Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study.

INTRODUCTION: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. MATERIALS AND METHODS: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. RESULTS: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). CONCLUSIONS: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Colorectal surgery in elderly patients: our experience with DaVinci Xi® System.

BACKGROUND: Robotic technology for colorectal surgery was introduced by Weber in 2002 to improve the benefits of the minimally invasive surgery already offered by the laparoscopic approach. AIMS: To evaluate the feasibility and the efficacy of the application of robotic surgery in elderly patients affected by colorectal diseases. METHODS: We reported the outcomes obtained during our first 50 colorectal robotic surgical performances with DaVinci Xi® System, and we compared the results assessed for patients younger or older than 70 years. RESULTS: We examined 28 patients younger and 22 older than 70 years who underwent colorectal robotic surgery in our institution from September 2014 to June 2016. We performed 15 right colectomies, 20 left colectomies, 15 rectal resections. Mean ASA score was significantly higher in the Elderly Group. No statistically significant differences have been revealed in terms of post-operative morbidity, hospital stay, first diet intake, first flatus canalization and oncological outcome. DISCUSSION: According to the prolonged operative time, robotic technology was initially reserved to young patients with good performance status in order to avoid systemic failures in elderly patients suffering from pre-existent comorbidities. Otherwise, once robotic approach safety and benefits in terms of better systemic outcomes were demonstrated, it started to be performed in elderly patients with satisfactory outcomes. CONCLUSION: Our experience revealed that robotic surgical approach is safe, feasible and offers many systemic benefits in elderly patients also with high ASA score. Age alone has not to be considered as exclusion criteria for robotic approach.

Double-stapling technique for transhiatal distal esophageal resection: feasibility test in a cadaver model.

OBJECTIVES: To assess the feasibility of a new surgical technique for the resection of the distal third of the esophagus and/or cardias for neoplasm. METHODS: This surgical technique consists of two steps: For this purpose we built a stainless steel support bar for the anvil that is thinner than the freespace of a standard linear suturing stapler (TATM). The support bar holds up a push rod that can be adapted to the hooking-unhooking of the anvil. RESULTS: We performed our new technique on five cadavers. We did not encounter any difficulty during the procedures. We tested the anastomosis with hydropneumatic assessment without recording any leaks. The esophago-enteric anastomosis was then opened without finding any mechanical defects related to the procedure. CONCLUSION: It can often be very difficult to fashion a safe hand-sewn pouch or a purse string around the anvil of an EEATM during the resection of the distal third of the esophagus or the cardias by a trans-hiatal approach. Moreover, there is no standardized procedure to minimize anastomotic leak. To avoid these mechanical problems we designed this innovative procedure, which is considered to be reproducible without significant training.

Percutaneous radiofrequency ablation versus surgical radiofrequency-assisted nodulectomy in treatment of small single nodes of hepatocellular carcinoma: our experience.

AIM: Surgical resection usually represents the treatment of choice for solitary hepatocellular carcinoma (HCC) in cirrhotic patients, with well preserved liver function; local ablative strategies are the best treatment option for patients with small tumors who are not candidates for surgical resection or liver transplantation. Several studies showed that percutaneous radiofrequency ablation (RFA) has similar efficacy to surgical nodulectomy in the treatment of early-stage HCC, and is associated with lower complication rates and costs than resection. The aim of this study was to compare the effectiveness of these treatments, in terms of morbidity, overall survival, tumor recurrence and causes of death. METHODS: Between January 2006 and January 2012 we observed 176 patients affected by HCC, 84 underwent curative treatment. The 40 patients presenting single HCC nodes smaller than 3 cm in diameter have been treated with radiofrequency-assisted surgical nodulectomy (N.=20) or with percutaneous radiofrequency (N.=20). RESULTS: No perioperative mortality occurred in the two groups. Perioperative morbidity was 5% in group A (1 case of peritoneal bleeding) and 5% in group B (1 case of hepatic abscess). Disease-free survival was slightly higher in surgically treated patients, but not statistically significative differences have been demonstrated (P<0.06); no local recurrences were observed in surgically treated patients. CONCLUSION: RF and surgical nodulectomy can be either used in treatment of early stage hepatocellular carcinoma; no differences in terms of morbidity, overall and disease free survival were observed; nodulectomy seems to prevent from tumor local recurrence.

Ultrastructural analysis of different-made staplers' staples.

AIM: Recently, Chinese-made mechanical staplers with lower price respect to American-made ones have been introduced in clinical practice. In literature, small case series compare the clinical outcomes of different staplers concluding that the new stapler devices perform as well as the American ones. The aim of this study is to compare with an ultrastructural analysis the staples of different staplers in order to verify the existence of differences that might explain significant price disparity and condition clinical outcomes. METHODS: Each stapler was subjected to morphological analysis, energy dispersive X-Ray spectroscopy, metal release assessment followed by inductively coupled plasma mass spectroscopy. P-values were considered statistically significant when <0.05. RESULTS: Autosuture staples have square section whereas the other American one and Chinese made staples have round sections. Roughness index and chips presence before and after ageing tests were comparable for all samples except for Ethicon Endo-Surgery stapler. Energy dispersive X-Ray spectroscopy showed that all staplers are made of pure Titanium but Ethicon Endo-Surgery staples are made with an alloy. Metal release analysis release statistically significant differences between samples in simulated body fluid 20 days solution (P=0.002) and in Aquaregia at 14 days solution. Discussion. Stapling devices have became routinely used in gastrointestinal surgery mainly because of operative time reduction. Recently, new Chinese-made mechanical staplers, with significantly lower prices, have been introduced in clinical practice. In literature, there are some studies that compare clinical outcomes of American-made and Chinese-made staplers on small groups of patients but doesn't exist any work which consider structural differences between traditional and new devices. In our study, for the first time, we propose a comparison between two American-made staplers and three Chinese-made staplers which evaluate morphology, metal composition and chemical staples release. CONCLUSION: Our study suggest that there are some ultrastructural differences between commercially available staplers with no correlation to price disparity. More studies are needed to confirm our results and to verify if our findings could condition clinical outcomes.

Idiopathic ileo-colonic varices in a young patient.

Colonic varices are an infrequent cause of rectal bleeding and haematochezia and they are often related to portal hypertension due to either haepatopathy or any other cause of obstruction of the portal circulation. A 20-year-old patient was studied after she suffered a serious episode of rectal bleeding, followed by syncope. In view of her clinical picture of serious rectal bleeding, which could not be kept under control by means of medical therapy or endoscopy, the patient underwent total video laparoscopic colectomy surgery with ileum-rectum anastomosis. The histological examination revealed prominent ectasia presence of venous vessels under the mucosa. Colonic varices are one of the most common causes of low gastroenteric bleeding and in most cases they are caused by portal hypertension or intestinal occlusion. In less common cases, they are caused by thrombosis of the splenic vein, cardiac insufficiency, venous mesenteric thrombosis, extrinsic compression on tumoral invasion. Idiopathic colonic varices are described in the literature as the cause of low gastroenteric bleeding in not more than 20 patients. Therapeutic options are conservative follow-up or surgery. As it happened in our case, surgery is generally the chosen treatment, in view of the risk of recurring bleeding, the young age of patients and the low degree of co-morbidity of patients. The prognosis for surgery of idiopathic colonic varices is very good at any age when compared with the one for the treatment of varices caused by cirrhosis of the liver, thus confirming the importance of diagnosing idiopathic varices, only after having ruled out the presence of other basic pathologies.

[Prototype of a system for electric conduction at contact with laparoscopic tools]. / Prototipo di sistema di conduzione elettrica per contatto a strumenti ad uso laparoscopico.

The authors present their prototype of a system for electric conduction at contact with laparoscopic tools, devised, designed and produced by them at the Politecnico di Torino, Department of Mechanical Engineering. The system consists of a two sided plate, one side is a non conducting adhesive surface to stick to the surgical glove and the other side is a subtle flexible shell of a conductor. The Authors used the instrument with surgical tools with a metallic handle, during three cholecystectomies. Nowadays all standard laparoscopic tools have the chance and the need to be electrified. Now the way commonly used to electrify a laparoscopic tool is using a wire plugged to a fixed conducting point of the instrument. This prototype has been devised and produced to avoid some discomforts met during the numerous manoeuvres of connecting and disconnecting the wire at the time of a surgical intervention. This device permits the direct transfer (by contact) of electric energy from the wire to surgical tools. The advantage is to be more rapid in changing surgical tools obtaining, immediately an electrified instrument in your hand.

[Combined dissector for laparoscopic esophageal myotomy: introduction of a prototype of dedicated instrumentation]. / Dissettore combinato per miotomia esofagea laparoscopica: presentazione di un prototipo di strumento dedicato.

The authors' aim in this article is to present the use of a combined dissector, devised, designed and patented by themselves, for laparoscopic oesophageal myomectomy in achalasic patients. The prototype was produced by Karl Storz Endoskope. This tool has a stem measuring 10 mm in diameter, with an operative push rod consisting of two upward bent jaws and an electrode that can emerge from the jaws as required by the surgeon. The authors used the dissector in two patients with a surgical achalasic mega-oesophagus. The two jaws can dissect and then divide the oesophageal muscular layer from the submucosal layer, whereas the electrode can cut the muscular fibres. The use of the combined dissector allows the surgeon to perform oesophageal myomectomy easily, with efficacy and safety, using only the right hand. The instrument requires a number of minor changes which are currently being planned.

[Cicatricial stenosis of colorectal anastomosis. Transanal treatment with circular stapler]. / Stenosi cicatriziale dell'anastomosi colorettale. Trattamento transanale con stapler circolare.

Anastomotic strictures complicating colorectal anastomoses can be difficult to treat. This condition must not be considered as an uncommon complication. In 20% of patients it may be a serious state that may require a therapy. Two patients treated successfully without complication with the transanal use of an CEEA stapler are presented. The staple cutter is safe and easy to use, and except for a conventional anoscope, no special equipment, including fluoroscope, is needed. On the basis of the successful results obtained, the procedure using staple cutter is recommended for the treatment of anastomotic stricture of the rectum.

Laparoscopic adrenalectomy: advantages of an atraumatic suction grasper.

Laparoscopic adrenalectomy still presents some technical problems. The impossibility of directly grasping the gland is the main difficulty. To overcome this problem, we have begun to use an atraumatic suction grasper. From September 1995 to December 1997, 15 laparoscopic adrenalectomies were performed. Group 1 comprised 8 patients operated on without the atraumatic suction grasper; group 2 consisted of 7 patients who underwent a laparoscopic adrenalectomy with the use of this new device. The surgical technique with the use of an atraumatic suction grasper is described. No significant difference was noted between the two groups except in the operative time, which was reduced in group 2, and in the surgeon's comfort. The reported advantages are a direct grasp of the adrenal gland without the risk of squeezing, rupture, or bleeding; a better exposure of the adrenal vessels; and shorter operating time.

Laparoscopic splenectomy. How to make it easier using an innovative atraumatic suction grasper.

BACKGROUND: With the evolution of laparoscopic surgery comes the need for specific instruments that apply traction to parenchymal tissue, like the spleen, without exposing the organ to the associated high risk of bleeding. To meet this need, we designed and developed a suction-cup grasper that allows easy grasping and manipulation of the spleen. Some of the difficulties usually encountered during laparoscopic splenectomy may be overcome by using this device. MATERIALS: The instrument consists of a cone-shaped, silicone rubber suction cup designed with an antislip internal surface. The cup is connected to a support arm with a flexible distal end that can be rotated. Traction is exerted with a commonly available suction system. The device is inserted through a 12-mm-diameter guide sheath. RESULTS: The two interventions performed with the atraumatic device were completed with laparoscopic technique. No complications arose during or after the operations. The average operating time was 110 min. The patients were discharged after 4 and 5 days postoperative, respectively. CONCLUSIONS: As a device specifically designed for grasping parenchymal organs, the atraumatic suction grasper affords the operator a faster and safer technique in laparoscopic splenectomy.

[Gallbladder carcinoma. Our experience]. / Carcinoma della colecisti. Nostra esperienza.

The authors report their experience of 18 patients with primary cancer of the gallbladder. On 10 patients at stage IV, 9 had a preoperative diagnosis, while at stage 0-1 and 2 the diagnosis was intraoperative or histologic. Every patient had a cholelithiasis at the same time. The authors discuss prophylactic cholecystectomy, even without specific symptoms, and emphasize the need for a better morphological and radiomorphological classification. In the light of the new microinvasive surgical techniques, they briefly discuss laparoscopic cholecystectomy and histologic diagnosis of carcinoma of the gallbladder.

Surgery of the incidentally discovered mass of the adrenal gland (incidentaloma).

The authors present their experience about surgery in adrenal gland incidentaloma, during a period of 12 years (1982-1993), at the VI Division of General Surgery, University of Turin. In 17 patients, of 70 who underwent adrenalectomy, the adrenal neoplasm was located thanks to a diagnostic investigation (ECI or CT) executed for other reasons. In ten cases was diagnosed adenoma, in five cases carcinoma, in two cases cysts. In the diagnostic approach to adrenal incidentaloma we did not search for possible hormonal activity, since the patients had been previously selected from specialized endocrinological centres. At present, biological markers not being certain or absolute radiological significance so as to detect benignant from malignant forms. In accordance with international Literature the size of the neoplasm is the discriminant element for adrenalectomy. We have removed the incidentaloma in all cases, be it clinically or subclinically functional and the silent forms > 4 cm as we have observed a statistically significant difference (p < 0.0002) between the benign and malignant lesions, particularly those measuring more than 4 cm in diameter. We suggest a screening with CT scan every three months in lesions < 4 cm, silent and those > 4 cm in patients over sixty years with a morphological aspect of the bening form.

[Parapapillary leiomyoma of the second duodenal portion: anatomo-clinical considerations]. / Il leiomioma parapapillare della seconda porzione duodenale: considerazioni anatomo-cliniche.

The authors describe a rare case of leiomyoma situated in the second duodenal portion near the Vater papillary diagnosed for over eight years. The preoperative investigation isn't able to explain certainly the characteristics and the anatomo-topographic relations of the lesion besides the anatomo-pathologic dates have left a border of uncertainty about the benignity of the lesion. These considerations, as agreed with the greater part of authors, show the necessity of early surgical treatment.

[Retroperitoneal paragangliomas. Considerations on a internephro-caval case]. / I paragangliomi retroperitoneali. Considerazioni su di un caso internefro-cavale.

A case of paraganglioma situated between right renal vein, right renal artery and inferior vena cava is here with described. The report constitutes the rise to frame with precision the tumor according with WHO classification. Moreover criteria are to be discussed for nature and seat diagnosis, as well for the choice of the best way of access.

[Inguinal hernia containing bladder and ureter. A clinical case]. / L'ernia inguinale a contenuto vescico-ureterale. Contributo clinico.

The authors describe an uncommon case of inguinal hernia with bladder and ureter content. Bladder herniation preoperative diagnosis has been achieved by means of clinical history, objective and instrumental examination (cystography). As usually happens, ureteral herniation was a chance finding; this could involve a trick in surgery setting up and doubts in the treatment methods.