SICOB Italian clinical practice guidelines for the surgical treatment of obesity and associated diseases using GRADE methodology on bariatric and metabolic surgery.

Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style changes in increasing and maintaining weight loss and ameliorating obesity-related complications and comorbidities. In patients affected by obesity and uncontrolled obesity-associated complications or high degrees of BMI (> 40 Kg/m2), metabolic bariatric surgery can be a valid therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for metabolic and bariatric surgery (MBS) and the choice of the most appropriate type of procedure have not been clarified so far.The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. Aim of the present guideline is to verify indications to surgery with respect to the presence of comorbid conditions, evaluate the different types of surgical approaches and endoscopic bariatric procedure and revise indication to revision surgery and postoperative procedures.

Mitochondrial DNA in Visceral Adipose Tissue in Severe Obesity: From Copy Number to D-Loop Methylation.

BACKGROUND: Peripheral alterations of mitochondrial DNA copy number (mtDNAcn) in obesity and associated co-morbidities have been previously shown. Furthermore, the possibility that methylation could occur in the mtDNA (in particular in the displacement loop, D-Loop) and regulate its functions has been raised. However, limited data about mtDNA methylation in adipose tissue are currently available. Since a strict crosstalk between the nucleus and mitochondria exists, especially in terms of the one-carbon cycle (that supports methylation reactions in the cell), we investigated methylation in selected areas of the mitochondrial and nuclear DNA and their expression in visceral adipose tissue (VAT) samples of patients with severe obesity. METHODS: VAT biopsies were collected from surgery patients to isolate DNA and RNA. Gene expression and mtDNAcn were assessed through qPCR. DNA methylation in both nuclear and mitochondrial areas were determined through bisulfite pyrosequencing. RESULTS: Methylation levels of the mtDNA were only marginally associated with the obesity degree (higher D-Loop methylation in severe obesity) and were not correlated with mtDNAcn. A significant correlation between D-Loop methylation and LINE-1 methylation was observed in VAT samples, and this was independent from the obesity degree. A progressive reduction of mtDNAcn and increase in NRF1 expression levels were measured in VAT in severe obesity. NRF1 expression was directly correlated with PPARG and MTHFR expression levels, while mtDNAcn was associated to TFAM expression. The correlation between mtDNAcn and TFAM expression was affected by the obesity status. CONCLUSIONS: This evidence supports the hypothesis that mtDNA alterations occur in obesity and a complex dynamic correlation between mitochondrial and nuclear DNA methylation exists, highlighting the need for further investigations.

Senescent macrophages in the human adipose tissue as a source of inflammaging.

Obesity is a major risk factor for type 2 diabetes and a trigger of chronic and systemic inflammation. Recent evidence suggests that an increased burden of senescent cells (SCs) in the adipose tissue of obese/diabetic animal models might underlie such pro-inflammatory phenotype. However, the role of macrophages as candidate SCs, their phenotype, the distribution of SCs among fat depots, and clinical relevance are debated. The senescence marker ß-galactosidase and the macrophage marker CD68 were scored in visceral (vWAT) and subcutaneous (scWAT) adipose tissue from obese patients (n=17) undergoing bariatric surgery and control patients (n=4) subjected to cholecystectomy. A correlation was made between the number of SCs and BMI, serum insulin, and the insulin resistance (IR) index HOMA. The monocyte cell line (THP-1) was cultured in vitro in high glucose milieu (60 mM D-glucose) and subsequently co-cultured with human adipocytes (hMADS) to investigate the reciprocal inflammatory activation. In obese patients, a significantly higher number of SCs was observed in vWAT compared to scWAT; about 70% of these cells expressed the macrophage marker CD68; and the number of SCs in vWAT, but not in scWAT, positively correlated with BMI, HOMA-IR, and insulin. THP-1 cultured in vitro in high glucose milieu acquired a senescent-like phenotype (HgSMs), characterized by a polarization toward a mixed M1/M2-like secretory phenotype. Co-culturing HgSMs with hMADS elicited pro-inflammatory cytokine expression in both cell types, and defective insulin signaling in hMADS. In morbid obesity, expansion of visceral adipose depots involves an increased burden of macrophages with senescent-like phenotype that may promote a pro-inflammatory profile and impair insulin signaling in adipocytes, supporting a framework where senescent macrophages fuel obesity-induced systemic inflammation and possibly contribute to the development of IR.

Complications after bowel resection for inflammatory bowel disease associated cancer: a systematic literature review.

INTRODUCTION: Inflammatory bowel disease (IBD) associated colorectal cancer represents the 1-2% of all patients affected by colorectal carcinoma, but it is frequent responsible for death in these patients. Aim of this systematic review was to report the complications after bowel resection in patients with IBD associated cancer. EVIDENCE ACQUISITION: A systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The search was carried out in PubMed, Embase, Cochrane and Web of Science databases. A total of 54,084 articles were found. Of these 38,954 were eliminated because were duplicates between the searches. Of the remaining 15,130 articles, 14,888 were excluded after screening title and abstract. EVIDENCE SYNTHESIS: Two-hundred-forty-two articles were fully analyzed, and 239 further articles were excluded. Finally, three articles were included for a total of 63 patients. Overall, 38 early postoperative complications (60.3%) were observed. Of these, anastomotic leakage occurred in 13 patients (20.6%). The indication for surgery was ulcerative colitis in 52 patients (82.5%), Crohn's disease in 8 patients (12.7%) and indeterminate colitis in 3 patients (4.8%). Intraoperative complications, readmission and postoperative mortality were not observed. CONCLUSIONS: Complication rate after bowel resection for IBD associated cancer is not different from complication rate after colorectal surgery for other diseases. Given the high probability of developing a cancer and the time correlated occurrence of malignancy in IBD patients, it should be debated if a surgical resection should be performed as soon as dysplasia is detected in IBD patients or earlier in their life.

Development and validation of a preoperative "difficulty score" for laparoscopic transabdominal adrenalectomy: a multicenter retrospective study.

BACKGROUND: A difficulty score for laparoscopic adrenalectomy (LA) is lacking in the literature. A retrospective cohort study was designed to develop a preoperative "difficulty score" for LA. METHODS: A multicenter study was conducted involving four Italian tertiary centers for adrenal disease. The population was randomly divided into two subsets: training group and validation one. A multicenter study was undertaken, including 964 patients. Patient, adrenal lesion, surgeon's characteristics, and the type of procedure were studied as potential predictors of target events. The operative time (pOT), conversion rate (cLA), or both were used as indicators of the difficulty in three multivariate models. All models were developed in a training cohort (70% of the sample) and validated using 30% of patients. For all models, the ability to predict complicated postoperative course was reported describing the area under the curve (AUCs). Logistic regression, reporting odds ratio (OR) with p-value, was used. RESULTS: In model A, gender (OR 2.04, p = 0.001), BMI (OR 1.07, p = 0.002), previous surgery (OR 1.29, p = 0.048), site (OR 21.8, p < 0.001) and size of the lesion (OR 1.16, p = 0.002), cumulative sum of procedures (OR 0.99, p < 0.001), extended (OR 26.72, p < 0.001) or associated procedures (OR 4.32, p = 0.015) increased the pOT. In model B, ASA (OR 2.86, p = 0.001), lesion size (OR 1.20, p = 0.005), and extended resection (OR 8.85, p = 0.007) increased the cLA risk. Model C had similar results to model A. All scores obtained predicted the target events in validation cohort (OR 1.99, p < 0.001; OR 1.37, p = 0.007; OR 1.70, p < 0.001, score A, B, and C, respectively). The AUCs in predicting complications were 0.740, 0.686, and 0.763 for model A, B, and C, respectively. CONCLUSION: A difficulty score based on both pOT and cLA (Model C) was developed using 70% of the sample. The score was validated using a second cohort. Finally, the score was tested, and its results are able to predict a complicated postoperative course.

Gastric ghrelin cells in obese patients are hyperactive.

BACKGROUND/OBJECTIVES: Distribution and activity of ghrelin cells in the stomach of obese subjects are controversial. SUBJECTS/METHODS: We examined samples from stomachs removed by sleeve gastrectomy in 49 obese subjects (normoglycemic, hyperglycemic and diabetic) and quantified the density of ghrelin/chromogranin endocrine cells by immunohistochemistry. Data were compared with those from 13 lean subjects evaluated by gastroscopy. In 44 cases (11 controls and 33 obese patients) a gene expression analysis of ghrelin and its activating enzyme ghrelin O-acyl transferase (GOAT) was performed. In 21 cases (4 controls and 17 obese patients) the protein levels of unacylated and acylated-ghrelin were measured by ELISA tests. In 18 cases (4 controls and 14 obese patients) the morphology of ghrelin-producing cells was evaluated by electron microscopy. RESULTS: The obese group, either considered as total population or divided into subgroups, did not show any significant difference in ghrelin cell density when compared with control subjects. Inter-glandular smooth muscle fibres were increased in obese patients. In line with a positive trend of the desacylated form found by ELISA, Ghrelin and GOAT mRNA expression in obese patients was significantly increased. The unique ghrelin cell ultrastructure was maintained in all obese groups. In the hyperglycemic obese patients, the higher ghrelin expression matched with ultrastructural signs of endocrine hyperactivity, including expanded rough endoplasmic reticulum and reduced density, size and electron-density of endocrine granules. A positive correlation between ghrelin gene expression and glycemic values, body mass index and GOAT was also found. All obese patients with type 2 diabetes recovered from diabetes at follow-up after 5 months with a 16.5% of weight loss. CONCLUSIONS: Given the known inhibitory role on insulin secretion of ghrelin, these results suggest a possible role for gastric ghrelin overproduction in the complex architecture that takes part in the pathogenesis of type 2 diabetes.

Laparoscopic repair of giant Morgagni hernia by direct suturing with V-Loc.

BACKGROUND: Morgagni hernias present technical challenges. The laparoscopic approach for repair was first described in 1992; however, as these hernias are uncommon in adult life, few data exist on the optimal method for surgical management. The purpose of this study was to analyze a method for laparoscopic repair of Morgagni giant hernias using laparoscopic primary closure with V lock (Medtronic, Covidien). METHODS: This case series describes a method of laparoscopic Morgagni hernia repair using primary closure. In all patients, a laparoscopic transabdominal approach was used. The content of the hernia was reduced into the abdomen, and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. Clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. Demographic data such as BMI and operative and postoperative data were collected. RESULTS: Retrospectively collected data for 9 patients were analyzed. There were 1 (11.1%) males and 8 (88.8%) females. The median BMI was 29.14±52 kg/m2. The median operative time was 80±25 minutes. There were no intraoperative complications or conversions to open surgery. Patients began a fluid diet on the first postoperative day and were discharged after a median hospital stay of 3±1.87 days. In a median follow-up of 36 months, we did not observe any recurrences. CONCLUSIONS: Transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for the repair of Morgagni hernia. In our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs.

Transanal endoscopic microsurgery in the treatment of large rectal adenomas.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique allowing to excise large rectal adenomas by local approach. This study shows the feasibility and results of a long term experience of TEM applied in this field. METHODS: A retrospective investigation was performed in patients affected by rectal adenomas (5-11 cm in diameter) who had undergone transanal endoscopic microsurgery from 1992 to 2015. A series of 207 patients met the inclusion criteria and were analyzed for characteristics, intraoperative and postoperative results and long-term follow-up. RESULTS: Median age was 71 years (52-83 years). Of the 207 total patients, 77 were women (37.2%) and 130 men (62.8%). Median distance from the anal verge was 8 cm (4-20 cm). Median size was 6 cm, with lesion ranging from 5 to 11 cm in diameter. Median operative time was 57 minutes (42-90 minutes). We observed 17 (8.2%) minor complications and 2 (0.9%) major complication according to the Clavien-Dindo classification. We did not observe any intraoperative or post-operative mortality. Histological examination showed preoperative undiagnosed cancer in 8 (3.8%) cases in which the pathologist revealed adenocarcinoma staged as T1 Sm1 according to the Kikuchi classification. The median follow-up was 115 months (12-288 months). Six recurrences (2.9%), we observed with a median time for recurrence of 14 months. CONCLUSIONS: TEM provides excellent oncological outcomes in the treatment of large benign rectal lesions, ensuring a minimal risk of resection margin infiltration at pathological examination, and is associated with low risk of complications.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones.

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

Two Decades of Laparoscopic Adrenalectomy: 326 Procedures in a Single-Center Experience.

AIM: Aim of this study is to evaluate the results of 20-year single-center laparoscopic adrenalectomy (LA), with different transperitoneal techniques. MATERIALS AND METHODS: Three hundred twenty-six adrenalectomies were performed from 1993 to 2013 using a transperitoneal approach through anterior access, flank access, and anterior submesocolic access (adopted by the author for left LA since 2004). RESULTS: Overall 142 men and 184 women (mean age 59.3 y) underwent 196 right, 113 left, and 17 bilateral adrenalectomies. There was 1 fatal outcome (0.30%) due to sepsis. Conversion to open surgery was required in 7 patients (2.14%) for intraoperative bleeding (n=5), paroxysmal hypertension during pheochromocytoma removal (n=1), and tearing of the colon during bilateral adrenalectomy in a patient with Cushing hyperplasia (n=1).There were 15 postoperative complications (4.60%) managed conservatively. CONCLUSIONS: Transperitoneal LA is a safe, minimally invasive procedure ensuring early recovery. The submesocolic access is faster and minimizes surgical dissection.

Management of adrenal incidentaloma by laparoscopic transperitoneal anterior and submesocolic approach.

PURPOSE: Laparoscopic adrenalectomy (LA) is becoming the main approach for incidentally discovered adrenal masses (adrenal incidentaloma (AI)). The aim of this study was to evaluate the results of LA with a transperitoneal anterior approach for right adrenal lesions and either a transperitoneal anterior or transperitoneal anterior submesocolic approach for the left-sided lesions. METHODS: The study is a retrospective analysis of prospectively collected data. From January 1994 to December 2012, 393 patients underwent LA, 117 of these for an AI. Sixty-seven (57.26 %) and 50 (42.73 %) patients underwent right and left adrenalectomy, respectively. The transperitoneal anterior approach was used in all 67 patients with right lesions (57.26 %) (group A) and in 13 patients with left-sided lesions (11.11 %) (group B). The transperitoneal anterior submesocolic approach was used in the remaining 37 left-sided lesions (31.62 %) (group C). RESULTS: Mean operative time in groups A, B, and C was 104.6 min (range 35-255), 148.9 min (range 80-210), and 82.7 min (range 45-230), respectively. One right and one left anterior LA (1.7 %) were converted to open surgery. There were one major and one minor complications (1.7 %). The mean lesion size was 4.73 cm (range 1-10 cm). Mean hospital stay was 3.6 days. CONCLUSIONS: With adequate experience, LA with a transperitoneal anterior approach for AI is a safe and effective procedure. Early control of the adrenal vein with minimal gland manipulation and limited surgical dissection are its major advantages. In case of left LA, the submesocolic approach reduces the operative time significantly.

On the suitability of Thiel cadavers for natural orifice transluminal endoscopic surgery (NOTES): surgical training, feasibility studies, and anatomical education.

BACKGROUND: Surgical training in virtual, animal and cadaver models is essential for minimally invasive surgery. Thiel cadavers are suitable for laparoscopy, but there are few data about the use of embalmed (Tutsch method) and slightly embalmed (Thiel method) cadavers in procedures of Natural Orifice Transluminal Endoscopic Surgery (NOTES), which are usually developed and learned on swine models and fresh frozen cadavers. The aim of this study was thus to assess the use of these cadavers for NOTES approaches. METHODS: The following surgical procedures were evaluated: transanal total mesorectal excision (four cadavers: one Tutsch, two Thiel, one fresh frozen), transanal ileorectal bypass (five cadavers: one Tutsch, three Thiel, one fresh frozen), and transvaginal appendectomy (two Tutsch cadaver). RESULTS: The Thiel method ensured tissue flexibility and consistency suitable for performing the above surgical procedures with good results and without complications, with only a small increase in rigidity with respect to fresh specimens. Cadavers embalmed with higher formalin concentrations (Tutsch method) were more difficult to use, due to high tissue rigidity and resistance of the abdominal wall to pneumoperitoneum, although NOTES accesses were possible. CONCLUSIONS: Thiel cadavers are suitable for transanal/transrectal and transvaginal NOTES approaches, for training surgical residents/specialists and also for surgical research. In minimally invasive surgery (and particularly in NOTES), integration between cadaver (fresh frozen and/or Thiel) and animal models would represent the gold standard, allowing guaranteed knowledge of and respect for human surgical anatomy and correct management of surgery on living subjects. NOTES approaches to human cadavers may also be proposed for the anatomical education of medical students.

Treatment of rectal cancer by transanal endoscopic microsurgery: experience with 425 patients.

AIM: To describe our experience in treating rectal cancer by transanal endoscopic microsurgery (TEM), report morbidity and mortality and oncological outcome. METHODS: A total of 425 patients with rectal cancer (120 T1, 185 T2, 120 T3 lesions) were staged by digital rectal examination, rectoscopy, transanal endosonography, magnetic resonance imaging and/or computed tomography. Patients with T1-N0 lesions and favourable histological features underwent TEM immediately. Patients with preoperative stage T2-T3-N0 underwent preoperative high-dose radiotherapy; from 1997 those aged less than 70 years and in good general health also underwent preoperative chemotherapy. Patients with T2-T3-N0 lesions were restaged 30 d after radiotherapy and were then operated on 40-50 d after neoadjuvant therapy. The instrumentation designed by Buess was used for all procedures. RESULTS: There were neither perioperative mortality nor intraoperative complications. Conversion to other surgical procedures was never required. Major complications (urethral lesions, perianal or retroperitoneal phlegmon and rectovaginal fistula) occurred in six (1.4%) patients and minor complications (partial suture line dehiscence, stool incontinence and rectal haemorrhage) in 42 (9.9%). Postoperative pain was minimal. Definitive histological examination of the 425 malignant lesions showed 80 (18.8%) pT0, 153 (36%) pT1, 151 (35.5%) pT2, and 41 (9.6%) pT3 lesions. Eighteen (4.2%) patients (ten pT2 and eight pT3) had a local recurrence and 16 (3.8%) had distant metastasis. Cancer-specific survival rates at the end of follow-up were 100% for pT1 patients (253 mo), 93% for pT2 patients (255 mo) and 89% for pT3 patients (239 mo). CONCLUSION: TEM is a safe and effective procedure to treat rectal cancer in selected patients without evidence of nodal involvement. T2-T3 lesions require preoperative neoadjuvant therapy.

Laparoscopic transperitoneal anterior adrenalectomy in pheochromocytoma: experience in 62 patients.

BACKGROUND: Aim was to evaluate the results in 62 patients undergoing laparoscopic adrenalectomy (LA) for the treatment of pheochromocytoma (PHE), with a transperitoneal anterior approach for lesions on the right side, and with a transperitoneal anterior submesocolic approach in case of left-sided lesions. METHODS: Sixty-two patients underwent LA for the treatment of PHE at two centers in Rome and Ancona (Italy). Two patients had bilateral lesions, for a total of 64 adrenalectomies. Sporadic PHE occurred in 57 patients (91.9 %) and in 5 (8.0 %) it was familiar. Thirty-six patients (58.0 %) underwent right adrenalectomy, 24 (38.7 %) left adrenalectomy, and in 2 cases (3.2 %) LA was bilateral. In 38 cases of right adrenalectomy (59.3 %) and in 5 cases of left adrenalectomy (7.8 %), the approach was a transperitoneal anterior one. A transperitoneal anterior submesocolic approach was used in 21 left adrenalectomy cases (32.8 %). RESULTS: Mean operative time for right and left transperitoneal anterior LA was 101 min (range 50-240) and 163 min (range 50-190), respectively. Mean operative time for left transperitoneal anterior submesocolic LA was 92 min (range 50-195). For bilateral adrenalectomy, mean operative time was 210 min (range 200-220). Conversion to open surgery occurred in 2 cases (3.22 %) due to extensive adhesions (1) and hemorrhage (1). One major and three minor complications were observed. Mobilization occurred on the first postoperative day. Hospitalization was 4.8 days (range 2-19). The lesions had a mean diameter of 4.5 cm (range 0.5-10). CONCLUSIONS: Early identification with no gland manipulation prior to closure of the adrenal vein is the main advantages of the transperitoneal anterior approach. PHE may be treated safely and effectively by a laparoscopic transperitoneal anterior approach for right-sided lesions and with a transperitoneal anterior submesocolic approach for left-sided ones.

Quality-of-life impairment after endoluminal locoregional resection and laparoscopic total mesorectal excision.

BACKGROUND: For selected patients with rectal cancer, endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to laparoscopic total mesorectal excision (LTME). Few data are available on quality of life (QoL) after LTME and TEM. This study aimed to compare short- and medium-term QoL for T1 rectal cancer patients undergoing LTME or ELRR by TEM. METHODS: This study investigated 35 patients with T1N0 rectal cancer who underwent TEM (n = 17) or LTME (n = 18). Quality of life was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-C38 questionnaires preoperatively and then 1, 6, and 12 months after surgery. RESULTS: Observation 1 month after LTME showed worsening in all items of both questionnaires. After ELRR, the QLQ-CR38 showed worsening of gastrointestinal (p = 0.005) and defecation problems (p = 0.001), and the QLQ-C30 showed worsening of global health status (p = 0.014), physical functioning (p = 0.02) role functioning (p = 0.003), fatigue (p = 0.002), and pain (p = 0.001). The QLQ-CR38 6 months after LTME showed worsening of body image (p = 0.009), micturition (p = 0.035), and gastrointestinal problems (p = 0.011), and the QLQ-C30 showed worsening of physical functioning (p = 0.003), role functioning (p = 0.002), fatigue (p = 0.004), and nausea/vomiting (p = 0.030). After ELRR, neither the QLQ-CR38 nor the QLQ-C30 questionnaire showed any worsening but demonstrated improvement in global health status and physical functioning. The QLQ-CR38 12 months after LTME showed significant improvement in defecation problems (p = 0.004) and weight loss (p = 0.003), and the QLQ-C30 showed significant improvement in global health status (p = 0.001), nausea and vomiting (p = 0.003), and pain (p = 0.005). After ELRR, the QLQ-C30 showed improvement in emotional functioning (p = 0.012), whereas no significant difference was observed by the QLQ-C38. CONCLUSIONS: Functional sequelae are present up to 1 month only after ELRR by TEM and up to 6 months after LTME. At 12 months, neither procedure showed a significant difference in QoL compared with preoperative status.

Cancer stem cell gene profile as predictor of relapse in high risk stage II and stage III, radically resected colon cancer patients.

Clinical data indicate that prognostic stratification of radically resected colorectal cancer based on disease stage only may not be always be adequate. Preclinical findings suggest that cancer stem cells may influence the biological behaviour of colorectal cancer independently from stage: objective of the study was to assess whether a panel of stemness markers were correlated with clinical outcome in resected stage II and III colon cancer patients. A panel of 66 markers of stemness were analysed and thus patients were divided into two groups (A and B) with most patients clustering in a manner consistent with different time to relapse by using a statistical algorithm. A total of 62 patients were analysed. Thirty-six (58%) relapsed during the follow-up period (range 1.63-86.5 months). Twelve (19%) and 50 (81%) patients were allocated into group A and B, respectively. A significantly different median relapse-free survival was observed between the 2 groups (22.18 vs 42.85 months, p=0.0296). Among of all genes tested, those with the higher "weight" in determining different prognosis were CD44, ALCAM, DTX2, HSPA9, CCNA2, PDX1, MYST1, COL1A1 and ABCG2. This analysis supports the idea that, other than stage, biological variables, such as expression levels of colon cancer stem cell genes, may be relevant in determining an increased risk of relapse in resected colorectal cancer patients.

Laparoscopic transperitoneal anterior adrenalectomy.

AIM: Aim of this study was to report the authors' experience with the anterior transperitoneal approach, and with an anterior submesocolic approach in case of left sided lesions. MATERIAL AND METHODS: From January 1994 to January 2011, 122 males and 170 females with a mean age of 50.7 years (range: 19-84) underwent laparoscopic adrenalectomy (LA) at 2 centers in Ancona and Rome (Italy) (that follow the same protocol). Fifteen patients underwent bilateral LA, the anterior transperitoneal approach was used in 233 cases (79.8%) and the anterior submesocolic in 59 (20.2%). One hundred and two patients had Conn's syndrome, 51 miscellaneous lesions, 55 Cushing's syndrome, 47 incidentalomas, 46 pheochromocytoma, 2 metastatic masses, 2 myelolipomas and 2 adrenogenital syndromes. The lesions had a mean diameter of 3.24 cm (range: 0.5-10). RESULTS: Mean operating time was 120 minutes (range: 30-390). Conversion to open surgery was required in 13 cases (4,45%). Blood pressure and heart rate were stable during the operation. There were 5 major complications. Mobilization and resumption of diet occurred on the first postoperative day. Mean hospital stay was 4.32 days (range: 2-30). DISCUSSION: Early identification and ligature of the adrenal vein, with minimal gland manipulation, are the major advantages, especially in case of pheochromocytoma. CONCLUSIONS: Adrenal masses can be successfully treated using a laparoscopic transperitoneal anterior approach, in presence of a suitable anesthesiological and surgical team's experience. KEY WORDS: Adrenal tumors, Laparoscopic adrenalectomy, Pheochromocytoma.

Nucleotide-guided mesorectal excision combined with endoluminal locoregional resection by transanal endoscopic microsurgery in the treatment of rectal tumors: technique and preliminary results.

BACKGROUND: Endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery (TEM) is an alternative treatment option for T1N0 rectal cancer and for selected patients with small T2N0 rectal cancer after neoadjuvant radiochemotherapy (n-RCT). The N parameter may remain undefined after transanal surgery. This study aimed to evaluate the role of a modified sentinel lymph node technique to improve N staging that the authors named "nucleotide-guided mesorectal excision" (NGME). METHODS: The study enrolled 41 patients (24 men and 17 women) with a mean age of 70.5 years. Preoperative staging identified dysplasia with no suspicion for cancer at imaging (n = 8), dysplasia with suspected malignancy at imaging (n = 15), no suspicion of malignancy at imaging after n-RCT (n = 2), cT1N0 (n = 6), cT2N0 (n = 6), cT3N0 (n = 3), and cT3N1 (n = 1). The patients underwent ELRR by TEM with NGME. Before surgery, 99m-technetium-marked nanocolloid was injected into the peritumoral submucosa. After resection, the residual defect was probed to detect residual radioactivity. If present, hot mesorectal fat was excised. RESULTS: With NGME, the mesorectal lymph node harvest increased from 0 to 10. Lymph nodes were isolated in the specimen or in hot mesorectal fat of 20 patients, 8 of whom had undergone n-RCT. The mean lymph node harvest was 2.75 ± 3.01 (range 1-10) in the irradiated patients and 2.91 ± 1.62 (range 1-6) in the nonirradiated patients (p = 0.87). The average number of lymph nodes in the irradiated patients was higher than in a previous historical series. CONCLUSIONS: The use of NGME during ELRR by TEM increases the lymph node harvest and may improve staging accuracy after transanal surgery.

Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy.

BACKGROUND AND PURPOSE: There is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3 years. METHODS: The subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; n = 164) or laparoscopic surgery (LS group; n = 126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0 months after OS and LS, respectively. RESULTS: There were 10 (6.1 %) versus 9 (7.1 %) deaths unrelated to cancer, 15 (9.1 %) versus 5 (4 %) cases of local recurrence, 7 (4.2 %) versus 5 (4 %) cases of peritoneal carcinosis, and 37 (22.5 %) versus 14 (11.1 %) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8 %). The OS group had a significantly higher probability of local recurrence and metastases (p < 0.001) with a significant higher probability of cancer-related death (p = 0.001) than the LS group. CONCLUSIONS: These findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.

Minimally invasive treatment of rectovaginal fistula.

BACKGROUND: Rectovaginal fistulas (RVFs) are a rare surgical condition. Their treatment is extremely difficult, and no standard surgical technique is accepted worldwide. This report describes a new approach using transanal endoscopic microsurgery (TEM) to treat RVFs. METHODS: A retrospective review of 13 patients who underwent repair of rectovaginal fistula using TEM between 2001 and 2008 was undertaken. The surgical technique is widely described, and the advantages of the endorectal approach are noted. RESULTS: The median follow-up period was 25 months, and the median age of the patients was 44 years (range, 25-70 years). The mean operative time was 130 min (range, 90-150 min), and the hospital stay was 5 days (range, 3-8 days). One patient experienced recurrence. This patient underwent reoperation with TEM and experienced re-recurrence. Two patients had minor complications (hematoma of the septum and abscess of the septum), which were treated with medical therapy. For two patients, a moderate sphincter hypotonia was registered. CONCLUSIONS: A new technique for treating RVFs using TEM is presented. The authors strongly recommend this approach that avoids any incision of the perineal area, which is very painful and can damage sphincter functions.