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Background: The aim of colonic stenting with self-expandable metallic stents in neoplastic colon obstruction is to avoid emergency surgery and thus potentially reduce morbidity, mortality, and need for a stoma. Concern has been raised, however, about the effect of colonic stenting on short-term complications and long-term survival. We compared morbidity rates after colonic stenting as a bridge to surgery (SBTS) versus emergency surgery (ES) in the management of left-sided malignant large-bowel obstruction., Methods: This multicentre randomised controlled trial was designed with the endorsement of the European Association for Endoscopic Surgery. The study population was consecutive patients with acute, symptomatic malignant left-sided large-bowel obstruction localised between the splenic flexure and 15 cm from the anal margin. The primary outcome was overall morbidity within 60 days after surgery., Results: Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 29/144 (13.9%) were excluded post-randomisation mainly because of wrong diagnosis at computed tomography examination. The remaining 115 patients (SBTS n = 56, ES n = 59) were deemed eligible for analysis. The complications rate within 60 days was 51.8% in the SBTS group and 57.6% in the ES group (p = 0.529). Although long-term follow-up is still ongoing, no statistically significant difference in 3-year overall survival (p = 0.998) and progression-free survival rates between the groups has been observed (p = 0.893). Eleven patients in the SBTS group and 23 in the ES group received a stoma (p = 0.031), with a reversal rate of 30% so far., Conclusions: Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.

Background: Laparoscopic sleeve gastrectomy (LSG) consists of a longitudinal resection of the stomach on the greater curvature, removing 75-80% of the stomach approximately and creating a cylindrical "sleeve"-like conduit. However, LSG can be associated with significant morbidity, and staple-line failure with dehiscence and gastric leak is one of the most severe complications. The aim of this study was to compare three different methods of gastric closure in terms of staple-line strength and leak pressures of the sleeved stomach., Methods: After performing standard stapled sleeve gastrectomies, the gastric specimens were carefully retrieved. Group 1 specimens were left with the staple line intact. In group 2, the staple line was reinforced with a 3-0 polypropylene running suture. The gastric remnants of group 3 were those in which the LSG was performed using Seamguard as the buttressing material. The burst-pressure was assessed using a portable gas sensor. The outcome parameters were: age of the patients, body mass index, buttress material (suture, Seamguard, etc.), leak pressure, volume infused, and leak site, among others., Results: Thirty-six sleeve gastrectomies were included in the final analysis. Each group consisted of 12 gastric specimens. There were no differences between groups in terms of age, sex, body mass index, and patient comorbidities. The leak pressure was significantly higher in group 2 (35 ± 11.7 vs. 102 ± 21.4 vs. 47 ± 19.1; p = <0.0005). The volume of liquid required to cause the leak was much greater in the group 3 (p = <0.001)., Conclusions: Oversewing is the reinforcement method that increases better the staple-line strength. It is the least expensive method of reinforcement and does not increase operative times significantly.

Introduction: Sigmoid volvulus is responsible for 8% of all intestinal obstructions. The most frequent presentation is in the elderly, with it occurring exceptionally in young people. Surgical resection is mandatory to prevent recurrence. Laparoscopic maneuvers in the long and distended bowel are difficult, and not much experience with these procedures has been reported., Materials and Methods, and Results: A 21-year-old man with antecedents of constipation had two episodes of rectal prolapse, and one episode of acute volvulation treated with decompressive endoscopy. A laparoscopic exploration was performed for definitive treatment. Transanal intubation with a large-bore tube permitted deflation of the bowel. A deep Douglas's pouch was observed with a mobile sigmoid loop that intussuscepted the rectum. A proctosigmoidectomy including the 5 cm of the upper rectum was performed without incident., Conclusion: Laparoscopic management of suboclusive colonic volvulus is feasible. Intraopertive transanal intubation permits deflation the loop and facilitates manipulation.

Background: Laparoscopic splenectomy (LS) is considerably more difficult to perform when the spleen is enlarged. The new technique of hand-assisted designed technique aimed to assist laparoscopic surgery allows the surgeon to insert his or her hand into the abdomen while maintaining the pneumoperitoneum, thus recovering the tactile sensation lost in conventional laparoscopic surgery., Object: In this study, we compared the immediate results of conventional LS and hand-assisted LS (HALS) in cases of splenomegaly., Methods: Between February 1993 and August 2001, 200 LS were attempted at two university hospitals. In 56 cases, splenomegaly (final spleen weight >700 g) was observed clinically or detected on radiological examination. We compared the first 36 patients operated on by conventional LS (group I) with the last consecutive 20 patients, who underwent HALS (group II). The study parameters were operative time, conversion rate, transfusion rate, morbidity and length of hospital stay., Results: The groups were comparable in terms of age (58 +/- 13 [ranges, l9-82] vs 58 +/- 16 years [range, 44-84] (ns), diagnosis, and spleen weight (1425 +/- 884 [range, 700-3400]) vs 1753 +/- 1124 g [range, 720-4500] (ns). HALS was associated with less morbidity (36% vs 10%) (ns), a shorter operative time (177 +/- 52 [range, 95-300]) vs 135 +/- 53 min [range, 85-270] (p <0.009), and a shorter hospital stay (6.3 +/- 3.3 [range, 3-14]) vs 4 +/- 1.2 [range, 2-7] days (p <0.05)., Conclusion: In cases of splenomegaly, HALS assisted laparoscopic surgery significantly facilitates the surgical maneuvers during LS while maintaining the advantages of a purely laparoscopic approach.

Background: Hand-assisted laparoscopic surgery (HALS) represents a useful alternative to conventional laparoscopic surgery (LS). Its potential advantages--(a quicker, safer procedure and less need to convert to open surgery) are due to the recovery of tactile feedback. However, HALS requires the performance of a mini-laparotomy when surgery commences, and the wound is stretched and compressed throughout the procedure. In addition, it is associated with a more intense manipulation of the intraabdominal viscera. All of these factors increase the surgical trauma, it is not known whether HALS maintains the minimally invasive characteristics of conventional LS. Therefore, we set out to study the applicability, immediate clinical outcome, inflammatory response, and cost of HALS compared with conventional LS using colectomy as a model., Methods: We performed a prospective randomized trial comparing laparoscopic-assisted colectomy with HAL colectomy. The aims of the study were to assess (a) perioperative features, including time, advantages, and conversion; (b) the patient's immediate clinical response, including recovery of bowel sounds, refeeding time, postoperative pain, local and general morbidity, and hospital stay; (c) the effect on the inflammatory response, using interleukin-6 (ILG) and C-reactive protein (CRP) measurements; (d) oncological issues, including intraoperative cytology and features of the specimen; and (d) the relative costs of the two procedures., Results: A total of 54 patients were enrolled in the study, 27 laparoscopic and 27 HALS. The operative times were similar, but HALS was associated with a far lower conversion rate--7% vs 23%. Immediate clinical outcomes, oncological features, and costs were similar for the two procedures, but HALS was associated with a significantly greater increase in IL6 and CRP than the conventional laparoscopic procedure., Conclusion: This comparative study shows that HALS simplifies difficult intraoperative situations, reducing the need for conversion. Although it is a more aggressive procedure, HALS preserves the features of a minimally invasive approach, maintains all of the oncological features of conventional laparoscopic surgery, and does not increase the cost. HALS should therefore be considered as a useful adjunct when difficult situations arise during conventional laparoscopic colectomy.