Surgical management protocol during the COVID-19 pandemic in an Italian non-referral center.

BACKGROUND: In the surgical scenario, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion worldwide entails on the one hand the need to continue to perform surgery at least in case of emergency or oncologic surgery, in patients with or without COronaVIrus Disease 2019 (COVID-19); and on the other hand, to avoid the pandemic diffusion both between patients and medical and nursing team. The aim of this study was to report our surgical management protocol during the COVID-19 pandemic in an Italian non-referral center. METHODS: Data retrieved during the outbreak for the COVID-19 pandemic, from March 8 to May 4, 2020 (study period) were analyzed and compared to data obtained during the same period in 2019 (control period). RESULTS: During the study period, 41 surgical procedures (24 electives, 17 emergency surgical procedures) underwent surgery in comparison to 99 procedures in the control period. Stratifying the procedures in elective and emergency surgery, and based on the indication for surgery, the only statistically significant difference was observed in the elective surgery regarding the abdominal wall surgery (0 vs. 13 procedures, P=0.0339). Statistically significant differences were not observed regarding the colorectal and the breast oncologic surgery. All stuff members were COVID-19 free. CONCLUSIONS: The present protocol proved to be safe and useful to prevent SARS-CoV-2 infection before and after surgery for both patients and stuff. The pandemic was responsible for the reduction in number of procedures performed, anyway for the oncologic surgery a statistically significant volume reduction in comparison to 2019 was not observed.

[Whole laparoacopic trans-hiatal extended total gastrectomy with the Or-Vil device: preliminary results in the treatment of Siewert type II and III tumors]. / Gastrectomia totale "trans-hiatally extended" totalmente laparoscopica con Or-Vil" device: risultati preliminari nel trattamento dei tumori Siewert tipo II e III.

Adenocarcinoma of the gastro-oesophageal junction is progressively rising in western countries and, because of its poor prognosis, presents a real clinical challenge for the oncological surgeon. We evaluate our initial experience with wholly laparoscopic trans-hiatal extended total gastrectomy with the Or-Vil device for treating Siewert type II and III tumours of the gastro-oesophageal junction. Ten patients were enrolled in the present study; ASA score, stage of disease, length of surgery, estimated blood loss, number of lymph nodes harvested, length of proximal margin clearance, morbidity and mortality were analysed. Mortality was nil and morbidity 20%; the average proximal clearance margin was 5.7 cm and all margins were tumour-free (RO). The number of lymph nodes harvested was 38 +/- 19. Neither anastomotic fistulas nor major dehiscence were observed. In our initial experience, wholly laparoscopic trans-hiatal extended total gastrectomy for treating Siewert type II and III tumours of the gastro-oesophageal junction is safe, effective and, according to our preliminary results, oncologically correct, but it remains a complex, advanced laparoscopic procedure, requiring major skills and adequate experience. Prospective, randomised trials--possibly multicentric--are required to establish its efficacy in terms of long-term oncological outcomes.

Use of a dynamic self-regulating prosthesis (P.A.D.) in inguinal hernia repair: our first experience in 214 patients.

Numerous techniques exist for inguinal hernia treatment. Currently, open mesh tension-free repair is regarded as the repair method of choice. In particular Lichtenstein repair is the most common procedure performed, although several articles have reported long-lasting postoperative pain and a higher recurrence rate than originally reported. This study describes the P.A.D. (Protesi Autoregolantesi Dinamica) prosthesis implantation technique and reports postoperative complications and long-term results. From June 2002 to May 2005 a total of 214 patients underwent P.A.D. prosthesis inguinal repair. All patients were male, with a mean age of 51 years. All hernias were treated via an open inguinal approach using the original technique described by Valenti, with slight modifications. A total of 171'patients (80%) were available to follow-up 3 years after surgery. Early postoperative complications occurred in 14 patients (8.4%). Four patients (12.1%), who had undergone regional anaesthesia, developed urinary retention. Wound infection occurred in 3 patients (1.4%). There were two direct recurrences (0.93%) whereas chronic postoperative inguinal pain was reported in 4.2% of patients. Within the limitations of a short follow-up, our results show that the P.A.D. prosthesis procedure is a reliable technique with a low recurrence rate and low postoperative morbidity.

[Laparoscopic total gastrectomy for multifocal gastric GIST: a case report and review of the literature]. / Gastrectomia totale laparoscopica per GIST gastrico multifocale: caso clinico e revisione della letteratura.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the GI tract, deriving from interstitial Cajal cell degeneration. Over 95% of GISTs express CD-117 and CD-34, thus differing from other mesenchymal-derived tumours. The aim of this study was to evaluate our experience with a multifocal GIST, treated by laparoscopic total gastrectomy, and review the literature. A 74-year-old man with a preoperative diagnosis of sub-cardial GIST, obtained by endoscopy, CT scan and endoscopic ultrasound, was submitted to laparoscopic total gastrectomy with an end-to-side oesophago-jejunal anastomosis, using the Or-Vil system. GISTs account for only 1% of all GI tumours, with a variable behaviour, from indolent forms to aggressive tumours with potential for hepatic and peritoneal metastasis. Surgery is the cornerstone of therapy, the aim being to obtain an R0 resection, so as to minimise the risk of recurrence. Laparoscopic total gastrectomy is an excellent solution for their treatment, with possible adjuvant therapy based on imatinib-mesylate, for high-risk GIST.

[Modulation of the extent of lymphadenectomy in early gastric cancer. Review of the literature and role of laparoscopy]. / Modulazione dell'estensione della linfadenectomia nell' "early gastric cancer". Review della letteratura e ruolo della laparoscopia.

Early gastric cancer is a gastric carcinoma confined to the mucosa or submucosa of the stomach, regardless of the presence of nodal involvement, which in any event is present only in about 20% of patients. This uncommon nodal involvement is a distinct clinical problem, because standard D2 lymphadenectomy constitutes overtreatment in more than 80% of patients. A review of the literature shows that the present surgical tendency for those patients who do not fulfill the Gotoda criteria (i.e. not amenable to an endoscopic mucosal or submucosal dissection) is to modulate the extent of the lymphadenectomy on the basis of the characteristics of the cancer: for mucosal early gastric cancers located in the upper third of the stomach, gastrectomy with D1 lymphadenectomy is sufficient; if located in the middle third the extent should be D1 +alpha (D1 + n. 7), while if located in the distal third, D1 +beta (D1 + n. 7,8a,9) is the best option. In all these cases, minimally invasive surgery can be a valid option, with results which are comparable to those of open surgery, but with all the advantages of the laparoscopic approach. For submucosal early gastric cancers, D1 +beta lymphadenectomy is indicated for neoplasia > 20 mm and of the protuberance type, while, for all other submucosal early gastric cancers (> 20 mm and of the depressed type, penetrating more than 500 micron into the submucosal layer, not differentiated, with lymphovascular invasion), standard D2 lymphadenectomy is the safest oncological procedure. In these cases, too, the laparoscopic approach can be a safe option, even if it requires greater laparoscopic skill.

[Five-year oncological results of laparoscopic versus open left hemicolectomy]. / Emicolectomia sinistra laparoscopica versus open: risultati oncologici a 5 anni.

Laparoscopic left hemicolectomy is still uncommon in surgical practice, because of both an unjustified fear of oncological inadequacy and technical difficulties with a steep learning curve. The aim of the present study was to analyse our 5-year experience with laparoscopic left hemicolectomy and its short- and long-term results. Thirty patients with non-metastatic non-infiltrating left colon cancer were treated laparoscopically and retrospectively compared to a group treated laparotomically and well matched for age, comorbidity and stage of disease in respect to the laparoscopic group. The duration of the laparoscopic procedures was longer, but intraoperative blood loss, passage of flatus and hospital stay were significantly less. Morbidity was similar and there was no 30 days mortality in either group. Specimen length and number of harvested lymph nodes were similar and 5-year cumulative survival curves showed no significant statistical difference (73.1% laparoscopic vs 70.8% open). Today, laparoscopic colon procedures are rarely performed, due both to fear of oncological inadequacy and to technical difficulties, yet several recent trials have presented evidence of safety, and oncological results comparable to those of the open counterpart. Our 5-year experience confirms these studies: our short- and long-term results show no statistical differences between the laparoscopic and "open" procedure. Laparoscopic left hemicolectomy is a safe, effective and oncologically adequate surgical procedure for non-metastatic non-infiltrating left colon cancer and is therefore a valid option for the surgical treatment of these neoplasms.

[Laparoscopic total mesorectal excision for extraperitoneal rectal cancer. Oncological outcome at 5 years]. / Total mesorectal excision laparoscopica per cancro del retto extraperitoneale. Outcome oncologico a 5 anni.

Total mesorectal excision (TME) is the cornerstone of surgical treatment for extraperitoneal rectal cancer. The aim of the present study was to analyse our five-year experience with laparoscopic TME, evaluating the overall five-year and disease-free survival rates. Twenty-five patients with low-middle rectal cancer were treated with laparoscopic TME. Patients with advanced rectal cancer were treated preoperatively with neoadjuvant radiochemotherapy. Five-year overall survival and disease-free survival were calculated according to the Kaplan-Meier method. Twenty-three ultralow anterior resections with Knight-Griffen anastomosis and 3 abdominoperineal resections were performed. At 30 days mortality was zero, while morbidity was 20% (all minor complications). The mean follow-up period was 30.5 months. Five-year overall survival was 80.2%, and five-year disease-free survival 80.9%. Our experience shows that laparoscopic TME is a safe and oncologically correct procedure. Oncologic outcomes were comparable to those reported in all major international experiences, and the results were very similar to those obtained with the laparotomic approach. However, it remains a complex technique, requiring an adequate learning curve. More prospective, randomised trials are needed in order to define laparoscopic TME as the new gold standard for the treatment of extraperitoneal rectal cancer.

[Laparoscopic versus open right hemicolectomy: 5-year oncology results]. / Emicolectomia destra laparoscopica versus open: risultati oncologici a 5 anni.

Laparoscopic right hemicolectomy has developed less markedly than rectosigmoid resection, probably because of the more complicated regional anatomy and greater difficulty in performing an adequate regional lymphectomy. The aim of the present study was to analyse our 5-year experience with laparoscopic right hemicolectomy. Twenty patients were enrolled with non-metastatic, non-infiltrating right colonic cancer, treated laparoscopically and compared to a group well matched for age, sex, comorbidity and stage of disease, treated laparotomically. The duration of the laparoscopic procedures was slightly longer, but intraoperative blood loss, passage of flatus and hospital stay were reduced compared to the laparotomic procedure. Morbidity was similar and there was no 30-day mortality in either group. Specimen length and number of harvested lymph nodes were similar and the 5-year cumulative survival curves showed no statistically significant difference (72.5% versus 72.2%). Our experience shows that laparoscopic right hemicolectomy is a safe, effective and oncologically adequate procedure, comparable in all respects to open hemicolectomy, but with all the advantages of the minimally invasive technique. Yet, it remains a complex surgical procedure, requiring skill and a long learning curve. Further studies, possibly prospective and randomised, are necessary to define the exact role of this technique for the treatment of non-metastatic, non-infiltrating right colonic cancer.

Laparoscopic incisional hernia repair: our experience with 105 consecutive cases.

Conventional repair of incisional hernia is associated with significant complications and a high recurrence rate (30-50%). The laparoscopic approach offers an effective alternative and reduces the recurrences to less than 5%. The aim of this study was to review our experience with laparoscopic incisional hernia repair. Medical records of all patients who underwent laparoscopic incisional hernia repair from January 2002 to December 2006 were reviewed. Demographic and postoperative data were recorded. The study population consisted of 105 patients, 72 females (68.5%) and 33 males (31.5%); the mean age was 56 years (range: 17-83 years). The mean fascial defect size was 116.9 cm2 and the average mesh size used was 256 cm2. Operative time was 118 min and the average hospital stay was 5 days. An expanded polytetrafluoroethylene (ePTFE) prosthesis was used In all patients. Perioperative complications occurred in 33 patients (31.4%) including seroma, cellulitis at the trocar site and prolonged ileus. During the follow-up there were 3 hernia recurrences (2.8%). Our study shows that laparoscopic incisional hernia repair resulted in a moderate rate of perioperative complications, a short hospital stay and a low recurrence rate. Hence the laparoscopic technique should be considered an effective and safe alternative to conventional incisional hernia repair.

[A rare case of obstructive jaundice and cholecystitis in hepatic fascioliasis in Italy]. / Un raro caso di ittero ostruttivo e colecistite da fascioliasi epatica in Italia.

The human infestation caused by Fasciola hepatica is a rare zoonosis, with an incidence of about 10 cases/year in Italy. We report a case of cholecystitis and obstructive jaundice in a patient affected by fascioliasis in which the diagnosis was secondary to the extraction of viable flukes from the bile duct during ERCP. The endoscopic examination permits, in addition to a rapid, correct diagnosis, direct clearance of the bile ducts. Oral drug therapy, when carried out following the endoscopic treatment, is aimed at killing any flukes potentially evading mechanical clearance. The healing achieved is confirmed by normalisation of antibody levels 6-12 months after therapy. Cholecystectomy is indicated and appropriate for the frequent occurrence of biliary colic related to acute and chronic cholecystitis and cholelithiasis, induced by the presence of the flukes. Infestation by Fasciola hepatica has to be considered among the differential diagnoses of obstructive jaundice. ERCP plays a major diagnostic and therapeutic role, and cholecystectomy, considering the pathogenetic effects of flukes on the organ, is mandatory.

The treatment of large midline incisional hernias using a retromuscular prosthetic mesh (Stoppa-Rives technique).

Incisional hernia is a common problem after abdominal surgery. Many repair techniques with prosthetic meshes have been proposed but there is no general agreement as to the best choice. Our retrospective experience with 35 patients treated using a large polypropylene mesh placed beneath the rectus muscles and above the peritoneum (Stoppa-Rives technique) is reported. There was no operative mortality. Major postoperative complications occurred in 7 (20%) patients. Wound infection developed in 5 (14.2%) patients and in one case the mesh had to be removed. The recurrence rate was 2.8%. In conclusion, retrorectus preperitoneal mesh repair is an effective technique with a low recurrence rate and very few postoperative complications.