Robot-Assisted Liver Resection and Cholecystectomy Using Indocyanine-Green for Intrahepatic Cholangiocarcinoma, in a Very Rare Anatomical Anomaly of 'Bipartite Liver'.

Robotic hepatobiliary surgery has significantly developed worldwide with substantial clinical results. Hepatobiliary anatomical anomalies increase the complexity of hepatobiliary resection with a relevant risk of iatrogenic lesions. Among congenital liver anomalies, the 'bipartite liver' is an extremely rare condition which might be associated with complex surgical dissection of the hepatic hilum. We herein report a rare case of congenital 'bipartite liver' associated with a cholangiocarcinoma of segment VI and calculous cholecystitis. The patient underwent robot-assisted segmentectomy and cholecystectomy with the use of indocyanine-green cholangiography and intraoperative ultrasound. A challenging hilar dissection was performed using this approach. To the best of our knowledge, this is the first case reported that describes a robot-assisted liver resection and cholecystectomy in a patient having a cholangiocarcinoma associated with this rare liver anomaly. The robotic approach was safe and effective and the 3D preoperative imaging, as well as the intraoperative green-indocyanine cholangiography was extremely useful, especially during hilar dissection and cholecystectomy.

Could diagnostic and therapeutic delay affect the prognosis of gastrointestinal primary malignancies in the COVID-19 pandemic era?

INTRODUCTION: Emergency situations, as the COVID-19 pandemic that is striking the world nowadays, stress the national health systems which are forced to rapidly reorganize their sources. Therefore, many elective diagnostic and surgical procedures are being suspended or significantly delayed. Moreover, patients might find it difficult to refer to physicians and delay the diagnostic and even the therapeutic procedures because of emotional or logistic problems. The effect of diagnostic and therapeutic delay on survival in patients affected by gastrointestinal malignancies is still unclear. EVIDENCE ACQUISITION: We carried out a review of the available literature, in order to determine whether the delay in performing diagnosis and curative-intent surgical procedures affects the oncological outcomes in patients with esophageal, gastric, colorectal cancers, and colorectal liver metastasis. EVIDENCE SYNTHESIS: The findings indicate that for esophageal, gastric and colon cancers delaying surgery up to 2 months after the end of the staging process does not worsen the oncological outcomes. Esophageal cancer should undergo surgery within 7-8 weeks after the end of neoadjuvant chemoradiation. Rectal cancer should undergo surgery within 31 days after the diagnostic process and within 12 weeks after neoadjuvant therapy. Adjuvant therapy should start within 4 weeks after surgery, especially in gastric cancer; a delay up to 42 days may be allowed for esophageal cancer undergoing adjuvant radiotherapy. CONCLUSIONS: Gastrointestinal malignancies can be safely managed considering that reasonable delays of planned treatments appear a generally safe approach, not having a significant impact on long-term oncological outcome.

Minimally Invasive Approach to Gastric GISTs: Analysis of a Multicenter Robotic and Laparoscopic Experience with Literature Review.

Background: Gastrointestinal stromal tumors (GISTs) are most frequently located in the stomach. In the setting of a multidisciplinary approach, surgery represents the best therapeutic option, consisting mainly in a wedge gastric resection. (1) Materials and methods: Between January 2010 to September 2020, 105 patients with a primary gastrointestinal stromal tumor (GISTs) located in the stomach, underwent surgery at three surgical units. (2) Results: A multi-institutional analysis of minimally invasive series including 81 cases (36 laparoscopic and 45 robotic) from 3 referral centers was performed. Males were 35 (43.2%), the average age was 66.64 years old. ASA score ≥3 was 6 (13.3%) in the RS and 4 (11.1%) in the LS and the average tumor size was 4.4 cm. Most of the procedures were wedge resections (N = 76; 93.8%) and the main operative time was 151 min in the RS and 97 min in the LS. Conversion was necessary in five cases (6.2%). (3) Conclusions: Minimal invasive approaches for gastric GISTs performed in selected patients and experienced centers are safe. A robotic approach represents a useful option, especially for GISTs that are more than 5 cm, even located in unfavorable places.

Transanal total mesorectal excision (TaTME): single-centre early experience in a selected population.

Total mesorectal excision (TME) represents the key principle in the surgical treatment of rectal cancer. Transanal mesorectal excision was introduced as a complement to conventional surgery to overcome its technical difficulties. The aim of this study was to evaluate the early surgical results following the introduction of this novel technique at our Unit. Between January and May 2016, 12 patients diagnosed with mid-low rectal adenocarcinoma were enrolled into this study and evaluated with regards demography, histopathology, peri-operative data and postoperative complications. The tumor was located in the middle rectum in 6 patients (50%), in the lower rectum in 6 patients (50%). Mean operative time was 356.5 ± 76.2 min (range 240-494). Eleven out 12 patients (91.6%) had less than 200 mL of intraoperative blood loss. Mean hospital stay was 10.9 ± 4.6 days (range 5-19). No mortality was recorded. Intraoperative complications were recorded in 1, while early post-operative complications (< 30 days) were observed in 5 patients (41.6%). Histopathology showed in all cases an intact mesorectum. Mean number of lymphnodes harvested was 13.6 ± 6.6 (range 4-29). Distal and circumferential margin was, respectively, of 20.8 ± 14.2 mm (range 2-45 mm) and 16.1 ± 7.6 mm (range 3-30 mm). The comparative analysis showed significant differences concerning mean operative time (p = 0.0473) and estimated blood loss (p = 0.0367). This study confirms this technique is safe and feasible, but more evidence to support its use over conventional laparoscopic surgery is needed.

A novel approach to stethoscope hygiene: A coat-pocket innovation.

BACKGROUND: The stethoscope is the most widely used instrument in healthcare. Studies have found similar rates of contamination on the stethoscope diaphragm and on physician fingertips after a single examination. Our aim was to test the effectiveness of an innovative portable device for disinfecting stethoscope membranes. METHODS: From November 2016 to May 2017, a cross-sectional study was conducted in four wards of a private clinic: General Ward (GW), Internal Medicine Ward (IMW), Post-Operative Observation Ward (POW) and Permanent Vegetative State Ward (PVSW). Five wearable medical devices, designed to disinfect stethoscope membranes automatically by means of UV-C radiation, were provided to operators. Spot checks were made for microbial counts of stethoscope membranes, classified as treated or otherwise on the basis of whether they were found coupled or otherwise with the devices. The percentage reduction in colony forming units (CFU) was calculated between the two groups. RESULTS: The number of tests of stethoscopes treated with the device was 116 out of 272. Untreated samples had a mean contamination of 132.2 CFU versus 6.9 CFU of treated samples: a 94.8% reduction (95% CI 91.3%-97.7). Highly significant statistical differences in CFU were found between untreated and treated membranes (p < 0.001). In particular, microbial contamination showed a reduction of 88.7% (CI 77.5%-96.05%) in PVSW, 95.9% (CI 88.2%-98.5%) in GW, 84.5% (CI 76.4%-90.5%) in IMW and 95.8% (CI 90.3%-98.1%) in POW. CONCLUSION: The devices proved effective and efficient in reducing the microbial load of stethoscope membranes. Wearing the device on the coat may act as a reminder of the need for hygiene.

Laparoscopic circular stapled longitudinal extramucosal pyloroplasty: an alternative technique for pyloric disruption.

OBJECTIVES: Oesophagectomy with gastric pull-up is the most common surgical procedure for oesophageal cancer. Pyloroplasty may be performed to facilitate stomach emptying, but its role is still controversial. When laparoscopic mobilization of the stomach is performed, conventional extramucosal pyloroplasty may be difficult to carry out; therefore, we describe a new technique for mechanical pyloric disruption. METHODS: We conceived the laparoscopic longitudinal extramucosal partial section of the anterior pyloric wall using a circular stapler. We performed it in 6 patients undergoing oesophagectomy for cancer, with the laparoscopic abdominal step before thoracotomy. RESULTS: The procedure was easy and safe and without intraoperative complications in all patients. Postoperative video-oesophagogram showed regular anastomosis and graft emptying. CONCLUSIONS: Our preliminary experience has led us to conclude that circular stapler longitudinal extramucosal pyloroplasty is an easy, safe and quick procedure that can be performed in laparoscopic surgery. Moreover, it seems to ensure a regular emptying of the graft as standard pyloroplasty does.

Rendezvous technique for cholecystocholedochal lithiasis in octogenarians: is it as effective as in younger patients, or should endoscopic sphincterotomy followed by laparoscopic cholecystectomy be preferred?

BACKGROUND: The treatment of cholecystocholedochal lithiasis (CCL) requires cholecystectomy and common bile duct (CBD) clearance, which can be achieved surgically or with a combination of surgery and endoscopy. The latter includes a two-stage-approach-preoperative retrograde cholangiography (ERC) and sphincterotomy (ST) followed by delayed laparoscopic cholecystectomy (LC), or vice versa-or a one-stage-approach-the rendezvous technique (RVT), where ERC, ST, and LC are performed during the same procedure. No data on the use of RVT in octogenarians have been reported in the literature so far. The study aims to show whether the RVT is as effective in elderly as in younger patients. Moreover, results of RVT are compared with those of a two-stage sequential treatment (TSST) in octogenarians, to identify the best approach to such a population. SUBJECTS AND METHODS: Prospectively collected data of 131 consecutive patients undergoing RVT for biliary tract stone disease were retrospectively analyzed. Two analyses were performed: (1) results of RVT (operative time, conversion rate, CBD clearance, morbidity/mortality, hospital stay, costs, and need for further endoscopy) were compared between octogenarians and younger patients, and (2) results of RVT in the elderly were compared with those of 27 octogenarians undergoing TSST for CCL. RESULTS: Octogenarians undergoing RVT were in poorer general condition (P<.0001) and had a higher conversion rate (P<.0001) and a longer hospital stay (P<.007) than younger patients. No differences in the rates of CBD clearance, surgery-related morbidity, mortality, and costs were recorded. Although octogenarians undergoing RVT were in poorer general condition than those undergoing TSST, the results of the two approaches were similar. CONCLUSIONS: RVT in the elderly seems to be as cost-effective as in younger patients; nevertheless, it may lead to a higher conversion rate and longer hospital stay. In octogenarians, RVT is not inferior to TSST in the treatment of CCL even for patients in poor condition.

Schwannoma of the colon: A case report.

Schwannomas are rare tumors originating from the Schwann cells, which form the neural sheath. These tumors occur most frequently in the head, neck, arms and limbs. Primary schwannomas of the colon and rectum are extremely rare; they are usually benign, but in extremely rare cases (2%), they can present with malignant degeneration if not surgically removed. The current study presents the case of a 65-year-old male with blood in the feces who underwent a colonoscopy that revealed an oval-shaped mass covered by ulcerated mucosa. A standard biopsy examination indicated a gelatinous carcinoma, and the patient consequently underwent a laparoscopic resection of the left colon. Histological examination revealed a schwannoma. Immunohistochemistry showed the tumor to be positive for S100 and vimentin, but negative for cluster of differentiation (CD)117, cytokeratin (CK)7, CK20, chromogranin, actin and synaptophysin, with a Ki-67 proliferative index of 3%. Lymph nodes were not involved. Overall, pre-operative biopsy examinations may be difficult for schwannomas, and immunohistochemistry is necessary for the correct diagnosis of this condition. In contrast to gastrointestinal stromal tumors, schwannomas are negative for CD117 and positive for S100 protein and vimentin. A Ki-67 index of ≥5% is strictly correlated with greater tumor aggressiveness. Therefore, the gold standard treatment for schwannomas is oncological radical surgical resection.

Pancreatico-jejunal anastomosis with invaginating jenunal "J"-loop. Preliminary report of a new technique.

INTRODUCTION: The pancreatic anastomosis is the most demanding step after pancreaticoduodenectomy (PD) and the pancreatic fistula (PF) is the most dreaded complication. Many techniques have been investigated to assess the best way to deal with the pancreatic stump after PD and none of these has shown to be superior in terms of statistically significant reduction of PF rate. We report the preliminary experience of a new technique of pancreaticojejunostomy (PJ). METHODS: Fifteen patients underwent PD for neoplasms with end-to-side PJ with dunking jejunal "J"-loop, between July 2011 and March 2014. The data about their post-operative outcomes were analyzed. RESULTS: There were no intra-operative neither post-operative deaths. One patient had a grade A PF (6.7%). Total post-operative complications occurred in 6 patients (40%), major post-operative complications occurred in 3 patients (20%). CONCLUSION: The new "sandwich" technique for dunking PJ after PD that we describe proved to be easy to perform and sure. It appears to be suitable for a dunking PJ when the diameter of the jejunum is too small than this of the pancreatic stump.

Closed hemorrhoidectomy with linear stapler: a consecutive series of 300 patients.

BACKGROUND: Hemorrhoidectomy is one of the most commonly performed anorectal operations. The aim of this study was to evaluate the safety and the efficacy of a new technique for sutured closed hemorroidectomy with linear stapler in a consecutive series of 300 patients. PATIENTS AND METHODS: Between January 2006 and December 2009, 300 patients (117 male, 183 female) (mean age, 52 (range 21-85) years) with grade III and IV hemorrhoids were treated with our modified technique with linear stapler with 6 cm vascular recharge. This technique essentially achieves a sutured closed hemorroidectomy. The primary end-points of the study were blood loss, time to achieve complete wound healing and recurrence; the secondary end-points were postoperative pain, operative time, hospital stay, patient satisfaction, need of analgesics and morbidity. RESULTS: Post-operative bleeding occurred in 8 patients (2.7%), requiring surgical hemostasis in 2 patients (0.6%). Overall, 132 patients (44%) reported no presence of pain, 43% defined it as light, the remaining 13% reported it as moderate and required the use of painkillers for about 1 month. Eight patients (2.7%) required postoperative temporary bladder catheterization because of acute urinary retention. The mean operative time was 13 minutes and the hospital stay was one day in 282 patients (94%), two days in 12 patients (4%) and three or more days in the remaining patients. None of the patients developed anal stenosis or fecal incontinence; 1 patient reported gas incontinence. The median follow-up was 23.4 months. All patients had complete wound healing within 6 months. Two patients had recurrent disease and were re-operated on with the same technique. CONCLUSION: Our modified sutured closed hemorrhoidectomy with linear stapler is a simple and safe technique and may be successfully applied for radical treatment in patients with third-degree or fourth-degree hemorrhoids.

Experimental analysis of a new algorithm for partial haplotype completion.

This paper deals with the computational problem of inferring complete information on haplotypes from haplotypes with missing data. This problem is one of the main issues in haplotyping, as the current DNA sequencing technology often produces haplotypes with missing bases and therefore the complete information on haplotypes has to be inferred through computational methods. In this paper, we propose a new algorithmic approach to the problem that assumes both the Coalescent and the Minimum Entropy models and we provide an experimental analysis relating it to the previously investigated approaches. In particular, the reconstruction of a perfect phylogeny from haplotypes with missing data is addressed.