 Giuseppe Currò,6 Antonio Maria Borzì,2 Filippo Drago,1 Giulia Malaguarnera1 1Department of Biomedical and Biotechnological Science, University of Catania, Catania, Italy; 2Research Center “The Great Senescence”, University of Catania, Catania, Italy; 3Department of Medical, Surgical Sciences and Advanced Technologies “Gian Filippo Ingrassia”, University of Catania, Catania, Italy; 4Department of Experimental and Clinical Medicine, University of Catania, Catania, Italy; 5Department of Biomedical Sciences, University of Sassari, Sassari, Italy; 6Department of Human Pathology, University of Messina, Messina, Italy Purpose: Portal vein thrombosis (PVT) is one of the severe complications of hepatocellular carcinoma (HCC). PVT deteriorates the liver, and its dysfunction increases the risk of bleeding, influencing the prognosis of patients with liver cirrhosis and HCC. The aim of our study was to investigate whether D-dimer testing could be a sensitive marker for the diagnosis and prognosis of HCC patients with PVT.Patients and methods: Between June 2010 and December 2015, 118 HCC patients were admitted to Cannizzaro Hospital, Catania, and 50 controls were recruited from their relatives for health examinations. All enrolled patients were diagnosed and pathologically confirmed as having HCC. D-dimer was measured with an enzyme-linked immunosorbent assay using 2 monoclonal antibodies against nonoverlapping determinants of D-dimer.Results: D-dimer levels in HCC patients with PVT were significantly higher vs HCC patients without PVT, P

Aims: The role of minimally invasive surgery of gastrointestinal stromal tumours (GISTs) of the stomach remains uncertain especially for large and/or difficult located tumours. We are hereby presenting a single-centre series of robot-assisted resections using the da Vinci Surgical System (Si or Xi). Subjects and Methods: Data of patients undergoing robot-assisted treatment of gastric GIST were retrieved from the prospectively collected institutional database and a retrospective analysis was performed. Patients were stratified according to size and location of the tumour. Difficult cases (DCs) were considered for size if tumour was >50 mm and/or for location if the tumour was Type II, III or IV sec. Privette/Al-Thani classification. Results: Between May 2010 and February 2017, 12 consecutive patients underwent robot-assisted treatment of GIST at our institution. DCs were 10/12 cases (83.3%), of which 6/10 (50%) for location, 2/10 (25%) for size and 2/10 (25%) for both. The da Vinci Si was used in 8 patients, of which 6 (75%) were DC, and the da Vinci Xi in 4, all of which (100%) were DC. In all patients, excision was by wedge resection. All lesions had microscopically negative resection margins. There was no conversion to open surgery, no tumour ruptures or spillage and no intraoperative complications. Conclusion: Our experience suggests a positive role of the robot da Vinci in getting gastric GIST removal with a conservative approach, regardless of size and location site. Comparative studies with a greater number of patients are necessary for a more robust assessment.

Background: Carcinoembryonic antigen (CEA) is a glycoprotein, which is present in the foetal colon, some benign conditions and different malignancies, particularly in colon adenocarcinoma. We focused this study on non-melanoma skin cancer (NMSC). NMSC is a common malignancy and it is an important source of morbidity and death in the world. In this study we evaluated whether CEA level increases in NMSC. Patients and Methods: A total of 566 patients with non-melanoma skin cancer (NMSC) were enrolled; 286 patients with NMSC showed CEA levels above normal values, and 280 showed CEA levels below normal values. Patients with high levels of CEA underwent abdominal ultrasound, gastro endoscopy, colonoscopy, and abdominal CT scans. Results: We studied 566 patients, 286 were positive to CEA and 280 were negative. Of the 286 patients positive to CEA, 132 had basal cell carcinoma (64 patients had an associated cancer) and 154 had squamous cell carcinoma (75 patients were affected by cancer). Of the 280 patients negative to CEA, 130 had basal cell carcinoma (12 were associated with cancer), and 150 had squamous cell carcinoma (18 were associated with cancer). The mean age of the 566 case control subjects were 65–81 years. Of the 10 subjects that were the positive control for CEA, two had cancer. Of the 556 subjects that were the negative control for CEA, three had cancer. Conclusions: In patients that present high serum levels of CEA, we give attention to adenocarcinoma tumour first. The pattern of association may be attributable to bias because the group with NMSC were frequently evaluated than those with no history of NMSC. Our results showed that out of 286 patients that were CEA-positive, 139 had cancer, and of the 280 that were CEA-negative, 30 had cancer. Therefore, 20% of patients do not follow the trend. Other markers should be investigated.

Background Peripheral neuropathy after surgical treatment is an under recognized potential untoward event. Pelvic surgery may be associated with nerve lesions by essentially three main mechanisms: transection, entrapment and pressure-stretching; the latter is the modality most frequently linked to patient's positioning on the operating room table. Presentation of the case A 25 years old woman, after undergoing a laparoscopic gynaecologic procedure lasted >3 hours, on postoperative day one presented with numbness over her lateral right leg and dorsum of the foot, right foot drop and gait instability due to compression-stretching of the right superficial peroneal nerve. Discussion Patient's diagnostic work up, treatment and outcome are reported and measures on how to prevent the occurrence of such type of lesion are outlined together with the importance of an early postoperative diagnosis in order to avoid permanent nerve damage. Conclusion Such lesions are sometimes so unexpected that delayed diagnosis leads to damages which are difficult or impossible to repair. Primary prevention plays a key role and it is realized by adhering to specific protocols. In the occurrence of the lesion a prompt diagnosis is highly recommendable and a comprehensive therapeutic plan is necessary to correctly address the specific pathology., Highlights • After undergoing a laparoscopic gynaecologic procedure lasted >3 hours, a 25 years old woman presented peripheral neuropathy. • Pelvic surgery may be associated with nerve lesions by transection, entrapment and pressure-stretching. • Such lesions are unexpected and diagnosis is delayed to a point when the damage is difficult or impossible to repair. • The treatment should take in account genetical variations of the population and biochemical derangements.

Key Clinical Message Laparoscopic cholecystectomy is a well‐known procedure for the treatment of most gallbladder diseases. Sometimes, it could be very difficult, in the presence of aberrations regarding the cystic duct, the cystic artery, or the gallbladder itself. Fluorescence laparoscopy using indocyanine green could be very useful for all the situations of anatomy aberrations.

The purpose was to evaluate the efficacy of near-infrared fluorescent cholangiography (FC) in real-time visualization of the biliary tree during elective laparoscopic cholecystectomy.Fifty consecutive elective laparoscopic cholecystectomies were performed with fluorescent cholangiography. FC was performed at three time points: following exposure of Calot's triangle, prior to any dissection; and after partial and complete dissection of Calot's triangle.The cystic duct (CD) was identified successfully by FC in 43 of 50 patients (86%) and in 45 of 50 patients (90%) before and after Calot's dissection respectively (p 0.05). The common hepatic duct (CHD) and the common bile duct (CBD) were identified successfully in 12 of 50 patients (24%) and in 33 of 50 patients (66%) before Calot's dissection respectively and in 26 of 50 patients (52%) and in 47 of 50 patients (94%) after complete Calot's dissection (p = 0.007 and p = 0.001, respectively). Significant differences were observed for CBD visualization rate, in relation to BMI after Calot's dissection (p 0.05) and history of cholecystitis, before Calot's dissection (p = 0.017). No bile duct injuries were reported.Fluorescent cholangiography can be considered as a useful tool for intra-operative visualization of the biliary tree during laparoscopic cholecystectomies.

Background This case report describes a spontaneous tumor lysis syndrome due to a rare solid tumor. Case presentation A 65-year-old white woman had tumor lysis syndrome, which represent a dangerous oncological emergency. This syndrome occurs usually with a hematological tumor, but in this case our patient had a solid tumor, which was a rare extraskeletal osteosarcoma, localized in her pelvic region. She also had lung metastases and bilateral hydronephrosis. After spontaneous tumor lysis syndrome, she had acute renal insufficiency, which was treated with hemodialysis and successively with rasburicase, Kayexalate (sodium polystyrene sulfonate), and febuxostat. Conclusion Tumor lysis syndrome represents an oncological emergency, which must be suspected and treated as soon as possible.

Traumatic injuries constitute a major risk for patients in emergency units. Point-of-care ultrasound may be a determinant in reducing the deleterious impact of complications and in prognosis.We describe the case of a 28-year-old female who reported cranial trauma, abdominal and thoracic trauma, and suspected bilateral fracture of the femur.Ultrasound was useful for evaluating and monitoring multiple organ failure.Combining cost-effective advantages with bedside real-time imaging, ultrasound is a powerful adjunct to standard clinical assessment in the management of polytrauma when it is administered at the point of care.le patologie traumatiche rappresentano il maggiore rischio dei pazienti nelle Unità di Emergenza. L’ecografia consentendo una diagnosi precoce sia del tipo di trauma sia delle complicanze che da questo potrebbero derivane, può rappresentare un mezzo importante per la prognosi e per l’eventuale terapia.A tale scopo, noi presentiamo un caso paradigmatico di una paziente di 28 anni che, a seguito di un incidente, aveva riportato dei traumi al cranio, all’addome e al torace e sospetta frattura bilaterale al femore. Al momento del ricovero la paziente era monitorizzata tramite ecografia. I dati venivano confermati sia dalla sintomatologia clinica obiettiva, sia dalla tomografia assiale computerizzata.l’uso dell’ecografia ha consentito una diagnosi precoce non solo del tipo di trauma, ma anche ha permesso un corretto intervento terapeutico ed un monitoraggio anche dell’attività cardiaca.L’ecografia presenta vantaggi dal punto di vista costo-beneficio ed è utile sia ai fini diagnostici, sia ai fini terapeutici.

Background The aim of this study was to compare the efficacy and safety of synchronous laparoscopic cholecystectomy with laparo-endoscopic rendez-vous (LRV) technique vs. sequential "delayed" approach with the main goal to compare the conversion rate and postoperative complications. Methods Patients diagnosed as having gallstones and CBD stones or sludge were enrolled in this study. From January 2013 to June 2015, 43 consecutive patients were submitted to the sequential treatment (ERCP prior to laparoscopic cholecystectomy) and the next consecutive 46 patients were submitted to undergo the rendez-vous technique. All endoscopic procedures in both groups were performed by the same endoscopist with the same technique. Data were collected on patient age, gender, latency operation time, duration of surgery, bilio-pancreatic events, hospital stay, mortality, conversion rate and postoperative complications. Results The overall mean age was 58 years-old (25-84 years) with 43 males (48.3%) and 46 females (51.7%). The conversion rate to open surgery was 11.6% in the "sequential group" vs. 2.2% in the LRV group with a P value 0.10. The reasons for conversion included in the first group unclear anatomy (in 2 patients) and severe adhesions (in the remnant 3 patient), and in the second group unclear anatomy (in one patient). No bilio-pancreatic events occurred in the waiting period for LC in the first group. No mortality was recorded in either group. Postoperative complications were seen in 7% of patients in the "sequential group" vs. 2.2% in the rendez-vous group (P value 0.35). Conclusions LRV does not present real advantages in comparison to delayed sequential approach in terms of conversion rate and postoperative complications. However, these results require further elaboration in studies on large numbers of patients undergoing LRV approach.

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.

In a preliminary experience, we claimed the potential value of 3D printing technology for pre-operative counseling and surgical planning. However, no objective analysis has ever assessed its additional benefit in transferring anatomical information from radiology to final users. We decided to validate the pre-operative use of 3D-printed anatomical models in patients with solid organs’ diseases as a new tool to deliver morphological information. Fifteen patients scheduled for laparoscopic splenectomy, nephrectomy, or pancreatectomy were selected and, for each, a full-size 3D virtual anatomical object was reconstructed from a contrast-enhanced MDCT (Multiple Detector Computed Tomography) and then prototyped using a 3D printer. After having carefully evaluated—in a random sequence—conventional contrast MDCT scans, virtual 3D reconstructions on a flat monitor, and 3D-printed models of the same anatomy for each selected case, thirty subjects with different expertise in radiological imaging (10 medical students, 10 surgeons and 10 radiologists) were administered a multiple-item questionnaire. Crucial issues for the anatomical understanding and the pre-operative planning of the scheduled procedure were addressed. The visual and tactile inspection of 3D models allowed the best anatomical understanding, with faster and clearer comprehension of the surgical anatomy. As expected, less experienced medical students perceived the highest benefit (53.9% ± 4.14 of correct answers with 3D-printed models, compared to 53.4 % ± 4.6 with virtual models and 45.5% ± 4.6 with MDCT), followed by surgeons and radiologists. The average time spent by participants in 3D model assessing was shorter (60.67 ± 25.5 s) than the one of the corresponding virtual 3D reconstruction (70.8 ± 28.18 s) or conventional MDCT scan (127.04 ± 35.91 s). 3D-printed models help to transfer complex anatomical information to clinicians, resulting useful in the pre-operative planning, for intra-operative navigation and for surgical training purposes.

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.

Isolated vascular injuries are rare in cases of blunt abdominal trauma, and superior mesenteric artery injury is extremely rare but potentially lethal. The incidence of this kind of life-threatening injury has increased in recent years. The diagnosis of these isolated injuries is difficult, and its delay is associated with a higher morbidity and mortality. The authors report on the case of a child with an isolated injury of the superior mesenteric artery caused by a lap belt, during a motor-vehicle crash which was successfully managed. Correct use of all types of restraints is to be recommended. The diagnosis of this rare intraabdominal vascular injury is possible especially when the major signs are evident, but an awareness of this rare possibility is essential for the outcome.

Background Biliary stones are a common disease in western countries, and its management has changed dramatically over the past decade. Due to the increase of the middle-aged people, a larger number of elderly patients are affected by this disease. Laparoscopic cholecystectomy (LC) represents the gold standard for the treatment of gallbladder stones, and in cholecystectomized patients, the treatment of CBD stones remains the exclusive work of the endoscopist. But if the patient still has the gallbladder with stones, the ideal management of CBD stones remains controversial. There are two treatment options: the two time (LC and pre or postoperative ERCP), and the one time procedures (trans cystic approach and CBD exploration and laparoendoscopic procedure called “rendezvous”:RV). The aim of the work is to analyse our results of the mininvasive treatment of the cholecysto-choledocolithiasis in elderly patients.

Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV). A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options. Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors’ comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems. There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Gastrointestinal tuberculosis (TB) is quite rare, representing only 3% of all extra-pulmonary cases. Blind gut and ileum are the most common gastrointestinal localizations, while appendix involvement is infrequent. Appendix involvement is usually related to symptoms of acute appendicitis since the caseous necrosis may lead to adhesions and surgical complications such as perforation. For this reason patients with suspected appendicular TB usually undergo surgery even without a secure diagnosis. In these cases, due to the absence of specific symptoms and signs, the diagnosis is delayed after surgery, thus resulting in a high percentage of important, and sometimes lethal, complications. Histopathological examination is often the only way to reach a diagnosis and to establish specific antibiotic therapy, while an early diagnosis could avoid surgical treatment. We report a case of appendicular TB not only for its rarity but also to discuss the difficulty in its diagnosis.

AIM: To investigate our clinical experience with combined laparo-endoscopic Rendezvous (RV) for the treatment of patients affected by gallstones and common bile duct (CBD) stones and especially to study the never evaluated opinion of the endoscopist concerning the difficulty of the intraoperative endoscopic procedure during the RV in comparison with standard endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: Eighty consecutive patients affected by cholecystolithiasis and diagnosed or suspected CBD stones were treated with a standardized “tailored” RV. The relevant technical features, the feasibility, the effectiveness in stone clearance, the safety but also the simple evaluation of difficulty and agreement of the endoscopist were analyzed with a questionnaire. RESULTS: The feasibility was 97.5% and the effectiveness 100% concerning CBD clearance and solution of coexisting problems at the papilla. Minor morbidity was 3.3%, the operating time was prolonged by a mean of 14 min, the mean hospital stay was 3.8 d and only one stone’s recurrence occurred. The endoscopist evaluated the procedure to be simpler than standard ERCP-ES in 81.2% of the cases. CONCLUSION: Simultaneous RV carries high effectiveness and safety at least comparable to those reported for other options. The endoscopist is very often satisfied with this approach because of the minimization of some steps of the endoscopic procedure and avoidance of relevant iatrogenic risk factors. If the mandatory collaboration between surgeons and endoscopists is guaranteed, this approach can often be preferable for the patient, the surgeon, the endoscopist and the hospital.

Endoscopic procedures on Vater's papilla are related to pancreatic damage with or without pathologic increase of pancreatic enzymes. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is a standard treatment for common bile duct stones, performed sequentially before or after laparoscopic cholecystectomy. The "rendezvous" (RV) procedure combines laparoscopic cholecystectomy, intra-operative cholangiography, and endoscopic bile duct clearance and is an alternative to the sequential treatment. We tried to analyze relevant differences between the two options concerning the main parameters of pancreatic damage.Thirty-eight patients treated for biliary stones were divided into two groups of 19 patients depending on the type of treatment (RV vs. ERCP) and were compared for post-procedural amylase and lipase levels; the duration of the endoscopic procedures, effectiveness, and complications were also recorded.A pathologic increase of serum amylase occurred in 15.7% of the RV group and 47.3% of the ERCP group with significant differences regarding amylase levels in the 6- and 66-hour samples (p0.003; p0.006). The mean duration of endoscopic procedure was significantly shorter in the RV group (17 vs. 26 minutes, p0.0001). RV was effective in common bile duct clearance in 100% of cases, while ERCP was effective in only 89.5%. Minor morbidity affected one patient in each group.This is the first report comparing combined laparoendoscopic RV versus ERCP for potential pancreatic damage and showing that RV reduces the number of patients with an iatrogenic pathologic increase of amylase when compared to ERCP, and also significantly reduces the duration of endoscopic procedure.

In performing experimental liver surgery, it is difficult to prolong anhepatic time because the animals do not tolerate prolonged portal and caval clamping. To counteract prolonged venous stasis, the authors previously developed a simple porto-intracaval shunt. The shunt consists of a self-constructed inverted Y silicone tube. The effectiveness of this shunt was studied comparing two groups of 10 rabbits with shunt (S) versus those with clamped portal and inferior caval vein (C). In the group of rabbits that underwent porto-intracaval shunt, the results concerning intraoperative mortality, intraoperative increase in distal portal vein pressure, and incidence of the histologic signs of gut damage were clearly improved. The proposed porto-intracaval shunt was therefore effective in reducing some principal negative effects of portal and caval clamping. This type of porto-intracaval shunt can be therefore useful allowing improvement of experimental models concerning liver surgery in little animals. In chirurgia sperimentale del fegato e difficile prolungare il tempo anepatico dato che gli animali non tollerano un clampaggio portale e cavale prolungato. Gli Autori hanno precedentemente sviluppato un semplice shunt porto-intracavale con l'intento di ovviare alla stasi venosa prolungata. Lo shunt e costituito da un tubo di silicone a forma di Y invertita. Nel presente studio viene analizzata l'efficacia di questo shunt confrontando un gruppo di dieci conigli con shunt (S) rispetto al gruppo sottoposto invece al clampaggio della vena porta e della vena cava inferiore (C). I risultati riguardo mortalita intraoperatoria, incremento intraoperatorio della pressione portale distale e presenza e distribuzione di segni istologici di danno intestinale sono chiaramente migliori nel gruppo con shunt intra-porto cavale. Lo shunt porto-intracavale proposto e risultato realmente efficace nel ridurre alcuni dei principali effetti negativi del clampaggio portale e cavale. Questo tipo di shunt porto-intra cavale puo essere quindi utile per migliorare le possibilita e i modelli di chirurgia sperimentale del fegato nei piccoli animali. © 2001 Wiley-Liss, Inc. MICROSURGERY 21:179–182 2001

To find a possible relationship between inflammation and CA19-9 tumor marker by analyzing data from patients with benign jaundice (BJ) and malignant jaundice (MJ).All patients admitted for obstructive jaundice, in the period 2005-2009, were prospectively enrolled in the study, obtaining a total of 102 patients. On admission, all patients underwent complete standard blood test examinations including C-reactive protein (CRP), bilirubin, CA19-9. Patients were considered eligible for the study when they presented obstructive jaundice confirmed by instrumental examinations and increased serum bilirubin levels (total bilirubin2.0 mg/dL). The standard cut-off level for CA19-9 was 32 U/mL, whereas for CRP this was 1.5 mg/L. The CA19-9 level was adjusted by dividing it by the value of serum bilirubin or by the CRP value. The patients were divided into 2 groups, MJ and BJ, and after the adjustment a comparison between the 2 groups of patients was performed. Sensitivity, specificity and positive predictive values were calculated before and after the adjustment.Of the 102 patients, 51 were affected by BJ and 51 by MJ. Pathologic CA19-9 levels were found in 71.7% of the patients. In the group of 51 BJ patients there were 29 (56.9%) males and 22 (43.1%) females with a median age of 66 years (range 24-96 years), whereas in the MJ group there were 24 (47%) males and 27 (53%) females, with a mean age of 70 years (range 30-92 years). Pathologic CA19-9 serum level was found in 82.3% of MJ. CRP levels were pathologic in 66.6% of the patients with BJ and in 49% with MJ. Bilirubin and CA19-9 average levels were significantly higher in MJ compared with BJ (P = 0.000 and P = 0.02), while the CRP level was significantly higher in BJ (P = 0.000). Considering a CA19-9 cut-off level of 32 U/mL, 82.3% in the MJ group and 54.9% in the BJ group were positive for CA19-9 (P = 0.002). A CA19-9 cut-off of 100 U/mL increases the difference between the two groups: 35.3% in BJ and 68.6% in MJ (P = 0.0007). Adjusting the CA19-9 value by dividing it by serum bilirubin level meant that 21.5% in the BJ and 49% in the MJ group remained with a positive CA19-9 value (P = 0.003), while adjusting the CA19-9 value by dividing it by serum CRP value meant that 31.4% in the BJ group and 76.5% in the MJ group still had a positive CA19-9 value (P = 0.000004). Sensitivity, specificity, positive predictive values of CA19-932 U/mL were 82.3%, 45% and 59.1%; when the cut-off was CA19-9100 U/mL they were, respectively, 68.6%, 64.7% and 66%. When the CA19-9 value was adjusted by dividing it by the bilirubin or CRP values, these became 49%, 78.4%, 69.4% and 76.5%, 68.6%, 70.9%, respectively.The present study proposes CRP as a new and useful correction factor to improve the diagnostic value of the CA19-9 tumor marker in patients with cholestatic jaundice.

Les fistules aorto-digestives sont definies comme la communication entre l'aorte et un segment intestinal et sont souvent la cause d'une hemorragie digestive haute catastrophique avec peu de survivants. Selon l'etiologie, les fistules aorto-digestives sont classifiees en tant que fistules aorto-digestives primaires ou fistules aorto-digestives secondaires (SAEF) apres chirurgie aortique anterieure. La recidive d'une fistule apres une SAEF precedente est definie comme une fistule aorto-digestive recidivante et n'est rapportee que dans de rares cas se produisant apres un delai imprevisible suivant le traitement chirurgical precedent. Nous decrivons un cas unique de fistule aorto-digestive recidivee, dans lequel le lien avec la recidive etait la presence des agrafes metalliques d'une suture agrafee pour fermer la paroi duodenale pendant la reparation anterieure de SAEF. Une revue des donnees publiees a ce sujet a ete faite pour analyser les caracteristiques cliniques, les resultats globaux, les facteurs de risque de la recidive, et les points techniques principaux du traitement chirurgical pour l'empecher.

Colonic perforation during endoscopic diagnostic or therapeutic procedures, represents an uncommon occurrence even if, together with haemorrhage, it is still the most common complication of colonoscopy, with an incidence ranging between 0.1% and 2% of all colonoscopic procedures. The ideal treatment in these cases remains elusive as the endoscopist and the surgeon have to make a choice case by case, depending on many factors such as how promptly the rupture is identified, the condition of the patient, the degree of contamination and the evidence of peritoneal irritation. Surgical interventions both laparotomic and laparoscopic, and other medical non-operative solutions are described in the literature. Only three cases have been reported in the literature in which the endoscopic apposition of endoclips was used to repair a colonic perforation during colonoscopy. Ours is the first case that the perforation itself was caused by the improper functioning of a therapeutic device.

Fecaloma is common in patients with damage to the autonomic nervous system in the large bowel associated with Chagas disease (inflammatory and neoplastic) or Hirschprung’s disease, in psychiatric patients and, more commonly, in elderly patients suffering with chronic constipation. Symptoms of fecaloma are usually nonspecific. Clinical examination can give the appearance of an abdominal tumor. Most cases of fecaloma are treated conservatively with digital evacuation and enemas. In severe and unremitting cases, surgery is required to prevent significant complications. Fecaloma should be considered in the differential diagnosis of any patient with history of chronic constipation and abdominal mass. We present the clinical case of an 85-year-old man with a history of chronic constipation presented to the emergency room with vague abdominal pain of 2 days’ duration. An erect abdominal X-ray and computed tomography revealed a supergiant faecaloma extending from the pubis up to the diaphragm associated to a megarectum and megacolon. The patient was treated successfully with digital evacuation and enemas.

Background The spread of the SARS-CoV2 virus, which causes COVID-19 disease, profoundly impacted the surgical community. Recommendations have been published to manage patients needing surgery during the COVID-19 pandemic. This survey, under the aegis of the Italian Society of Endoscopic Surgery, aims to analyze how Italian surgeons have changed their practice during the pandemic. Methods The authors designed an online survey that was circulated for completion to the Italian departments of general surgery registered in the Italian Ministry of Health database in December 2020. Questions were divided into three sections: hospital organization, screening policies, and safety profile of the surgical operation. The investigation periods were divided into the Italian pandemic phases I (March–May 2020), II (June–September 2020), and III (October–December 2020). Results Of 447 invited departments, 226 answered the survey. Most hospitals were treating both COVID-19-positive and -negative patients. The reduction in effective beds dedicated to surgical activity was significant, affecting 59% of the responding units. 12.4% of the respondents in phase I, 2.6% in phase II, and 7.7% in phase III reported that their surgical unit had been closed. 51.4%, 23.5%, and 47.8% of the respondents had at least one colleague reassigned to non-surgical COVID-19 activities during the three phases. There has been a reduction in elective (> 200 procedures: 2.1%, 20.6% and 9.9% in the three phases, respectively) and emergency ( Conclusion This survey offers three faithful snapshots of how the surgical community has reacted to the COVID-19 pandemic during its three phases. The significant reduction in surgical activity indicates that better health policies and more evidence-based guidelines are needed to make up for lost time and surgery not performed during the pandemic.