Long-Term Outcomes of Robotic Versus Laparoscopic Total Mesorectal Excisions: A Propensity-Score Matched Cohort study of 5-year survival outcomes.

Objective: To compare long-term outcomes between laparoscopic and robotic total mesorectal excisions (TMEs) for rectal cancer in a tertiary center. Background: Laparoscopic rectal cancer surgery has comparable long-term outcomes to the open approach, with several advantages in short-term outcomes. However, it has significant technical limitations, which the robotic approach aims to overcome. Methods: We included patients undergoing laparoscopic and robotic TME surgery between 2013 and 2021. The groups were compared after propensity-score matching. The primary outcome was 5-year overall survival (OS). Secondary outcomes were local recurrence (LR), distant recurrence (DR), disease-free survival (DFS), and short-term surgical and patient-related outcomes. Results: A total of 594 patients were included, and after propensity-score matching 215 patients remained in each group. There was a significant difference in 5-year OS (72.4% for laparoscopy vs 81.7% for robotic, P = 0.029), but no difference in 5-year LR (4.7% vs 5.2%, P = 0.850), DR (16.9% vs 13.5%, P = 0.390), or DFS (63.9% vs 74.4%, P = 0.086). The robotic group had significantly less conversion (3.7% vs 0.5%, P = 0.046), shorter length of stay [7.0 (6.0-13.0) vs 6.0 (4.0-8.0), P < 0.001), and less postoperative complications (63.5% vs 50.7%, P = 0.010). Conclusions: This study shows a correlation between higher 5-year OS and comparable long-term oncological outcomes for robotic TME surgery compared to the laparoscopic approach. Furthermore, lower conversion rates, a shorter length of stay, and a less minor postoperative complications were observed. Robotic rectal cancer surgery is a safe and favorable alternative to the traditional approaches.

Effect of a Patient Blood Management system on perioperative transfusion practice and short-term outcomes of colorectal cancer surgery.

BACKGROUND: Patients undergoing colorectal cancer surgery may require a blood transfusion. However, blood transfusions are associated with postoperative complications and long-term oncologic outcomes. Patient blood management (PBM) is an evidence-based multimodal approach for blood transfusion optimisation. We sought to investigate the effects of PBM implementation in blood transfusion practice and on short-term postoperative outcomes. MATERIALS AND METHODS: This study retrospectively reviewed data from 2,080 patients who had undergone colorectal cancer surgery at a single centre from 2015 to 2020. PBM was implemented in 2018, and outcomes were compared between the pre-PBM (2015-2017) and the post-PBM (2018-2020) periods. RESULTS: A total of 951 patients in the pre-PBM group and 1,129 in the post-PBM group were included. The transfusion rate of the total number of packed red blood cells (PRBCs) used decreased after PBM implementation (16.3 vs 8.3%; p<0.001). The rate of appropriately transfused PRBCs increased from the pre-PBM period to the post-PBM period (42 vs 67%; p<0.001). There was no significant difference in rates of complications between the two groups (23.0 vs 21.5%; p=0.412); however, a reduction in both anastomosis leakage (5.8 vs 3.7%; p=0.026) and the length of stay after surgery (LOS) (10.3±11.2 vs 8.2±5.7 days; p<0.001) was reported after PBM implementation. DISCUSSION: The PBM programme optimised the transfusion rate in patients undergoing colorectal cancer surgery. Implementation of the PBM programme had a positive effect on postoperative length of stay and anastomosis leakage while no increase in the risk of other complications was reported.

Role of Indocyanine Green Fluorescence Imaging in Minimally Invasive Resection of Colorectal Liver Metastases.

Indocyanine green (ICG) fluorescence imaging is an easy and reproducible method to detect hepatic lesions, both primary and metastatic. This review reports the potential benefits of this technique as a tactile mimicking visual tool and a navigator guide in minimally invasive liver resection of colorectal liver metastases (CRLM). PubMed and MEDLINE databases were searched for studies reporting the use of intravenous injection of ICG before minimally invasive surgery for CLRM. The search was performed for publications reported from the first study in 2014 to April 2021. The final review included 13 articles: 6 prospective cohort studies, 1 retrospective cohort study, 3 case series, 1 case report, 1 case-matched study, and 1 clinical trial registry. The administered dose ranged between 0.3 and 0.5 mg/kg, while timing ranged between 1 and 14 days before surgery. CRLM detection rate ranged between 30.3% and 100% with preoperative imaging (abdominal computed tomography/magnetic resonance imaging), between 93.3 and 100% with laparoscopic ultrasound, between 57.6% and 100% with ICG fluorescence, and was 100% with combined modalities (ICG and laparoscopic ultrasound) with weighted averages of 77.42%, 95.97%, 79.03%, and 100%, respectively. ICG fusion imaging also allowed to detect occult small-sized lesions, not diagnosed preoperatively. In addition, ICG is effective in real-time assessment of surgical margins by evaluating the integrity of the fluorescent rim around the CRLM.

Diaphragmatic hernia as a spontaneous sequela of a surgically-treated left infiltrating renal tumor: a case report.

A diaphragmatic hernia is a protrusion of abdominal structures within the thoracic cavity through a defect in the diaphragm, which can be either congenital or acquired. Diaphragmatic rupture, as a sequela following abdominal surgery, is rarely documented. Approximately 80% of the reported cases, the injury occurred on the left side. We discuss a case of a 37 year-old male who underwent a left nephrectomy with ipsilateral adrenalectomy and diaphragmatic resection, by direct reconstruction that developed the sequela of a diaphragmatic hernia. We chose a surgical transthoracic approach for herniation repair.

Early right hepatectomy for severe liver trauma: a case report.

Liver is frequently involved and injured in blunt abdominal trauma. Although over the last three decades the management of blunt hepatic trauma has gradually shifted toward nonoperative approach whit a significant reduction in overall mortality, surgery remains the main option for hemodinamically unstable patients whit severe liver injuries. A 16-yr-old male in good health suffered a blunt abdominal trauma from a sport accident falling while playing football resulting in a grade V liver injury according to the American Association for the Surgery of Trauma Organ Injury Score. He underwent first to liver packing and next to an early right hepatectomy to arrest the clinical condition impairment In high grade liver injuries, liver resection makes possible to effectively control bleeding, remove necrotic tissue and prevent complications as bile leak. Nevertheless when patient's clinical condition continue to deteriorate despite optimal management a quickly and experienced hands performed hepatectomy may solve the situation.

Spontaneous Bilateral Adrenal Haemorrhage after Duodenopancreatectomy: a case report.

it is difficult to diagnose because of its nonspecific presentation. This condition frequently occurs in association with an extreme physical stress and may lead to acute adrenal insufficiency or death if not promptly and properly treated. We report a rare case of acute bilateral adrenal hemorrhage with adrenal insufficiency following duodenopancreatectomy for ampulloma in absence of surgical complications. Early diagnosis and corticosteroid replacement with aggressive management of the precipitating pathology are essential to enable a successful outcome.

Adult Wilms tumor: Case report.

Wilms tumor (WT) occurs infrequently in adults. Even rarer is adult WT with extension by direct intravascular spread into the right side of the heart. The present report describes a WT with intracaval and intracardiac extension in a 38-year-young man. In addition, thrombus extension above the infrahepatic IVC represents a major technical topic for surgeons because of the possible occurrence of uncontrollable hemorrhages and tumor fragmentation. We report the results of a surgical approach to caval thrombosis including the isolation of the IVC from the liver as routinely performed during liver harvesting. The morphologic and immune-histochemical findings confirmed the diagnosis.

Adaptive support ventilation versus synchronized intermittent mandatory ventilation with pressure support in weaning patients after orthotopic liver transplantation.

BACKGROUND: The extubation phase is an extremely critical moment in patients who have undergone orthotopic liver transplantation, who do not always have the advantage of long-lasting positive-pressure ventilation and positive expiratory end pressure; these factors can lead to splanchnic venous congestion, and this is why a rapid extubation can represent a great benefit for the graft. METHODS: The aim of this study was to compare the adaptive support ventilation (ASV) mode with the standard mode of weaning in our intensive care unit, synchronized intermittent mandatory ventilation with pressure support (P-SIMV), in patients who received orthotopic liver transplantation. ASV is a positive-pressure mode, in which pressure level and respiratory rate are automatically adjusted according to measured lung dynamics at each breath. Eligible patients were assigned to either ASV or P-SIMV group. The weaning protocol was based on the individual respiratory activity and structured in 4 different phases. RESULTS: The average length of intubation was significantly shorter in the ASV group than in the P-SIMV group (90±13 vs 153±22 minutes, P=.05). The total modifications to the ventilator settings were significantly larger in the P-SIMV group (1.5±1 vs 6±2; P=.003). CONCLUSIONS: Our results suggest that although both procedures are safe and easy to apply, ASV is superior in terms of weaning times, and it simplifies respiratory management. The better patient-machine interaction in ASV has been highlighted by other authors for different clusters of patients.

Expanded criteria for hepatocellular carcinoma after liver transplantation: a 20-year evolution.

BACKGROUND/AIM: Milan Criteria (MC) consent excellent survivals for hepatocellular carcinoma (HCC) after liver transplantation (LT). However, several new expanded criteria were proposed, with the intent to increase the HCC patients eligible for LT, maintaining acceptable recurrence rates. The aim of the present study was to analyze a cohort of HCC patients, evaluating the evolutions in its management during the last 20 years and comparing the disease-free survivals among three different periods. METHODOLOGY: HCC patients (n = 122) were transplanted and stratified in three periods: 1st (1988-1998, liberal selection), 2nd (1999-2003, use of MC) and 3rd (2004-2008, use of UCSF criteria). The three periods were analyzed and their survivals were compared. RESULTS: Statistical differences were reported at univariate analysis regarding to both dimensional (total tumor diameter) and biological (alpha feto-protein, microvascular invasion) HCC features. Comparing the 5-year survival rates, a progressive increase was observed in the three periods (62.6%, 87.9% and 88.4%, respectively), with a significant difference between 1st and the second periods (p = 0.008). CONCLUSIONS: In our experience, use of UCSF criteria is safe, with a contemporaneous increased number of transplants and better survivals. Introduction of new selection criteria, also based on biological features, is on the way.

Hepatic resection for giant haemangioma in a patient with a contemporaneous adult polycystic liver disease.

Hepatic resection for giant haemangioma in a patient with a contemporaneous adult polycystic liver disease. According to Gigot classification, and to the characteristics of haemangioma surgery in these patients can be considered safe. We report the case of a 55 year-old man affected by an adult polycystic liver disease (PCLD) and a contemporaneous symptomatic haemangioma of the III segment. At the preoperative imaging scans, APCLD was classified in a type II grading according to Gigot classification. The patient underwent surgery: a wedge resection of the III segment with the exportation of the haemangioma and a fenestration of a large cyst placed in the VIII segment were performed. Post-operative course was regular and the patient was discharged uneventfully in post-operative 9th day, with a total regress of the initial symptoms. APCLD and haemangioma are two benign conditions that do not require surgery except if they cause important symptoms, such as pain. The good clinical conditions of the patient, the moderate gravity of the APCLD and the particular exofitic localisation of the cavernous haemangioma gave us the possibility to make a safe surgery for the patient. To the best of our knowledge, this is the first case reported in literature in which a liver resection for haemangioma in patient with APCLD was performed. In conclusion, liver resection for haemangioma is not contraindicated, mainly if it is symptomatic, even in the contemporaneous presence of an APCLD.

Later diagnosed with a neuroendocrine tumor, case report of a 60-year-old.

Neuroendocrine tumours of the colon and rectum are infrequent. Clinical manifestations are not different from standard adenocarcinoma. Symptoms are non specific; the most common are abdominal pain, nausea and vomiting, weight loss and gastrointestinal blood loss. We report an advanced case of transverse colon neuroendocrine carcinoma with multiple metastasis. When these tumours are diagnosed, they have distance disease related to a poor prognosis for the patient. Surgery is the treatment that can offer a greater chance of survival to these patients.

Management of hepatitis C virus infection in liver transplantation with adacolumn apheresis.

Recurrent hepatitis C virus (HCV) is a major cause of liver transplant loss, hepatic failure, and retransplantation need. Posttransplantation antiviral therapy in patients with evidence of recurrent disease is the mainstay of management. Although HCV is a hepatocellular pathogen, there is increasing evidence that the virus can infect and persist in other cells. In particular, granulocytes and monocytes/macrophages are known to constitute extrahepatic sites for HCV replication and dissemination. The aim of this study was to apply Adacolumn apheresis as a possible therapeutic alternative to conventional drug therapy to manage HCV infections. Seven patients who underwent liver transplantation for HCV-related cirrhosis were eligible for the study. The patients underwent 5 1-hour sessions for 5 consecutive days. The first treatment was performed in the anhepatic phase of liver transplantation with the intent to early reduce infected granulocytes and monocytes/macrophages. The patients were evaluated over the 5 days after inclusion with 3- and 6-months follow-ups. Early apheresis treatments in the anhepatic phase and over the following 4 days after transplantation produced low viral loads in 4 patients, negative viral loads in 2 patients, and increased viremia in 1 patient. At follow-up, the viremia load was stable in 6 patients without increased transaminase levels. At the end of the treatment cycle, almost all immune cells of the 6 patients maintained CD4+/CD8+ T-cell ratios. The optimal timing of treatment initiation is unknown, but early preemptive therapy is recommended to decrease the risk for recurrent infection. Although this study investigated the responses among a small number of patients, it documented that the Adacolumn changed cellular immunity, promoting early virologic responses.

An unusual case of hepatic carcinosarcoma.

We report a rare case of a hepatic carcinosarcoma with rabdomyosarcomatous differentiation in its sarcomatous component. A 71-year old Caucasian female patient underwent a liver resection for a 4-cm lesion developed on an underlying HCV-related cirrhosis. Post-operative course was uneventful and the patient was discharged 5 days after surgery. At pathology, the tumor presented the features of hepatocellular carcinoma and rhabdomyosarcoma Three months later the patient experienced a liver recurrence, dying 2 months later for systemic disease. The reported case presents several peculiarities, i.e. the female gender, the HCV-related cirrhotic status, and the European origin of the patient. However, the outcome of our case confirms that this neoplasm pursues a highly aggressive course with poor prognosis.

Does caval reconstruction technique affect early graft function after liver transplantation? A preliminary analysis.

BACKGROUND: In the past decades, the inferior vena cava (IVC) reconstruction technique has undergone several evolutions, such as biopump, piggyback technique (PB), and laterolateral approach (LLPB). Several advantages are reported comparing the PB technique to biopump use. However, comparison between PB and LLPB has not been as well investigated. The aim of this study was to compare the results in terms of immediate graft function and intermediate graft survival among 3 subgroups characterized by distinct caval reconstruction techniques. METHODS: We retrospectively analyzed a cohort of 200 consecutive adult patients who underwent liver transplantation from January 2001 to December 2009. The patients were stratified according to 3 caval reconstructive techniques: biopump (n=135), PB (n=32) and LLPB (n=33). RESULTS: The LLPB group showed the shortest cold and warm ischemia times and the best immediate postoperative graft function. Survival analysis revealed LLPB patients to present the best 1-year graft survival rates: namely, 90.9% versus 75.0% and 74.1% among the PB and biopump groups, respectively (log-rank tests: LLPB vs biopump: P=.03; LLPB vs PB: P=.05). In our experience, LLPB showed the best graft survivals with an evident reduction in both cold and warm ischemia times. However, it is hard to obtain an irrefutable conclusion owing to the retrospective nature of this study, the small sample, and the different periods in which the groups were transplanted. CONCLUSIONS: LLPB technique was a safe procedure that minimized the sequelal of ischemia-reperfusion damage. This technique yielded results superior to venovenous bypass. No definitive conclusions can to be obtained in this study comparing classic PB or LLPB.

[6 cases of small intestine lymphoma]. / Sei casi di linfoma dell'intestino tenue.

The Authors report six cases of primitive and secondary intestinal lymphomas. Surgical radicality was achieved only in three of them. In the other cases surgical resection carried out in emergency and late histological diagnosis did not allow a correct surgical treatment. Peri-operative mortality was 16%. Five patients underwent adequate radiation and chemo-therapy programme. Recurrences, secondary localizations, or other neoplasms elsewhere, require a prolonged follow up period for these patients.