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1.  Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital 
BMC Surgery  2014;14:14.
Background
Laparoscopic appendectomy is not yet unanimously considered the “gold standard” in the treatment of acute appendicitis because of its higher operative time, intra-abdominal abscess risk, and costs compared to open appendectomy. This study aimed to compare outcomes and cost of laparoscopic and open appendectomy in a district hospital.
Methods
A retrospective analysis of 230 patients who underwent appendectomy at the Division of General Surgery of the Civil Hospital of Ragusa, Italy, from May 2008 to May 2012 was performed. The variables analyzed included patients data (age, gender, previous abdominal surgery, preoperative WBC count, duration of symptoms, ASA risk score), rate of uncomplicated or complicated appendicitis, operative time, postoperative complications, length of hospital stay, and total costs. The patients were divided in two groups according to the surgical approach and compared for each variable. The results were analyzed using the t Student test for quantitative variables, and the Chi-square test with Yates correction and Fisher exact test for categorical.
Results
Laparoscopic appendectomy was performed in 139 patients, open appendectomy in 91. Two cases (1.4%) were converted to open procedure and included in the laparoscopic group data. Patient data and rate of complicated appendicitis were similar in the two study groups. There was no statistical difference (p = 0.476) in the mean operative time between the laparoscopic (52.2 min; range, 20–155) and open appendectomy (49.3 min; range, 20–110) groups. The overall incidence of minor and major complications was significantly lower (p = 0.006) after laparoscopic appendectomy (2.9%, 4 cases) than after open appendectomy (13.2%, 12 cases); rate of intra-abdominal abscess were similar. The length of hospital stay was significantly shorter (p = 0.001) in laparoscopic group (2.75 days; range, 1–8) than in open group (3.87 days; range, 1–19). The mean total cost was 2282 Euro in laparoscopic group and 2337 Euro in open group, with a no significant difference of 55 Euro (p = 0.812).
Conclusion
Laparoscopic appendectomy is associated with fewer complications, shorter hospital stay, and similar operative time, intra-abdominal abscess rate, and total costs, compared with open appendectomy. Therefore, laparoscopic appendectomy can be recommended as preferred approach in acute appendicitis.
doi:10.1186/1471-2482-14-14
PMCID: PMC3984427  PMID: 24646120
Laparoscopic appendectomy; Open appendectomy; Costs; Complications; Intra-abdominal abscess; Operative time; Length of hospital stay
2.  Follicular nodules (Thy3) of the thyroid: is total thyroidectomy the best option? 
BMC Surgery  2014;14:12.
Background
Identification of the best management strategy for nodules with Thy3 cytology presents particular problems for clinicians. This study investigates the ability of clinical, cytological and sonographic data to predict malignancy in indeterminate nodules with the scope of determining the need for total thyroidectomy in these patients.
Methods
The study population consisted of 249 cases presenting indeterminate nodules (Thy3): 198 females (79.5%) and 51 males (20.5%) with a mean age of 52.43 ± 13.68 years. All patients underwent total thyroidectomy.
Results
Malignancy was diagnosed in 87/249 patients (34.9%); thyroiditis co-existed in 119/249 cases (47.79%) and was associated with cancer in 40 cases (40/87; 45.98%). Of the sonographic characteristics, only echogenicity and the presence of irregular margins were identified as being statistically significant predictors of malignancy. 52/162 benign lesions (32.1%) and 54/87 malignant were hypoechoic (62.07%); irregular margins were present in 13/162 benign lesions (8.02%), and in 60/87 malignant lesions (68.97%). None of the clinical or cytological features, on the other hand, including age, gender, nodule size, the presence of microcalcifications or type 3 vascularization, were significantly associated with malignancy.
Conclusions
The rate of malignancy in cytologically indeterminate lesions was high in the present study sample compared to other reported rates, and in a significant number of cases Hashimoto’s thyroiditis was also detected. Thus, considering the fact that clinical and cytological features were found to be inaccurate predictors of malignancy, it is our opinion that surgery should always be recommended. Moreover, total thyroidectomy is advisable, being the most suitable procedure in cases of multiple lesions, hyperplastic nodular goiter, or thyroiditis; the high incidence of malignancy and the unreliability of intraoperative frozen section examination also support this preference for total over hemi-thyroidectomy.
doi:10.1186/1471-2482-14-12
PMCID: PMC3946766  PMID: 24597765
Follicular neoplasm; Thyroid cancer; Thyroid; Fine needle aspiration; Cytology
3.  Intraoperative use of enriched collagen and elastin matrices with freshly isolated adipose-derived stem/stromal cells: a potential clinical approach for soft tissue reconstruction 
BMC Surgery  2014;14:10.
Background
Adipose tissue contains a large number of multipotent cells, which are essential for stem cell-based therapies. The combination of this therapy with suitable commercial clinically used matrices, such as collagen and elastin matrices (i.e. dermal matrices), is a promising approach for soft tissue reconstruction. We previously demonstrated that the liposuction method affects the adherence behaviour of freshly isolated adipose-derived stem/stromal cells (ASCs) on collagen and elastin matrices. However, it remains unclear whether freshly isolated and uncultured ASCs could be directly transferred to matrices during a single transplantation operation without additional cell culture steps.
Methods
After each fat harvesting procedure, ASCs were isolated and directly seeded onto collagen and elastin matrices. Different time intervals (i.e. 1, 3 and 24 h) were investigated to determine the time interval needed for cellular attachment to the collagen and elastin matrices. Resazurin-based vitality assays were performed after seeding the cells onto the collagen and elastin matrices. In addition, the adhesion and migration of ASCs on the collagen and elastin matrices were visualised using histology and two-photon microscopy.
Results
A time-dependent increase in the number of viable ASCs attached to the collagen and elastin matrices was observed. This finding was supported by mitochondrial activity and histology results. Importantly, the ASCs attached and adhered to the collagen and elastin matrices after only 1 h of ex vivo enrichment. This finding was also supported by two-photon microscopy, which revealed the presence and attachment of viable cells on the upper layer of the construct.
Conclusion
Freshly isolated uncultured ASCs can be safely seeded onto collagen and elastin matrices for ex vivo cellular enrichment of these constructs after liposuction. Although we observed a significant number of seeded cells on the matrices after a 3-h enrichment time, we also observed an adequate number of isolated cells after a 1-h enrichment time. However, this approach must be optimised for clinical use. Thus, in vivo studies and clinical trials are needed to investigate the feasibility of this approach.
doi:10.1186/1471-2482-14-10
PMCID: PMC3936703  PMID: 24555437
Adipose tissue-derived stem/stromal cells; Stromal vascular fraction; Liposuction; Fat grafting; Biomaterials; Collagen-based scaffolds; Regeneration and tissue engineering
4.  Changes in obesity-related diseases and biochemical variables after laparoscopic sleeve gastrectomy: a two-year follow-up study 
BMC Surgery  2014;14:8.
Background
To evaluate changes in obesity-related diseases and micronutrients after laparoscopic sleeve gastrectomy (LSG).
Methods
We started the procedure in May 2007, and by December 2011, 117 patients could be evaluated for a two year follow-up. Comparisons of preoperative status with 12 and 24 months postoperative status were made for body mass index (BMI), obesity-related diseases and micronutrients.
Results
Major complications included bleeding requiring transfusion at 5.1%, leak at 1.7% and abscess without a visible leak at 0.9%. Mean BMI was reduced from 46.6 (standard deviation (SD) 6.0) kg/m2 to 30.6 (SD 5.6) kg/m2 at two years, and resolution occurred for 80.7% of patients with type 2 diabetes, 63.9% with hypertension, 75.8% with hyperlipidemia, 93.0% with sleep apnea, 31.4% with musculoskeletal pain, 85.4% with snoring and 73.3% with urinary incontinence. Amenorrhea resolved in all premenopausal females. The proportion of patients with symptomatic gastroesophageal reflux disease increased from 12.8% to 27.4%. The prevalence of patients with low ferritin-levels increased, while 25-hydroxyvitamin D (25(OH)D) deficiency decreased postoperatively.
Conclusions
LSG is an effective procedure for morbid obesity and obesity-related diseases, but the technique should be further explored particularly to avoid gastroesophageal reflux.
doi:10.1186/1471-2482-14-8
PMCID: PMC3923733  PMID: 24517247
Sleeve gastrectomy; Obesity; Comorbidities; Complications
5.  Effect on the tensile strength of human acellular dermis (Epiflex®) of in-vitro incubation simulating an open abdomen setting 
BMC Surgery  2014;14:7.
Background
The use of human acellular dermis (hAD) to close open abdomen in the treatment process of severe peritonitis might be an alternative to standard care. This paper describes an investigation of the effects of fluids simulating an open abdomen environment on the biomechanical properties of Epiflex® a cell-free human dermis transplant.
Methods
hAD was incubated in Ringers solution, blood, urine, upper gastrointestinal (upper GI) secretion and a peritonitis-like bacterial solution in-vitro for 3 weeks. At day 0, 7, 14 and 21 breaking strength was measured, tensile strength was calculated and standard fluorescence microscopy was performed.
Results
hAD incubated in all five of the five fluids showed a decrease in mean breaking strength at day 21 when compared to day 0. However, upper GI secretion was the only incubation fluid that significantly reduced the mechanical strength of Epiflex after 21days of incubation when compared to incubation in Ringer’s solution.
Conclusion
hAD may be a suitable material for closure of the open abdomen in the absence of upper GI leakage and pancreatic fistulae.
doi:10.1186/1471-2482-14-7
PMCID: PMC3916513  PMID: 24468201
Acellular dermis; Open abdomen; Breaking strength; Biologicals
6.  An atypical presentation of intrahepatic perforated cholecystitis: a modern indication to open cholecystectomy. Report of a case 
BMC Surgery  2014;14:6.
Background
Intrahepatic gallbladder perforation with chronic liver abscess formation was anecdotically reported in the literature. The aim of this work is to report a case of intrahepatic gallbladder perforation and its atypical clinical presentation.
Case presentation
A 62-year-old male patient came to our observation; his medical history showed intermittent fever up to 39-40°C of about 2 weeks and anorexia, with an overall weight loss of about 12 Kg. Physical examination of the abdomen was negative. An ultrasound of the liver and an abdominal CT angiogram detected a disomogeneous hypoechoic-hypodense area in the 5th segment of the liver. Differential diagnosis between hepatic abscess or gallbladder cancer remained open. A surgical exploration was planned. After laparoscopic exploration, a conversion to open procedure with an atypical resection of the 5th hepatic segment was performed. Histologic examination of the specimen showed an intrahepatic chronic perforation of the gallbladder with intrahepatic abscess.
Conclusion
To the best of our knowledge, 18 cases have been reported in the literature as a Niemeier type I perforation. Clinical presentation, even in its extreme rarity, is more often acute. Differential diagnosis between gallbladder cancer versus liver abscess remains controversial. Open approach is mandatory in such cases.
doi:10.1186/1471-2482-14-6
PMCID: PMC3930071  PMID: 24468118
Intrahepatic perforation; Hepatic abscess; Chronic perforation; Chronic cholecystitis
7.  Impact of neoadjuvant chemotherapy with PELF-protocoll versus surgery alone in the treatment of advanced gastric carcinoma 
BMC Surgery  2014;14:5.
Background
In a retrospective study we analyzed the impact of neoadjuvant chemotherapy (CTx) with the PELF - protocol (Cisplatin, Epirubicin, Leukovorin, 5-Fluoruracil) on mortality, recurrence and prognosis of patients with advanced gastric carcinoma, UICC stages Ib-III.
Methods
64 patients were included. 26 patients received neoadjuvant CTx followed by surgical resection, 38 received surgical resection only. Tumor staging was performed by endoscopy, endosonography, computed tomography and laparoscopy. Patients staged Ib – III received two cycles of CTx according to the PELF-protocol. Adjuvant chemotherapy was not performed at all.
Results
Complete (CR) or partial response (PR) was seen in 20 patients (77%), 19% showing CR and 58% PR. No benefit was observed in 6 patients (23%). Two of these 6 patients displayed tumor progression during CTx. Major toxicity was defined as grade 3 to 4 neutropenia or gastrointestinal side effects. One patient died under CTx because of neutropenia and was excluded from the overall patient collective. The curative resection rate was 77% after CTx and 74% after surgery only. The perioperative morbidity rate after CTx was 39% versus 66% after resection only. Recurrence rate after CTx was 38% and 61% after surgery alone; we detected an effective reduction of locoregional recurrence (12% vs. 26%). The overall survival was 38% after CTx and 42% after resection only. The 5-year survival rates were 45% in responders, 20% in non - responders and 42% in only resected patients. A subgroup analysis indicates that responders with stage III tumors may benefit with respect to their 5-year survival in comparable patients without neoadjuvant CTx. As to be expected, non-responders with stage III tumors did not benefit with respect to their survival. The 5-year-survival was approximated using a Kaplan-Meier curve and compared using a log-rank test.
Conclusion
In patients with advanced gastric carcinoma, neoadjuvant CTx with the PELF- protocol significantly reduces the recurrence rate, especially locoregionally, compared to surgery alone. In our study, there was no overall survival benefit after a 5-year follow-up period. Alone a subgroup of patients with stage III tumors appear to benefit significantly in the long term from neoadjuvant CTx.
doi:10.1186/1471-2482-14-5
PMCID: PMC3909936  PMID: 24461063
Neoadjuvant chemotherapy; PELF; Advanced gastric cancer
8.  Complete pathological response (ypT0N0M0) after preoperative chemotherapy alone for stage IV rectal cancer 
BMC Surgery  2014;14:4.
Background
Complete pathological response occurs in 10–20% of patients with rectal cancer who are treated with neoadjuvant chemoradiation therapy prior to pelvic surgery. The possibility that complete pathological response of rectal cancer can also occur with neoadjuvant chemotherapy alone (without radiation) is an intriguing hypothesis.
Case presentation
A 66-year old man presented an adenocarcinoma of the rectum with nine liver metastases (T3N1M1). He was included in a reverse treatment, aiming at first downsizing the liver metastases by chemotherapy, and subsequently performing the liver surgery prior to the rectum resection. The neoadjuvant chemotherapy consisted in a combination of oxaliplatin, 5-FU, irinotecan, leucovorin and bevacizumab (OCFL-B). After a right portal embolization, an extended right liver lobectomy was performed. On the final histopathological analysis, all lesions were fibrotic, devoid of any viable cancer cells. One month after liver surgery, the rectoscopic examination showed a near-total response of the primary rectal adenocarcinoma, which convinced the colorectal surgeon to perform the low anterior resection without preoperative radiation therapy. Macroscopically, a fibrous scar was observed at the level of the previously documented tumour, and the histological examination of the surgical specimen did not reveal any malignant cells in the rectal wall as well as in the mesorectum. All 15 resected lymph nodes were free of tumour, and the final tumour stage was ypT0N0M0. Clinical outcome was excellent, and the patient is currently alive 5 years after the first surgery without evidence of recurrence.
Conclusion
The presented patient with stage IV rectal cancer and liver metastases was in a unique situation linked to its inclusion in a reversed treatment and the use of neoadjuvant chemotherapy alone. The observed achievement of a complete pathological response after chemotherapy should promote the design of prospective randomized studies to evaluate the benefits of chemotherapy alone in patients with stages II-III rectal adenocarcinoma (without metastasis).
doi:10.1186/1471-2482-14-4
PMCID: PMC3900671  PMID: 24438090
Pathological complete response; Stage iv rectal cancer; Preoperative chemotherapy; Oxaliplatin
9.  BMC Surgery reviewer acknowledgement 2013 
BMC Surgery  2014;14:2.
Contributing reviewers
The editors of BMC Surgery would like to thank all our reviewers who have contributed their time to the journal in Volume 13 (2013).
doi:10.1186/1471-2482-14-2
PMCID: PMC3893518
10.  Percutaneous balloon kyphoplasty for the treatment of vertebral compression fractures 
BMC Surgery  2014;14:3.
Background
Vertebral compression fractures (VCFs) constitute a major health care problem, not only because of their high incidence but also because of their direct and indirect negative impacts on both patients’ health-related quality of life and costs to the health care system. Two minimally invasive surgical approaches were developed for the management of symptomatic VCFs: balloon kyphoplasty and vertebroplasty. The purpose of this study was to evaluate the effectiveness and safety of balloon kyphoplasty in the treatment of symptomatic VCFs.
Methods
Between July 2011 and June 2012, one hundred and eighty-seven patients with two hundred and fifty-one vertebras received balloon kyphoplasty in our hospital. There were sixty-five male and one hundred and twenty-two female patients with an average age of 74.5 (range, 61 to 95 years). The pain symptoms and quality of life, were measured before operation and at one day, three months, six months and one year following kyphoplasty. Radiographic data including restoration of kyphotic angle, anterior vertebral height, and any leakage of cement were defined.
Results
The mean visual analog pain scale decreased from a preoperative value of 7.7 to 2.2 at one day (p < .05) following operation and the Oswestry Disability Index improved from 56.8 to 18.3 (p < .05). The kyphotic angle improved from a mean of 14.4° before surgery to 6.7° at one day after surgery (p < .05). The mean anterior vertebral height increased significantly from 52% before surgery to 74.5% at one day after surgery (p < .05) and 70.2% at one year follow-up. Minor cement extravasations were observed in twenty-nine out of two hundred and fifty-one procedures, including six leakage via basivertebral vein, three leakage via segmental vein and twenty leakage through a cortical defect. None of the leakages were associated with any clinical consequences.
Conclusions
Balloon kyphoplasty not only rapidly reduced pain and disability but also restored sagittal alignment in our patients at one-year follow-up. The treatment of osteoporotic vertebral compression fractures with balloon kyphoplasty is a safe, effective, and minimally invasive procedure that provides satisfactory clinical results.
doi:10.1186/1471-2482-14-3
PMCID: PMC3922728  PMID: 24423182
11.  The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia 
BMC Surgery  2014;14:1.
Background
Although minimally invasive repair of giant hiatal hernias is a very surgical challenge which requires advanced laparoscopic learning curve, several reports showed that is a safe and effective procedure, with lower morbidity than open approach. In the present study we show the outcomes of 13 patients who underwent a laparoscopic repair of giant hiatal hernia.
Methods
A total of 13 patients underwent laparoscopic posterior hiatoplasty and Nissen fundoplication. Follow-up evaluation was done clinically at intervals of 3, 6 and 12 months after surgery using the Gastro-oesophageal Reflux Health-Related Quality of Life scale, a barium swallow study, an upper gastrointestinal endoscopy, an oesophageal manometry, a combined ambulatory 24-h multichannel impedance pH and bilirubin monitoring. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge.
Results
There were no intraoperative complications and no conversions to open technique. Symptomatic GORD-HQL outcomes demonstrated a statistical significant decrease of mean value equal to 3.2 compare to 37.4 of preoperative assessment (p < 0.0001). Combined 24-h multichannel impedance pH and bilirubin monitoring after 12 months did not show any evidence of pathological acid or non acid reflux.
Conclusion
All patients were satisfied of procedure and no hernia recurrence was recorded in the study group, treated respecting several crucial surgical principles, e.g., complete sac excision, appropriate crural closure, also with direct hiatal defect where possible, and routine use of antireflux procedure.
doi:10.1186/1471-2482-14-1
PMCID: PMC3898021  PMID: 24401085
Giant hiatal hernia; Hiatoplasty; Antireflux surgery; Hiatal mesh reinforcement; Sac excision; Crural closure
12.  Mastectomy for management of breast cancer in Ibadan, Nigeria 
BMC Surgery  2013;13:59.
Background
Modified radical mastectomy remains the standard therapeutic surgical operation for breast cancer in most parts of the world. This retrospective study reviews mastectomy for management of breast cancer in a surgical oncology division over a ten year period.
Methods
We reviewed the case records of consecutive breast cancer patients who underwent mastectomy at the Surgical Oncology Division, University College Hospital (UCH) Ibadan between November 1999 and October 2009.
Results
Of the 1226 newly diagnosed breast cancer patients over the study period, 431 (35.2%) patients underwent mastectomy making an average of 43 mastectomies per year. Most patients were young women, premenopausal, had invasive ductal carcinoma and underwent modified radical mastectomy as the definitive surgical treatment. Prior to mastectomy, locally advanced tumors were down staged in about half of the patients that received neo-adjuvant combination chemotherapy. Surgical complication rate was low. The most frequent operative complication was seroma collection in six percent of patients. The average hospital stay was ten days and most patients were followed up at the surgical outpatients department for about two years post-surgery.
Conclusions
There was low rate of mastectomy in this cohort which could partly be attributable to late presentation of many patients with inoperable local or metastatic tumors necessitating only palliative or terminal care. Tumor down-staging with neo-adjuvant chemotherapy enhanced surgical loco-regional tumor control in some patients. The overall morbidity and the rates of postoperative events were minimal. Long-term post-operative out-patients follow-up was not achieved as many patients were lost to follow up after two years of mastectomy.
doi:10.1186/1471-2482-13-59
PMCID: PMC3878251  PMID: 24354443
Breast cancer; Mastectomy; Nigeria
13.  Management of acute upside-down stomach 
BMC Surgery  2013;13:55.
Background
Upside-down stomach (UDS) is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. Symptoms may vary heavily as they are related to reflux and mechanically impaired gastric emptying. UDS is associated with a risk of incarceration and volvulus development which both might be complicated by acute gastric outlet obstruction, advanced ischemia, gastric bleeding and perforation.
Case presentation
A 32-year-old male presented with acute intolerant epigastralgia and anterior chest pain associated with acute onset of nausea and vomiting. He reported on a previous surgical intervention due to a hiatal hernia. Chest radiography and computer tomography showed an incarcerated UDS. After immediate esophago-gastroscopy, urgent laparoscopic reduction, repair with a 360° floppy Nissen fundoplication and insertion of a gradually absorbable GORE® BIO-A®-mesh was performed.
Conclusion
Given the high risk of life-threatening complications of an incarcerated UDS as ischemia, gastric perforation or severe bleeding, emergent surgery is indicated. In stable patients with acute presentation of large paraesophageal hernia or UDS exhibiting acute mechanical gastric outlet obstruction, after esophago-gastroscopy laparoscopic reduction and hernia repair followed by an anti-reflux procedure is suggested. However, in cases of unstable patients open repair is the surgical method of choice. Here, we present an exceptionally challenging case of a young patient with a giant recurrent hiatal hernia becoming clinically manifest in an incarcerated UDS.
doi:10.1186/1471-2482-13-55
PMCID: PMC3830558  PMID: 24228771
Upside-down stomach; Hiatal hernia; Paraesophageal hernia; Gastric incarceration; Gastric outlet obstruction; Gastric volvulus
14.  Treatment modality in type II odontoid fractures defines the outcome in elderly patients 
BMC Surgery  2013;13:54.
Background
Odontoid fractures account for approximately 20% of all fractures of the cervical spine. They represent the most common cervical spine injury for patients older than 70 years, the majority being type II fractures (65-74%), which are considered to be relatively unstable. The management of these fractures is controversial. Possible treatment options are either conservative or surgical. Surgical procedures include either anterior screw fixation of the odontoid or posterior C1/C2 fusion. The aim of this study was to compare the outcome of the three treatment modalities in elderly patients.
Methods
Between June 2004 and February 2010, all patients older than 65 years (n = 47) with type II fractures of the odontoid according to the Anderson and D’Alonso classification were retrospectively reviewed.
Results
In the non-operatively managed cohort, 11 patients (79%) died postoperatively within a mean period of 23 months. In all other cases (n = 3), radiographs demonstrated non-union. The mean lateral displacement was 1.9 mm (range 0–5,8 mm) and a mean angulation of 29,1° (range 0-55°) was found.
Anterior screw fixation was carried out in 17 patients. The non-union rate in this cohort was 77%. In patients with a posterior C1-C2 fusion, a bony fusion of the posterior elements was found in 15 of 16 cases (93%). Survival rates were significantly higher among the group of patients who were treated with anterior screw fixation or posterior C1/C2 fusion compared to the conservatively treated group.
Conclusion
We found the best clinical results with low rates of non-union as well as low mortality rates following posterior C1/C2 fusion making this our treatment of choice especially in an elderly patient collective.
doi:10.1186/1471-2482-13-54
PMCID: PMC3833842  PMID: 24206537
15.  Current status of robotic bariatric surgery: a systematic review 
BMC Surgery  2013;13:53.
Background
Bariatric surgery is an effective treatment to obtain weight loss in severely obese patients. The feasibility and safety of bariatric robotic surgery is the topic of this review.
Methods
A search was performed on PubMed, Cochrane Central Register of Controlled Trials, BioMed Central, and Web of Science.
Results
Twenty-two studies were included. Anastomotic leak rate was 8.51% in biliopancreatic diversion. 30-day reoperation rate was 1.14% in Roux-en-Y gastric bypass and 1.16% in sleeve gastrectomy. Major complication rate in Roux-en-Y gastric bypass resulted higher than in sleeve gastrectomy ( 4,26% vs. 1,2%). The mean hospital stay was longer in Roux-en-Y gastric bypass (range 2.6-7.4 days).
Conclusions
The major limitation of our analysis is due to the small number and the low quality of the studies, the small sample size, heterogeneity of the enrolled patients and the lack of data from metabolic and bariatric outcomes. Despite the use of the robot, the majority of these cases are completed with stapled anastomosis. The assumption that robotic surgery is superior in complex cases is not supported by the available present evidence. The major strength of the robotic surgery is strongly facilitating some of the surgical steps (gastro-jejunostomy and jejunojejunostomy anastomosis in the robotic Roux-en-Y gastric bypass or the vertical gastric resection in the robotic sleeve gastrectomy).
doi:10.1186/1471-2482-13-53
PMCID: PMC3826835  PMID: 24199869
Morbid obesity; Bariatric surgery; Robotic; Roux-en-Y gastric bypass; Robot assisted; Gastric bypass; Sleeve gastrectomy; Gastric banding; Duodenal switch; Surgical outcomes; Complications; Anastomotic leak
16.  Distraction test of the posterior superior iliac spine (PSIS) in the diagnosis of sacroiliac joint arthropathy 
BMC Surgery  2013;13:52.
Background
The sacroiliac joint (SIJ) is a frequently underestimated cause of lower back (LBP). A simple clinical test of sufficient validity would be desirable. The aim of this study was to evaluate the diagnostic value of a new PSIS distraction test for the clinical detection of SIJ arthropathy and to compare it to several commonly used clinical tests.
Methods
Consecutive patients, where a SIJ pathology had been confirmed by an SIJ infiltration were enrolled (case group, 61 SIJs in 46 patients). Before infiltration, patients were tested for pain with PSIS distraction by a punctual force on the PSIS in medial-to-lateral direction (PSIS distraction test), pain with pelvic compression, pelvic distraction, Gaenslen test, Thigh Thrust, and Faber (or Patrick’s) test. In addition, these clinical tests were applied to both SIJs of a population of individuals without history of LBP (control group, 64 SIJs in 32 patients).
Results
Within the investigated cohort, the PSIS distraction test showed a sensitivity of 100% and a specificity of 89% for SIJ pathology. The accuracy of the test was 94%, the positive predictive value (PPV) was 90% and the negative predictive value (NPV) was 100%. Pelvic compression, pelvic distraction, Gaenslen test, Thigh Thrust, and Faber test were associated with a good specificity (> 90%) but a poor sensitivity (< 35%).
Conclusions
Within our population of patients with confirmed SIJ arthropathy the PSIS distraction test was found to be of high sensitivity, specificity and accuracy. In contrast, common clinical tests showed a poor sensitivity. The PSIS distraction test seems to be an easy-to-perform and clinically valuable test for SIJ arthropathy.
doi:10.1186/1471-2482-13-52
PMCID: PMC3827936  PMID: 24175954
Sacroiliac joint pain; Provocation test; Joint infiltration; Diagnostic value
17.  Pedunculated lipoma causing colo-colonic intussusception: a rare case report 
BMC Surgery  2013;13:51.
Background
Intussusception is a relatively common cause of intestinal obstruction in children but a rare clinical entity in adults, representing fewer than 1% of intestinal obstructions in this patient population. Colonic lipomas are uncommon nonepithelial neoplasms that are typically sessile, asymptomatic and incidentally found during endoscopy, surgery, or autopsy.
Case presentation
A 55-year old man visited our emergency department with severe abdominal pain, multiple episodes of vomiting, abdominal distension. Abdominal ultrasound sonography and computed tomography showed a sausage-shaped mass presenting as a target sign, suggestive of intussusception. Surgery revealed a hard elongated mass in the right colon wihch telescoped in the transverse colon and caused colo-colonic intussusception. Rhigt hémicolectomy was performed and pathology documented a mature submucosal lipoma of the colon. We describe the difficulties in diagnosis and management of this rare cause of bowel obstruction and review the literature on adult intussusceptions.
Conclusion
A large submucosal lipoma is a very rare cause of colon intussusception that presents as intestinal obstruction in patients without malignancy. CT and magnetic resonance imaging remain the methods of choice for studying abdominal lipomas, particularly those rising into the layers of the colonic wall. Surgical resection remains the treatment of choice and produces an excellent prognosis.
doi:10.1186/1471-2482-13-51
PMCID: PMC3818566  PMID: 24171703
Intussusception; Lipoma; Abdominal computed tomography; Colo-colic; Invagination
18.  Resection of a malignant paraganglioma located behind the retrohepatic segment of the inferior vena cava 
BMC Surgery  2013;13:49.
Background
Resection of a retrocaval paraganglioma is technically challenging due to limited tumor accessibility and proximity to the vena cava.
Case presentation
A large, malignant paraganglioma was found behind the retrohepatic segment of the inferior vena cava of a 60-year-old male. During resection of this rare paraganglioma, the left lateral lobe of the liver, a portion of the caudate lobe of the liver, and the gallbladder were also removed. Unfortunately, the patient died six months after surgery due to hepatic metastasis.
Conclusion
This case demonstrates that a partial hepatectomy may be necessary to improve tumor accessibility during resection of a retrocaval paraganglioma, particularly if the tumor is proximal to the vena cava. Furthermore, palliative treatments may help prevent tumor recurrence and metastasis of malignant paragangliomas.
doi:10.1186/1471-2482-13-49
PMCID: PMC3840563  PMID: 24164783
Paraganglioma; Inferior vena cava; Partial hepatectomy; Malignant
19.  A double blind randomized controlled trial comparing primary suture closure with mesh augmented closure to reduce incisional hernia incidence 
BMC Surgery  2013;13:48.
Background
Incisional hernia is the most frequently seen long term complication after laparotomy causing much morbidity and even mortality. The overall incidence remains 11-20%, despite studies attempting to optimize closing techniques. Two patient groups, patients with abdominal aortic aneurysm and obese patients, have a risk for incisional hernia after laparotomy of more than 30%. These patients might benefit from mesh augmented midline closure as a means to reduce incisional hernia incidence.
Methods/design
The PRImary Mesh Closure of Abdominal Midline Wound (PRIMA) trial is a double-blinded international multicenter randomized controlled trial comparing running slowly absorbable suture closure with the same closure augmented with a sublay or onlay mesh. Primary endpoint will be incisional hernia incidence 2 years postoperatively. Secondary outcomes will be postoperative complications, pain, quality of life and cost effectiveness.
A total of 460 patients will be included in three arms of the study and randomized between running suture closure, onlay mesh closure or sublay mesh closure. Follow-up will be at 1, 3, 12 and 24 months with ultrasound imaging performed at 6 and 24 months to objectify the presence of incisional hernia. Patients, investigators and radiologists will be blinded throughout the whole follow up.
Disccusion
The use of prosthetic mesh has proven effective and safe in incisional hernia surgery however its use in a prophylactic manner has yet to be properly investigated. The PRIMA trial will provide level 1b evidence whether mesh augmented midline abdominal closure reduces incisional hernia incidence in high risk groups.
Trial registration
Clinical trial.gov NCT00761475.
doi:10.1186/1471-2482-13-48
PMCID: PMC3840708  PMID: 24499111
20.  A survey of surgical team members’ perceptions of near misses and attitudes towards Time Out protocols 
BMC Surgery  2013;13:46.
Background
Medical errors are inherently of concern in modern health care. Although surgical errors as incorrect surgery (e.g., wrong patient, wrong site, or wrong procedure) are infrequent, they are devastating events to experience. To gain insight about incidents that could lead to incorrect surgery, we surveyed how surgical team members perceive near misses and their attitudes towards the use of Time Out protocols in the operating room. We hypothesised that perceptions of near-miss experiences and attitudes towards Time Out protocols vary widely among surgical team members.
Methods
This cross-sectional study (N = 427) included surgeons, anaesthetists, nurse anaesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members’ experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room.
Results
In the operating room, 38% of respondents had experienced uncertainty of patient identity, 81% had experienced uncertainty of the surgical site or side, and 60% had prepared for the wrong procedure. Sixty-three per cent agreed that verifying the correct patient, site, and procedure should be a team responsibility. Thus, only nurse anaesthetists routinely performed identity checks prior to surgery (P ≤ 0.001). Of the surgical team members, 91% supported implementation of a Time Out protocol in their operating rooms.
Conclusion
The majority of our surgical personnel experienced near misses with regard to correct patient identity, surgical site, or procedure. Routines for ensuring the correct patient, site, and surgical procedure must involve all surgical team members. We find that the near-miss experiences are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery.
doi:10.1186/1471-2482-13-46
PMCID: PMC3851944  PMID: 24106792
Surgery; Operating room; Near misses; Medical errors; Checklist
21.  Experience with a new prosthetic anal sphincter in three coloproctological centres 
BMC Surgery  2013;13:45.
Background
Fecal incontinence is a common and severely disabling disorder. For patients with severe fecal incontinence, surgery may prove to be the only adequate treatment option.
Methods
This study reports on 43 patients that were treated with a prosthetic sphincter system between 2005 and 2009 in three coloproctological centres. Main Outcome Measures: complications, anal pressures before and after surgery, fecal continence score.
Results
The new artificial sphincter system significantly improves continence but leads to some complications in clinical practice. After implantation of the device, continence improved significantly (Keller & Jostarndt continence score 2.6 to 14.3 (P < 0.01)). With the band activated, resting pressure improved significantly as compared to baseline (10.7 mmHg vs. 66.1 mm Hg, P < 0.01). The same holds for anal sphincter squeeze pressure (32.2 mmHg versus 85.9 mm Hg, P < 0.01). Complications occurred in 21 patients (48.8%): 10 surgical and 13 technical. Two patients were affected by both technical and surgical problems. The median time of the occurrence was 3 months postop. In five patients difficulties arose within the first postoperative month leading to explantation of the device in three patients. 90% of complications occurred in the first year.
Conclusions
The soft anal band of AMI (AAS), a new artificial anal sphincter, improves severe anal incontinence, but it must be regarded as a last treatment option to avoid a stoma.
doi:10.1186/1471-2482-13-45
PMCID: PMC3853926  PMID: 24502440
Fecal incontinence; Prosthetic sphincter; Treatment option
22.  Incidence of pain after inguinal hernia repair in the elderly. A retrospective historical cohort evaluation of 18-years’ experience with a mesh & plug inguinal hernia repair method on about 3000 patients 
BMC Surgery  2013;13(Suppl 2):S19.
Background
Chronic pain after prosthetic inguinal hernioplasty is one of the most important current issues in the current literature debate. Mechanisms related to pain development are only partially known. Influence of age as well as other factors is still unclear. The aim of this work was to evaluate whether development of chronic pain after open prosthetic plug and mesh inguinal hernioplasty is influenced by age.
Methods
Analysis was retrospectively conducted, dividing our cohort of patients (2,902) who had undergone prosthetic open plug&mesh inguinal hernioplasty from Jannuary 1994 to May 2012, following only the age criterion (cut-off 65 yrs.), into two groups (Gr.A<65 yrs, Gr.B>65 yrs.). All patients were routinely submitted to a postoperative questionnaire. Complications such as analgesic assumption were registered in both groups. Pain intensity was classified following the Visual Analogic Scale (VAS). Incidence of chronic pain, discomfort, and numbness, was assessed in both groups. Statistical significance was assessed by X2-test.
Results
Only 0.2% of patients suffered from a recurrence in our cohort. Postoperative chronic pain was observed in Gr. A in 0.12% of patients vs Gr.B 0.09% (p>0.05). Incidence of other postoperative symptoms such as discomfort or numbness were slightly prevalent on young patients (respectively p = 0.0286 and p = 0.01), while for hyperesthesia and sensation of foreign body no statistically significant difference of incidence between groups was observed.
Conclusions
Real chronic pain after inguinal hernioplasty is a rare clinical entity. Other causes of chronic pain should be accurately researched and excluded. In young patients psychological factors seem to show a slight influence. There was no influence of age on chronic postoperative pain incidence after inguinal hernioplasty.
doi:10.1186/1471-2482-13-S2-S19
PMCID: PMC3850950  PMID: 24268023
23.  Mesenteric ischemia: the importance of differential diagnosis for the surgeon 
BMC Surgery  2013;13(Suppl 2):S51.
Background
Intestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.
Methods
Basing on our institutions experience, 163 cases of mesenteric ischemia/infarction from various cases, investigated with CT and undergone surgical treatment were retrospectively evaluated, in particular trought the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).
Results
To make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial, venous) and non occlusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.
Conclusion
The radiological findings of mesenteric ischemia have different course in case of different etiology. In venous etiology the progression of damage results faster than arterial even if the symptomatology is less acute; bowel wall thickening is an early finding and easy to detect, simplifying the diagnosis. In arterial etiology the damage progression is slower than in venous ischemia, bowel wall thinning is typical but difficult to recognize so diagnosis may be hard. In the NOMI before/without reperfusion the ischemic damage is similar to AAMI with additional involvement of large bowel parenchymatous organs. In reperfusion after NOMI and after AAMI the CT and surgical findings are similar to those of AVMI, and the injured bowel results quite easy to identify. The prompt recognition of each condition is essential to ensure a successful treatment.
doi:10.1186/1471-2482-13-S2-S51
PMCID: PMC3850956  PMID: 24267670
Intestinal ischemia; Computed Tomography; Emergency radiology
24.  Diagnostic utility of BRAFV600E mutation testing in thyroid nodules in elderly patients 
BMC Surgery  2013;13(Suppl 2):S37.
Background
Thyroid cancer is a rare disease characterized by the subtle appearance of a nodule. Fine-needle cytology (FNC) is the first diagnostic procedure used to distinguish a benign from a malignant nodule. However, FNC yields inconclusive results in about 20% of cases. BRAFV600E mutation is the most frequent genetic alteration in papillary thyroid carcinoma (PTC); its high prevalence makes this oncogene a useful marker to refine inconclusive FNC results. However, the prevalence of the BRAFV600E mutation depends on detection methods, geographical factors, and age. The aim of this study is to determine the prevalence of BRAFV600E mutation and its utility as a diagnostic tool in elderly subjects.
Methods
FNC from 92 PTC patients were subjected to the analysis of BRAF mutation by pyrosequencing and direct sequencing; age-dependent prevalence was also determined.
Results
BRAF mutation analysis was successful in all FNC specimens. BRAFV600E was documented in 62 (67.4%) and in 58 (63.0%) PTCs by pyrosequencing and direct sequencing, respectively. BRAFV600E prevalence did not correlate with patient's age at diagnosis. Twenty out of 32 PTCs (62.5%) were correctly diagnosed by BRAF mutation analysis in inconclusive FNC results.
Conclusions
Detection of BRAFV600E in cytology specimens by pyrosequencing is a useful diagnostic adjunctive tool in the evaluation of thyroid nodules also in elderly subjects.
doi:10.1186/1471-2482-13-S2-S37
PMCID: PMC3850960  PMID: 24267957
25.  Usefulness of CT-scan in the diagnosis and therapeutic approach of gallstone ileus: report of two surgically treated cases 
BMC Surgery  2013;13(Suppl 2):S6.
Background
Gallstone ileus is a rare cause of gastrointestinal obstruction, more frequent in elderly patients, whose treatment is essentially surgical, although some para-surgical and mini-invasive possibilities exist, allowing the solution of such obstructive condition in a completely non-invasive way.
Description
In our study, after reporting two cases of biliary ileus managed by our surgical division, we will analyze the most suitable diagnostic procedures and the therapeutic approaches to this pathology.
Conclusions
Gallstone ileus is a quite rare pathology in population, but affects more frequently elderly people; The treatment of this disease is mainly surgical.
doi:10.1186/1471-2482-13-S2-S6
PMCID: PMC3850963  PMID: 24268073

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