Analysis of HIV quasispecies and virological outcome of an HIV D+/R+ kidney-liver transplantation.

INTRODUCTION: Transplantation among HIV positive patients may be a valuable therapeutic intervention. This study involves an HIV D+/R+ kidney-liver transplantation, where PBMC-associated HIV quasispecies were analyzed in donor and transplant recipients (TR) prior to transplantation and thereafter, together with standard viral monitoring. METHODS: The donor was a 54 year of age HIV infected woman: kidney and liver recipients were two HIV infected men, aged 49 and 61. HIV quasispecies in PBMC was analyzed by ultra-deep sequencing of V3 env region. During TR follow-up, plasma HIV-1 RNA, HIV-1 DNA in PBMC, analysis of proviral integration sites and drug-resistance genotyping were performed. Other virological and immunological monitoring included CMV and EBV DNA quantification in blood and CD4 T cell counts. RESULTS: Donor and TR were all ART-HIV suppressed at transplantation. Thereafter, TR maintained a nearly suppressed HIV-1 viremia, but HIV-1 RNA blips and the increase of proviral integration sites in PBMC attested some residual HIV replication. A transient peak in HIV-1 DNA occurred in the liver recipient. No major changes of drug-resistance genotype were detected after transplantation. CMV and EBV transient reactivations were observed only in the kidney recipient, but did not require specific treatment. CD4 counts remained stable. No intermixed quasispecies between donor and TR was observed at transplantation or thereafter. Despite signs of viral evolution in TR, HIV genetic heterogeneity did not increase over the course of the months of follow up. CONCLUSIONS: No evidence of HIV superinfection was observed in the donor nor in the recipients. The immunosuppressive treatment administrated to TR did not result in clinical relevant viral reactivations.

The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology.

At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.

Fluorescence-based bowel anastomosis perfusion evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry.

BACKGROUND: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry. METHODS: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications. RESULTS: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013-0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not. CONCLUSION: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.

Colorectal surgery during the COVID-19 outbreak: do we need to change?

The outbreak of COVID-19 has led some leading surgical societies to postpone colorectal cancer resections, support the employment of low-risk strategies in patients requiring colorectal surgery, such as construction of a stoma rather than primary anastomosis, in order to minimize the risk of potentially life-threatening complications. They have also recommended against the use of the laparoscopic approach. However, the evidence supporting these recommendations is scarce. The aim of this study was to assess the outcomes of colorectal resections during the COVID-19 pandemic. This is a retrospective review of a prospective institutional database. All consecutive patients undergoing elective or emergent colorectal resections between March 9 and April 15, 2020, were compared to those treated in the same period of time in 2019. Despite an overall reduction in the surgical activity of 56.3% in 2020, the two groups were similar in terms of absolute numbers of colorectal resections, type of surgery and use of laparoscopy. The overall postoperative complications rate was similar: 20% in 2019 versus 14.9% in 2020 (p = 0.518), without any difference in terms of severity. No patient during the postoperative course got infected by COVID-19, as well as none from the surgical team. Median length of hospital stay was 5 days in both groups (p = 0.555). Postponing surgery in colorectal cancer patients and performing more stomas rather than direct anastomosis is not justified. The routine use of laparoscopy should not be abandoned, thus not depriving patients of its clinically relevant early short-term benefits over open surgery.

Are there any limits for laparoscopy in splenomegaly? Our experience.

Laparoscopic splenectomy in the case of massive or supermassive splenomegaly has been associated with higher conversion rates and morbidity. The purpose of our study is to evaluate the feasibility and safety of laparoscopic splenectomy for massive spleens and to identify if there are limits beyond which the laparoscopic approach is not recommended in massive and supermassive spleens. This is a retrospective study of 93 consecutive laparoscopic splenectomies in adult patients performed by a single surgeon, from January 2008 to December 2017. The data collected included the patient's age, sex, ASA, spleen weight, volume and dimension, type of disease, hospital stay, surgical technique, operative time. Median splenic weight was 400 g (range 65-3800 g) and median volume was 1365 cc (range 600-3800). Median operative time was 120 min and the overall conversion rate was 5.4%. Globally, 52 patients (55.9%) had a normal-weight spleen, 25 (26.9%) had massive and 16 (17.2%) had supermassive splenomegaly. In splenomegaly group (n = 41), patient's age, percentage of malignant diagnosis, spleen weight, anteroposterior (AP), medio-lateral (ML) and craniocaudal (CC) diameter, surgical time and conversion rate were significantly higher compared to normal-weight spleen patients. None of the normal-weight spleen patients underwent open conversion, while 5 patients among 41 splenomegalic cases underwent laparotomic conversion (12.2%). Comparing massive and super-massive patients, the latter showed longer operative time and hospital length of stay, and higher conversion rate. We identified as significant cut-off limits for higher conversion risk a spleen weight ≥ 1300 g and a spleen CC diameter ≥ 22 cm. In our experience laparoscopy was the gold standard in the case of spleen weight and diameter equal to or less than 1300 g and 22 cm, but it was safe and feasible also in the case of larger spleens, taking into account the greater risk of conversion.

Colon Adenocarcinoma during Pregnancy: A Case Report and Review of the Literature.

Colorectal cancer (CRC) during pregnancy presents an estimated incidence of 1 : 13,000, and it is associated with diagnostic and therapeutic challenges. Here, we present the case of a 38-year-old woman, 25 weeks and 5 days pregnant, who was transferred to our Obstetrics and Gynecology Department from a local hospital with the diagnosis of intestinal obstruction. Magnetic Resonance Imaging (MRI) showed marked distension with hydroaerial levels of the enterocolic loops upstream of a concentric parietal thickening of the descending colon, stenosing, extended longitudinally for about 4 cm. An exploratory laparotomy was performed with resection of the colon splenic flexure and mechanical end-terminal anastomosis. Histological examination of the operating piece highlighted the presence of moderately differentiated (G2) colon adenocarcinoma (stage pT3N1b). The operation was followed by a single course of oxaliplatin and 5-FU plus leukovorin. The patient had a vaginal delivery at 37 weeks + 2 days of gestational age, following induction of labor and giving birth to a male infant whose weight was 2670 gr with apgar 9/9. We underline the pivotal role of attention to unspecific symptoms, early diagnosis, and active treatment in changing the clinical course of CRC.

A Plea for Surgery in Pancreatic Metastases from Renal Cell Carcinoma: Indications and Outcome from a Multicenter Surgical Experience.

BACKGROUND: Pancreatic metastases from renal-cell carcinoma (RCC-PMs) are rare. Surgery may play a role in improving overall (OS) and disease-free survival (DFS). METHODS: Clinical-pathological features, surgery and follow-up data of patients with RCC-PMs operated on in three pancreatic surgical centers (2000-2019) were retrospectively evaluated. RESULTS: Thirty-nine patients (21 male/18 female, averaging 65 years) were enrolled. RCC-PMs were metachronous in 36 patients (mean 94 months, up to 24 years after nephrectomy), multiple in 21 patients, and with a median size of 2.5 (range, 0.7-7.5) cm. All the patients underwent pancreatic surgery (33 standard resections, 6 limited resections). Fifteen patients had post-operative complications (morbidity 38.5%). The median DFS was 63 months, and 19 out of 36 patients showed a disease recurrence. The median OS was 134 months, and 13 out of 36 patients were alive with no evidence of disease. At univariate analysis, lymph node positivity (HR 5.1, 95% CI 1.5-18), multi-visceral resection (HR 3.4, 95% CI 1.1-10) and synchronous RCC-PMs (HR 13, 95% CI 3-55) were significantly associated with a short OS. CONCLUSION: Surgery may allow a DFS up to 17 years in more than one third of patients, even after limited resections. Splenectomy and lymph node dissection are not mandatory.

Clinical outcomes and quality of life associated with the use of a biosynthetic mesh for complex ventral hernia repair: analysis of the "Italian Hernia Club" registry.

With the development of newer meshes and approaches to hernia repair, it is currently difficult to evaluate their performances while considering the patients' perspective. The aim of the study was to assess the clinical outcomes and quality of life consequences of abdominal hernia repairs performed in Italy using Phasix and Phasix ST meshes through the analysis of real-world data to support the choice of new generation biosynthetic meshes. An observational, prospective, multicentre study was conducted in 10 Italian clinical centres from May 2015 to February 2018 and in 15 Italian clinical centres from March 2018 to May 2019. The evaluation focused on patients with VHWG grade II-III who underwent primary ventral hernia repair or incisional hernia intervention with a follow-up of at least 18 months. Primary endpoints included complications' rates, and secondary outcomes focused on patient quality of life as measured by the EuroQol questionnaire. Seventy-five patients were analysed. The main complications were: 1.3% infected mesh removal, 4.0% superficial infection requiring procedural intervention, 0% deep/organ infection, 8.0% recurrence, 5.3% reintervention, and 6.7% drained seroma. The mean quality of life utility values ranged from 0.768 (baseline) to 0.967 (36 months). To date, Phasix meshes have proven to be suitable prostheses in preventing recurrence, with promising outcomes in terms of early and late complications and in improving patient quality of life.

Italian multi-society modified Delphi consensus on the definition and management of anastomotic leakage in colorectal surgery.

INTRODUCTION: The incidence of anastomotic leak (AL) has not decreased over the past decades and some important grey areas remain in its definition, prevention, and management. The aim of this study was to reach a national consensus on the definition of AL and to identify key points to be applied in clinical practice. METHODS: A 3-step modified Delphi method was used to establish consensus. Ten representative members of the major Italian surgical scientific societies with proven colorectal expertise were selected after a call to action. After a comprehensive literature search, each expert drew a list of evidence-based statements which were voted in round one by the scientific board. Panel members were asked to mark "totally disagree", "partially agree" or "totally agree" for each statement and provide comments. The same voting method was used for round 2. Round 3 consisted of a final face-to-face meeting. RESULTS: Thirty-three statements (clustered into 14 topics) were included in round 1. Following the third voting round, a final list of 16 items was formulated, which encompass the following 9 topics: AL definition, patient- and operative-related risk factors, prevention measures, bowel preparation, surgical technique, intraoperative assessment, early diagnosis, radiological diagnosis and management of specific patterns of AL. The overall response rate was 100% for all items in all the three rounds. CONCLUSIONS: This Delphi survey identified items that expert colorectal surgeons agreed were important to be applied in the prevention, diagnosis, and management of AL. This represents the first consensus involving all relevant national scientific societies, defining important and shared concepts in the diagnosis and management of AL.

I-ACTSS-COVID-19-the Italian acute care and trauma surgery survey for COVID-19 pandemic outbreak.

The sudden COVID-19 outbreak in Italy has challenged our health systems and doctors faced the challenge of treating a large number of critically ill patients in a short time interval. Acute care surgeons, although not directly involved in treating COVID-19 + patients, have often modified their daily activity to help in this crisis. We have designed the first Italian survey on the effect of COVID-19 outbreak on Acute Care Surgery activity and submitted it to emergency surgeons in all the country to evaluate the experiences, trends, attitudes and possible educational outcomes that this emergency brought to light. A total of 532 valid surveys were collected during the study period. Lombardy and Lazio had the major answer rate. 96% of responders noticed a decrease in surgical emergencies. The outbreak affected regions and hospitals in different ways depending on the local incidence of infection. Half of responders modified their approach to intra-abdominal infections towards a more conservative treatment. 43% of responders, mainly in the North, were shifted to assist non-surgical patients. There has been a direct but non-homogeneous involvement of emergency surgeons. Almost all hospitals have responded with specific pathways and training. Both emergency surgery and trauma activity have changed and generally decreased but the majority of surgeons have operated on suspected COVID-19 patients.

The Italian National Registry for minimally invasive pancreatic surgery: an initiative of the Italian Group of Minimally Invasive Pancreas Surgery (IGoMIPS).

The value of minimally invasive pancreatic surgery (MIPS) is still uncertain, despite the growing number of publications, including reviews and meta-analyses, and the quick diffusion of these procedures worldwide. The Italian Group of Minimally Invasive Pancreas Surgery (IGoMIPS) was created under the auspices of three Scientific Societies: Associazione Italiana Studio Pancreas (AISP), Associazione Italiana Chirurgia Epato-Bilio-Pancreatica (AICEP, former IT-IHPBA), and Società Italiana di Chirurgia Endoscopica (SICE). The main aim of IGoMIPS is to develop and implement a national registry for MIPS. IGoMIPS was founded on February 22, 2019 in Pisa. The IGoMIPS registry became operational in September 2019, following approval by the Ethic Committees of founding Institutions, inscription into the Registry of Patient Registries (RoPR), and a wrap-up meeting held in Bologna during the Annual Congress of the Italian Surgical Society. During this meeting IGoMIPS members approved that the Italian Registry will provide data to the European Registry, while retaining the right to analyze and publish Italian data. An audience survey was also conducted to obtain information on perceived value and current implementation of MIPS in founding Institutions. MIPS is performed in 94.7% of IGoMIPS centers, including pancreaticoduodenectomy in 42.1%. Robotic assistance was employed in 52.6% of Institutions. The annual volume of MIPS was 6-10 cases in 38.9% of the centers, 11-20 cases in 16.7%, 21-30 cases in 22.2%, and > 30 cases in 22.2%. The registry was felt to be extremely important for both safety improvement and educational purposes by 94.5% of the centers.

Surgery in COVID-19 patients: operational directives.

The current COVID-19 pandemic underlines the importance of a mindful utilization of financial and human resources. Preserving resources and manpower is paramount in healthcare. It is important to ensure the ability of surgeons and specialized professionals to function through the pandemic. A conscious effort should be made to minimize infection in this sector. A high mortality rate within this group would be detrimental.This manuscript is the result of a collaboration between the major Italian surgical and anesthesiologic societies: ACOI, SIC, SICUT, SICO, SICG, SIFIPAC, SICE, and SIAARTI. We aim to describe recommended clinical pathways for COVID-19-positive patients requiring acute non-deferrable surgical care. All hospitals should organize dedicated protocols and workforce training as part of the effort to face the current pandemic.

"Single center experience of laparoscopic hysteroannessiectomy and histopathological outcomes in transgender men".

This article presents a retrospective descriptive analysis about female-to-male (FtM) gender-affirmation nongenital surgical procedures involving the gynecological team at the CIDIGeM (Centro Interdipartimentale Disturbi di Identità di Genere Molinette) Center in Turin. From 2004 to 2019, seventy FtM transsexual patients underwent hysteroannessiectomy: the chosen surgical technique involved a Total Laparoscopic Hysterectomy. The patients presented a median age of 30.5 years (range 21-53). No patients presented intraoperative complications, the median of surgery time was 80 min (range 40-150) and the hospital stay median was 5 days (range: 2-25). Histopathological examinations were negative for cancer in all patients except for one unknown case of grade 3 cervical intraepithelial neoplasia. Total Laparoscopic Hysterectomy is confirmed to be the method of choice in the group of FtM transsexuals: this approach has several advantages over abdominal hysterectomy, including more rapid recovery, fewer wound or abdominal wall infections; moreover, it has enabled us to preserve the vital structures needed for reconstruction of external genitalia. Cancer risk is still considered an area of priority in transgender research; thus, we underline the importance of performing a histopathological examination of the surgical specimen.

Budget Impact Analysis of a Biosynthetic Mesh for Incisional Hernia Repair.

PURPOSE: With the development of newer prostheses for hernia repair, it is nowadays difficult to understand the total cost of managing patients treated with these advanced medical devices, especially in the complex abdomen, in which various complications may occur. The aim of this study was to determine the economic implications of these prostheses in order to inform decision making in the management of incisional hernia repair. METHODS: A budget impact analysis model was developed to evaluate the economic consequences related to the management of patients undergoing complex (Centers for Disease Control and Prevention wound class II-III or Ventral Hernia Working Group grade 2/3) incisional hernia repair through biosynthetic, synthetic, or biological meshes, from the hospital perspective in Italy. The model was populated with complication rates mainly retrieved from the literature to compare the current scenario with 60%, 10%, and 30% rates of synthetic, biosynthetic, and biological mesh utilization, respectively, with future hypothetical scenarios that consider increasing rates of biosynthetic mesh utilization with respect to the other types of mesh in the next 5 years. Hospital costs of the different events were estimated based on health care resource consumption derived from an electronic survey addressed to key opinion leaders in the field. FINDINGS: The analysis compared the current scenario with future hypothetical scenarios that consider increasing utilization rates of biosynthetic meshes of 25%, 38%, and 44% in the next 1, 3, and 5 years, as estimated by clinicians. Considering 40,000 incisional hernia repairs per year, an increasing use of the biosynthetic meshes may result in a decrease in the total hospital budget of about €153 million in the next 5 years, with a savings per patient of about €770. IMPLICATIONS: The findings of this study support the use of biosynthetic meshes for complex abdominal wall repairs in Italy, showing a potential decrease in the hospital budget in Italy after the diffusion of the new biosynthetic prostheses. Further studies and data from clinical practice would provide additional information to increase the understanding of the economic sustainability of these advanced devices.

Erythrocyte glutathione transferase in kidney transplantation: a probe for kidney detoxification efficiency.

Erythrocyte glutathione transferase (e-GST) is overexpressed in case of increased blood toxicity and its level correlates with the kidney disease progression. Thus, it represents a probe of kidney efficiency against circulating toxins. We measured the activity of e-GST in patients with transplant kidney from living and cadaver donors, correlated its level to biochemical parameters of kidney function, and measured the level of oxidized albumin as a probe of oxidative stress using a new simple procedure. Interestingly, the activity of e-GST in transplant patients from cadaver donors (N = 153) is very high (11.7 U/gHb) compared to healthy subjects (N = 80) ( 5.6 U/gHb). Lower values were observed in transplant patients with kidney from living donors (N = 16) (9.8 U/gHb). Except for steroids, no correlation has been found with the immunosuppressive therapies and routine clinical and laboratory parameters. Also serum oxidized albumin, which reveals oxidative stress, is significantly higher in transplant patients from cadaver donors (53%) compared to that from living donors (36%). Overall, these data indicate that most of transplant kidneys from cadavers lost part of the detoxifying power against circulating toxins and suffer a relevant oxidative stress compared to those coming from living donors. A case report suggests that e-GST could represent a very early marker of incipient graft rejection. In conclusion, e-GST may be used to check the decline or maintenance of the kidney detoxification competence during post-transplantation course.

Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial).

BACKGROUND: The aim of colonic stenting with self-expandable metallic stents in neoplastic colon obstruction is to avoid emergency surgery and thus potentially reduce morbidity, mortality, and need for a stoma. Concern has been raised, however, about the effect of colonic stenting on short-term complications and long-term survival. We compared morbidity rates after colonic stenting as a bridge to surgery (SBTS) versus emergency surgery (ES) in the management of left-sided malignant large-bowel obstruction. METHODS: This multicentre randomised controlled trial was designed with the endorsement of the European Association for Endoscopic Surgery. The study population was consecutive patients with acute, symptomatic malignant left-sided large-bowel obstruction localised between the splenic flexure and 15 cm from the anal margin. The primary outcome was overall morbidity within 60 days after surgery. RESULTS: Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 29/144 (13.9%) were excluded post-randomisation mainly because of wrong diagnosis at computed tomography examination. The remaining 115 patients (SBTS n = 56, ES n = 59) were deemed eligible for analysis. The complications rate within 60 days was 51.8% in the SBTS group and 57.6% in the ES group (p = 0.529). Although long-term follow-up is still ongoing, no statistically significant difference in 3-year overall survival (p = 0.998) and progression-free survival rates between the groups has been observed (p = 0.893). Eleven patients in the SBTS group and 23 in the ES group received a stoma (p = 0.031), with a reversal rate of 30% so far. CONCLUSIONS: Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.

Timing of cholecystectomy in acute biliary pancreatitis: is it still reasonable to wait?

BACKGROUND: Acute gallstone-related pancreatitis is a potentially life-threatening condition, and its adequate therapy is represented by cholecystectomy. The aim of this study was to analyze the best surgical strategy, and the optimal timing. METHODS: All cases of acute pancreatitis of biliary origin occurred between January 2007 and December 2013 in Gradenigo Hospital (Turin, Italy) undergone to a surgical procedure, were reviewed. Patients were divided in two groups, based on the timing of cholecystectomy, and compared. RESULTS: Out of 2233 cholecystectomies performed in the mentioned time interval, we have identified 79 patients that fulfill the selection criteria. 24 patients were treated with an index-stay procedure, while 55 with a delayed approach. Length of stay was significantly lower in patients that underwent to an early laparoscopic cholecystectomy (9 vs. 13 days, P=0.003), while no differences were found in terms of length of intervention, intraoperative complications, postoperative stay and mortality. Patients treated with delayed surgery had a 28.6% recurrence rate of acute pancreatitis, with an odds ratio of 10.28 (P=0.02). CONCLUSIONS: Early laparoscopic cholecystectomy should be performed in suitable patients in the index admission, reducing overall risks, avoiding or at least minimizing recurrencies, and rationalizing the scarce economic resources.

"Ultra-rapid" sequential treatment in cholecystocholedocholithiasis: alternative same-day approach to laparoendoscopic rendezvous.

There is still no consensus about timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in the treatment of cholecystocholedocholithiasis. The aim of our retrospective study is to analyze the optimal timing of surgical treatment in patients presenting concurrent choledocholithiasis, choosing to perform a sequential endoscopic plus surgical approach, introducing a same-day two-stage alternative. All cases of cholecystocholedocholithiasis occurred between January 2007 and December 2014 in "Gradenigo" Hospital (Turin-Italy) were reviewed. Patients were divided into three groups, based on the timing of cholecystectomy after endoscopic retrograde cholangiopancreatography, and compared. Out of 2233 cholecystectomies performed in the mentioned time interval, have been identified 93 patients that fulfill the selection criteria. 36 patients were treated with a same-day approach, while 29 within first 72 h and 28 with delayed surgery. The overall length of stay was significantly lower in patients that were treated with a same-day approach (4.7 days), compared with other groups (p = 0.001), while no significant differences were found in terms of length of surgical intervention, intraoperative complications and conversions to open procedure, postoperative stay, morbidity and mortality. Patients treated with delayed surgery had a 18 % recurrency rate of biliary events, with an odds ratio of 14.13 (p = 0.018). Same-day two-stage approach should be performed in suitable patients at the index admission, reducing overall risks, improving the patients' quality-of-life, preventing recurrency, leading to a significant cost abatement; furthermore, this approach allows same outcomes of laparoendoscopic rendezvous, avoiding technical and organizational troubles.

The new approach to the rectal cancer: 'down-to-up' double endolaparoscopic pelvic access. Preliminary evaluation of outcomes.

Laparoscopic access in low anterior rectal resection is widely adopted, performing an 'up-to-down' dissection. The aim of this study is to present and analyze the outcomes of a novel surgical 'down-to-up' total mesorectal excision technique that could obviate to the well-known issues of the standard treatment. 18 suitable patients underwent double endolaparoscopic pelvic access (DEPA) 'down-to-up' technique. DEPA TME was completed in all patients, with intact mesorectum. Mean operative time was 365 min (range 280-510 min). The morbidity rate was 22%, including three radiologically detected leakage (grade A) and one pelvic abscess, requiring only a conservative management. Mortality rate at 30 and 90 days was 0%. Resection margins were negative in all patients. A median of 11 nodes (range 5-19) was retrieved per specimen. Mean length of hospital stay was 9 days (range 7-19 days). Patients were followed for an average of 14 months (range 0-42 months), with no recurrence. Despite exiguous patient's sample in this pilot study, transanal endoscopic TME with laparoscopic assistance seems to be feasible and safe, and is a promising alternative to open and laparoscopic TME. However, a conspicuous functional and oncologic long-term evaluation is required, before the widespread adoption could be recommended.