The Added Value of Intraoperative Near-Infrared Fluorescence Imaging in Elective Laparoscopic Cholecystectomy.

Bile duct injury is a major complication of laparoscopic cholecystectomy (LC). Intraoperative cholangiogram is useful, but faster techniques are available to assist the surgeon, like near-infrared fluorescent cholangiography (NIFC) with indocyanine green (ICG). The aim of our study is to evaluate the usefulness of NIFC during LC. This is a retrospective study conducted on prospectively recorded data of the General Surgery department of Trieste Academic Hospital, Italy. All patients underwent elective LC from January 2016 to January 2020. Patients were randomly divided in 2 groups: in one group, only white light imaging was used (n = 98 patients), in the NIFC group (n = 63) ICG was used. NIFC has been chosen more frequently by residents than consultants (P = .002). Operative time and length of stay resulted shorter in ICG group (P = .002 and .006), and this group showed also fewer intraoperative complications (P = .007). NIFC does not require any learning curve and makes surgery faster and safer.

Serum carcinoembryonic antigen pre-operative level in colorectal cancer: revisiting risk stratification.

BACKGROUND: Biomarkers may play a role as predictive and prognostic factors in colorectal cancer patients. The aims of the study were to verify the prognostic role of pre-operative serum carcinoembryonic antigen (CEA) level in predicting overall survival and risk of recurrence in a cohort of colorectal cancer patients and to evaluate optimal cut-off values. METHODS: A retrospective cohort analysis was performed on colorectal cancer patients undergoing elective curative surgery between 2004 and 2019 at an Italian Academic Hospital. Main outcomes were overall survival, disease-free survival at 3-years and risk of local, loco-regional and distant recurrence during follow-up. A receiver operating characteristic (ROC) curve analysis was plotted using CEA pre-operative values and follow-up data in order to estimate the optimal cut-off values. RESULTS: A total of 559 patients were considered. The mean CEA value was 12.1 ± 54.1 ng/mL, and the median 29.3 (0-4995) ng/mL. The ROC curve analysis identified 12.5 ng/mL as the best CEA cut-off value to predict the risk of metastatic development after surgery in stage I-III colorectal cancer patients, and 10 ng/mL as the best CEA cut-off value to predict overall survival and disease-free survival in stage III-IV patients. These data suggest a stratification of colorectal cancer patients in three classes of risk: a low risk class (CEA <10 ng/mL), a moderate risk class (CEA 10-12.5 ng/mL) and a high risk class (CEA >12.5 ng/mL). CONCLUSION: In conclusion, pre-operative serum CEA measurements could integrate information to enhance patient risk stratification and tailored therapy.

Ileocecal valve syndrome and vitamin b12 deficiency after surgery: a multicentric prospective study.

Patients undergoing colon resection are often concerned about their functional outcomes after surgery. The primary aim of this prospective, multicentric study was to assess the intestinal activity and health-related quality-of-life (HRQL) after ileocecal valve removal. The secondary aim was to evaluate any vitamin B12 deficiency. The study included patients undergoing right colectomy, extended right colectomy and ileocecal resection for either neoplastic or benign disease. Selected items of GIQLI and EORTC QLQ-CR29 questionnaires were used to investigate intestinal activity and HRQL before and after surgery. Blood samples for vitamin B12 level were collected before and during the follow-up period. The empirical rule effect size (ERES) method was used to explain the clinical effect of statistical results. Linear mixed effect (LME) model for longitudinal data was applied to detect the most important parameters affecting the total score. A total of 158 patients were considered. Applying the ERES method, the analysis of both questionnaires showed clinically and statistically significant improvement of HRQL at the end of the follow-up period. Applying the LME model, worsening of HRQL was correlated with female gender and ileum length when using GIQLI questionnaire, and with female gender, open approach, and advanced cancer stage when using the EORTC QLQ-CR29 questionnaire. No significant deficiency in vitamin B12 levels was observed regardless of the length of surgical specimen. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory.

Correction to: Ileocecal valve syndrome and vitamin b12 deficiency after surgery: a multicentric prospective study.

One of the co-author Eliana Cagnazzo has been incorrectly published. The correct co-author name has been copied below.

Totally Laparoscopic Transgastric Resection of a Gastric Submucosal Fibrolipoma and Concomitant Sleeve Gastrectomy in a Morbidly Obese Patient.

INTRODUCTION: To evaluate feasibility and safety of a totally laparoscopic transgastric resection with concomitant sleeve gastrectomy in a morbidly obese presenting with benign lesion located along the lesser gastric curvature. MATERIALS AND METHODS: We report the case of a morbidly obese patient with an incidental submucosal lesion of the lesser curvature radiologically consistent with fibrolipoma at preoperative work-up. Benign nature of the mass was then confirmed EUS-biopsy. RESULTS: A combinated laparoscopic transgastric approach was successfully attempted resulting in a complete excision of the submucosal lesion and concomitant sleeve gastrectomy. Intraoperative and definitive histology confirmed the benign nature of the mass. Postoperative course was uneventful. CONCLUSION: Concomitant transgastric resection of submucosal benign lesions during laparoscopic sleeve gastrectomy represents both a safe and feasible surgical approach in morbidly obese patients. Preoperative work-up is of great importance in order to assess the benign nature of the lesion.

Association between benign thyroid disease and breast cancer: a single center experience.

BACKGROUND: The relationship between breast cancer (BC) and thyroid disease (TD) is still controversial. The aim of the study was to investigate the possible coexistence of TD in patients with newly diagnosed BC and its correlation with BC clinical presentation with regard to menopausal status and stage of disease. METHODS: This is a retrospective cohort study of all patients treated for primary BC between 2014 and 2016 at the Breast Unit of Trieste University Hospital. Clinical charts and reports were reviewed for coexisting thyroid disorders (i.e. hyperthyroidism, hypothyroidism, benign TD, thyroid cancer, thyroid autoimmunity) and menopausal status at the time of BC diagnosis. Biomolecular profile, stage, and grading of BC were also evaluated. RESULTS: A total of 786 women and 7 men were included in the study. Co-presence of TD was found in 161(20.3%) cases: of these, 151(19.4%) patients presented benign TD and 10(1.3%) patients presented thyroid carcinoma. Thyroid autoimmunity was found in 51(32%) patients. Regarding thyroid function, 88(55%) patients had hypothyroidism, 19(12%) hyperthyroidism, and 54(33%) normal thyroid function. No statistically significant correlation was found between age and TD (p = 0.16), although TD was more common in women aged ≥60 years. Women with BC diagnosed at pre-menopausal age were more likely to have thyroid autoimmune diseases (45% vs. 29%, p = 0.05). No association was detected among BC molecular profiles with either thyroid autoimmunity (p = 0.26) or altered thyroid function (p = 0.63). High-grade BC was more frequent in women with hyperthyroidism (52.9%, p = 0.04), but the grading was independent from the presence of thyroid autoimmune disease (p = 0.87). BC stage was related to both thyroid autoimmunity (p = 0.04) and thyroid function (p < 0.001), with 55.2% of women affected by benign TD presenting with stage I BC and more aggressive BCs found in hypothyroid patients. CONCLUSIONS: According our study results, patients with primary BC present a greater incidence of autoimmunity disorders, especially when diagnosed in the pre-menopausal setting. However, further prospective studies are required to definitively prove causality.

Enhanced Recovery after Bariatric Surgery: 202 Consecutive Patients in an Italian Bariatric Center.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways have been shown to improve postoperative outcomes. However, its application in bariatric surgery is still limited. The aim of the study was to define the safety of ERAS in bariatric patients with regard to postoperative complications, length of hospital stay (LOS), and readmission rates within 30 days from surgery. METHODS: The effectiveness and safety of an ERAS protocol was prospectively investigated in morbidly obese patients who underwent bariatric surgery in a single-institute experience over a 2-year period. RESULTS: Between June 2016 and September 2018, a total of 89 laparoscopic sleeve gastrectomy (SG), 105 Roux-en-Y gastric bypass (RYGB), and 8 one-anastomosis gastric bypass (OAGB) were performed. Twenty patients (9.9%) were revisional cases. Mean (standard deviation, SD) BMI and age at time of surgery were 43.2 (± 6.2) kg/m2 and 46 (± 11.3) years, respectively. Median (range) surgical time was 118 (45-255) minutes. Overall postoperative complication rate was 7.4%, with 6 (3.0%) patients developing grade III-IV complications according to the Clavien-Dindo classification. Median (range) LOS was 2 (1-50) days, with mean (SD) LOS of 2.3 (± 3.6) days. Overall, 36.6% of patients were discharged by first postoperative day and 77.7% by second postoperative day. Readmission rate was 4.5%. No mortality was observed during the study period. CONCLUSIONS: According to the results of the present study, ERAS in primary and revisional bariatric surgery is safe and feasible, with short LOS, low morbidity and readmission rates, and no mortality. A significant reduction of mean LOS was progressively noted over the study period.

Outcomes of laparoscopic surgery for pT3/pT4 colorectal cancer in young vs. old patients.

BACKGROUND: Laparoscopy for locally advanced colorectal cancer is not standardized yet and its potential risks and benefits in elderly patients are still under debate. The aim of this study was to evaluate clinical and oncologic results of laparoscopic surgery for pT3/pT4 lesions in both old and young people. METHODS: Between 2006 and 2015, 115 patients aged <70 years and 112 patients aged ≥70 years underwent elective laparoscopic surgery for pT3/pT4 colorectal cancer presenting without distant metastasis at the Department of General Surgery, Trieste. Characteristics of the study populations, including demographic, operative and tumor features, were prospectively collected and short-term and long-term clinical, pathologic and oncologic outcomes were retrospectively analyzed. RESULTS: No difference was found in terms of tumor features, type and duration of surgery, and quality of resection. Old patients were found to have significantly higher rates of conversion (P=0.02) and postoperative mortality(P=0.03), whereas postoperative complications and reintervention rates - although higher in the elderly - did not differ on statistical analysis (P=0.13 and P=0.19, respectively). Local and distant recurrence rates were not statistically different between the two groups (P=0.64 and P=0.34, respectively). Adjuvant chemotherapy was more frequently offered to young people (P<0.001), who were considered significantly healthier than old ones (P<0.001). Overall survival was significantly lower among the elderly (P=0.001), but 5-year disease-free survival did not differ between the two groups (P=0.09). CONCLUSIONS: Laparoscopic surgery for locally advanced lesions is feasible, but old patients present an increased risk of conversion and postoperative morbidity and mortality, which may alter long-term outcomes determining an apparent decrease in survival.

Non-operative management of rectal cancer: future perspectives turning into reality?

The management of rectal cancer has considerably changed over the last decades and complete response to neoadjuvant chemoradiotherapy is becoming a common clinical entity. There is still no consensus on the definition of complete response to neoadjuvant treatment prior to surgery. Treatment programs are mostly heterogeneous and non-randomized. In addition, techniques to diagnose complete response are still unclear and there is no uniformity in surveillance modality of those patients managed without operative intervention. We review the most recent evidences reported in literature.

Laparoscopic vs. open approach for pT3/pT4 colorectal cancer in the elderly: ten-year experience in a single center.

BACKGROUND: The role of laparoscopic surgery for pT3/pT4 colorectal cancer (CRC) is still under debate. The aim of this study was to compare the outcomes of laparoscopic and open procedures for pT3/pT4 CRC in elderly patients. METHODS: From January 2004 to December 2015, 225 patients aged ≥70 years underwent elective colorectal surgery for pT3/pT4 CRC at the Department of General Surgery, University Hospital of Trieste. Patients' demographics, tumor's characteristics, intraoperative factors, short-term and long-term outcomes were retrospectively analyzed. RESULTS: The study included 113 patients undergone open surgery and 112 who underwent laparoscopic surgery. Age was found to be statistically different between the two group, with open surgery patients being older than laparoscopic ones (P=0.009). The tumor location differed between the two groups (P=0.004), determining a variation in the incidence of surgical procedures performed (P<0.001). No other statistically significant differences were found in terms of intraoperative, histopathologic and oncologic factors. CONCLUSIONS: Laparoscopy is as safe as open surgery for pT3/pT4 CRC and it is often feasible, though in old patients higher conversion rates should be anticipated than in younger ones.