Comparabilità e valutazione dei servizi sanitari

  • Nerina Agabiti1

  1. Dipartimento di epidemiologia del servizio sanitario regionale, Lazio
Nera Agabiti -

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Ricerca bibliografica periodo dal 16 settembre 2014 – 01 dicembre 2014

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Stringa: (((“Quality Indicators, Health Care"[Mesh] OR "Quality Assurance, Health Care"[Mesh] OR "Outcome Assessment (Health Care)" [Mesh:NoExp] OR Outcome*[tiab] OR “quality indicators”[tiab], OR appropriateness [tiab] OR indicator* [TIAB] OR procedure [TIAB] OR efficacy[tiab] OR effectiveness[tiab]) AND ("hospitals"[MeSH] OR hospital[tiab] OR mortality[tw] OR patient* [tiab]) AND (italy[mesh] OR ital* [tiab] OR ita [la] OR ital* [ad]) AND (“2014/09/16”[PDat] : “2014/12/01”[PDat])) NOT ((animals [mesh] NOT humans [mesh]) OR "Genetics"[Mesh] OR "Neurophysiology"[Mesh] "Drug Therapy"[Mesh] OR "Naturopathy"[Mesh] OR "drug therapy "[Subheading] OR Editorial[ptyp] OR "Case Reports "[Publication Type] OR Letter[ptyp] OR Clinical Trial, Phase I[ptyp] OR Clinical Trial, Phase II[ptyp]))
1. Cappabianca P(1), Cavallo LM(2), Solari D(2), Stagno V(2), Esposito F(2), de Angelis M(2). Endoscopic Endonasal Surgery for Pituitary Adenomas.
World Neurosurg. 2014 Dec;82(6S):S3-S11. doi: 10.1016/j.wneu.2014.07.019.
Author information: (1)Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy. Electronic address: (2)Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy.

BACKGROUND: Pituitary surgery is a continuous evolving specialty of the neurosurgeons' armamentarium, which requires precise anatomic knowledge, technical skills, and integrated culture of the pituitary pathophysiology. Actually it cannot be considered only from a technical standpoint, but rather a procedure resulting from the close cooperation among different specialists (e.g., ophthalmologists, neuroradiologists, endocrinologists, neurosurgeons, otorhinolaryngologists, anesthesiologists, neurophysiologists, pathologists, instrument manufacturers). METHODS: The "pure" endoscopic endonsal surgery is a procedure performed through the nose, with the endoscope alone throughout the whole approach and without any transsphenoidal retractor. The procedure consists of three main aspects: exposure of the lesion, removal of the relevant pathology, and reconstruction, going through three different steps, the nasal, the sphenoid, and the sellar phases. CONCLUSIONS: The endoscopic approach offers some advantages due to the endoscope itself: a superior close-up view of the relevant anatomy and an enlarged working angle are provided with an increased panoramic vision inside the surgical area. Concerning results in terms of mass removal, relief of clinical symptoms, cure of the underlying disease, and complication rate, these are, at least, similar to those reported in the major microsurgical series, but patient compliance is by far better. Besides the advantages to the patients, the surgeons-because of the wider and closer view of the surgical target area and the increase of the scientific activity as from the peer-reviewed literature on the topic in the past 10 years, the smoothing of interdisciplinary cooperation-, and the institutions (shorter postoperative hospital stay and increase of the case load)- the adoption of endoscopy in transsphenoidal surgery has gained a strong foothold.

2. Petrelli F(1), Coinu A(2), Riboldi V(3), Borgonovo K(4), Ghilardi M(5), Cabiddu M(6), Lonati V(7), Sarti E(8), Barni S(9). Concomitant platinum-based chemotherapy or cetuximab with radiotherapy for locally advanced head and neck cancer: A systematic review and meta-analysis of published studies.
Oral Oncol. 2014 Nov;50(11):1041-1048. doi: 10.1016/j.oraloncology.2014.08.005. Epub 2014 Aug 28.
Author information: (1)Medical Oncology Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address: (2)Medical Oncology Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address: (3)Radiotherapy Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address: (4)Medical Oncology Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address: (5)Medical Oncology Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address: (6)Medical Oncology Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address: (7)Medical Oncology Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address: (8)Radiotherapy Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address: (9)Medical Oncology Unit, Oncology Department, Azienda Ospedaliera Treviglio, Treviglio, BG, Italy. Electronic address:

The combinations of radiotherapy (RT) plus chemotherapy (CTRT) with cisplatin or, alternatively, RT plus cetuximab (RT+CET), are the treatments of choice for locally advanced squamous cell carcinoma of the head and neck (HNSCC). We performed a systematic review and meta-analysis of published studies reporting the efficacy of these 2 combined modality therapies for the treatment of locoregionally advanced HNSCC. We performed a systematic search of PUBMED, EMBASE, Web of Science, SCOPUS, and the Cochrane Register of Controlled Trials. Meta-analysis was performed using the fixed- or random-effects models. The primary endpoints were 2-year overall survival (OS), 2-year progression-free survival (PFS), and 2-year locoregional relapse (LRR), reported as risk ratios (RRs) and 95% confidence intervals (CIs). Fifteen trials, including a total of 1808 patients, were analysed. Three of these trials were prospective, and 12 were retrospective. Overall, for locally advanced HNSCC, concomitant CTRT significantly improved 2-year OS (RR=0.66; 95% CI, 0.46-0.94; P=0.02), 2-year PFS (RR=0.68; 95% CI, 0.53-0.87; P=0.002), and 2-year LRR (RR=0.63; 95% CI, 0.45-0.87; P=0.005) compared to RT+CET. For the treatment of locally advanced HNSCC, platinum-based CTRT is associated with a better OS and PFS compared to RT+CET, and this is probably attributed to improved locoregional disease control. Thus, platinum-based CTRT should remain the standard of care until equivalence with RT+CET can be prospectively demonstrated.

3. Tampieri A(1), Giovannini E, Rusconi AM, Cristoni L, Bendanti D, Cenni P, Lenzi T. Safety and feasibility of intravenous rt-PA in the Emergency Department without a neurologist-based stroke unit: an observational study.
Intern Emerg Med. 2014 Nov 28. [Epub ahead of print]
Author information: (1)Emergency Department, Ospedale Civile Santa Maria della Scaletta. Imola, Via Montericco 4, Imola (Bologna), 40026, Italy,

Early intravenous thrombolysis has proven to be a safe and effective therapy for selected patients with acute ischemic stroke (AIS). Nowadays, thrombolysis is usually delivered by neurologists in "hub" referral centers. However, only a few among eligible patients actually receive treatment. Barriers to early administration of thrombolysis are represented by delays in presentation to referral centers, in-hospital and transfer delays, as well as changes in symptoms during assessment time. The aim of this study is to evaluate the safety and rate of thrombolysis provided in Emergency Department (ED) of a district hospital without neurological stroke team. Consecutive patients with AIS treated with intravenous thrombolysis were prospectively enrolled in this observational study, conducted between May 2010 and December 2013. The main outcomes evaluated were: mortality, symptomatic intracerebral hemorrhage (ICH), systemic adverse events, and neurological recovery. Secondly, all patients admitted with ischemic stroke were retrospectively screened to assess the reasons for exclusion to treatment and the rate of thrombolysis delivered. During the study period, 43 patients with AIS received intravenous rt-PA treatment. The mortality rate at three months was 9.5 % (4/43; 95 % CI 2.6-22.1) and total ICH at any-time CT scan imaging was 18.6 % (8/43; 8.4-33.4). At seven days or at discharge, 35/43 patients (81.4 %; 66.6-91.6) presented a neurological improvement and 46.5 % (20/43; 31.2-62.3) a complete neurological recovery presenting a normal NIHSS, while 9.5 % of patients remained in steady conditions and other 9.5 % worsened (4/43; 2.6-22.1). Outcomes do not appear to be very different from those reported in SITS-MOST study cohort. Among the overall 732 patients with AIS, 117 (16.0 %; 13.4-18.8) were eligible for age and arrived within the three-hour window of time, and the thrombolysis rate was 5.9 % (43/732; 4.3-7.8). Administration of rt-PA in an ED setting without neurological specialized stroke unit seems to be feasible and safe after adequate training. Thrombolysis rate found seems to be favorably comparable with the national average in specialist stroke units. If such data were confirmed by studies of greater dimension, this may imply the ability to perform thrombolysis even in smaller centers without the neurologist, thus being able to treat a greater number of patients in the times proven effective for thrombolysis.

4. Bacchetti S(1), Pasqual EM(1), Bertozzi S(1), Londero AP(1), Risaliti A(1). Curative versus palliative surgical resection of liver metastases in patients with neuroendocrine tumors: a meta-analysis of observational studies.
Gland Surg. 2014 Nov;3(4):243-51. doi: 10.3978/j.issn.2227-684X.2014.02.05.
Author information: (1)1 Department of Surgery, 2 University of Udine, AOU "Santa Maria della Misericordia", Udine, Italy.

BACKGROUND: The role of surgical therapy in patients with liver metastases from neuroendocrine tumors (NETs) is unclear. In this study, the results obtained with curative or palliative resection, by reviewing recent literature and performing a meta-analysis, were examined. MATERIALS AND METHODS: A systematic review and meta-analysis of observational studies published between January 1990 and October 2013 were performed. Studies that evaluated the different survival between patients treated by curative or palliative surgical resection of hepatic metastases from NETs were considered. The collected studies were evaluated for heterogeneity, publication bias, and quality. To calculate the pooled hazard ratio (HR) estimate and the 95% confidence interval (95% CI), a fixed-effects model was applied. RESULTS: After the literature search, 2,546 studies were found and, among 38 potentially eligible studies, 3 were considered. We did not find a significant longer survival in patients treated with curative surgical resection of hepatic metastases when compared to palliative hepatic resection HR 0.40 (95% CI: 0.14-1.11). In one study, palliative resection of hepatic metastases significantly increased survival when compared to embolization. CONCLUSIONS: Curative and also palliative surgery of NETs liver metastases may improve survival outcome. However, further randomized clinical trials are needed to elucidate this argument.

5. Behrens F(1), Cañete JD(2), Olivieri I(2), van Kuijk AW(2), McHugh N(2), Combe B(2). Tumour necrosis factor inhibitor monotherapy vs combination with MTX in the treatment of PsA: a systematic review of the literature.
Rheumatology (Oxford). 2014 Oct 27. pii: keu415. [Epub ahead of print]
Author information: (1)CIRI/Division of Rheumatology and Fraunhofer Institute IME, Translational Medicine and Pharmacology, Goethe University, Frankfurt/Main, Germany, Arthritis Unit, Rheumatology Department, Hospital Clinic and IDIBAPS, Barcelona, Spain, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Italy, Rheumatology Department, Reade/Jan van Breemen Research Institute, Amsterdam, The Netherlands, Rheumatology Department, Royal National Hospital for Rheumatic Diseases, Bath, UK and Departement de Rhumatologie Hôpital Lapeyronie-Université Montpellier I, UMR 5535, Montpellier, France. (2)CIRI/Division of Rheumatology and Fraunhofer Institute IME, Translational Medicine and Pharmacology, Goethe University, Frankfurt/Main, Germany, Arthritis Unit, Rheumatology Department, Hospital Clinic and IDIBAPS, Barcelona, Spain, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Italy, Rheumatology Department, Reade/Jan van Breemen Research Institute, Amsterdam, The Netherlands, Rheumatology Department, Royal National Hospital for Rheumatic Diseases, Bath, UK and Departement de Rhumatologie Hôpital Lapeyronie-Université Montpellier I, UMR 5535, Montpellier, France.

OBJECTIVES: The aim of this study was to review the available evidence on TNF inhibitor monotherapy vs combination therapy with MTX in PsA. METHODS: A literature search was conducted up to and including October 2013 for randomized controlled trials (RCTs) and observational studies comparing TNF inhibitor monotherapy vs combination therapy with MTX in patients with PsA. Key information was extracted from the abstracts and/or full text of the articles retrieved. RESULTS: Eleven published articles and three conference abstracts were retrieved, reporting on six RCTs of four TNF inhibitors. Most RCTs found no differences in efficacy for peripheral arthritis between patients treated with or without MTX. However, the studies were not powered to answer this question. Some data suggest that concomitant MTX may reduce the progression of structural damage. No significant differences in other outcomes have been reported. Data on TNF inhibitor monotherapy vs MTX combination therapy were reported from six registries. Three registries reported that the use of concomitant MTX did not affect the efficacy of TNF inhibitor therapy. Data from three European Union registries suggest that TNF inhibitor (especially mAbs) drug survival is superior in patients taking concomitant MTX, while one Canadian registry reported no difference. CONCLUSION: Available evidence on the efficacy and safety of TNF inhibitor monotherapy vs add-on MTX therapy shows little or no improvement with combination therapy, although the use of concomitant MTX appears to prolong TNF inhibitor drug survival of mAb TNF inhibitors. Registries and observational studies have the potential to fill some of the knowledge gaps in this area.

6. Couchoud C(1), Bolignano D(2), Nistor I(3), Jager KJ(4), Heaf J(5), Heimburger O(6), Van Biesen W(7); on Behalf of the European Renal Best Practice (ERBP) Diabetes Guideline Development Group. Dialysis modality choice in diabetic patients with end-stage kidney disease: a systematic review of the available evidence.
Nephrol Dial Transplant. 2014 Sep 23. pii: gfu293. [Epub ahead of print]
Author information: (1)REIN registry, Agence de la biomédecine, Saint-Denis La Plaine, France. (2)CNR-Institute of Clinical Physiology, Reggio Calabria, Italy ERBP, Ghent University Hospital, Ghent, Belgium. (3)Nephrology Department, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania. (4)ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. (5)Department of Nephrology B, Copenhagen University hospital at Herlev, Herlev, Denmark. (6)Division of Renal Medicine, Department of Clinical Science, Karolinska Institutet, Huddinge University Hospital, Stockholm, Sweden. (7)Chair of ERBP, Renal Division, Ghent University Hospital, Ghent, Belgium.

BACKGROUND: Diabetes is the leading cause of end-stage kidney disease (ESKD). Because of conflicting results in observational studies, it is still subject to debate whether in diabetic patients the dialysis modality selected as first treatment (haemodialysis or peritoneal dialysis) may have a major impact on outcomes. We therefore aimed at performing a systematic review of the available evidence. METHODS: MEDLINE, EMBASE and CENTRAL databases were searched until February 2014 for English-language articles without time or methodology restrictions by highly sensitive search strategies focused on diabetes, end-stage kidney disease and dialysis modality. Selection of relevant studies, data extraction and analysis were performed by two independent reviewers. RESULTS: Twenty-five observational studies (23 on incident and 2 on prevalent cohorts) were included in this review. Mortality was the only main outcome addressed in large cohorts. When considering patient survival, results were inconsistent and varied across study designs, follow-up period and subgroups. We therefore found no evidence-based arguments in favour or against a particular dialysis modality as first choice treatment in patients with diabetes and ESKD. However, peritoneal dialysis (PD) as first choice seems to convey a higher risk of death in elderly and frail patients. CONCLUSIONS: The available evidence derived from observational studies is inconsistent. Therefore evidence-based arguments indicating that HD or PD as first treatment may improve patient-centred outcomes in diabetics with ESKD are lacking. In the absence of such evidence, modality selection should be governed by patient preference, after unbiased patient information.

Breve commento a cura di N. Agabiti
Anche in questo secondo lavoro si affronta il tema del confronto di efficacia tra tecniche, in questo caso tecniche dialitiche in pazienti diabetici con insufficienza renale cronica. Si tratta di una revisione sistematica mirata a valutare l’impatto sugli esiti della emodialisi versus la dialisi peritoneale. La metodologia della revisione è rigorosa, con due revisori indipendenti che hanno valutato i risultati della ricerca condotta su diverse banche dati (Medline, EMBASE e CENTRAL) dagli anni ’90 fino al 2014. Sono stati analizzati 25 studi osservazionali. L’esito in studio principale è al mortalità. I risultati sono molto variabili e soprattutto è stata evidenziata una grande eterogeneità nelle metodologie. Pertanto gli Autori non sono stati in grado di formulare una chiara conclusione. E’ stato solo evidenziato che i pazienti diabetici nei quali come prima scelta venga fatta la dialisi peritoneale sembrano avere una maggiore probabilità di morire, evidente solo nella categoria di età anziana. Non essendoci evidenze sufficienti di efficacia maggiore per l’una o per l’altro tipo di dialisi, la scelta dovrebbe essere guidata dalle preferenze del paziente.

7. Tamini N(1), Rota M(1), Bolzonaro E(1), Nespoli L(1), Nespoli A(1), Valsecchi MG(1), Gianotti L(2). Single-incision versus standard multiple-incision laparoscopic cholecystectomy: a meta-analysis of experimental and observational studies.
Surg Innov. 2014 Oct;21(5):528-45. doi: 10.1177/1553350614521017. Epub 2014 Mar 6.
Author information: (1)Milano-Bicocca University, San Gerardo Hospital, Monza, Italy. (2)Milano-Bicocca University, San Gerardo Hospital, Monza, Italy

OBJECTIVE: The advantages of single-incision surgery for the treatment of gallstone disease is debated. Previous meta-analyses comparing single-incision laparoscopic cholecystectomy (SILC) and standard laparoscopic multiport cholecystectomy (SLMC) included few and underpowered trials. To overcome this limitation, we performed a meta-analysis of randomized and nonrandomized studies. METHODS: A MEDLINE, EMBASE, and Cochrane Library literature search of studies published in and comparing SILC with SLMC was performed. The primary outcome was safety of SILC as measured by the overall rate of postoperative complications and biliary spillage. Feasibility was another primary outcome as measured by the conversion and operative time. Postoperative pain, length of hospital stay, perioperative blood loss, time to return to normal activity, and cosmetic satisfaction were secondary outcomes. RESULTS: We identified 43 studies of which 30 were observational reports and 13 experimental trials, for a total of 7489 patients (2090 SILC and 5389 SLMC). The overall rate of complications was comparable between groups (relative risk [RR] = 1.08; 95% CI = 0.87-1.35; P = .46), as were the rates of biliary spillage (RR = 1.16; 95% CI = 0.73-1.84; P = .53) and conversion rate (RR = 0.88; 95% CI = 0.53-1.46; P = .62). Operative time was in favor of SLMC (weighted mean difference = 0.73; 95% CI = 0.67-0.79; P < .0001). Secondary outcomes favored SILC, but with marginal advantages. CONCLUSIONS: SILC is a feasible technique but without any significant advantage over SLMC for relevant end points. Although secondary outcomes favored SILC, the small magnitude of the advantage and the low quality of assessment methods question the clinical significance of these benefits.

8. Hu JC(1), Gandaglia G(2), Karakiewicz PI(3), Nguyen PL(4), Trinh QD(5), Shih YC(6), Abdollah F(3), Chamie K(7), Wright JL(8), Ganz PA(9), Sun M(10). Comparative effectiveness of robot-assisted versus open radical prostatectomy cancer control.
Eur Urol. 2014 Oct;66(4):666-72. doi: 10.1016/j.eururo.2014.02.015. Epub 2014 Feb 19.
Author information: (1)Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. Electronic address: (2)Cancer Prognostics Health Outcomes Unit, University of Montreal Health Centre, Montreal, Quebec, Canada; Department of Urology, Universita Vita-Salute San Raffaele, Milan, Italy. (3)Cancer Prognostics Health Outcomes Unit, University of Montreal Health Centre, Montreal, Quebec, Canada; Department of Urology, University of Montreal Health Center, Montreal, Quebec, Canada. (4)Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA. (5)Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Boston, MA, USA. (6)Section of Hospital Medicine, Department of Medicine Program in the Economics of Cancer, University of Chicago, Chicago, IL, USA. (7)Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. (8)Department of Urology, University of Washington School of Medicine, and Fred Hutchinson Cancer Research Center, Seattle, WA, USA. (9)Cancer Prevention and Control Research at the Jonsson Comprehensive Cancer Center, Fielding School of Public Health, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. (10)Cancer Prognostics Health Outcomes Unit, University of Montreal Health Centre, Montreal, Quebec, Canada. Comment in Eur Urol. 2014 Oct;66(4):673-5; discussion 675-6.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) remains controversial, and no improvement in cancer control outcomes has been demonstrated over open radical prostatectomy (ORP). OBJECTIVE: To examine population-based, comparative effectiveness of RARP versus ORP pertaining surgical margin status and use of additional cancer therapy. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective observational study of 5556 RARP and 7878 ORP cases from 2004 to 2009 from Surveillance Epidemiology and End Results-Medicare linked data. INTERVENTION: RARP versus ORP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Propensity-based analyses were performed to minimize treatment selection biases. Generalized linear regression models were computed for comparison of RP surgical margin status and use of additional cancer therapy (radiation therapy [RT] or androgen deprivation therapy [ADT]) by surgical approach. RESULTS AND LIMITATIONS: In the propensity-adjusted analysis, RARP was associated with fewer positive surgical margins (13.6% vs 18.3%; odds ratio [OR]: 0.70; 95% confidence interval [CI], 0.66-0.75), largely because of fewer RARP positive margins for intermediate-risk (15.0% vs 21.0%; OR: 0.66; 95% CI, 0.59-0.75) and high-risk (15.1% vs 20.6%; OR: 0.70; 95% CI, 0.63-0.77) disease. In addition, RARP was associated with less use of additional cancer therapy within 6 mo (4.5% vs 6.2%; OR: 0.75; 95% CI, 0.69-0.81), 12 mo (OR: 0.73; 95% CI, 0.62-0.86), and 24 mo (OR: 0.67; 95% CI, 0.57-0.78) of surgery. Limitations include the retrospective nature of the study and the absence of prostate-specific antigen levels to determine biochemical recurrence. CONCLUSIONS: RARP is associated with improved surgical margin status relative to ORP for intermediate- and high-risk disease and less use of postprostatectomy ADT and RT. This has important implications for quality of life, health care delivery, and costs. PATIENT SUMMARY: Robot-assisted radical prostatectomy (RP) versus open RP is associated with fewer positive margins and better early cancer control because of less use of additional androgen deprivation and radiation therapy within 2 yr of surgery.

9. Minutolo V(1), Licciardello A, Arena M, Nicosia A, Di Stefano B, Calì G, Arena G. Laparoscopic cholecystectomy in the treatment of acute cholecystitis: comparison of outcomes and costs between early and delayed cholecystectomy.
Eur Rev Med Pharmacol Sci. 2014 Dec;18(2 Suppl):40-6.
Author information: (1)Department of Surgical Sciences, Organ Transplantation and Advances Technologies, University of Catania, Catania, Italy.

BACKGROUND: Several trials showed that early laparoscopic cholecystectomy is superior to delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis. However actual practice does not conform to current evidence. The aim of this study is to compare outcomes and total hospital costs between early and delayed laparoscopic cholecystectomy for acute cholecystitis. PATIENTS AND METHODS: A retrospective analysis of patients with acute cholecystitis that underwent a laparoscopic cholecystectomy at our institutions was performed. Patients were divided into 2 groups on the basis of the treatment received and statistical analysis was performed. RESULTS: The study included 91 patients, 52 female and 39 male, with a mean age of 55. Early surgery was performed in 32 cases and delayed surgery in 59 cases. The two groups were comparable for demographics data and severity of disease on admission. There was a no significant difference (p = 0.174) in the mean operative time between early (54.8 min) and delayed group (47.8 min). Conversion rate was higher in the early group (34.3% vs. 20.3%), but difference was not statistically significant (p = 0.223). The overall complications rate was comparable (18.7% early vs. 16.9% delayed, p = 0.941). Length of postoperative stay (4.3 vs. 3.8 days) was similar (p = 0.437), but total hospital stay was significantly 4 days shorter in the early group (p < 0.0001). The mean total cost was higher for the delayed group (4171 vs. 6041), with a significant difference of 1870 Euro (p < 0.0001). CONCLUSIONS: Early laparoscopic cholecystectomy has an outcome comparable to the delayed procedure, with a shorter total hospital stay and lower total costs, and it should be considered as the preferred approach in treatment of acute cholecystitis.

10. Buzzatti N(1), Maisano F(2), Latib A(3), Taramasso M(2), Denti P(3), La Canna G(3), Colombo A(3), Alfieri O(3). Comparison of Outcomes of Percutaneous MitraClip Versus Surgical Repair or Replacement for Degenerative Mitral Regurgitation in Octogenarians.
Am J Cardiol. 2014 Nov 29. pii: S0002-9149(14)02172-9. doi: 10.1016/j.amjcard.2014.11.031. [Epub ahead of print]
Author information: (1)Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy. Electronic address: (2)Department of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland. (3)Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy.

Octogenarians affected by mitral regurgitation (MR) are an increasing high-risk population. MitraClip repair is emerging as a promising option for this kind of patients. In this retrospective study, the outcomes of patients aged ≥80 years, affected by isolated degenerative MR, who underwent isolated transcatheter (n = 25) or surgical (n = 35, 29 repairs and 6 replacements) mitral intervention from September 2008 to February 2014 were compared. MitraClip patients had higher mean age (84.5 ± 3.2 vs 81.9 ± 2.0 years, p <0.01), median Logistic Euroscore 19.4 (11.1 to 29.0) versus 8.4 (7.0 to 10.1) (p <0.01), median Society of Thoracic Surgeons predicted mortality 5.3 (3.5 to 6.6) versus 2.7 (2.3 to 3.9) (p <0.01), and more advanced New York Heart Association class (III to IV in 68% vs 37%, p = 0.02). At 30 days, 1 death occurred in the MitraClip group (p = 0.2). MitraClip was associated with significantly less complications (p <0.05) but more residual MR >2 (p <0.01). Two-year actuarial survival rate was 90% for MitraClip versus 97% for surgery (p <0.01). Higher Society of Thoracic Surgeons mortality was associated with reduced follow-up survival rate (p = 0.01). Two-year actuarial freedom from MR >2 was 70% versus 100%, respectively (p <0.01). New York Heart Association class and quality of life improved after MitraClip and were similar to surgical patients. Recurrent MR >2 was not significantly associated with follow-up mortality in this elderly setting. After the introduction of MitraClip, octogenarian patients with isolated degenerative MR receiving mitral treatment significantly increased (p <0.01). In conclusion, MitraClip patients, despite being older, more symptomatic, and affected by more co-morbidities showed significantly reduced postoperative complications. Two-year mortality was higher in the MitraClip group likely because of co-morbidities. Transcatheter mitral repair resulted in more octogenarians being treated compared with the past.

11. Ditto A(1), Martinelli F(2), Bogani G(2), Gasparri ML(3), Di Donato V(4), Zanaboni F(2), Lorusso D(2), Raspagliesi F(2). Implementation of laparoscopic approach for type B radical hysterectomy: A comparison with open surgical operations.
Eur J Surg Oncol. 2014 Nov 6. pii: S0748-7983(14)01196-2. doi: 10.1016/j.ejso.2014.10.058. [Epub ahead of print]
Author information: (1)Gynecologic Oncology Unit, National Cancer Institute, Milan, Italy. Electronic address: (2)Gynecologic Oncology Unit, National Cancer Institute, Milan, Italy. (3)Department of Obstetrics and Gynecologic University, "La Sapienza", Rome, Italy. (4)Gynecologic Oncology Unit, National Cancer Institute, Milan, Italy; Department of Obstetrics and Gynecologic University, "La Sapienza", Rome, Italy.

OBJECTIVE: To investigate the safety, feasibility and effectiveness of laparoscopic approach in the management patients undergoing modified radical hysterectomy for early stage cervical cancer. METHODS: Consecutive data of 157 women who had class II radical hysterectomy, for stage IA2 and stage IB1 <2 cm cervical cancer, were prospectively collected. Data of patients undergoing surgery via laparoscopy (LRH) were compared with those undergoing open surgical operations (RAH). A propensity-matched comparison (1:1) was carried out to minimize as possible selection biases. Post-operative complications were graded per the Clavien-Dindo classification. Five-year survival outcomes were assessed using Kaplan-Meier model. RESULTS: After the exclusion of 37 (23.5%) patients on the basis of propensity-matching, 60 patients undergoing LRH were compared with 60 patients undergoing RAH. No between-group differences in baseline, disease and pathological variables were observed (p > 0.05). Patients undergoing surgery via laparoscopy experienced longer operative time than patients undergoing RAH; while LRH correlated whit shorter length of hospitalization and lower blood loss in comparison to RAH. Intra- and post-operative complication rate was similar between groups (p = 1.00). The execution of LRH or RAH did not influence site of recurrence (p > 0.2) as well as survival outcomes, in term of 5-year disease-free (p = 0.29, log-rank test) and overall survivals (p = 0.50, log-rank test). CONCLUSION: Laparoscopic approach is a safe procedure, upholds the results of RAH, reducing invasiveness of open surgical operations. Further large prospective investigations are warranted.

12. Pontone G(1), Andreini D(2), Bertella E(3), Petullà M(3), Russo E(4), Innocenti E(4), Mushtaq S(3), Gripari P(3), Loguercio M(3), Segurini C(3), Baggiano A(3), Conte E(3), Beltrama V(3), Annoni A(3), Formenti A(3), Guaricci AI(5), Casella M(4), Fassini G(4), Giovannardi M(3), Veglia F(3), Tondo C(4), Pepi M(3). Comparison of cardiac computed tomography versus cardiac magnetic resonance for characterization of left atrium anatomy before radiofrequency catheter ablation of atrial fibrillation.
Int J Cardiol. 2015 Jan 20;179:114-21. doi: 10.1016/j.ijcard.2014.10.030. Epub 2014 Nov 8.
Author information: (1)Centro Cardiologico Monzino, IRCCS, Milan, Italy. Electronic address: (2)Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Cardiovascular Sciences and Community Health, University of Milan, Italy. (3)Centro Cardiologico Monzino, IRCCS, Milan, Italy. (4)Cardiac Arrhythmias Research Center, Centro Cardiologico Monzino, IRCCS, Milan, Italy. (5)Ospedali Riuniti, Department of Cardiology, University of Foggia, Italy.

BACKGROUND: The outcome of radiofrequency catheter ablation (RFCA) has been improved by the pivotal role of cardiovascular imaging such as cardiac computed tomography (CCT) or cardiac magnetic resonance (CMR) for the characterization of left atrium (LA) anatomy before RFCA. The aim of this study is to compare the procedural characteristics, overall radiation exposure and clinical outcomes between RFCA guided by image integration with CCT versus CMR. METHODS: Four-hundred patients with drug-refractory paroxysmal or persistent AF referred to RCFA were matched with the propensity score matching analysis to CCT (n: 200) or CMR (n: 200) for evaluation of LA before RFCA procedure. Left atrium diameter, left atrium volume, variant of pulmonary veins' anatomy, pulmonary veins' ostial dimensions, procedural characteristics, overall radiation exposure and rate of AF recurrence after RFCA were measured and compared between the two groups. RESULTS: The 2 groups were homogeneous with similar follow-up (557±302 vs. 523±265days, respectively, p:0.24). The CCT group showed higher LA volume vs. CMR group (117±46 vs. 101±40mL, p<0.001). No differences were observed regarding procedural characteristics. AF recurrence at follow-up was similar (29% vs. 26%, p:0.5) despite a higher radiation exposure in the CCT group vs. CMR group (40.4±23.7mSv vs. 32.8±23.5mSv, p<0.005). LA volume detected by CMR was the most robust independent predictor of AF recurrence at multivariate analysis [(HR: 1.08 (1.01-1.15), p: 0.02]. CONCLUSIONS: CCT and CMR provide similar information before RFCA. However, RFCA CMR-guided is associated with a lower overall cumulative radiation despite similar outcome in comparison with CCT-guided RFCA.

13. Bogani G(1), Cromi A(1), Serati M(1), Di Naro E(2), Casarin J(1), Marconi N(1), Pinelli C(3), Ghezzi F(1). Hysterectomy in patients with previous cesarean section: comparison between laparoscopic and vaginal approaches.
Eur J Obstet Gynecol Reprod Biol. 2015 Jan;184:53-7. doi: 10.1016/j.ejogrb.2014.11.005. Epub 2014 Nov 21.
Author information: (1)Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy. (2)Department of Obstetrics and Gynecology, University of Bari, Bari, Italy. (3)Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy. Electronic address:

OBJECTIVE: To evaluate surgery-related outcomes of laparoscopic (LH) and vaginal hysterectomy (VH) in patients with a history of previous cesarean section (CS). STUDY DESIGN: Data on 289 consecutive patients with a history of CS undergoing VH (n=49, 17%) and LH (n=219, 76%) were collected. Basic descriptive statistics, univariate and multivariate analyses were performed to evaluate surgery-related outcomes. A propensity-matched algorithm was applied in order to reduce allocation biases between groups. RESULTS: Patients undergoing LH were more likely to have a history of multiple cesarean sections (44% vs. 18%; p=0.001). Additionally, uterine weight was greater among patients undergoing LH than VH (median weight: 235 (range, 45-2830) vs. 150 (range, 40-710)g; p<0.001). Three patients in each group experienced procedural bladder injuries (3/219 (1%) vs. 3/49 (6%); p=0.07; RR: 1.65; 95%CI: 0.74, 3.68). The rate of grade 3 or worse postoperative complications was balanced between LH and VH (1% vs. 0%; p=1.00). Patients undergoing LH experienced a shorter length of hospital stay in comparison to patients undergoing VH (1 vs. 2 days; p=0.02). Considering the overall population, we observed via multivariate analysis that age (OR: 1.003 (95%CI: 1.001, 1.004) per 10-year increase in age; p=0.002), VH (OR: 17.80 (95%CI: 1.762, 180,378); p=0.01) and number of cesarean sections≥2 (OR: 27.70 (95%CI: 1.976, 388,285); p=0.01) increased the risk of developing bladder injuries during hysterectomy. CONCLUSIONS: LH is a safe and feasible procedure in patients with previous CS, and it is associated with a low bladder injury rate.

14. De Rango P(1), Ferrer C(2), Coscarella C(2), Musumeci F(3), Verzini F(4), Pogany G(2), Montalto A(3), Cao P(2). Contemporary comparison of aortic arch repair by endovascular and open surgical reconstructions.
J Vasc Surg. 2014 Oct 30. pii: S0741-5214(14)01732-7. doi: 10.1016/j.jvs.2014.09.006. [Epub ahead of print]
Author information: (1)Unit of Vascular and Endovascular Surgery, Hospital S. Maria della Misericordia, University of Perugia, Perugia, Italy. Electronic address: (2)Unit of Vascular Surgery, Hospital S. Camillo-Forlanini, Rome, Italy. (3)Unit of Cardiac Surgery, Department of Cardiosciences, Hospital S. Camillo-Forlanini, Rome, Italy. (4)Unit of Vascular and Endovascular Surgery, Hospital S. Maria della Misericordia, University of Perugia, Perugia, Italy.

OBJECTIVE: This study analyzed total aortic arch reconstruction in a contemporary comparison of current open and endovascular repair. METHODS: Endovascular (group 1) and open arch procedures (group 2) performed during 2007 to 2013 were entered in a prospective database and retrospectively analyzed. Endovascular repair (proximal landing zones 0-1), with or without a hybrid adjunct, was selected for patients with a high comorbidity profile and fit anatomy. Operations involving coverage of left subclavian artery only (zone 2 proximal landing: n = 41) and open hemiarch replacement (n = 434) were excluded. Early and midterm mortality and major complications were assessed. RESULTS: Overall, 100 (78 men; mean age, 68 years) consecutive procedures were analyzed: 29 patients in group 2 and 71 in group 1. Seven group 1 patients were treated with branched or chimney stent graft, and 64 with partial or total debranching and straight stent graft. The 29 patients in group 2 were younger (mean age, 61.9 vs 70.3; P = .005), more frequently females (48.2% vs 11.3; P < .001) with less cardiac (6.9% vs 38.2%; P = .001), hypertensive (58.5% vs 88.4%; P = .002), and peripheral artery (0% vs 16.2%; P = .031) disease. At 30 days, there were six deaths in group 1 and four in group 2 (8.5% vs 13.8%; odds ratio, 1.7; 95% confidence interval, 0.45-6.66; P = .47), and four strokes in group 1 and one in group 2 (odds ratio, 0.59; 95% confidence interval, 0.06-5.59; P = 1). Spinal cord ischemia occurred in two group 1 patients and in no group 2 patients. Three retrograde dissections (1 fatal) were detected in group 1. During a mean follow-up of 26.2 months, two type I endoleaks and three reinterventions were recorded in group 1 (all for persistent endoleak), and one reintervention was performed in group 2. According to Kaplan Meier estimates, survival at 4 years was 79.8% in group 1 and 69.8% in group 2 (P = .62), and freedom from late reintervention was 94.6% and 95.5%, respectively (P = .82). CONCLUSIONS: Despite the older age and a higher comorbidity profile in patients with challenging aortic arch disease suitable and selected for endovascular arch repair, no significant differences were detected in perioperative and 4-year outcomes compared with the younger patients undergoing open arch total repair. An endovascular approach might also be a valid alternative to open surgery in average-risk patients with aortic arch diseases requiring 0 to 1 landing zones, when morphologically feasible. However, larger concurrent comparison and longer follow-up are needed to confirm this hypothesis.

15. Asimakopoulos AD(1), Miano R, Annino F, Micali S, Spera E, Iorio B, Vespasiani G, Gaston R. Robotic radical nephrectomy for renal cell carcinoma: a systematic review.
BMC Urol. 2014 Sep 18;14:75. doi: 10.1186/1471-2490-14-75.
Author information: (1)UOC of Urology, Department of Experimental Medicine and Surgery, University of Tor Vergata, Policlinico Casilino, Rome, Italy.

BACKGROUND: Laparoscopic radical nephrectomy (LRN) is the actual gold-standard for the treatment of clinically localized renal cell carcinoma (RCC) (cT1-2 with no indications for nephron-sparing surgery). Limited evidence is currently available on the role of robotics in the field of radical nephrectomy. The aim of the current study was to provide a systematic review of the current evidence on the role of robotic radical nephrectomy (RRN) and to analyze the comparative studies between RRN and open nephrectomy (ON)/LRN. METHODS: A Medline search was performed between 2000-2013 with the terms "robotic radical nephrectomy", "robot-assisted laparoscopic nephrectomy", "radical nephrectomy". Six RRN case-series and four comparative studies between RRN and (ON)/pure or hand-assisted LRN were identified. RESULTS: Current literature produces a low level of evidence for RRN in the treatment of RCC, with only one prospective study available. Mean operative time (OT) ranges between 127.8-345 min, mean estimated blood loss (EBL) ranges between 100-273.6 ml, and mean hospital stay (HS) ranges between 1.2-4.3 days. The comparison between RRN and LRN showed no differences in the evaluated outcomes except for a longer OT for RRN as evidenced in two studies. Significantly higher direct costs and costs of the disposable instruments were also observed for RRN. The comparison between RRN and ON showed that ON is characterized by shorter OT but higher EBL, higher need of postoperative analgesics and longer HS. CONCLUSIONS: No advantage of robotics over standard laparoscopy for the treatment of clinically localized RCC was evidenced. Promising preliminary results on oncologic efficacy of RRN have been published on the T3a-b disease. Fields of wider application of robotics should be researched where indications for open surgery still persist.

Breve commento a cura di N. Agabiti
La chirurgia robotica si sta diffondendo in molte aree chirurgiche e vi è necessità di conoscere i vantaggi rispetto alle tecniche tradizionali. In riferimento ai tumori renali localizzati, la nefrectomia radicale laparoscopica è considerata la tecnica di scelta (gold standard). Le evidenze di efficacia della tecnica robotica sono invece ancora limitate. Gli Autori propongono una revisione sistematica della letteratura sul ruolo della terapia robotica nella nefrectomia e analizzano studi comparativi tra la tecnica robotica e la tecnica tradizionale “aperta”. La ricerca della letteratura (Medline) ha riguardato gli anni 2000-2013. Sono stati identificati sei studi “case-series” e quattro studi comparativi. Il risultato principale della ricerca è che le evidenze sono ancora molto limitate. E’ stato identificato un solo studio prospettico. Il confronto tra tecniche tradizionale “aperta” vs robotica mostra nessuna sostanziale differenza negli esiti studiati eccetto che per un tempo operatorio più lungo nel caso la tecnica robotica. Inoltre sono stati evidenziati alti costi della tecnica robotica rispetto alla tradizionale con particolare riferimento alla strumentazione stessa. A parte il vantaggio sul tempo operatorio, la tecnica tradizionale sembra associarsi a maggiore probabilità di perdita di sangue, necessità di analgesici nel postoperatorio e ad una maggiore durata della degenza. Gli Autori concludono che la nefrectomia con tecnica robotica è sicura ed efficace tuttavia non ci sono sufficienti evidenze per dimostrare la superiorità rispetto alla chirurgia tradizionale. Il tema del rischio di “over-techonology” in medicina è molto rilevante da porre alla discussione della comunità scientifica.

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