Colorectal surgery in elderly patients: our experience with DaVinci Xi® System.

BACKGROUND: Robotic technology for colorectal surgery was introduced by Weber in 2002 to improve the benefits of the minimally invasive surgery already offered by the laparoscopic approach. AIMS: To evaluate the feasibility and the efficacy of the application of robotic surgery in elderly patients affected by colorectal diseases. METHODS: We reported the outcomes obtained during our first 50 colorectal robotic surgical performances with DaVinci Xi® System, and we compared the results assessed for patients younger or older than 70 years. RESULTS: We examined 28 patients younger and 22 older than 70 years who underwent colorectal robotic surgery in our institution from September 2014 to June 2016. We performed 15 right colectomies, 20 left colectomies, 15 rectal resections. Mean ASA score was significantly higher in the Elderly Group. No statistically significant differences have been revealed in terms of post-operative morbidity, hospital stay, first diet intake, first flatus canalization and oncological outcome. DISCUSSION: According to the prolonged operative time, robotic technology was initially reserved to young patients with good performance status in order to avoid systemic failures in elderly patients suffering from pre-existent comorbidities. Otherwise, once robotic approach safety and benefits in terms of better systemic outcomes were demonstrated, it started to be performed in elderly patients with satisfactory outcomes. CONCLUSION: Our experience revealed that robotic surgical approach is safe, feasible and offers many systemic benefits in elderly patients also with high ASA score. Age alone has not to be considered as exclusion criteria for robotic approach.

Percutaneous radiofrequency ablation versus surgical radiofrequency-assisted nodulectomy in treatment of small single nodes of hepatocellular carcinoma: our experience.

AIM: Surgical resection usually represents the treatment of choice for solitary hepatocellular carcinoma (HCC) in cirrhotic patients, with well preserved liver function; local ablative strategies are the best treatment option for patients with small tumors who are not candidates for surgical resection or liver transplantation. Several studies showed that percutaneous radiofrequency ablation (RFA) has similar efficacy to surgical nodulectomy in the treatment of early-stage HCC, and is associated with lower complication rates and costs than resection. The aim of this study was to compare the effectiveness of these treatments, in terms of morbidity, overall survival, tumor recurrence and causes of death. METHODS: Between January 2006 and January 2012 we observed 176 patients affected by HCC, 84 underwent curative treatment. The 40 patients presenting single HCC nodes smaller than 3 cm in diameter have been treated with radiofrequency-assisted surgical nodulectomy (N.=20) or with percutaneous radiofrequency (N.=20). RESULTS: No perioperative mortality occurred in the two groups. Perioperative morbidity was 5% in group A (1 case of peritoneal bleeding) and 5% in group B (1 case of hepatic abscess). Disease-free survival was slightly higher in surgically treated patients, but not statistically significative differences have been demonstrated (P<0.06); no local recurrences were observed in surgically treated patients. CONCLUSION: RF and surgical nodulectomy can be either used in treatment of early stage hepatocellular carcinoma; no differences in terms of morbidity, overall and disease free survival were observed; nodulectomy seems to prevent from tumor local recurrence.

Laparoscopic transperitoneal hernia repair (TAPP) in emergency: long-term follow-up in a high volume centre.

PURPOSE: Aim of this study was to analyse feasibility, safety and effectiveness of laparoscopic transperitoneal hernia repair (TAPP) approach to inguinal hernias in the emergency setting, with a longer follow-up than the studies present in literature. METHODS: We retrospectively analysed all patients who underwent emergency TAPP hernia repair in San Marco Hospital (Zingonia, Italy), from September 2010 to June 2020. A prospectively collected database of 685 consecutive TAPP hernia repair was reviewed. Feasibility and safety were evaluated through operative time, conversion rate, perioperative mortality, morbidity and prosthesis infection rate. Effectiveness was assessed by recurrence and complication rate, acute (during admission) and chronic (during follow-up) pain by Visual Analogic Scale (VAS), and recovery to normal activity in a long-term follow-up (mean period 1718 days). RESULTS: The final study group included 47 patients. The mean age was 59.6 years (range 22-89), 29 patients were male and 18 were female. The mean operation time was 64 min. Two cases were converted to open approach (4%). In four cases bowel resection became necessary (8.5%). Appendicectomy and omentectomy occurred once and twice, respectively (2% and 4%), and orchiectomy was required in two patients (4%). Seroma was the only postoperative complication that we registered in four patients. During a mean follow-up period of 1718 days, there was no recurrence of the hernia or other complications. Five patients referred mild occasional groin pain (VAS < 3), with quick relief without taking any pain killers. CONCLUSION: TAPP approach is a safe, feasible and effective therapeutic option for groin hernias in emergency setting. No recurrence or severe complications were reported in over 4 years of follow-up.

Photodissociation of pyrrole-ammonia clusters by velocity map imaging: mechanism for the H-atom transfer reaction.

The photodissociation dynamics of pyrrole-ammonia clusters (PyH·(NH(3))(n), n = 2-6) has been studied using a combination of velocity map imaging and non-resonant detection of the NH(4)(NH(3))(n-1) products. The excited state hydrogen-atom transfer mechanism (ESHT) is evidenced through delayed ionization and presents a threshold around 236.6 nm, in agreement with previous reports. A high resolution determination of the kinetic energy distributions (KEDs) of the products reveals slow (∼0.15 eV) and structured distributions for all the ammonia cluster masses studied. The low values of the measured kinetic energy rule out the existence of a long-lived intermediate state, as it has been proposed previously. Instead, a direct N-H bond rupture, in the fashion of the photodissociation of bare pyrrole, is proposed. This assumption is supported by a careful analysis of the structure of the measured KEDs in terms of a discrete vibrational activity of the pyrrolyl co-fragment.

Bruxism and nocturnal groaning.

Sleep bruxism (SB) is a sleep-related movement disorder, characterized by tooth grinding and/or clenching. The causes of SB range from psychosocial factors to an excessive sleep arousal response. Some studies showed that SB episodes during sleep are under the influences of transient activity of the brainstem arousal. Nocturnal groaning (NG) is a parasomnia characterized by an expiratory monotonous vocalization occurring during sleep, especially in REM sleep and during the second half of the night. The pathogenesis of NG remains still unclear and many hypotheses arose, ranging from the persistence of a vestigial ventilatory pattern rather than an expiratory upper airways' obstruction. Sleep microstructure fluctuation might modulate the NG, since the end of the NG episode usually is synchronized with a cortical arousal and an autonomic activation. Further studies should clarify the pathophysiology of SB and NG, especially when the two phenomena are associated.

Excited state hydrogen transfer dynamics in substituted phenols and their complexes with ammonia: ππ*-πσ* energy gap propensity and ortho-substitution effect.

Lifetimes of the first electronic excited state (S(1)) of fluorine and methyl (o-, m-, and p-) substituted phenols and their complexes with one ammonia molecule have been measured for the 0(0) transition and for the intermolecular stretching σ(1) levels in complexes using picosecond pump-probe spectroscopy. Excitation energies to the S(1) (ππ*) and S(2) (πσ*) states are obtained by quantum chemical calculations at the MP2 and CC2 level using the aug-cc-pVDZ basis set for the ground-state and the S(1) optimized geometries. The observed lifetimes and the energy gaps between the ππ* and πσ* states show a good correlation, the lifetime being shorter for a smaller energy gap. This propensity suggests that the major dynamics in the excited state concerns an excited state hydrogen detachment or transfer (ESHD/T) promoted directly by a S(1)/S(2) conical intersection, rather than via internal conversion to the ground-state. A specific shortening of lifetime is found in the o-fluorophenol-ammonia complex and explained in terms of the vibronic coupling between the ππ* and πσ* states occurring through the out-of-plane distortion of the C-F bond.

Magnetization transfer and diffusion-weighted imaging in nocturnal frontal lobe epilepsy.

The authors assessed the presence of brain abnormalities in 21 patients with nocturnal frontal lobe epilepsy (NFLE), using magnetization transfer ratio (MTR) and mean diffusivity (;D) histograms. Compared with healthy volunteers and patients with idiopathic generalized epilepsy, patients with NFLE had lower MTR (p = 0.002 and 0.01) and;D (p = 0.03 and 0.04) histogram peak heights. Subtle and widespread abnormalities related to intra- and extracellular distribution and motion of water are detectable in the brains of patients with NFLE.

Cardiac autonomic activity during wakefulness and sleep in REM sleep behavior disorder.

In REM sleep behavior disorder (RBD) it has been reported that tachycardia may not accompany the impressive movements associated with dream mentation. Up to now there are no data concerning the cardiac autonomic activity during wakefulness as well as during sleep out of nocturnal dream-enacting behaviors, in RBD. We evaluated 14 RBD patients. Our study shows that only 36% of patients had normal results in all traditional autonomic tests during wakefulness. Moreover, RBD patients had a reduced tonic and phasic heart rate variability during sleep. Autonomic evaluation during sleep may show impairment earlier than the traditional tests during wakefulness. No difference was found between idiopathic RBD patients and symptomatic ones.

Effect of melatonin on sleep microstructure: preliminary results in healthy subjects.

The ability of melatonin (MLT) to potentiate the effects of gamma-aminobutyric acid and the benzodiazepines has been demonstrated repeatedly in animal models, and recent experimental data favored the hypothesis that MLT, given together with threshold doses of benzodiazepines, could significantly improve the quality of sleep. This preliminary study was designed to compare the effects of MLT (100 mg) with those of a benzodiazepine hypnotic [triazolam (TRI) 0.125 mg] and to explore the effects of a combination of MLT and TRI at a low dose in healthy volunteers. No significant changes in the classical polysomnographic variables were observed following MLT, TRI and MLT + TRI, whereas MLT and especially MLT + TRI resulted in significant modulation of some microstructural parameters. These changes were paralleled by ameliorated subjective sleep quality. A combination of MLT and low benzodiazepine doses could avoid the residual, dose-related benzodiazepine effects.

Slow wave sleep and cyclic alternating pattern (CAP) in HIV-infected asymptomatic men.

Alterations of sleep structure have been reported in asymptomatic human immunodeficiency virus (HIV)-infected subjects. In these patients some authors have found an increased percentage of slow wave sleep (SWS) and a SWS preponderance in the second half of the night, as well as subjective sleep complaints. Other authors have found an increased stage 1 non-rapid eye movement (NREM) and reduced stage 2 NREM percentages in asymptomatic subjects. We evaluated the macrostructure and the microstructure (cyclic alternating pattern, CAP) of sleep in nine HIV-infected asymptomatic men without sleep complaints or psychiatric illness, in comparison with nine age-matched controls. Our study showed a decreased amount of SWS and a significantly higher CAP rate in HIV-subjects, suggesting an altered organization of the sleep process in these patients.

Cardiac autonomic nervous activity in sleep-related painful erections.

Sleep-related painful erections (SRPE) are characterized by penile pain that occurs during erections, typically during REM sleep. Afflicted individuals usually have normal erections during wakefulness. The disorder could be related to an altered autonomic function only during sleep. The aim of this study was to evaluate tonic and phasic heart rate (HR) modifications during sleep in 10 SRPE patients compared to 25 age-matched controls. A reduced cardiac vagal activity during sleep, as well as a trend towards a higher HR acceleration in relation to spontaneous body movements, have been found in SRPE patients. The possible beta-adrenergic hyperactivity during sleep in these patients could explain the reported efficacy of a beta-blocker, such as propranolol, in this disorder.

Snoring & sleep apnea: a population study in Italian women.

The aim of this cross-sectional study was to evaluate the prevalence of sleep-disordered breathing by means of a validated portable instrument (MESAM IV) and to investigate the relationship between snoring and sleep apnea in a sample of Italian middle-aged female population. We randomly chose 750 subjects aged 40 to 65 years and 365 agreed to participate to the study. In this group, 19.7% of subjects were every-night snorers according to the questionnaire; when recorded, 54.2% snored for more than 10% of the night, and 7.1% for more than 50% of the night. Sleep apnea was also common: 10.7% of subjects had a respiratory disturbances per hour (RDI) between 5 and 9, 7.7% an RDI between 10 and 19, and 2.2% had an RDI > or =20. Snoring percentage and RDI were significantly correlated. However, 50% of subjects who snored for more than half the night had no evidence of sleep apnea. Snoring amount >50% resulted influenced by body mass index, while RDI>10 was influenced by neck diameter. We concluded that in middle-aged women, both snoring and sleep apnea are very common. A high percentage of snoring is not essential for the occurrence of sleep apnea, nor it necessarily indicates the presence of sleep apnea.

SER252PHE and 776INS3 mutations in the CHRNA4 gene are rare in the Italian ADNFLE population.

41 patients (19 sporadic and 22 familial) affected by autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) were analyzed for the presence of two mutations (Ser252Phe, 776ins3) in the CHRNA4 gene, reported to be associated with this disease. Electroclinical findings of sporadic forms were indistinguishable from familial ones. In none of the patients, these mutations were found by dot blot analysis with allele specific oligonucleotides. These data, obtained on the largest group so far studied, suggest the rarity of the reported mutations.

Heart rate variability during sleep in snorers with and without obstructive sleep apnea.

Changes in sympathetic and vagal tone may be the substrate for the development of cardiac arrhythmias in patients with obstructive sleep apnea (OSA). The cardiovascular responses in the traditional autonomic tests show great interindividual and intraindividual variations. During sleep there are repetitive modifications of heart rate (HR) that are not influenced by psychologic factors or the patient's cooperation. For this reason, we evaluated HR modifications in relation to spontaneous body movements (BM) and sleep apneas during nonrapid eye movement (NREM) and rapid eye movement (REM) sleep in habitual snorers with normal and pathologic respiratory disturbance index (RDI). From 132 consecutive patients referred to our sleep center for habitual snoring and/or daytime somnolence, we selected 35 male patients younger than 60 years without clinical evidence of autonomic dysfunction. They were divided into three groups: group A (RDI < 10); group B (RDI > 10 and < 20); and group C (RDI > 20). No significant difference was found among the three groups in the HR variability related to BM. In the evaluation of bradytachyarrhythmias related to apneic events of 20 to 30 s, we found a significant difference between group A and the other two groups. In patients with RDI > 10, a reduced HR variability related to a reduced sympathetic tone in the post-apnea phase was observed. Some authors suggested that an HR increase during the post-apnea period can be used as an index of "brainstem arousal." Our results seem to indicate a reduced apnea-related "arousability" in patients with RDI > 10. This finding might be one of the factors contributing to the worsening of OSA.

Snoring and nocturnal oxygen desaturations in an Italian middle-aged male population. Epidemiologic study with an ambulatory device.

Recent studies have suggested that portable monitoring may be a valid means of finding respiratory disturbances in epidemiologic research on a large scale. The aim of this cross-sectional study was to evaluate by means of an appropriately validated portable instrument (MESAM 4) the nocturnal oxygen desaturations in a representative sample of adult male population in North Italy. We randomly chose 750 subjects: 399 subjects (53.2 percent) agreed to participate and a complete evaluation of nocturnal recording was possible in 349 subjects (87.5 percent). Seventeen percent of subjects were every-night snorers; a number of oxygen desaturations per hour (ODI) > 10 was found in 13.7 percent, and an ODI > 20 resulted in 4.8 percent. Age, neck circumference corrected for height, snoring time (measured by MESAM), and self-reported snoring were the variables best explaining ODI in our multivariate approach. This study reports the highest prevalence, using nocturnal oxygen desaturation indices as marker, of sleep-disordered breathing than any reported until now in a general population.

Melatonin and delayed sleep phase syndrome: ambulatory polygraphic evaluation.

The present study objectively evaluated the efficacy of oral 5 mg day-1 melatonin in advancing the sleep-wake rhythm in patients with delayed sleep phase syndrome (DSPS). Six patients underwent ambulatory sleep monitoring for 72 h before and 48 h after 1 month of melatonin treatment. In each patient melatonin was administered on the basis of his own estimated dim light melatonin onset (DLMO) delay. Mean advances in sleep onset time of 115 min and in final awakening hour of 106 min were found after treatment, with no significant changes in sleep architecture parameters. Our study objectively confirms previous data obtained by a sleep-wake subjective diary on the efficacy of melatonin DSPS.

Refined mapping of CHRNA3/A5/B4 gene cluster and its implications in ADNFLE.

The chromosome 15q24 region, containing the CHRNA3/A5/B4 gene cluster, coding for the alpha3, alpha5 and beta4 subunits of neuronal nicotinic acetylcholine receptors, has been reported to be linked to autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) in one family. However, nor the gene nor the mutation involved have been identified. We report the refined mapping of CHRNA3/A5/B4 cluster. Segregation analyses of CHRNA3/A5/B4 polymorphisms in families showing recombinations for 15q24 G¿en¿ethon STR markers allowed to position the cluster in a 0.6 cM interval, between STRs D15S1027 and D15S1005. This location is external to the 15q24-ADNFLE-linked region, therefore excluding the involvement of this cluster in the pathogenesis of ADNFLE in the 15q24-linked family. Moreover, these data provide more precise information for further linkage studies.

Cardiac autonomic function during sleep of never-depressed borderline subjects: a pilot study.

In a controlled 48 h ambulatory polysomnographic study of never-depressed subjects with DSM-III-R borderline (BDL) personality disorder (PD) we obtained measures of tonic and phasic heart rate variability. Subjects with BDL PD showed a significantly smaller index of tonic heart rate decrease during NREM sleep than normal controls. This is unlikely to be a state-dependent finding and it may derive from relative augmentation of adrenergic function compared to cholinergic function between wakefulness and NREM sleep. Hyperadrenergic states in BDL PD have already been suggested by studies of other biological indicators: a smaller index of tonic heart rate decrease may be a further correlate of core psychobiological dimensions such as impulsivity and affective instability.

Autonomic function in narcolepsy: power spectrum analysis of heart rate variability.

Ten narcoleptic patients that had never been treated previously and ten healthy volunteers of comparable age underwent 48-h polygraphic recording to assess the effects of wakefulness and sleep on beat-to-beat heart rate variability by means of power spectrum analysis. The study revealed decreased power in the low frequencies (LF) during sleep (whereby an increase of the power in this band is associated with sympathetic activation) compared with wakefulness, with minimal values during stage 3-4 non-REM sleep and higher levels during REM sleep, both in patients and controls. Significantly reduced power in high frequencies (HF; mainly expression of parasympathetic control) and a significantly increased LF/HF ratio during wakefulness before sleep in narcoleptics compared with controls were found. Our study excludes a primary disturbance of cardiac autonomic nervous system in narcoleptics but suggests an altered circadian autonomic function in these patients.