Pietro Ursi

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4-5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment. METHODS: An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST. RESULTS: Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections). CONCLUSIONS: dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1-2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided.

Colovesical fistula (CVF) is an abnormal communication between bowel and urinary bladder. Main causes are represented by complicated diverticular disease, colonic and bladder cancer and iatrogenic complications. Diagnosis is often based on patognomonic signs: faecaluria, pneumaturia and recurrent urinary tract infections. Treatment of CVF includes non-surgical and surgical strategy. The non-surgical treatment is reserved to selected patients who are unfit for surgery. Surgery of CVFs is determined by the site of the colonic lesion and patient's comorbidity. However the surgical one-stage approach should be preferred, reserving the multi-stage procedure in patients with a pelvic abscess, or with advanced malignancy, or previous radiation therapy. The sole defunctioning stoma may be an option to improve the quality of life in patients unfit for bowel resection. In open surgery the standard operative management consists in resection and anastomosis of the involved bowel segment and closure of the bladder. Laparoscopic treatment of CVFs is feasible and safe if performed by skilled surgeons. Robotic surgery for CVF treatment is safe and feasible similarly to laparoscopic one and it seems to reduce the conversion rate with respect to laparoscopy. However, further studies are needed to evaluate the advantages of robotic surgery over laparoscopy in the management of CVF. Currently, in Literature it is still debated which is the best surgical approach for CFV treatment due to the lack of RCTs and CCTs, the small sample size and the short follow-up. Further studies with higher quality and larger sample size are necessary to state the gold standard surgical treatment of CVFs.

Introduction . In obese patients with hiatal hernia (HH), laparoscopic sleeve gastrectomy (LSG) with cruroplasty is an option but use of prosthetic mesh crura reinforcement is debated. The aim was to compare the results of hiatal closure with or without mesh buttressing during LSG. Methods . Gastroesophageal reflux disease (GERD) was assessed by the Health-Related Quality of Life (GERD-HRQL) questionnaire before and after surgery in two consecutive series of patients with esophageal hiatus ≤ 4 cm 2 . After LSG, patients in group A (12) underwent simple cruroplasty, whereas in group B patients (17), absorbable mesh crura buttressing was added. Results . At mean follow-up of 33.2 and 18.1 months for groups A and B, respectively (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M1"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn>0.006</mml:mn></mml:math>), the mean preoperative GERD-HRQL scores of 16.5 and 17.7 (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M2"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn>0.837</mml:mn></mml:math>) postoperatively became 9.5 and 2.4 (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M3"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn>0.071</mml:mn></mml:math>). In group A, there was no difference between pre- and postoperative scores (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M4"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn>0.279</mml:mn></mml:math>), whereas in group B, a highly significant difference was observed (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M5"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn>0.002</mml:mn></mml:math>). The difference (Δ) comparing pre- and postoperative mean scores between the two groups was significantly in favor of mesh placement (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M6"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn>0.0058</mml:mn></mml:math>). Conclusions . In obese patients with HH and mild-moderate GERD, reflux symptoms are significantly improved at medium term follow-up after cruroplasty with versus without crura buttressing during LSG.