One-step versus two-step procedure for management procedures for management of concurrent gallbladder and common bile duct stones. Outcomes and cost analysis.

BACKGROUND: The management of cholelithiasis and choledocholithiasis combined is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. This study aims to demonstrate how, on the basis of the personal experience, the Rendez-vous technique, that combines the two techniques in a single-stage operation is better than the sequential treatment. METHODS: Between June 2017 to December 2019, 40 consecutive patients with cholelithiasis and choledocholithiasis combined were enrolled for the study: 20 were treated with the sequential treatment and 20 with the Rendez-vous method. The preoperative diagnostic work-up was similar in the two group. The endpoints of the study included incidence of endoscopic and surgical complications, rate of hospitalization and cost analysis. RESULTS: The study showed no difference in demographic parameters between the two groups, but the success rate of clearance of CBD was significantly smaller for sequential arm, with the need of additional procedures. We found a statistical reduction of postoperative acute pancreatitis, hospital stay and charges in Rendez-vous group, at the expense of a prolonged total operating time. CONCLUSIONS: The data of the study confirm the superiority of the Rendez-vous technique because it resolves cholelithiasis associated with choledocholithiasis in a single surgical act, with greater acceptance of the patient who avoids a second invasive surgical act, and with a reduction in complications; moreover, it requires shorter hospitalization, resulting in reduced costs. We propose this option in the management of cases where preoperative ERCP-ES has failed. KEY WORDS: Common bile duct stones, Cholecysto-choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Endoscopic sphincterotomy, Laparoscopic cholecystectomy, Laparo-endoscopic Rendez-vous.

Hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma in noncirrhotic liver. A case report and systematic review.

INTRODUCTION: Hepatocellular carcinoma (HCC) is the sixth most common cancer. Spontaneous rupture of HCC is an acute complication with a high mortality rate. The HCC principally arises in the background of chronic liver disease and cirrhosis of the liver. In the last few years, the rising incidence of HCC in noncirrhotic liver suggests the presence of other factors that may play a role in liver carcinogenesis. METHODS: We reviewed all cases treated at the University Surgical Department of Ospedali Riuniti of Foggia from 2009 to 2018. Only a single case of hemoperitoneum caused by spontaneous rupture of HCC in noncirrhotic liver was found. An extensive search of the relevant literature was carried out using MEDLINE, and a total of 58 published studies were screened from the sources listed. CONCLUSIONS: The management of this devastating emergency should be carefully analyzed, with stabilization of vital signs as soon as possible. Patient with ruptured HCC and hemoperitoneum without a prior history of cirrhosis and viral infections benefited from the role of transcatheter arterial embolization (TAE) as the preliminary treatment in order to have a more precise diagnosis and an optimal stabilization of the patient. Delayed or staged hepatectomy after TAE represents the definitive treatment.

Right hemicolectomy: laparoscopic versus robotic approach.

BACKGROUND: Minimally invasive surgery for colorectal cancer has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic surgery is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic right colon resection in comparison with the laparoscopic approach. METHODS: Between January 2014 and May 2017, fifteen laparoscopic right hemicolectomies were compared to seven robotic ones. The primary data points included operation time, length of hospital stay, extraction site incision length, complications, and conversions. When malignancy was the indication for surgery, additional data points have been added. RESULTS: The study showed no difference in parameters between the two groups, but estimated blood loss was significantly smaller for Robotic arm. We found a prolonged total operative room time in the robotic arm, while the surgical time is similar in two groups. The data collected about specimen length and number of lymph nodes suggest that robotic procedure is oncologically similar to laparoscopic one. CONCLUSIONS: Robotic approach allows performance of adequate dissection of the right colon with radical lymphadenectomy as in laparoscopic surgery, confirming the safety and oncological efficacy of this technique, with acceptable results and short-term outcomes. KEY WORDS: Da Vinci surgery, XI, Laparoscopic colorectal surgery, Right hemicolectomy, Robot.

Bilateral central neck dissection in the treatment of early unifocal papillary thyroid carcinomas with poor risk factors A mono-institutional experience.

INTRODUCTION: Papillary thyroid carcinoma is the most common type of thyroid cancer worldwide. While total thyroidectomy is widely considered the standard surgical approach for papillary thyroid carcinomas, the role of central lymphadenectomy in early stage poor-risk papillary thyroid tumors is still a matter of debate. This study was designed to assess surgical complications and local disease control rates in patients affected by poor-risk early stage papillary thyroid carcinomas. METHODS: We retrospectively analyze three groups of patients affected by poor-risk early stage papillary thyroid carcinomas treated with three alternative surgical strategies: I) routine total thyroidectomy; II) total thyroidectomy and routine central lymphadenectomy; III) total thyroidectomy and central lymphadenectomy upon positive intraoperative histological evaluation of lymph node involvement. RESULTS: Data from patients treated with routine total thyroidectomy showed 32% of persistence of disease in the central compartment with concurrent positivity in laterocervical compartment in 25% of these cases. By contrast, patients receiving total thyroidectomy and routine central lymphadenectomy showed the involvement of central compartment in 40% of cases, while the remaining 60% of patients were free from lymph node metastases. Finally, patients undergoing total thyroidectomy and central lymphadenectomy upon positive intraoperative lymph node biopsy exhibited lack of persistence of lymph node involvement in central compartment after surgery. Of note, postsurgical complications were lower in patients undergoing conservative surgical approaches. CONCLUSIONS: These data suggest that central lymphadenectomy, performed only in case of positive intraoperative lymph node biopsy, ensures reduced incidence of postoperative complications and optimal loco-regional disease control. KEY WORDS: Bilateral central neck dissection, Intraoperative lymph node biopsy, Papillary thyroid carcinoma, Poor risk factors.

Robotic voluminous paraesophageal hernia repair: a case report and review of the literature.

BACKGROUND: The treatment for sliding esophageal hernia with mild gastroesophageal reflux is usually conservative, but surgical treatment is recommended for refractory sliding esophageal hernia, paraesophageal hernia liable to prolapse, or paraesophageal hernia with ulceration and/or stenosis. Robotic surgery overcomes laparoscopic pitfalls by providing steady-state three-dimensional visualization, augmented dexterity with endo-wrist movements, and superior ergonomics for the surgeon. CASE PRESENTATION: To investigate robotic paraesophageal hernia repair, a literature search was conducted using PubMed with the following key words: mini invasive surgery, robotic surgery, hiatal hernia, and Nissen fundoplication. We present the case of a 44-year-old Italian woman with a 20-year history of gastroesophageal reflux disease refractory to medical treatment, who underwent robotic Nissen fundoplication. In our center, we use the da Vinci® Xi™ Surgical System, which is an advanced tool for minimally invasive surgery. CONCLUSIONS: Various reports published in the literature suggested that the robot-assisted approach was effective and was associated with very low postoperative morbidity and was accompanied by satisfactory symptomatic and anatomical radiological outcomes during a follow-up period. The robotic approach to paraesophageal repair is safe and effective with low complication rates. With increased experience, the operative time, length of stay, and complications decrease without compromising surgical principles.

Surgical management of non-parasitic hepatic cysts A single center experience and a review of the literature.

AIM: We present our experience in the laparoscopic management of the hepatic cysts (SHCs) and the polycystic liver disease (PCLD), and a literature review. MATERIAL AND METHODS: Between 2005 and 2018, laparoscopic deroofing was performed in 28 consecutive patients. There were 19 cases with SHCs and only 9 cases with PCLD (Gigot's type I). CT scan was performed in all cases to assess the characteristics, dimensions, and exact position of the lesion. Surgery was planned for all patients because of evident and persistent symptomatology, RESULTS: We have analyzed operative time, surgical procedure, blood loss, hospital stay, complications, and medium follow- up period. All the patients underwent laparoscopic deroofing of the larger cysts and puncturing of the smaller cysts. The total morbidity recorded was 25% (7/28), 3 cases in the group of SHCs (16 %) and 4 cases in the PCLD one (44%) and was characterized of 3 cases of ascites through trocar insertion sites after removal of drainage tube and 4 case of pleural effusion. DISCUSSION: There were no significant group differences in term of length of hospital stay. The follow-up period (a mean of 24 months) confirmed that all the patients remained free of symptoms and relapse of the disease. CONCLUSION: The technical feasibility and the good short- and medium-term results made the laparoscopic approach the procedure of choice for the management of symptomatic liver cysts. KEY WORDS: Hepatic cyst, Liver disease, Minimally invasive surgery.

Endoscopy for treating minor post-cholecystectomy biliary fistula A review of the literature.

AIM: Laparoscopic cholecystectomy for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography. The aim of this study was to assess the effectiveness of endoscopic strategy in the management of minor biliary injuries. MATERIAL OF STUDY: Twenty-two patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 2007 and 2017 and they were all treated with endoscopic approach, with ERCP in order to confirm the nature of the injury and decompress the bile duct with sphincterotomy, stent insertion, or the placement of nasobiliary drains. In 15 patients, the leak was diagnosed by persistent bile drainage, in the other 7 patients without a drain the biliary leak was suspected because of symptoms in the immediate postoperative period. RESULTS: Controlled biliary fistulae were established in all 22 patients (100%), without further intervention. A complete cholangiogram was obtained in all patients (100%). The most common sites of minor leak were the cystic duct stump and the Luschka duct, but in one patients the site of the leak was unclear. DISCUSSION: Early in the series, sphincterotomy alone or nasobiliary tube placement was performed. Subsequently patients underwent sphincterotomy with stent insertion, in order to promote preferential drainage of bile into the duodenum. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. The median hospital stay was 15 days (range, 10-31 days) post-laparoscopic cholecystectomy. ERCP was performed 4-6 weeks later to document healing of the leaking point and to remove the stent. Routine follow was at median 50 days. CONCLUSIONS: This review confirms that postoperative minor biliary injuries can be successful managed by endoscopic ERCP biliary decompression. KEY WORDS: Bile leak, Bile duct injury, Biliary fistula, Endoscopy, ERCP, Laparoscopic cholecystectomy.

Cervical Esophagotomy for Foreign Body Extraction: A Case Report and Extensive Literature Review of the Last 20 Years.

BACKGROUND Voluntary and involuntary ingestion of foreign bodies is a common condition; in most cases they pass through the digestive tract, but sometimes they stop, creating emergency situations for the patient. We report a case of meat bolus with cartilaginous component impacted in the cervical esophagus, with a brief literature review. CASE REPORT A 64-year-old man came to our attention for retention in the cervical esophagus of a piece of meat accidentally swallowed during lunch. After a few attempts of endoscopic removal carried out previously in other hospitals, the patient has been treated by us with a cervical esophagotomy and removal of the foreign body, without any complications. We checked the database of PubMed, Scopus, and the Cochrane Library from January 2007 to January 2017 in order to verify the presence of randomized controlled trials, clinical trials, retrospective studies, and case series regarding the use of the cervical esophagotomy for the extraction of foreign bodies impacted in the esophagus. CONCLUSIONS The crucial point is to differentiate the cases that must be immediately treated from those requiring simple observation. Endoscopic treatment is definitely the first therapeutic option, but in case of failure of this approach, in our opinion, cervical esophagotomy could be a safe, easy, viable, durable approach for the extraction of foreign bodies impacted in the cervical esophagus. Our review does not have the purpose of providing definitive conclusions but is intended to represent a starting point for subsequent studies.

What is the treatment of tracheal lesions associated with traditional thyroidectomy? Case report and systematic review.

Aim: The aim of this study is to review the literature focusing on various treatments based on time of tracheal injury and on different surgeons' personal experience. Methods: We retrospectively reviewed all cases of total thyroidectomy performed at the University Surgical Department of Ospedali Riuniti of Foggia from 2006 to 2017. Only a single case of tracheal lesion due to traditional total thyroidectomy was found. An extensive search of the relevant literature was carried out using MEDLINE (PubMed). We included articles that reported article type, patient number, sex, age, reasons for surgery, time of tracheal perforation intraoperatively or delayed rupture, symptoms, diagnosis, type of surgical procedure, pathological report and follow-up. Results: A total of 156 published studies were screened from the sources listed. Of these, 15 studies were included in the present study. We introduced our case in the analysis. A total of 16 patients were totally analysed. There were seven males (43.7%) and seven females (43.7%), and for two patients, gender was not available. The mean patient age was 41.6 years. Conclusions: The literature review showed very few cases treated differently. However, it would be good to standardise treatments. Tracheal perforation, if encountered, needs to be managed appropriately in centres of expertise with a high volume of thyroidectomies.

One stage surgery for synchronous liver metastasis from a neuroendocrine tumor of the colon. A case report.

INTRODUCTION: Neuroendocrine tumors (NETs) are a heterogeneous group of tumors. NET of colon represent less than 1% of colonic tumors. Synchronous liver metastases, present in 75-80%, are considered significant adverse prognostic indicators. Liver is the second commonest site for metastasis in patients with colorectal neuroendocrine tumors. Available treatment options include surgical resection, chemotherapy, biotherapy. Surgery is the gold standard for curative therapy and it is strictly related to the localization, the grade of tumor, and the stage of disease. CASE REPORT: We present a 64-year-old man with clinical carcinoid syndrome. Colonoscopy revealed ileocecal valve vegetating mass with negative biopsy. CT scans of thorax and abdomen showed a voluminous lesion (10 cm of diameter) of right liver. CEA, CA 19.9 and aFP were all normal. Only urinary 5HIAASerum 5-hydroxyindoleactic acid and blood Chromogranin A were positive. Surgical strategy was to treat the primary tumor and the liver synchronous metastasis in one stage surgery. DISCUSSION: Management of NETs liver metastases is challenging and requires aggressive therapy. Currently, there are many therapeutic options for metastatic NETs. Although complete surgical resection remains the optimal therapy and aggressive surgical resection increases the 5-year survival of NETs with solitary liver metastasis to 100%. In this case, clinical status with doubt of carcinoid syndrome was essential for diagnosis and for subsequent surgical strategy with one stage surgery. CONCLUSION: Resection of the primary tumor, liver metastases, and local mesenteric lymph node metastases is thought to strictly promote long-term survival and quality of life. Typically, a multidisciplinary approach is a cornerstone for decision making while dealing with this aggressive disease. KEY WORDS: Carcinoid syndrome, Liver surgery, NETs, Neuroendocrine tumor, One stage surgery, Synchronous liver metastasis.

Haemostasis in Thyroid Surgery: Collagen-Fibrinogen-Thrombin Patch versus Cellulose Gauze-Our Experience.

Purpose. Postoperative hemorrhage is fortunately uncommon but potentially life-threatening complication of thyroid surgery that increases the postoperative morbidity and the hospital stay. In this study we compare the efficacy of collagen patch coated with human fibrinogen and human thrombin (CFTP) (group C) and oxidized regenerated cellulose gauze (group B) versus traditional hemostatic procedures (group A) in thyroid surgery. Methods. From January 2011 to December 2013, 226 were eligible for our prospective, nonrandomized, comparative study. Patients requiring a video-assisted thyroidectomy without drain, "near total," or hemithyroidectomy were excluded. Other exclusion criteria were a diagnosis of malignancy, substernal goiter, disorders of hemostasis or coagulation, and Graves or hyperfunctioning thyroid diseases. Outcomes included duration of operation, drainage volume, and postoperative complications. Results. Our results show a significant reduction in drainage volume in group C in comparison with the other two groups. In group C there was no bleeding but the limited numbers do not make this result significant. There were no differences in terms of other complications, except for the incidence of seroma in group B. Conclusion. The use of CFTP reduces the drainage volume, potentially the bleeding complications, and the hospital stay. These findings confirm the efficacy of CFTP, encouraging its use in thyroid surgery.

Laparoscopic antegrade cholecystectomy: a standard procedure?

Retrograde approach ("fundus first") is often used in open surgery, while in laparoscopic cholecystectomy (LC) is less frequent. LC, with antegrade access, is done by putting in traction the infundibulum and going up to the fundus before to clip the cystic. Our study analyzes a number of surgical procedures performed by experienced surgeons in laparoscopy. From 2002 to 2015, 1740 laparoscopic cholecystectomies were performed at our Institution. The operative procedure performed since 2002 consists of the incision of the visceral peritoneum from the infundibulum away from Calot's triangle along the gallbladder bed up to the fundus. Then it continues from the fundus up to the infundibulum. RESULTS: There were no bile duct injuries. Average operative time was 40 min. 22 conversions to an open procedure (1.3%) occurred, in cases of acute cholecystitis and cirrhotic patient. Postoperative stay was mean 2 days with no delayed sequelae on follow up. CONCLUSIONS: gallbladder antegrade dissection for laparoscopic cholecystectomy can reduce the time of surgery and is an easier technique to perform. Therefore, it can be proposed as the standard procedure and not only be used for difficult cholecystectomies.

Defining a therapeutic program for recurrent acute pancreatitis patients with unknown etiology.

AIM: To define a therapeutic program for mild-moderate acute pancreatitis (AP), often recurrent, which at the end of the diagnostic process remains of undefined etiology. MATERIAL AND METHODS: In the period 2011-2012, we observed 64 cases of AP: 52 mild-moderate, 12 severe; biliary 39, biliary in alcoholic chronic pancreatitis 5, unexplained recurrent 20. The clinical and instrumental evaluation of the 20 cases of unexplained AP showed 6 patients with biliary sludge, 4 microlithiasis, 4 sphincter of Oddi dysfunction, and 6 cases that remained undefined. RESULTS: Among 20 patients with recurrent, unexplained AP at initial etiological assessment, we performed 10 video laparo cholecystectomies (VLCs), 2 open cholecystectomies and 4 endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomies (ERCP/ES) in patients who had undergone previous cholecystectomy; 4 patients refused surgery. Among these 20 patients, 6 had AP that remained unexplained after second-level imaging investigations. For these patients, 4 VLCs and 2 ERCP/ES were performed. Follow-up after six months was negative for further recurrence. CONCLUSION: The recurrence of unexplained acute pancreatitis could be treated with empirical cholecystectomy and/or ERCP/ES in cases of previous cholecystectomy.