Laparoscopic colorectal resection for deep infiltrating endometriosis: can we reliably predict anastomotic leakage and major postoperative complications in the early postoperative period?

BACKGROUND: Anastomotic leakage (AL) and major complications after colorectal resection for deep infiltrating endometriosis (DIE) have a remarkable impact on patient outcomes. The aim of this study is to assess the predictive value of C-reactive protein (CRP), procalcitonin (PCT), white blood cell count (WBCs) and the Dutch Leakage Score (DLS) as reliable markers in the early diagnosis of AL and major complications after laparoscopic colorectal resection for DIE. METHODS: 262 consecutive women undergoing laparoscopic colorectal resection for DIE between September 2017 and September 2018 were prospectively enrolled. WBCs, CRP, PCT and DLS were recorded at baseline and on postoperative day (POD) 2, 3 and 6 then statistically analyzed as predictors of AL and severe postoperative complications. RESULTS: The AL rate was 3.2%. The major morbidity rate was 11.2%. No postoperative mortality was recorded. The postoperative trend of DLS and serum levels of CRP and PCT, but not WBCs, were significantly higher in women developing AL and severe complications. DLS had better sensitivity and specificity than biomarkers on all postoperative days as a predictor of AL and major complications. CRP and PCT have a low positive predictive value (PPV) and a high negative predictive value (NPV) for AL and major complications on POD3 and POD6. The risk of malnutrition was significantly related to AL. CONCLUSIONS: The combination of DLS as a standardized postoperative clinical monitoring system and CRP and PCT as serum biomarkers, allows the exclusion of AL and major complications in the early postoperative period after laparoscopic colorectal resection for DIE, thus ensuring a safe patient discharge.

Intracorporeal Ileocolic Anastomosis in Laparoscopic Right Colectomy: A New Way to Make it Simple?

Although there has been a recent increase in the use of laparoscopy in colorectal surgery, the percentage of patients who undergo surgery using entirely minimally invasive techniques is still quite low, and there are substantial differences among centers. It has been argued that the limiting factor in the use of laparoscopic procedures is not the tumor or patient characteristics, but rather the number of surgeons with adequate skills to perform an entirely laparoscopic colectomy. To address this issue, we report here our totally laparoscopic right colectomy technique, with particular focus on a new way to perform the enterotomy closure, which may simplify ileocolic anastomosis.

Randomized Trial on Fast Track Care in Colorectal Surgery for Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To study the application of a fast-track care protocol in colorectal surgery for deep infiltrating endometriosis. Bowel endometriosis is an infrequent but not rare condition that often needs intestinal surgery and imposes a high economic burden on society. DESIGN: Prospective randomized trial (Canadian Task Force classification I). SETTING: Tertiary referral center. PATIENTS: Two hundred twenty-seven patients with preoperative evidence of bowel endometriosis. INTERVENTIONS: We randomly assigned 227 patients with preoperative evidence of bowel endometriosis to a fast-track protocol (no preoperative bowel preparation, early restoration of diet, no postoperative antibiotics, and early postoperative mobilization) or conventional care for laparoscopic intestinal surgery. Randomization was obtained on a double-blind, date-based schedule, and all procedures were performed by a homogenous group of expert surgeons. Surgical outcomes and a health economic evaluation were assessed. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital stay. Patient's well-being and intraoperative and postoperative complications up to 30 days after surgery were also assessed. Subsequently, direct medical costs were analyzed. Patients assigned to the fast-track protocol were discharged earlier (median 3 vs 7 days, p < .001) with no significant differences in subjective well-being (p = .55). Operative details, postoperative complications, and need of temporary ileostomy were similar (p = .89) between groups as well as readmission rates within 30 days (p = .69). The application of a fast-track protocol resulted in an overall significant reduction of costs (USD 6699 vs 8674, p < .01), and differences were more evident in cases of protective stoma (7652 vs 8793, p < .05) and surgery with postoperative complications (10 835 vs 14 005, p < .01). CONCLUSION: The application of a fast-track care protocol for laparoscopy in cases of pelvic and intestinal endometriosis does not increase the risk of complications and ensures a reduction of medical costs.

Over-Sewing of Staple Line in Laparoscopic Sleeve Gastrectomy: Initial Experience of a Comparative Study.

INTRODUCTION: The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. Recently, over-sewing has been proposed as a cost-effective and helpful method for reinforcing the staple line. The purpose of this study was to report our initial experience with LSG comparing over-sewing over the entire staple line with the upper-third staple line. MATERIALS AND METHODS: All obese patients seen at Negrar Sacro Cuore, Don Calabria Hospital were entered into our prospective database and were retrospectively evaluated. Complications (divided as major complications: leaks and bleeding; and minor complications: dysphagia, esophagitis, and reflux disease) and reoperations were recorded for all patients. Complications were graded according to the Clavien classification system. RESULTS: From February 2015 to March 2016, 30 patients underwent LSG. Patients were divided in two groups according to over-sewing: Group A-over-sewing over the entire staple line; and Group B upper-third over-sewing. Mean total operative time was longer in Group A-90 minutes-compared with 85 minutes in Group B. In regard to minor complications, we reported one esophagitis and two cases of dysphagia in Group B and one dysphagia in Group A. Gastroesophageal reflux was higher in Group B than in Group A (3 vs. 1, p=0.149). Three major complications were observed (10%): two bleeding and one hematoma in Group B and no major complications occurred in Group A. All major complications were conservatively treated. No leaks were reported in both groups. No mortality was observed. CONCLUSIONS: Over-sewing of the staple line was associated with fewer leaks but no conclusions can be drawn regarding the effects of over-sewing on staple line bleedings. Before standardizing surgical techniques further, trials are necessary to improve our knowledge about over-sewing in LSG.

Primary schwannoma of the thyroid gland involving the isthmus: report of a case.

Primary thyroid schwannomas are extremely rare tumors and there are very few reports of such tumors in the literature. This report presents a rare case of schwannoma involving the isthmus of the thyroid in a 47-year-old male, presenting as a symptomatic predominating cold nodule within a multinodular goiter. The patient underwent total thyroidectomy. The histological examination indicated an Antoni A-type schwannoma. The clinical, radiological and pathological findings of the tumor are discussed, emphasizing the difficulty in reaching a correct preoperative diagnosis. Only 18 cases of primary schwannoma of the thyroid gland have so far been described in the literature and, this is only the second report of thyroid schwannoma localized in the isthmus.

iColon, a patient-focused mobile application for perioperative care in colorectal surgery: Results from 444 patients.

AIM: The aim of this study is to assess if a patient-focused mobile application can increase compliance with active Enhanced Recovery After Surgery (ERAS) items and thereby improve surgery-related outcomes and patient satisfaction. METHOD: This is a prospective observational study of patients admitted for elective colorectal surgery, under the ERAS protocol, and having access to the mobile application iColon during all perioperative phases. RESULTS: The 444 participants were included in the study. The overall adherence to the use of iColon was 62.4%. The overall adherence to active ERAS items was 74.1%. Adherence to the use of iColon significantly impacted adherence to active ERAS items. The use of the application was negatively related with factors such as age, type of disease, and postoperative complications. In the postdischarge phase, low adherence to active ERAS items typically indicates an increased likelihood of readmission; however, the use of iColon correlated significantly with a reduction in the 30-day readmission rate. A survey regarding patient satisfaction and confidence in using iColon resulted in positive feedback in more than 94% of cases, while 92.7% reported better quality of care. CONCLUSION: Our findings suggest that digital health tools are beneficial and effective in the follow up of patients after early discharge. Our mobile application, iColon, represents user-friendly technology that is well-accepted. It has real-world implications in increasing adherence to active ERAS items, which results in an improvement in perceived quality of care by its users.

iColon, a patient-focused mobile application for perioperative care in colorectal surgery: an observational, real-world study protocol.

INTRODUCTION: The enhanced recovery after surgery (ERAS) protocol provides optimised care guidelines for patients undergoing elective colorectal surgery. To ensure high compliance with active ERAS elements, patients must be educated to actively participate in the perioperative care pathway. Mobile health is a rapidly expanding area of the digital health sector that is effective in educating and engaging patients during follow-up. iColon is a mobile application designed by the Operative Unit of General Surgery of IRCCS Sacro Cuore Don Calabria Hospital of Negrar of Valpolicella, which is specifically targeted at patients undergoing elective colorectal surgery. iColon is organised into ERAS phases, and it provides real-time feedback to surgeons about a patient's adherence to perioperative active ERAS elements. METHODS AND ANALYSIS: We hypothesise that by providing a patient-focused mobile application, compliance with active ERAS elements could be improved.The first coprimary objective is to build patient confidence in using the mobile application, iColon, during perioperative care. The second coprimary objective is to establish patient compliance with active ERAS elements.Secondary objectives include examining: length of stay, 30-day readmission rate, postoperative complications and patient satisfaction of received care.This study is a prospective observational real-world study of patients undergoing elective colorectal surgery who are following the ERAS protocol and using iColon during perioperative periods between September 2020 and December 2022.By educating and engaging patients in the ERAS protocol, the mobile application, iColon, should stimulate patients to be more proactive in managing their healthcare by complying more closely with active ERAS elements. ETHICS AND DISSEMINATION: This study has been approved by the local Ethics Committee with the protocol number 29219 of 25 May 2020. The results will be actively disseminated through peer-reviewed journals, conference presentations and various community engagement activities.

The value of intraoperative frozen section examination of sentinel lymph nodes in surgical management of breast carcinoma.

PURPOSE: In breast cancer staging, the need for intraoperative sentinel lymph node (SLN) evaluation has still not been adequately established. This study investigates the impact of intraoperative frozen section (FS) evaluation of SLN to avoid subsequent axillary lymph node dissection (ALND) in patients with positive SLN. METHODS: A retrospective review of 364 breast cancer patients undergoing SLN biopsy with intraoperative FS evaluation of SLN was performed. RESULTS: Sensitivity and accuracy of FS examination of SLN were 76.4% and 94.2%, respectively. The sensitivity was significantly higher in larger tumors (p < 0.01). No significant correlation was found between FS and histologic type. A second intervention was avoided in 83.9% of the patients with positive SLN. CONCLUSIONS: Intraoperative FS examination of the SLN is a useful predictor of axillary lymph node status in breast cancer patients. The majority of SLN-positive patients allows for immediate ALND in a one-stage surgical procedure.

Hostile pelvis: how to avoid permanent stoma.

The aim was to report our experience with delayed colo-anal anastomosis (DCA) to avoid permanent stoma for complex rectal cases evaluating short- and long-term outcomes. Nine patients who underwent DCA from 2011 to 2016 were collected and analysed case by case. We considered medical history and surgical outcomes. Long-term bowel function was evaluated using the Wexner and low anterior resection syndrome (LARS) score at 6, 12 and 24 months. The range from previous surgery and salvage procedure was 337 days. All cases were performed with a full laparoscopic approach. The median length of hospital stay was 15 days. The median follow-up was 970.5 days. There was no peri-operative mortality. Two patients developed a post-operative pelvic abscess that required redo surgery. Long-term post-operative complications were mucosal prolapsed, anastomosis retraction and anastomotic stricture. The average values of LARS and Wexner scores were, respectively, at 6 months 33.7 and 16.2, at 12 months 28.5 and 11.7, at 24 months 21.1 and 6.7. Colo-anal sleeve delayed anastomosis appears a real answer to avoid permanent stoma in selected patients. The laparoscopic procedure is safe and feasible for skilful mini-invasive surgeons. Our experience describes the complexity of clinical history of these patients underlying a slow, but progressive improvement in continence after restoration of bowel continuity.

Depth of Intestinal Wall Infiltration and Clinical Presentation of Deep Infiltrating Endometriosis: Evaluation of 553 Consecutive Cases.

INTRODUCTION: Intestinal involvement in endometriosis was first described by Sampson in 1922. The reported incidence ranges between 3% and 37% in patients diagnosed with endometriosis. In literature, there are few studies that correlate the severity of endometriosis (in terms of intestinal infiltration) and its clinical presentation. The aim of this study was to review the correlation between the severity of symptoms, the depth of intestinal wall infiltration, and lymph node involvement in our tertiary referral center. MATERIALS AND METHODS: We retrospectively analyzed 553 patients who had undergone intestinal resection for deep infiltrating endometriosis at our institution (Sacro Cuore Negrar Hospital) between 2004 and 2009. Based on intestinal wall infiltration, we divided patients into three groups (Group A: intestinal infiltration that reaches the muscle layer, Group B: infiltration to the submucosa, and Group C: endometriosis reaches the mucosa). Symptoms, intestinal stenosis, and positive lymph nodes were compared in the three groups with the chi-square test. RESULTS: No statistical correlation was found between symptoms and the intestinal wall infiltrations. The three groups were also compared on the basis of positive visceral lymph nodes and we did find a statistical difference (P = .05) in the lymph node count in the two main groups. CONCLUSION: There seems to be no statistically significant difference in symptoms between patients with different degrees of infiltration. Although visceral lymph node involvement has been occasionally described in literature, we found that it is related to submucosal infiltration.