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Objective: The role of antral resection (AR) in laparoscopic sleeve gastrectomy (LSG) is still a greatly debated topic in the literature. The aim of this study was to evaluate the results and complications of AR in LSG., Patients and Methods: In this observational comparative study, 101 patients who underwent LSG were divided into two groups based on the extent of antral resection: 1 cm from the pylorus (1-DP group), or 6 cm from the pylorus (6-DP group). The %EWL (%Excess weight loss), resolution of T2D (Type 2 Diabetes Mellitus) and GLP-1 were investigated 48 hours before surgery and 3, 6 and 12 months after LSG. Postoperative complications in the first 30 days after surgery were also compared between the two groups using the Clavien-Dindo (CD) score., Results: A significant difference in %EWL was observed at 3 and 6 months in favor of the 1-DP group (38.9% and 57.8%, respectively) compared to the 6-DP group (31.4% and 49.7%, respectively). No difference in T2D resolution was observed between two groups during the follow-up period, with similar changes in GLP-1. Statistically significant differences were found between 1-DP and 6-DP group for the reintervention rate (CD III, 7.7% and 1.9%, respectively; p = 0.02) and life-threatening complications requiring intensive care unit management (CD IV, 3.8% and 0%, respectively, p = 0.03)., Conclusions: In LSG, sparing the antrum is associated with a significant reduction in the rate of postoperative complications, but the metabolic and weight results are comparable to those for antrum resection.

Setting: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes., Objectives: This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG., Patients and Methods: This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR)., Results: GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance., Conclusions: Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication., Competing Interests: None

Objective: The objective of our study is to investigate whether diabetes mellitus could adversely affect post-laparoscopic sleeve gastrectomy (LSG) weight loss., Patients and Methods: A retrospectively recorded database of patients who underwent LSG from September 2018 to September 2019 in our Hospital in L'Aquila was analyzed. The post-operative weight loss was evaluated in terms of body mass index (BMI) variation, percentage of excess weight loss (%EWL) and percentage of total weight loss (%TWL). The association between these parameters and diabetes was analyzed at 3 and 6 months of follow-up., Results: The two groups (patients with and without diabetes) were considered comparable in terms of anthropometric and preoperative parameters. At 3 and 6 months of follow-up, the decrease in BMI resulted to be directly associated with the time and the group. The mean BMI at 3 and 6 months was higher in patients with diabetes. Changes in % EWL and % TWL were similar in both groups., Conclusions: It is rational to expect a lower weight loss in obese diabetic patients after LSG. This should not be considered as a contraindication to bariatric surgery that, being a metabolic surgery, has as main goal the resolution or improvement of co-morbidities.

Objectives: Laparoscopic sleeve gastrectomy is gaining popularity as a bariatric option. Gastric leak is the most dreaded septic complication after this procedure. This study investigated levels of drain amylase that could be useful for predicting gastric leak before its clinical presentation., Subjects and Methods: This prospective observational study was carried out in 167 patients who underwent sleeve gastrectomy for morbid obesity between February 2014 and March 2020. Measurement of drain amylase levels (DALs) was adapted as a routine procedure. The results of the receiver operative characteristic (ROC) curve analysis revealed an optimal drain amylase levels cutoff point of 814.18 IU/L. Consequently, the DALs were classified as DALs &lt814.18 or DALs ≥814.18 for all subsequent analyses., Results: Gastric leak occurred in 6 patients. Drain amylase levels of 167 patients were tested. The mean value for patients without leak was 71.13 ± 72.11 IU/L; for patients with leak, it was 4,687 ± 6,670 IU/L (p &lt 0.001). Using ROC curve analysis, the mean ± standard error of the area under the curve for DALs on postoperative day 1 was 0.9927 ± 0.0075, CI = 0.978-1.00, and a cutoff level at 814.18 IU/L for predicting gastric leak achieved 83.33% sensitivity and 100% specificity with positive predictive value of 100% and negative predictive value 99.38%. All patients with a leak, but one, had a drain amylase level >814.18 IU/L., Conclusion: The determination of drain amylase levels after sleeve gastrectomy is a significant indicator of gastric leak with high sensitivity and specificity., (© 2021 The Author(s) Published by S. Karger AG, Basel.)

Introduction: Indocyanine green (ICG) fluorescent angiography has been routinely applied for various laparoscopic procedures to evaluate the tissue blood supply. A promising branch for this technology is represented by bariatric surgery, especially to estimate the risk of gastric leak after laparoscopic sleeve gastrectomy (LSG), which seems mainly related to ischemia of the stomach., Materials and Methods: 43 consecutive patients from January 2018 to March 2019 underwent in our institution LSG with intravenous injection of 5 ml ICG after the realization of gastric tube to evaluate the blood supply of the gastric tube., Results: In all 43 cases, there have been no adverse events related to ICG. The vascular supply to stomach was estimated "satisfactory" along the stapled line in all cases. However, one patient showed signs and symptoms indicative of gastric leak in the fifth post-op day and diagnosis was confirmed by CT scan with Gastrografin., Conclusions: From our preliminary data, the intraoperative view of the blood supply of the stomach does not seem to represent a prognostic factor for the risk of gastric leak, suggesting a complex multifactorial etiology (intragastric hypertension? Abnormal inflammatory response?) which needs further data to be established.

Gastric leak remains the main complication after sleeve gastrectomy, but there are no standardized guidelines for its treatment. Good results have been reported using endoscopic double-pigtail stent. To estimate its effectiveness, we carried out this systematic review. Eleven eligible articles were identified by searching PubMed, Embase, and Cochrane Library databases. A total of 385 patients met the inclusion criteria. The pooled proportion of successful leak closures by using double pigtail drainage was 83.41%. The proportion of successful leak closures by using double pigtail drainage by experienced operators as first-line treatment was 84.71%. Our review suggested that double-pigtail stent could be a valid approach to manage the postbariatric gastric leak, with low rate of complications and a good tolerance by patients. More high-quality studies with large samples sizes should be undertaken to better evaluate and compare the variety of techniques available., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic sleeve gastrectomy (LSG) has become a very frequent procedure in bariatric surgery. Despite its simplicity, it can have serious complications. Among these, gastric leak is one of the most feared complications. Numerous intraoperative maneuvers have been suggested in an attempt to decrease the incidence of leak. In our center, we decided to study one of the intraoperative measures proposed, which consists in positioning the suture machine to 1.5 cm from His corner., Methods: This retrospective study reported 101 cases of LSG performed in our center from 2012 to 2017. The patients were divided into two groups, with comparable anthropometric parameters and comparable inclusion criteria. In the two groups the operative technique used was the same, except for a maneuver: in the second group, attention was paid to keep a distance from the angle of at least 1.5 cm., Results: On a total of 101 procedures performed, the overall complication rate was 4,95%. In group 1 the rate of gastric staple line leak was 6.78%. In group 2 the rate was 2.38%., Conclusions: The analyzed surgical technique seems to decrease the risk of leak without significantly impacting weight loss, and we have noticed in our clinical experience a decrease in the incidence of fistula from the time this measure was adopted. Also the statistical analysis encourage the continuation of experimentation.

Introduction: : To date, there are no studies investigating whether laparoscopic cholecystectomy (LC) is technically more complex in patients waiting for kidney transplant. The aim of this study is to create a user-friendly score to identify high-risk cases for complex LC integrating end-stage renal disease (ESRD)., Materials and Methods: We retrospectively analysed 321 patients undergoing LC during the period 2014-2016. Two groups were compared: ESRD group (n = 25) versus control group (n = 296). Concerning statistical analysis, continuous variables were compared using Kruskal-Wallis' test, dummy variables with Chi-square test or Fisher's exact test when appropriate. A multivariable logistic regression analysis was performed to identify risk factors for complex LC. A backward conditional method was used to design the final model., Results: : Seventy out of 321 (21.8%) cases were considered as complex, with a higher prevalence in the ESRD group (32.0 vs. 20.9%; P = 0.2). Using a multivariable logistic regression analysis, we formulated a score based on the independent risk factors for complex LC: 4×(previous cholecystitis) +5 × (previous ESRD) +1 × (age per decade) +2 × (previous open abdominal surgery). High-risk cases (score ≥ 10) were more commonly reported in the ESRD group (72.0 vs. 24.7%; P < 0.0001)., Conclusion: : Although several scores investigating the risk for complex LC have been proposed, none of them has focused on ESRD. This is the first series demonstrating that ESRD is an independent risk factor for technical complexity in LC. We developed a score to offer surgeons an extra tool for pre-operative evaluation of patients requiring LC., Competing Interests: None

Introduction: The most frequent and severe complication after laparoscopic sleeve gastrectomy is gastric leak. Nowadays, there is no specific standard recommendation for its management, but the endoscopic placement of a double-pigtail drain across the leak has been proven to be effective and minimally invasive. Stent displacement into the abdominal cavity is not common and intrasplenic migration is even more rare., Case Presentation: We report a case of a 49-year-old woman with intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak., Discussion: Pigtail drain migration involving the spleen is rare but may potentially expose the patient to the risk of parenchymal abscess or haemorrhage. Often the clinic does not indicate early this complication., Conclusion: We underline the need for a close radiologic follow-up, regardless of clinical conditions, in all patients treated with double-pigtail drain and its early removal in case of migration., (Copyright © 2018 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Fournier's gangrene is a rapidly progressing necrotizing fasciitis, involving perineal, perianal, or genital regions, and it constitutes a true surgical emergency. Surgical excision of all necrotic tissue is required, and multiple debridements may be necessary to remove all nonviable tissue. After surgical intervention for debridement, reconstruction may be necessary. We present our experience in the treatment of tissue loss after Fournier's gangrene of genital and perianal regions with the use of biological mesh (derma porcine mesh) in association with vacuum-assisted closure therapy.

Ectopic pancreas is a rare congenital abnormality probably due to a derangement of embryologic development of digestive tract. Its frequency is reported in the literature between 0.5-14% predominantly distributed in the stomach, duodenum, jejunum. Such condition is extremely difficult to be diagnosed, in fact most of the case of ectopic pancreas are an accidental finding. We describe a case of ectopic pancreas located in the Meckel's diverticulum, resected at laparotomy performed for colonic disease. Although in retrospective review symptoms from ectopic pancreas are reported in up to 50% of the cases our patient was free of symptoms. In addition the finding of ectopic pancreas in Meckel's diverticulum has been described only seldom in the previous literature. Treatment however should always be resection in order to prevent complications that may occur, although rarely.

Background: Melatonin induces sleep and modulates immune system. Aim of the paper is to show a possible relation between impaired rhythm of melatonin secretion and the onset of postoperative septic complications and insomnia in old patients undergoing surgery., Methods: Fifty old patients, aged from 60 to 94 years, have been studied; 39.5% of the patients had neoplastic disease. Melatonin serum levels have been evaluated by ELISA technique at 12 p.m., 3 a.m. 8 a.m. immediately before operation. Postoperative clinical findings of insomnia and septic complications have been recorded., Results: The melatonin serum mean values of all the patients were 16.3 pg/ml at 12 p.m., 22.4 pg/ml at 3 a.m. and 7.1 pg/ml at 8 a.m. Neoplastic patients showed the higher values of melatonin (26.696 pg/ml, 33.143 pg/ml, 9.185 pg/ml), long-lived patients (> 90 years) the lower. The melatonin secretion curve of the old patients with postoperative insomnia (19.961 pg/ml, 20.297 pg/ml, 9.378 pg/ml) or postoperative septic complications (20.695 pg/ml, 16.183 pg/ml, 6.036 pg/ml) was significantly different compared with that of other patients. The peak was advanced, lower and decreased slowly in the midnight., Conclusions: The study seems to show a possible correlation between impaired rhythm of melatonin secretion and postoperative insomnia and postoperative sepsis in old patients undergoing surgery.

Intramural hematoma of the duodenum is a rare event which is usually associated with trauma. Because of the rarity of this problem, there has been little conformity of opinions as to diagnosis and treatment of this disease. The authors report on a case of intramural hematoma of the duodenum post-traumatically occurred in a young woman. Etiopathogenesis, diagnosis and treatment of hematoma of the duodenum are thoroughly examined in the present study. Plain abdominal radiography, oral barium study, ultrasound examination, CT and RNM are diagnostic tools in this disease. It appears that most patients with intramural hematoma of the duodenum would respond well to conservative management; surgery should be reserved for those cases that remain obstructed over seven days or have evidence of peritonitis. However surgery is mandatory in cases of uncertain diagnosis. The evacuation of hematoma is considered the most effective and safest surgical treatment.

Hypocholesterolemia seems to represent a significant predictive factor of morbidity and mortality in critically ill patients. The authors, on the basis of recent literature data, aim to clarify the possible correlation between preoperative hypocholesterolemia and the risk of septic postoperative complications .205 patients undergoing to surgery for gastrointestinal diseases were the object of the study. Patients undergoing "minor" abdominal surgery or video-laparoscopic surgery and classified ASA III-IV were excluded. In all the patients, we considered retrospectively risk factors for postoperative septic complications as follows: preoperative blood concentration of cholesterol, malnutrition, obesity, diabetes, neoplasm, preoperative sepsis, type and duration of operations, antibiotics and regimen of use. Type and incidence of postoperative local or systemic septic complications were recorded. The patients have been stratified according to blood concentration of cholesterol and to the presence or absence of other risk factors. The incidence of postoperative sepsis was 35.1%. The highest incidence of postoperative septic complications (72.7%) was encountered, significantly (X2 = 7.6, p < 0.001), in the patients (11 cases, 5.9%) with cholesterol levels below 105 mg/dl). The results of this study seems to indicate a significant relationship between preoperative hypocholesterolemia and the incidence of septic complications after surgery. Moreover, evaluation of blood cholesterol levels before major surgery might represent a predictive factor of septic risk in the postoperative period.

It is well known that surgery significantly decreases immune responses. Laparoscopic cholecystectomy (LC) is a "miniinvasive" surgical procedure; and on the basis of this consideration we have investigated if and how the immune response is modified in patients after laparoscopic cholecystectomy compared to patients who underwent open cholecystectomy. Immune activity [neutrophils, total lymphocytes count, lymphocytes subpopulations, human leukocyte antigen-DR (HLA-DR)] was evaluated in 53 patients 1 day before surgery and respectively, 1, 3, and 6 days after surgery; 26 patients underwent "open" cholecystectomy and 27 LC. A day after surgery, patients with open cholecystectomy showed a significant increase (p < 0.05) in plasma neutrophils, while they were almost unchanged in LC patients. Monocyte antigen HLA-DR was reduced in patients with "open" cholecystectomy. We recorded two cases (7.6%) of respiratory tract infection in the "open" group. In conclusion, LC strongly reduces postoperative (p.o.) pain and hospitalization, and it promotes earlier recovery and return to normal activity, avoiding p.o. immunosuppression, mostly due to conservation of HLA-DR activity, with less p.o. morbidity compared to that seen with open surgery.

Simple anorectal surgery can be routinely employed on a one-day surgery (ODS) bases; however complications such as bleeding, urinary retention, and postoperative pain represent a limitation in this respect. In this paper we report preliminary results of our experience in surgery for haemorrhoids, anal fissures and fistulas, achieved in two years on 232 patients. Our protocol includes admission in the morning of the operation and preoperative evaluation by means of ECG, coagulation profile, assay of beta-HCG for female patients. The patients, prepared with a self-administered enema and perianal applications of prilocaine-lidocaine ointment, is taken in the operative room were a venous line is placed and an anaesthesiologist proceed to monitoring of ECG, blood pressure and oximetry. 211 patients were operated under locoregional anaesthesia performed by the surgeon by means of bilateral pudendal nerves blocking. Whereas the remaining underwent general or spinal anesthesia. With this approach we performed 106 haemorrhoidectomies, 96 sphincterotomies, 19 of which with posterior anoplasty and 30 fistulectomy or fistulotomy. 60 mg of ketorolac have been injected locally at the end of operation in order to improve postoperative pain control. Patients undergoing hemorrhoidectomy, anoplasty, fistulotomy or fistulectomy were discharged after 24 hours whereas those undergoing sphincterotomy went home the same day. We reported 4 early postoperative complications in the haemorrhoids group with an incidence of 1.7% (two bleedings, one urinary retention and one fever) treated conservatively. Postoperative pain resulted adequately controlled by a low dosage of NSAID (a mean of 3.7 doses of 30 mg ketorolac/patient). Our satisfactory results seem to suggest continuing the practice of one-day surgery in proctology.

Background: It is well known that surgery induces an acute inflammatory response associated with significant increase of interleukin-6 (IL-6) and C reactive protein (CRP). Laparoscopic cholecystectomy (LC) is a so called "mini-invasive" surgical intervention and on the basis of this consideration it has been investigated if and how serological markers of inflammation are modified in patients after laparoscopic cholecystectomy compared to patients undergoing open cholecystectomy., Methods: The acute phase of inflammation (IL-6, CRP and body temperature) was evaluated in 53 patients one day before surgery and p.o. after 1, 3 and 6 days; 26 patients underwent "open" cholecystectomy and 27 LC., Results: One day after surgery patients with open cholecystectomy showed significant increase (p < 0.05) of IL-6, CRP and body temperature, while these parameters were almost unchanged in patients with LC. In patients with "open" cholecystectomy, 2 p.o. complications (pneumonia) were observed., Conclusions: In conclusion, LC, although it requires longer operative time, strongly reduces p.o. pain, hospitalization, promotes earlier recovery and return to normal activity, avoiding the acute phase of p.o. inflammation with better p.o. morbidity compared to open surgery.

The results with five pediatric patients (6-15 years) who underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis are reported here. One patient had associated hematological disease (sickle-cell anemia). All five children were submitted to surgery using the laparoscopic technique. Intraoperative cholangiography was performed in two cases with uncertain ductal and vascular intraoperative anatomy. None of the operations was converted to open cholecystectomy, and there were no operative complications. The mean hospital stay was 2.2 days (range 2-3 days). All five children were able to return to normal activity within a week. No long-term complications were seen in any of the patients during an average follow-up period of 10.6 months (range 8-14). We believe that laparoscopic cholecystectomy in children is safe and effective, and that it is an important alternative to open cholecystectomy. However, prospective comparative studies of the procedure are necessary.

Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial clearly assessing the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and establishing the severity in order to plan the appropriate treatment. Forty-nine ABP patients were diagnosed by ultrasound (75.5%) or by laboratory findings (22.5%). Following Ranson and APACHE II scoring, 15 cases (30.6%) were classified as severe, 34 (69.3%) as mild. All patients with severe ABP had emergency ERCP + ES (within 24-48 hours) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. In severe cases operative endoscopy cured pancreatic inflammation in 11 cases. Subsequent LC never showed serious morbidity, but subcutaneous emphysema in one case. In 4 cases laparotomy was required since pancreatic necrosis was present, with 75% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 8.8% morbidity. IOC showed choledochal stones in 32.5% of cases, while in severe cases stones in the biliary tree were showed in 80% of cases. In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hours as well as in mild cases (LC + IOC) when surgery is done within 10 days.

Recent clinical studies suggest that laparoscopic cholecystectomy (LC) causes less depression of cell-mediated immunity than open cholecystectomy. LC is a so called "mini invasive" surgical presidia, and on the basis of this consideration we have investigated if and how the immune response is modified in patients with acute cholecystitis after laparoscopic cholecystectomy compare to patients undergone open cholecystectomy. Immune-activity (neutrophils, total lymphocytes count, lymphocytes subpopulations, HLA-DR, 6-Interleukin, skin multitests) was evaluated in 28 patients 24-36 hours before surgery and p.o. after 1, 3 and 6 days: 16 patients underwent "open" cholecystectomy and 12 LC. One day after surgery patients with open cholecystectomy showed significant increase (p < or = 0.05) of plasma neutrophils and 6-Interleukin, while these parameters were almost unchanged in patients with LC. Moreover, skin tests showed ipo or anergic response in the majority (81.8%) of patients with "open" surgery compare to patients with LC (10.5%): (p < or = 0.05). Finally monocyte antigen HLA-DR was also reduced in patients with "open" cholecystectomy: in this group we also recorded 2 cases (12.5%) of respiratory tract infection. In conclusion, LC for acute cholecystitis, avoids p.o. immunosuppression with better p.o. morbidity compare to open surgery.

Despite the exponentially increasing number of laparoscopic cholecystectomies on adults to date, there is a paucity of reports in the literature about this new technique in pediatric patients. From September 1992 to February 1995, 140 patients underwent laparoscopic cholecystectomy. Since July 1993, in our institution, five pediatric patients (three females and two males) with a diagnosis of cholelithiasis underwent laparoscopic cholecystectomy. The age of the patients ranged from 6 to 15 years (mean 8.8 years) and they weighed 18-58 kg (mean 28.4 kg). All five patients had biliary cholic and ultrasound evidence of cholelithiasis. One patient had associated hematological disease (sickle cell disease). All 5 children were operated using the laparoscopic approach technique. Operative cholangiography was performed in cases with ductal and vascular intraoperative anatomy unclear. No operation was converted to open cholecystectomy. Intraoperative cholangiography was performed successfully (100%). The mean time of surgery was 50.2 minutes (range from 38 to 68). There were no operative complications. The mean hospital stay was 2.2 days (range 2 to 3 days). All five returned to their activity within a week. No long-term complications were seen in all patients throughout an average follow-up period of 10.6 months (range 8-14). The benefits of laparoscopic cholecystectomy in children are clear and obvious. It is safe and effective and should now be the treatment of choice for cholelithiasis in pediatric patients.