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Objective Intra-abdominal infections (IAIs) after elective colorectal surgery impact significantly the short- and long-term outcomes. In the era of fast-track surgery, they often come to light after discharge from hospital. Early diagnosis is therefore essential. C-reactive protein levels have proved to be accurate in this setting. Procalcitonin has been evaluated in several studies with conflicting results. This meta-analysis aimed to compare the predictive abilities of C-reactive protein and procalcitonin in the occurrence of IAIs after elective colorectal surgery. Methods This meta-analysis included studies analyzing C-reactive protein and/or procalcitonin levels at postoperative days 2, 3, 4, and/or 5 as markers of intra-abdominal infection after elective colorectal surgery. Methodological quality was assessed by the QUADAS2 tool. The area under the curve summary receiver-operating characteristic was calculated for each day and each biomarker, using a random-effects model in cases of heterogeneity. Results The meta-analysis included 11 studies (2692 patients). An IAI occurred in 8.9% of the patients. On postoperative day 3, area under the curve was 0.80 (95% CI, 0.76-0.85) for C-reactive protein and 0.78 (95% CI, 0.68-0.87) for procalcitonin. On postoperative day 5, their predictive accuracies were 0.87 (95% CI, 0.80-0.93) and 0.90 (95% CI, 0.82-0.98), respectively. The accuracy of C-reactive protein and procalcitonin did not differ at any postoperative day. Conclusions Levels of inflammatory markers under the cutoff value between postoperative days 3 and 5 ensure safe early discharge after elective colorectal surgery. Procalcitonin seems not to have added value as compared to C-reactive protein in this setting.

Background: Sacrococcygeal pilonidal disease (SPD) is a common surgical condition for which a multitude of surgical treatments have been described. The present review aimed to evaluate the efficacy and safety of a novel endoscopic procedure for the treatment of SPD. Methods: An organized literature search was conducted. Electronic databases including PubMed/Medline, Scopus, Embase, and Cochrane library were searched for articles that assessed the endoscopic treatment for SPD. The main outcome parameters were failure of the technique including persistence and recurrence of SPD, postoperative complications and pain, time to complete healing, and time to return to work. Results: Nine studies with a total of 497 patients were included. Mean age of patients was 24.8 years. Mean operation time was 34.7 min. The procedure was performed as day-case surgery in all studies. The mean Visual analogue score of pain within the first week was 1.35. Failure of the technique was recorded in 40 (8.04%) patients, 20 (4.02%) had persistent SPD and 20 (4.02%) developed recurrence. The weighted mean failure rate of the technique was 6.3% (95% CI 3.6–9.1). Mean weighted complication rate was 1.1% (95% CI 0.3–2.4). Mean time to complete healing was 32.9 days and mean time to return to work was 2.9 days. Conclusion: The endoscopic treatment of pilonidal sinus is a promising and safe method of treatment of SPD. The main advantages of the endoscopic treatment as compared to conventional surgery are the minimal postoperative pain, quick healing, and short time to return to work and daily activities.

reply to a letter that questions a previous article

Letter answering the question arises from a previous article

OBJECTIVES: We designed a multicentric, observational study to test if Procalcitonin (PCT) might be an early and reliable marker of anastomotic leak (AL) after colorectal surgery (ClinicalTrials.govIdentifier:NCT01817647). BACKGROUND: Procalcitonin is a biomarker used to monitor bacterial infections and guide antibiotic therapy. Anastomotic leak after colorectal surgery is a severe complication associated with relevant short and long-term sequelae. METHODS: Between January 2013 and September 2014, 504 patients underwent colorectal surgery, for malignant colorectal diseases, in elective setting. White blood count (WBC), C-reactive protein (CRP) and PCT levels were measured in 3rd and 5th postoperative day (POD). AL and all postoperative complications were recorded. RESULTS: We registered 28 (5.6%) anastomotic leaks. Specificity and negative predictive value for AL with PCT less than 2.7 and 2.3 ng/mL were, respectively, 91.7% and 96.9% in 3rd POD and 93% and 98.3% in 5th POD. Receiver operating characteristic curve for biomarkers shows that in 3rd POD, PCT and CRP have similar area under the curve (AUC) (0.775 vs 0.772), both better than WBC (0.601); in 5th POD, PCT has a better AUC than CRP and WBC (0.862 vs 0.806 vs 0.611). Measuring together PCT and CRP significantly improves AL diagnosis in 5th POD (AUC: 0.901). CONCLUSIONS: PCT and CRP demonstrated to have a good negative predictive value for AL, both in 3rd and in 5th POD. Low levels of PCT, together with low CRP values, seem to be early and reliable markers of AL after colorectal surgery. These biomarkers might be safely added as additional criteria of discharge protocols after colorectal surgery.

Transanal endoscopic microsurgery is a faster and safer alternative to traditional surgical treatment of adenomas and low-risk (T1) rectal tumors. However, although overall survival appears similar, transanal endoscopic microsurgery has been shown to have higher recurrence rates.The aim of this study was to investigate the management of patients with local recurrence after transanal endoscopic microsurgery and to evaluate their long-term outcome.This study was a retrospective review of medical records.Patients were treated at a large tertiary-care hospital in Rome, Italy, between 1990 and 2011.Of 298 patients who underwent local excision with transanal endoscopic microsurgery, 144 patients with rectal adenocarcinoma were included in the study.Local excision was performed with transanal endoscopic microsurgery. In all cases complete full-thickness excision was attempted.Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed. Survival was calculated using the Kaplan-Meyer method and groups were compared with the log-rank test.Tumors were classified as pT1 in 86 patients (59.7%), pT2 in 38 (26.4%), and pT3 in 20 (13.9%). Median follow-up was 85 (range, 3-234) months. Median time to recurrence was 11.5 (range, 1-62) months; 44 patients had local or distal recurrence or both. The rate of local recurrence for patients with pT1 tumors was 11.6% (10/86). A total of 27 patients (18.8%) with local recurrence were eligible for salvage surgery: 17 had radical salvage resection, 9 had transanal re-excision, and 1 refused surgery. Overall 5-year survival was 83% in all 144 patients, and 92% in patients with pT1 tumors. The overall 5-year survival rate was higher in patients who had the radical salvage procedure than in those who had transanal re-excision (69% vs 43%; p = 0.05).The study was limited by its retrospective nature, lack of technology at the beginning of the study, and the mixed nature of the study group.The outcome after transanal excision for rectal cancer depends on close surveillance for early detection of recurrence. In patients able to undergo surgery, endoluminal or pelvic recurrence should be treated with an immediate radical salvage operation. Overall long-term survival after local excision with transanal endoscopic microsurgery followed by radical salvage surgery in cases of local recurrence is comparable to overall survival after initial radical surgery.

Anastomotic leak after gastrointestinal surgery is a severe complication associated with relevant short and long-term sequelae. Most of the anastomoses are currently performed with a surgical stapler that is required to have appropriate characteristics in order to guarantee good performances. The aim of our study was to evaluate, ex vivo, pressure resistance and tensile strength of anastomosis performed with different circular staplers available in the market. We studied 7 circular staplers of 3 different companies, 3 of them used for gastrointestinal anastomosis and 4 staplers for hemorrhoidal prolapse excision. A total of 350 anastomoses, 50 for each of the 7 staplers, were performed using healthy pig fresh intestine, then injected saline solution and recorded the leaking pressure. There were no statistically significant differences between the mean pressure necessary to induce an anastomotic leak in the various instruments (p >0.05). For studying tensile strength, we performed a total of 350 anastomoses with 7 different circular staplers on a special strong paper (Tyvek), and then recorded the maximal tensile force that could open the anastomosis. There were statistically significant differences between one brand stapler vs other 2 companies staplers about the strength necessary to open the staple line (p

Background Anastomotic leak (AL) after gastrointestinal surgery is a severe complication associated with relevant short- and long-term sequelae. Most of the anastomosis are currently performed with a surgical stapler that is required to have appropriate characteristics to guarantee good performances. The aim of our study was to evaluate, in the laboratory, pressure resistance and tensile strength of anastomosis performed with different surgical linear staplers, available in the market. Materials and methods We have been studying three linear staplers, with diverse cartridges and staple heights, of three different companies, used for gastrointestinal anastomosis and gastric or intestinal closure. We performed 50 anastomosis for each device, with the pertinent different cartridges, on fresh pig intestine, for a total of 350 anastomosis, then injected saline solution and recorded the pressure that provokes a leak on the staple line. There were no statistically significant differences between the mean pressure necessary to induce an AL in the various instruments (P > 0.05). For studying the tensile strength, we performed a total of 350 anastomosis with the different linear staplers on a special strong paper (Tyvek), then recorded the maximal tensile force that could open the anastomosis. Results There were no statistically significant differences between the different staplers about the strength necessary to open the staple line (P > 0.05). Conclusions we demonstrated that different linear staplers of three companies available in the market give comparable anastomotic pressure resistance and tensile strength. This might suggest that small dissimilarities between different devices are not involved, at least as major parameters, in AL etiology.

We would like to offer our experience with an unreported type of metastasis to Bauhin’s valve deriving from gallbladder adenocarcinoma as well as determining intestinal obstruction. An 83-year-old woman presented with intestinal obstruction of 2 days duration. Contrast-enhanced CT scan of the abdomen documented distended small-bowel loops and a 31 x 23 mm lesion in the right iliac fossa with distal ileal and cecal involvement (Fig. 1); additionally, a centimetric metastasis was observed in segment IV of the liver. An initial conservative management resulted successful permitting elective colonoscopy to visualize a polypoid lesion at the Bauhin’s valve (Fig. 2); biopsies were noncontributory. At this point, we decided to perform a right colectomy associated with an ultrasound-guided

PURPOSE To compare laparoscopic and open repair of incisional hernia in terms of complications and failure rates. METHODS Between June 2005 and April 2012, 252 patients underwent incisional hernia repair. Of these, 126 underwent laparoscopic and 126 open repair. The median follow-up was 38.7 months. RESULTS Baseline characteristics [age, body mass index, American Society of Anesthesiologists (ASA) score, comorbidities, hernia size, and follow-up] did not differ significantly. Mean operative time was similar (72 vs. 83 min). Laparoscopic repair was associated with less postoperative pain, less postoperative complications (3.9% vs. 13.4%, P=0.012), and shorter hospital stay (3.5 vs. 4.3, P=0.002). Recurrence occurred in 6 patients of group 1 and in 7 patients of group 2 (4.7% vs. 5.5%, P=not significant). CONCLUSIONS In this study, the trend in favor of laparoscopic treatment for incisional hernias is remarkable. Fewer postoperative complications and shorter hospital stay with similar operative time may balance the higher costs associated with the technique.

Pyogenic granuloma (PG) is a benign vascular lesion occurring most commonly on the acral skin of children. It is a capillary hemangioma of lobular subtype, often prone to bleeding. Surgical removal of the lesion is indicated to prevent bleeding and avoid diagnostic uncertainty. We describe a successful surgical removal of a rectal PG with transanal endoscopic microsurgery and review the reports of gastrointestinal tract PG in the international literature.

Dear Editor: Laparoscopic colorectal resection is equivalent to open resection in terms of oncologic outcomes, with superior perioperative results. Usually, an abdominal incision is required for anastomosis and specimen extraction. Recently, natural orifice specimen extraction (NOSE) and intracorporeal anastomosis have been proposed to improve the quality of laparoscopic colon resections. Transvaginal and transanal specimen extraction have been reported in association with right and left colic intracorporeal anastomosis and these two technical innovations may maximize the advantages of laparoscopic surgery. We present a case of double colon resection with intracorporeal anastomosis and transvaginal specimens extraction. A 73-year-old female obese patient was admitted for rectal bleeding and hypochromic microcytic anemia. Past medical history was significant for hypertension, COPD, myocardial infarction, treated with double stenting 4 years before, and sigmoid diverticular disease with several episodes of diverticulitis in the last 6 years. Her BMI was 36 kg/m. She denied any change in bowel habits, neither constipation nor diarrhea. She underwent colonoscopy revealing a gradually narrowing stenosis of the sigmoid with intact mucosa. Multiple biopsies were negative for cancer and confirmed the inflammatory disease. Due to the stenosing lesion, the procedure was incomplete and a virtual colonoscopy was performed. A right-colon mass, highly suspected for cancer but apparently not involving the lymph nodes, was found. Metastatic disease was excluded with contrast-enhanced total body CT scan. Preoperative carcinoembryonic antigen (CEA) level was normal (

To discuss the diagnostic and therapeutic aspects of spontaneous esophageal perforation. It is considered a surgical emergency with high rate of mortality. Its diagnosis can be difficult since the presentation is often nonspecific and can be confused with others disorders. Many strategies have been advocated for its management. Prompt diagnosis and early treatment are required to decrease the poor prognosis of this condition. A conservative therapy may be effective in selected cases.We described a successful non-surgical closure of a spontaneous esophageal perforation using an endoscopic stent, in an severely ill old patient. Although the treatment was delayed because of a late diagnosis, the patient survived the usually fatal condition.The key to improve the prognosis of this life-threatening emergency is the immediate and correct diagnosis and the most appropriate selection of the primary employed procedure.

BACKGROUND: Pancreatic carcinoma frequently infiltrates the portal vein or the superior mesenteric vein; pancreatectomy combined with portal vein/superior mesenteric vein resection represents a potentially curative treatment in these cases but is still a controversial procedure. METHODS: After performing a computerized Medline search, 12 series published during the last 8 years were selected, enrolling 399 patients who underwent pancreatectomy combined with portal vein/superior mesenteric vein resection for pancreatic carcinoma. Data were examined for information about indications, operation, adjuvant therapies, histopathology of resected specimens, perioperative results, and survival. Also, previous literature regarding the issue was extensively reviewed. RESULTS: Operative mortality and postoperative complication rates ranged from 0 to 7.7% and 16.7% to 54%, respectively. Median survival varied from 13 to 22 months; 5-year survival rate ranged from 9% to 18%. CONCLUSIONS: The current literature suggests that portal vein/superior mesenteric vein resection combined with pancreatectomy is a safe and feasible procedure that increases the number of patients who undergo curative resection and, therefore, provides important survival benefits to selected groups of patients. This procedure should always be considered in case of suspected tumor infiltration of portal/superior mesenteric vein to achieve clear resection margins, in the absence of other contraindications for resection.

Cavernous hemangiomas are rare, benign, non-functioning neoplastic lesions that often involve liver and skin. Hemangiomas of the adrenal gland are very uncommon, and usually found accidentally in otherwise asymptomatic patients. This paper reports the only case of a large cavernous hemangioma removed with transperitoneal laparoscopic adrenalectomy and reviews the literature.

Introduction Les infections intra-abdominales representent les complications les plus frequentes et les plus graves en termes de morbi-mortalite apres chirurgie colorectale programmee, en raison notamment d’un diagnostic souvent trop tardif. Plusieurs marqueurs ont ete etudies dans la litterature pour predire leur apparition, en particulier la proteine C-reactive (CRP) et la procalcitonine (PCT), mais avec des resultats contradictoires. L’objectif de cette meta-analyse etait de comparer les capacites predictives de la CRP et de la PCT dans la survenue des infections intra-abdominales apres chirurgie colorectale programmee en tenant compte de l’ensemble des donnees publiees et de leur heterogeneite. Methodes Les bases de donnees bibliographiques Medline et Cochrane ont ete consultees afin d’identifier les etudes portant sur le dosage de la CRP et/ou PCT a j2 et/ou j3 et/ou j4 et/ou j5. Seules les etudes ayant comme critere de jugement les infections intra-abdominales apres chirurgie colorectale programmee ont ete retenues. La qualite methodologique a ete evaluee par l’outil QUADAS2. Pour chaque biomarqueur et a chaque temps, les estimations de la sensibilite et specificite obtenues dans les differentes etudes ont ete utilisees pour estimer la courbe ROC resumee (SROC) et l’aire sous la courbe (AUC) correspondante. Le modele bivarie a effet aleatoire de DerSimonian and Laird a ete applique pour tenir compte de l’heterogeneite des estimations. L’analyse principale portait sur les valeurs de CRP et PCT obtenues a j4. Resultats Au total, 11 articles rassemblant 2692 patients ont ete inclus dans la meta-analyse. Sur l’ensemble des etudes, la frequence d’infections intra-abdominales etait de 9,6 %. A j4, la sensibilite variait entre 75 et 100 % et la specificite entre 60 et 76 % pour la CRP suivant les seuils choisis par les auteurs. Pour la PCT, la sensibilite variait entre 69 et 82 %, et la specificite entre 40 et 71 %. Il n’existait pas de difference significative entre CRP (AUC : 0,79 (IC 95 % [0,75–0,83]) et PCT (0,72 (IC 95 % [0,66–0,77]) a j4. Il n’existait pas non plus de differences significatives pour j2, j3 et j5. Conclusion Les resultats preliminaires suggerent que la PCT n’a pas une capacite predictive significativement superieure a la CRP pour les infections intra-abdominales apres chirurgie colorectale programmee. Avec un cout inferieur a la PCT, le dosage de la CRP a j4 pourrait etre privilegie pour predire les infections intra-abdominales.

Xanthogranulomatous inflammation (XGI) is a disease of unknown origin, most frequently described in the kidney and gallbladder; its localization in the colorectal tract is extremely rare. The extension of the typical inflammatory process to the surrounding tissues may lead to misdiagnosis as cancer. We report the case of a 56-year-old woman presenting to the Emergency Department with pain, increased levels of α1 and α2 proteins and C-reactive protein (17.5 mg/dL; normal value 0-0.5), and a palpable mass, localized in the right lower quadrant of the abdomen. A computed tomography scan showed a large right cecal mass with necrotic areas, local inflammation of retroperitoneal fat, and enlargement of local lymph nodes. Because of the high suspicion of colic abscess as well as malignancy and worsening of the clinical condition, the patient underwent right colectomy after 4 d of antibiotic treatment. Pathology revealed xanthogranulomatous inflammation involving the ileocecal valve. We review the reports of large bowel tract XGI in the international literature.

Purpose Procalcitonin (PCT) is a biomarker used to help sepsis diagnosing and monitoring and guide antibiotic therapy. Anastomotic leak (AL) after colorectal surgery is a severe complication associated with relevant short- and long-term sequelae. The aim of our study is to assess the predictive value of PCT levels to early diagnose AL after colorectal surgery. Methods Between September 2011 and September 2012, a series of 99 patients underwent colorectal surgery in our institution. In all cases, white blood cell (WBC) count, C-reactive protein (CRP), and PCT levels were measured in first, third, and fifth postoperative day (POD). Anastomotic leaks and all other postoperative complications were recorded. Results We registered 7 ALs (7.1%). Decreased PCT levels had a significant negative predictive value (NPV) for AL in third and fifth POD (96.7% and 96.7%, respectively), compared with CRP and WBC. The best diagnostic performance was obtained with the combination of PCT and CRP measurements in third and fifth POD (area under the curve, 0.87 and 0.94, respectively). In 5th POD, PCT improves diagnosis, but not in a statistically significant way (area under the curve, 0.86). Conclusions Compared with more established biochemical values such as CRP and WBC, PCT is an earlier, more sensitive, and reliable marker of AL. Increased PCT levels in early PODs after colorectal surgery may provide a more effective way to detect AL, before clinical symptoms appear. Moreover, normal PCT values might be also a useful marker to facilitate a safe and early discharge of selected patients after colorectal surgery.

Esophageal perforation has a high rate of mortality. Many strategies have been advocated for its management. Therapeutic options are surgical repair or resection, endoscopic placement of self-expandable metallic stents or, in selected cases, conservative management. We describe a case of a 75-year-old man admitted to our hospital for forceful vomiting since 24 hours. The patient was treated with endoscopic placement of a covered self expandable metallic stent. Although the late diagnosis delayed the treatment, the patient survived the usually fatal condition. The stent removal was performed 8 weeks after implantation. Immediate and correct diagnosis are the key elements in improving survival of patients with esophageal perforation. This has to be associated to the selection of the most appropriate treatment. Implantation of covered self-expandable metallic stents in compromised patients with esophageal perforation is a safe and feasible alternative to operative treatment.

Background: Several authors have demonstrated the safety and feasibility of laparoscopy in selected cases of abdominal emergencies. The aim of the study was to analyse the current Italian practice on the use of laparoscopy in abdominal emergencies and to evaluate the impact of the 2012 national guidelines on the daily surgical activity. Methods: Two surveys (42 closed-ended questions) on the use of laparoscopy in acute abdomen were conducted nationwide with an online questionnaire, respectively, before (2010) and after (2014) the national guidelines publication. Data from two surveys were compared using Chi-square or Fisher’s exact test, and data were considered significant when p < 0.05. Results: Two-hundred and one and 234 surgical units answered to the surveys in 2010 and 2014, respectively. Out of 144,310 and 127,013 overall surgical procedures, 23,407 and 20,102, respectively, were abdominal emergency operations. Respectively 24.74 % (in 2010) versus 30.27 % (in 2014) of these emergency procedures were approached laparoscopically, p = 0.42. The adoption of laparoscopy increased in all the considered clinical scenarios, with statistical significance in acute appendicitis (44 vs. 64.7 %; p = 0.004). The percentage of units approaching Hinchey III acute diverticulitis with laparoscopy in 26–75 % of cases (14.0 vs. 29.7 %; p = 0.009), those with >25 % of surgeons confident with laparoscopic approach to acute diverticulitis (29.9 vs. 54 %; p = 0.0009), the units with >50 % of surgeons confident with laparoscopic approach to acute appendicitis, cholecystitis and perforated duodenal ulcer, all significantly increased in the time frame. The majority of respondents declared that the 2012 national guidelines influenced their clinical practice. Conclusions: The surveys showed an increasing use of laparoscopy for patients with abdominal emergencies. The 2012 national guidelines profoundly influenced the Italian surgical practice in the laparoscopic approach to the acute abdomen.