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Background Minimally invasive pancreaticoduodenectomy (PD) remains one of the most challenging abdominal procedures, and its application is poorly reported in the literature so far. To date, few data are available comparing a minimally invasive approach to open PD. The aim of the present study is to compare the robotic and open approaches for PD at a single institution. Methods Data from 83 consecutive PD procedures performed between January 2002 and May 2010 at a single institution were retrospectively reviewed. Patients were stratified into two groups: the open group ( n  = 39; 47%) and the robotic group ( n  = 44; 53%). Results Patients in the robotic group were statistically older (63 years of age versus 56 years; p  = 0.04) and heavier (body mass index: 27.7 vs. 24.8; p  = 0.01); and had a higher American Society of Anesthesiologists (ASA) score (2.5 vs. 2.15; p  = 0.01) when compared to the open group. Indications for surgery were the same in both groups. The robotic group had a significantly shorter operative time (444 vs. 559 min; p  = 0.0001), reduced blood loss (387 vs. 827 ml; p  = 0.0001), and a higher number of lymph nodes harvested (16.8 vs. 11; p  = 0.02) compared to the open group. There was no significant difference between the two groups in terms of complication rates, mortality rates, and hospital stay. Conclusions The authors present one of the first studies comparing open and robotic PD. While it is too early to draw definitive conclusions concerning the long-term outcomes, short-term results show a positive trend in favor of the robotic approach without compromising the oncological principles associated with the open approach.

Background Application of the robot for Roux-en-Y gastric bypass has been slow to evolve, despite its rapid acceptance in other fields. This is largely due to associated costs of technology, reports of increased operative time, and inadequate data available to correlate the benefits of robotics to a clinical outcome. The authors present a comparative study between laparoscopic and robot-assisted Roux-en-Y gastric bypass performed at a specialized institution for robotic surgery. Materials and method A total of 135 consecutive Roux-en-Y gastric bypass procedures were performed from January 2006 to December 2009 by a single surgeon. The first 45 were performed laparoscopically and the remaining 90 were robot-assisted. Patient demographics, operative time, complication rate, length of stay, long-term weight loss, and follow-up for the two groups were gathered from a prospectively maintained database and statistically analyzed. Results The overall operative time was significantly shorter for the robot-assisted procedures than for the laparoscopic procedures (207 ± 31 vs. 227 ± 31 min) ( P  = 0.0006). The robotic set-up time remained constant at 13 ± 4 min. 30 robotic cases were necessary in order to perform the procedure in less time than with the laparoscopic approach ( P  = 0.047). Mortality was 0% in both groups, with no conversions to open surgery and no transfusions. Early morbidities and percentage of excess weight loss at 1 year were comparable for the two groups. Conclusions The use of the robot for performing the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass does not increase the operative time or the rate of specific complications. The short-term outcomes of the robot-assisted procedure are comparable to those found with the conventional laparoscopic method.

Background Prophylactic negative-pressure wound therapy (pNPWT) may prevent surgical site infection (SSI) after laparotomy, but existing meta-analyses pooling only high-quality evidence have failed to confirm this effect. Recently, several randomized controlled trials (RCTs) have been published. We performed an updated systematic review and meta-analysis to determine if pNPWT reduces the incidence of SSI after laparotomy. Methods MEDLINE, Embase, CENTRAL and Web of Science were searched on the 25.08.2021 for RCTs reporting on the incidence of SSI in patients who underwent laparotomy with and without pNPWT. The systematic review was compliant with the AMSTAR2 recommendation and registered into PROSPERO. Risk ratios (RR) for SSI in patients with pNPWT, and risk difference (RD) between control and pNPWT patients, were obtained using random effects models. Heterogeneity was quantified using the I 2 value, and investigated using subgroup analyses, funnel plots and bubble plots. Risk of bias of included RCTs was assessed using the RoB2 tool. Results Eleven RCTs were included, representing 973 patients who received pNPWT and 970 patients who received standard wound dressing. Pooled RR and RD between patients with and without pNPWT were of, respectively, 0.665 (95% CI 0.49–0.91, I 2 : 38.7%, p  = 0.0098) and −0.07 (95% CI −0.12 to −0.03, I 2 : 53.6%, p  = 0.0018), therefore demonstrating that pNPWT decreases the incidence of SSI after laparotomy. Investigation of source of heterogeneity identified a potential small-study effect. Conclusion The protective effect of pNPWT against SSI after laparotomy is confirmed by high-quality pooled evidence.

IntroductionBowel viability can be difficult to evaluate during emergency surgery. Near-infrared (NIR) fluorescence angiography allows an intraoperative assessment of organ perfusion during elective surgery and might help to evaluate intestinal perfusion during emergency procedures. The aim of this study was to assess if NIR modified operative strategy during emergency surgery.Materials and methodsFrom July 2014 to December 2015, we prospectively evaluated all consecutive patients, who had NIR assessment during emergency surgery. Primary endpoint was the modification of operative strategy after the assessment with NIR. Secondary endpoints were general post-operative outcomes, including reoperation rate.ResultsFifty-six patients were included in the study. Mean age was 64 ± 17 years. An exploratory laparoscopy was performed in 39% (n = 22) and an open surgery in 61% of cases (n = 34). Conversion rate to open surgery was 41% (n = 9). 32 patients had a bowel resection. In 32% of the cases (n = 18), the result of the NIR test led to a modification of the operative strategy. Among them, 33% (n = 6) had a larger resection or a resection, which was initially not planned. The other 12 patients (67%) had finally no resection, which was initially thought to be performed. Importantly, none of those patients needed a reoperation for ischemia. Mean time for performing NIR test was 167 s (± 121). Overall reoperation rate was 16.1% (n = 9). Two patients had an anastomotic leak. Eight patients (14.3%) died within the first 30 post-operative days; however, none of them presented a bowel ischemia or an anastomotic leak.ConclusionNIR is an easy and short procedure, which can be performed during emergency surgery to assess bowel perfusion. It may help the surgeon to preserve intestinal length or to define the exact limits of resection. Overall, we report a modification of operative strategy in up to one-third of evaluated patients.

PurposeMucosal advancement flap (MAF) is the best option for complex anal fistula (AF) treatment. Recurrence is not rare and the best surgical option for his handling is a challenge considering the incontinence risk and the healing rate. We aimed to determine the feasibility and outcomes of a second MAF for recurrent complex AF previously treated with mucosal advancement flap.MethodsWe retrospectively identified 32 patients undergoing two or more MAF for recurrent AF in a larger cohort of 121 consecutive cases of MAF operated by the same senior colorectal surgeon. Only complex AF of cryptoglandular origin was enrolled. A long-term follow-up was performed collecting clinical and functional data.ResultsAmong 121 patients (group A) treated with mucosal advancement flap, 32 (26.4%) (group B) recurred with a complex AF requiring a second mucosal advancement flap procedure. Success rate of group B is 78.1%. Six patients of group B recurred a second time, another MAF was performed with healing in all cases. Complication rate (Clavien Dindo 3b) of group B is 9.4% compared to 8.3% of group A. A slight continence deficit (Miller score 1, 2, and 4) was detected after the first MAF in 3 patients. The Miller score for these patients did not change after the subsequent MAF.ConclusionsMAF is effective for treatment of complex recurrent AF. A pre-existing MAF procedure does not worsen the healing rate of the second flap. The rate of surgical complications is similar with those reported in the literature for MAFs.

Purpose It is currently unknown whether NASH (nonalcoholic steatohepatitis), as compared to simple steatosis, is associated with impaired postoperative weight loss and metabolic outcomes after RYGB surgery. To compare the effectiveness of Roux-en-Y gastric bypass (RYGB) on patients with NASH versus those with simple nonalcoholic fatty liver (NAFL). Materials and Methods We retrospectively retrieved data from 515 patients undergoing RYGB surgery with concomitant liver biopsy. Clinical follow-up and metabolic assessment were performed prior to surgery and 12 months after surgery. We used multivariate analysis of variance (MANOVA) and propensity score matching and we assessed for changes in markers of hepatocellular injury and metabolic outcomes. Results There were 421 patients with simple NAFL, and 94 with NASH. Baseline alanine and aspartate aminotransferases were significantly higher in patients with NASH ( p  < 0.01). Twelve months after the RYGB surgery, as determined by both MANOVA and propensity score matching, patients with NASH exhibited a significantly greater reduction in alanine aminotransferase ( ß -coefficient − 12 iU/l [− 22 to − 1.83], 95% CI, adjusted p  = 0.021) compared to their NAFL counterparts (31 matched patients in each group with no loss to follow-up at 12 months). Excess weight loss was similar in both groups ( ß -coefficient 4.54% [− 3.12 to 12.21], 95% CI, adjusted p  = 0.244). Change in BMI was comparable in both groups (− 14 (− 16.6 to − 12.5) versus − 14.3 (− 17.3 to − 11.9), p  = 0.784). Conclusion After RYGB surgery, patients with NASH experience a greater reduction in markers for hepatocellular injury and similar weight loss compared to patients with simple steatosis.

The name of the second author of this article was incorrectly presented as “Riccardo Scarpa Cosimo” this should have been “Cosimo Riccardo Scarpa”.

Background While laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed procedures for morbid obesity in the USA, robotic application has been viewed as a valid option. However, the technique is not firmly established with single robotic docking. The objective of this video is to demonstrate the technical details of performing a standardized monoquadrant robotic Roux-en-Y gastric bypass (RRYGB). Methods Between April 2008 and May 2009, 15 patients meeting the NIH consensus criteria for bariatric surgery underwent a monoquadrant RRYGB. The data were prospectively collected in a dedicated bariatric database and reviewed retrospectively. The patient was positioned supine. Subsequent to creating a 30-ml gastric pouch using a series of endostaplers, the da Vinci robotic system (Intuitive, Sunnyvale, CA) was docked cranially. The robotic arms were attached in the double cannulation fashion. The gastrojejunostomy (GJ) was performed by a robot-assisted hand-sewn double-layered technique, followed by the creation of a jejunojejunostomy (JJ) with an endostapler. The common enterotomy of the JJ was closed with robot-assisted hand-sewn double-layered fashion. The bridge of jejunum between the GJ and JJ was transected separating both anastomoses. The mesenteric defect was not routinely closed at the end of the procedure. Results There were 13 women and 2 men with a median age of 36 years included in this study. The procedure was successfully accomplished by a monoquadrant robotic technique in 14 cases (93.3%). One case was converted to open procedure because of an intra-operative enterotomy by an endostapler. The mean operative time was 202 min (range 158–353 min). There was no postoperative complication, notably no GI leak or anastomotic bleeding. The median hospital stay was 2.4 days (range 1.7–4 days). The mean weight loss after 1 year was 38.5 kg. Conclusions This video highlights the feasibility of performing a standardized monoquadrant RRYGB in its entirety with single docking of the da Vinci robotic system.

Bacterial osteomyelitis implicates inflammation of the bone and bone marrow. All implant infections have an osteitis component, since the implant itself is inert to microorganisms. Many experts advocate that if the bone is infected, it may remain infected throughout life and even beyond unless amputation is performed. This chapter talks about epidemiology, and pathogenesis under which osseous modification, biofilm, and neutrophil defects, are described. It also talks about surgical treatment, and hyperbaric oxygen therapy, among others, for the treatment of Osteomyelitis. Diabetic foot osteomyelitis and arthroplasty‐related osteomyelitis, are two of the various special features of osteomyelitis discussed in the chapter. It is very difficult to evaluate osteomyelitis in small clinical studies or single centers. Sample size and international definitions need to be improved and more prospective and multicenter cohort studies performed to broaden and advance current knowledge.

Introduction Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease. Methods Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan–Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021). Results One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / − 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / − 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12–1.13%), at 5 years: 1.07% (0.50–2.28%), at 10 years: 2.14% (1.07–4.25%) and at 15 years: 2.14% (1.07–4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years. Conclusion The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.