Identification and management of subvesical bile duct leakage after laparoscopic cholecystectomy: A systematic review.

Bile leak is a rare complication after Laparoscopic Cholecystectomy. Subvesical bile duct (SVBD) injury is the second cause of minor bile leak, following the unsuccessful clipping of the cystic duct stump. The aim of this study is to pool available data on this type of biliary tree anatomical variation to summarize incidence of injury, methods used to diagnose and treat SVBD leaks after LC. Articles published between 1985 and 2021 describing SVBD evidence in patients operated on LC for gallstone disease, were included. Data were divided into two groups based on the intra or post-operative evidence of bile leak from SVBD after surgery. This systematic report includes 68 articles for a total of 231 patients. A total of 195 patients with symptomatic postoperative bile leak are included in Group 1, while Group 2 includes 36 patients describing SVBD visualized and managed during LC. Outcomes of interest were diagnosis, clinical presentation, treatment, and outcomes. The management of minor bile leak is controversial. In most of cases diagnosed postoperatevely, Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is the best way to treat this complication. Surgery should be considered when endoscopic or radiological approaches are not resolutive.

TaTME approach as a rescue during a laparoscopic TME for high rectal cancer. A case report.

INTRODUCTION AND IMPORTANCE: In the last years, transanal total mesorectal excision (TaTME) has been described in rectal cancer treatment, especially in challenging patients, difficulties in pelvic exposure and limitations of instrumentation improving not only dissection but also the preservation of autonomic pelvic nerves and the achievement of a restorative procedure. Here we report a case report of anterior laparoscopic rectal resection for adenocarcinoma of the high-mid rectum converted to transanal approach. CASE PRESENTATION: A 69-year-old male presented hepatic nodules during radiological follow-up for prostate cancer treated with radical prostatectomy and adjuvant radiotherapy (70 Gy). The biopsy of the lesion demonstrated the presence of a metastatic lesion of an adenocarcinoma, with suspected intestinal origin. Then, we perform an endoscopic examination, which showed the presence of a rectal lesion, which cause a bowel stenosis extended from the middle part to the upper part of the rectum. After chemoradiotherapy, an anterior rectal resection was performed. During surgery we could not perform the resection of the rectum due the thickness and fibrosis of the tissue, despite we used different branded mechanical stapler. So, we decided to complete the surgical treatment starting a TaTME procedure with resolution of the problem. CLINICAL DISCUSSION: TaTME is a relatively new technique that had already become a valid option in the treatment of low rectal cancer, and, nowadays, also in the treatment of inflammatory bowel disease. As reported in literature, this technique has a number of advantages, especially in narrow pelvis and it is very useful in low rectal surgery. CONCLUSION: This case report aims to describe the possible use of TaTME procedure as a rescue also when this approach is not the first choice.

Transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA) for ulcerative colitis: medium term functional outcomes in a single centre.

BACKGROUND: Transanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA), considering postoperative complications and medium-term functional outcomes. METHODS: Our Center has experienced the transanal approach for proctectomy and IPAA since August 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Fecal continence, genito-urinary activity and global quality of life at 1 and 6 months after ileostomy reversal have been assessed. RESULTS: Until March 2019, 8 patients underwent transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA). In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning loop ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding, not required a re-invertation. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively using previously validated quality of life questionnaires (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, genitourinary and sexual functions were also investigated, showing comparable results with the literature data. CONCLUSIONS: In our experience, transanal proctocolectomy and ileal pouch-anal anastomosis provided good short and medium-term functional results in UC.

Topographic lymph node staging system shows prognostic superiority compared to the 8th edition of AJCC TNM in gastric cancer. A western monocentric experience.

INTRODUCTION: The current Tumor Node Metastasis staging system (TNM) for gastric cancer classifies the extent of lymph node metastasis based upon the number of lymph nodes involved. Choi et al. have recently proposed a new anatomical classification based upon the regionality of the involved nodes. This new classification seems to have a better predictive prognostic value than the traditional one. We investigated the prognostic role of the new anatomical based classification, reviewing our institutional gastric cancer database. METHODS: We performed a retrospective chart review of 329 patients who underwent gastrectomy at our Institution from 2003 to 2017. We excluded from data analysis any patient with distant metastases at the time of first diagnosis and or surgery, pathology other than adenocarcinoma, lymphadenectomy less than D2, impossibility to identify location of lymph nodes (LNs) on pathological report and neoadjuvant chemotherapy. The extent of D2 lymphadenectomy was defined according to Japanese Gastric Cancer Association criteria. LN metastasis were reclassified into three topographic groups (lesser, greater curvature, and extraperigastric nodes) and staged according to Choi. The new N stage was combined with the current pT according to the 8th edition of TNM and a new hybrid TNM stage was established. All patients were followed up until June 2019. The prognostic performance of the new stage and of the current anatomical numeric based system (TNM) was analyzed and assessed by the C-index, AIC and likelihood ratio χ2 value. RESULTS: In predicting both Overall Survival (OS) and Disease free Survival (DFS) the new N stage and the new TNM staging system had the highest C-index and likelihood ratio χ2 value and the lowest Akaike Information Criterion (AIC), showing a better accuracy and displaying a better prognostic performance. CONCLUSIONS: Our study is the first from the Western world to compare the new hybrid classification, based on the anatomical location of metastatic nodes, to the 8th of American Joint Committee on Cancer (AJCC) TNM staging system. Our findings on a small, monocentric sample suggest that hybrid topographic lymph node staging system is more accurate than TNM.

An omental mass. Any idea?

INTRODUCTION: Pseudomyxoma extraperitonei (PE) is a rare finding. The most common cause is the rupture of a mucocele of the appendix into the retroperitoneum. PRESENTATION OF CASE: Here we report a case of a 52 years old female patient with a mass in the right abdomen and vague lower abdominal pain underwent resection of a extraperitoneal encapsulated mass. The histopathological examination revealed a mucinous pseudomyxoma with a low grade of differentiation. DISCUSSION: We report a case of pseudomyxoma extraperitonei with a review of literature. CONCLUSION: The treatment of pseudomyxoma differs substantially depending on whether it is intraperitoneal or extraperitoneal. The risk of recurrence is such that follow-up, based on a physical examination, CT scan and serum markers, is essential.

Hepatic portal venous gas after colonoscopy: A case report and review.

INTRODUCTION: Hepatic portal venous gas (HPVG) is a rare radiological finding in which gas enters the portal venous system and it is associated in case of necrotizing colitis with a mortality of 75%. We report a case of iatrogenic HPVG with a review of literature. PRESENTATION OF CASE: A 41 years old patient underwent total colectomy and ileal pouch- anal anastomosis with derivative ileostomy for a familiar adenomatous polyposis coli in June 2008. A stenosis of the pouch-anal anastomosis developed. The patient underwent several endoscopic dilations. A recurrence of the stenosis was observed. The patient underwent to several endoscopic procedure. After the last colonoscopy the patient showed a fever with abdominal pain. A CT scan showed little peri-anastomotic collections and massive hepatic portal venous gas. DISCUSSION: The management of HPVG varied from surgical intervention to non-operative procedure. The surgical approach it's reserved to clinically unstable patients or those with evidence of peritonitis or bowel perforation. Stable patients, like those with an HPVG consequence of an endoscopic procedure, can be treated with non- operative management. CONCLUSION: Our experience confirm that hepatic portal venous gas can be related to endoscopic procedure; thus, it can be managed on the basis of patient's general clinical conditions, and in selected cases it will disappear without therapeutic interventions with a good outcome.

Spilled gallstones simulating peritoneal carcinomatosis: A case report and literature review.

INTRODUCTION: Laparoscopic cholecystectomy (LC) has become the "gold standard" for the treatment of symptomatic gallstones. However, this surgical technique increases the risk of bile duct injury and lost gallstones. Since over 90% of split gallstones never become symptomatic, they often present as incidental findings on CT-scans. Careful removal of as many stones as possible, intense irrigation and suction are recommended. It has been reported that 8.5% of lost gallstones will lead to a complication, most common are abscesses. PRESENTATION CASE: We report a case of spilled gallstones simulating peritoneal metastases on radiological investigations. Diagnosis was very difficult, not even an US-guided biopsy of the lesion was decisive. Only a diagnostic laparoscopy confirms the diagnosis. DISCUSSION: The reaction associated with lost gallstones can mimic other causes, such as soft tissue sarcoma, malignant lymphoma or, as in our case peritoneal carcinomatosis. CONCLUSION: Spilled gallstones are associated with uncommon, but significant complications, and even the diagnosis of such a condition can cause serious difficulties. Serious effort must be made to prevent gallbladder perforation, and accidental stone spillage should be promptly recognized and properly managed.

The role of minimally invasive surgery in the treatment of cholangiocarcinoma.

Cholangiocarcinoma (CC) is the second most common type of primary liver cancer after hepatocellular carcinoma. Surgical resection is considered the only curative treatment for CC. In general, laparoscopic liver surgery (LLS) is associated with improved short-term outcomes without compromising the long-term oncological outcome. However, the role of LLS in the treatment of CC is not yet well established. In addition, CC may arise in any tract of the biliary tree, thus requiring different types of treatment, including pancreatectomies and extrahepatic bile duct resections. This review presents and discusses the state of the art in the laparoscopic and robotic surgical treatment of all types of CC. An electronic search was performed to identify all studies dealing with laparoscopic or robotic surgery and cholangiocarcinoma. Laparoscopic resection in patients with intrahepatic CC (ICC) is feasible and safe. Regarding oncologic adequacy, as R0 resections, depth of margins, and long-term overall and disease-free survival, laparoscopy is comparable to open procedures for ICC. An adequate patient selection is required to obtain optimal results. Use of laparoscopy in perihilar CC (PHC) has not gained popularity. Further studies are still needed to confirm the benefit of this approach over conventional surgery for PHC. Laparoscopic pancreaticoduodenectomy for distal CC (DCC) represents one of the most advanced abdominal operations owing to the necessity of a complex dissection and reconstruction and has also had small widespread so far. Minimally invasive surgery seems feasible and safe especially for ICC. Laparoscopy for PHC is technically challenging notably for the caudate lobectomy. Not least as for the LLR, the robotic approach for DCC appears technically achievable in selected patients.