DDS-SIRC Cooperative Conferences Feel the Burn: RFA for Chronic Radiation Proctitis.

Chronic radiation proctitis, although relatively rare, can be the source of severe comorbidity in patients who had undergone prior radiotherapy for pelvic malignancy. Although current treatments for radiation proctitis include argon plasma coagulation, heater probe, bipolar neodymium/yttrium aluminum garnet (Nd: YAG) lasers, these interventions are often burdened by the frequent occurrence of rectal ulcerations and stenosis. Since radiofrequency ablation (RFA) is frequently used to ablate esophageal malignancy and pre-malignancy, we report the efficacy of RFA using through the scope system in two patients with rectal bleeding due to radiation proctitis. In both cases, the procedure was well-tolerated with hemostasis achieved after 1 or 2 sessions of RFA. Mucosal re-epithelialization was observed in areas of previous bleeding with no stenosis or ulceration observed at follow-up.

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure.

INTRODUCTION: The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature. METHODS: A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology. CONCLUSIONS: In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Role of Inflammatory Biomarkers (NLR, LMR, PLR) in the Prognostication of Malignancy in Indeterminate Thyroid Nodules.

Indeterminate follicular thyroid lesions (Thyr 3A and 3B) account for 10% to 30% of all cytopathologic diagnoses, and their unpredictable behavior represents a hard clinical challenge. The possibility to preoperatively predict malignancy is largely advocated to establish a tailored surgery, preventing diagnostic thyroidectomy. We analyzed the role of the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR) and the lymphocyte-to-monocyte ratio (LMR) as prognostic factors of malignancy for indeterminate thyroid nodules. In patients affected by cytological Thyr 3A/3B nodules, NLR, PLR and LMR were retrospectively compared and correlated with definitive pathology malignancy, utilizing student's t-test, ROC analysis and logistic regression. One-hundred and thirty-eight patients presented a Thyr 3A and 215 patients presented a Thyr 3B. After the logistic regression, in Thyr 3A, none of the variables were able to predict malignancy. In Thyr 3B, NLR prognosticated thyroid cancer with an AUC value of 0.685 (p < 0.0001) and a cut-off of 2.202. The NLR results were also similar when considering the overall cohort. The use of cytological risk stratification in addressing the management of indeterminate thyroid nodules in patients is not always reliable. NLR is an easy and reproducible inflammatory biomarker capable of improving the accuracy of preoperative prognostication of malignancy.

Thyroid-Bed Schwannoma Mimicking a Thyroid Neoplasm: A Challenging Diagnosis: Report of a Case and Literature Review.

BACKGROUND: Schwannomas, also called neurinomas, are rare benign tumors of the neural cells that can develop from the sheaths of nervous structures of several districts, although the most frequent sites are the cranial nerves (25%-45%). Rarely, cases show neck schwannomas in the thyroid parenchyma, while the cases of thyroid-bed schwannomas mimicking a thyroid-gland lesions are anecdotal. METHODS: We report the case of a 70-year-old man with a preoperative-imaging diagnosis of a thyroid neoplasm, confirmed as Thyr 4 by fine-needle cytology. RESULTS: During surgery, an extra-thyroidal lesion was discovered, determined to be a neck schwannoma through definitive pathology. A literature review of cases of thyroid-bed-lesion schwannomas misinterpreted as thyroid neoplasms was carried out. CONCLUSIONS: In the case of suspicious extra-thyroidal lesions, we advocate for a close routine cooperation between the cytologist, the radiologist, and the surgeon in the attempt to reach an accurate preoperative diagnosis.

Severe rectal prolapse and solitary rectal ulcer in a young anorectic woman with myxoid degeneration of visceral adipose tissue.

Rectal prolapse is a disorder in which the rectum protrudes from the anal canal. Solitary rectal ulcer may coexist. Both conditions have been associated with chronic constipation and excessive straining during defecation. Rectal prolapse has been rarely reported in women suffering from anorexia nervosa. Lack of rectal support because of loss of ischiorectal fat has been proposed as one of the possible mechanisms in this condition, together with chronic constipation and abuse of laxative. We report the case of an anorexic woman with a severe rectal prolapse and bleeding requiring urgent Altmeier's procedure. Surgery was complicated by dehiscence of the anastomosis and volvulus, requiring ileostomy and laciniae debridement. Pathological analysis of all the surgical samples taken from different abdominal sites highlighted changes in the visceral adipose tissue consisting in nodular aggregates of small adipocytes dispersed in a myxoid matrix surrounding blood vessels within abundant fibrosis. The morphologic features resemble those observed in primordial fetal fat and are comparable to those observed in cancer associated cachexia. The diffuse myxoid degeneration of visceral adipose tissue may play a role in the pathogenesis of rectal prolapse in patients with anorexia nervosa. Besides starvation, the mechanism sustaining myxoid degeneration of the adipose tissue is not entirely clear. Whenever possible improving nutritional and clinical conditions should be ideal before any surgical approach.

Laparoscopic two-step abdomino-parasacral resection of a giant pelvic lipoma: a case report.

Background: Pelvic lipomas, particularly when massive in size, present unique surgical challenges due to their intricate anatomical location and proximity to vital structures. Complete resection of tumor is the basic principle. In this case, we demonstrated the complete resection of a huge pelvic lipoma by laparoscopy combined with a transsacral approach, which was rarely reported in the relevant literature. According to our case, a two-step abdomino-parasacral approach provides more flexibility, but also a safe and easier dissection in deep pelvic. Case Description: A 74-year-old female presented to the outpatient clinic, complaining of abdominal distension and difficulty in defecation for over 6 months. The patient had no obvious concomitant symptoms and she had a history of hypertension. After completing the relevant tests, the patient was diagnosed with a pelvic tumor, possibly a lipoma. We performed a two-step abdomino-parasacral approach to remove the tumor and the tumor was confirmed as lipoma. There was no tumor recurrence sign after 7 months follow-up for the patient. Conclusions: A two-step abdomino-parasacral resection of the lipomatous tumor were advantageous to manage en bloc resection of a giant pelvic lipoma in our case report. This case report can provide some reference for the treatment of pelvic giant lipoma in the future.

Outcomes and Follow-Up Trends in Adrenal Leiomyosarcoma: A Comprehensive Literature Review and Case Report.

Background: Leiomyosarcoma (LMS) originating from the adrenal gland is exceedingly rare, constituting a minute fraction of soft tissue sarcomas. Due to its rarity, with less than 50 documented cases in English medical literature, the diagnosis and management of adrenal LMS remain challenging. The aim of this study was to perform a review of the literature, in order to evaluate the prognosis of these rare cancers and report our specific case. Methods: A systematic review of the literature was conducted using PubMed, Web of Science, Google Scholar, and Scopus databases, up to December 2020. The search utilized MeSH terms such as "Adrenal Gland Neoplasms," "Leiomyosarcoma," "Adrenalectomy," and "Smooth Muscle Tumor." The inclusion criteria focused on studies reporting patients with a histopathological diagnosis of adrenal leiomyosarcoma. The PRISMA guidelines were followed to ensure a comprehensive analysis. Results: Out of 63 identified studies, 43 met the inclusion criteria and were reviewed. These studies highlighted the rarity and aggressive behavior of adrenal leiomyosarcoma. Surgical excision remains the cornerstone of treatment, often complemented by adjuvant therapies. The reviewed case involved a 52-year-old woman who underwent a right laparoscopic adrenalectomy for a 9 × 7 × 6 cm grade 3 leiomyosarcoma. Despite subsequent adjuvant chemotherapy, hepatic metastases were detected, illustrating the aggressive nature of the disease. The literature underscores the importance of histopathological analysis and long-term surveillance for managing disease progression. Conclusions: Optimal management of adrenal leiomyosarcoma requires a multidisciplinary approach and meticulous follow-up. The rarity of the disease poses challenges for standardizing treatment, but surgical excision and tailored adjuvant therapies show promise. Further research is essential to refine treatment strategies and improve prognosis for this rare malignancy.

CC vs. CC-Plus: A Comparison between Two Cranial-to-Caudal Approaches for Laparoscopic Right Hemicolectomy: A Single-Center Retrospective Study.

BACKGROUND: Colorectal cancer is a leading cause of cancer-related deaths worldwide, with approximately 1.9 million new cases and over 935,000 deaths in 2020. Right-sided colon cancer, a subset of colorectal cancer, represents a significant health burden. Laparoscopic colon surgery has significantly improved postoperative recovery. The superiority of one approach or landmark over another is still argued about due to the lack of large-scale prospective studies. However, deep understanding both of the anatomical variation and characteristics of each approach is of extreme importance to minimizing adverse effects and maximizing patient benefit after laparoscopic right hemicolectomy. Among these, the cranial-to-caudal approach offers advantages such as reduced intraoperative blood loss, shorter operation time, and decreased risk of vascular injury. The purpose of this study is to compare the efficacy and safety of two cranial-to-caudal approaches for laparoscopic right hemicolectomy (LRH). Specifically, the study aims to evaluate the differences between the conventional cranial-to-caudal approach with medial ligation of the middle colic vein (MCV), and the cranial-to-caudal approach with cranial MCV ligation and surgical trunk sheath opening (CC-plus). The goal is to determine which method offers superior outcomes in terms of intraoperative blood loss, operation time, and overall patient recovery. MATERIALS AND METHODS: This single-center retrospective study compared two cranial-to-caudal approaches for LRH. The study included 51 patients who underwent LRH between January 2021 and November 2023 at the Second Affiliated Hospital, Zhejiang University School of Medicine. Patients were divided into two groups: Group A (26 patients) used the cranial-to-caudal approach with medial ligation of the middle colic vein (MCV), and Group B (25 patients) used the cranial-to-caudal approach with cranial MCV ligation and surgical trunk sheath opening (CC-plus). General characteristics, intraoperative parameters, and postoperative outcomes were compared. Statistical analysis was performed using SPSS version 20.0, with significance set at p < 0.05. RESULTS: There were no significant differences between the groups regarding age, gender, tumor location, or clinical staging. All patients achieved R0 resection with no perioperative deaths. The CC-plus group had significantly reduced intraoperative blood loss and shorter operation time compared to the CC group (p < 0.05). No significant differences were found in first postoperative exhausting time, first postoperative defecation time, and postoperative hospital stay between the two groups. Furthermore, no significant differences were evaluated in postoperative complications (surgical site infection (SSI), ileus or bowel obstruction, refractory diarrhea, anastomotic leakage, deep vein thrombosis (DVT), hemorrhage) between the two groups on a median follow up of 12.6 months. Pathological examination showed no significant differences in total lymph nodes dissected and tumor stage. CONCLUSIONS: The cranial-to-caudal approach with MCV ligation via the cranial approach (CC-plus) is a safe and effective method for LRH, offering advantages in terms of reduced operation time and intraoperative blood loss. This study's findings suggest that the CC-plus approach may be superior to the conventional cranial-to-caudal approach.

Early Breast Cancer: Could Combined LOCalizerTM and Ultrasound Localization Replace the Metallic Wire? A Multicentric Study.

Background: Breast localization plays a key role in early breast cancer (BC) surgery. The current gold standard is wire-guided localization (WGL), despite the known disadvantages. The patients often experience anxiety and discomfort due the metallic wire placed in the breast, and surgeons are compelled to perform the surgery on the same day as the radiological release of the wire to prevent migrations or breakages. Various wireless systems have been proposed as alternative to WGL. LOCalizerTM offers the advantage of providing the exact distance from the marker called Tag. The combined technique using LOCalizerTM and US allows for determining the distance from the BC margin, a critical surgical goal for oncological radicality. Methods: Patients referred for breast surgery to two Italian hospitals were enrolled and divided into two groups: Group A, including patients undergoing a combined approach, and group B, including patients treated with conventional WGL. Results: The combined approach with LOCalizerTM and US was associated with better outcomes in terms of oncological radicality, cosmetic results, and patients' satisfaction. Conclusions: In the current study, LOCalizerTM associated with US could be considered an excellent approach for localizing non-palpable BC. Further larger comparative studies are needed to address this issue.

Ultrasound predictive parameters of difficult airway in thyroid surgery: a pilot study.

Difficult airway is a major life-threatening complication during induction of general anesthesia. In thyroid surgery, intubation could be complicated by airway distortion because of the enlarged thyroid gland. Recently, ultrasonography has been proposed as a potential modality for airway assessment and management. The aim of the study is to evaluate ultrasound-based measurement of airway parameters in 13 selected patients with compressive goiter and tracheal deviation scheduled for thyroidectomy before induction of general anesthesia. Specifically, we detected the distance between the skin and retro-isthmic trachea (DSRIT) and the distance between the sub isthmic trachea and the carotid artery (DCSIT) at the side of the dominant lobe. We compared ultrasound measures before intubation with Cormack-Lehane laryngoscopes grades recorded during tracheal intubation.

Impact of the COVID pandemic on melanoma thickness and ulceration: a meta-analysis.

The global healthcare sector faced immense challenges due to the COVID-19 pandemic. Oncologists noted reduced cancer screening, which impacted melanoma diagnosis and treatment, leading to concerns about delayed care and poorer outcomes. This review analyzes how the pandemic influenced melanoma ulceration risk and Breslow thickness index through a meta-analysis of published studies. Following PRISMA guidelines, we conducted a systematic review of literature from January 2021 to December 2022 on cutaneous melanoma before and during the COVID-19 pandemic. Upon screening 1854 manuscripts, the review led to 13 studies meeting inclusion standards. The quality assessment followed MINORS and Newcastle-Ottawa Scale criteria. Regarding ulceration, post-COVID ulceration surpassed pre-COVID levels significantly, with a risk ratio of 1.31 and an estimated odds ratio of 1.41, indicating a 44% rise post-COVID. As for Breslow thickness, studies show a rising trend in the Breslow index post-COVID, but less significantly, with an effect size of 0.08 regarding the meta-analysis model (P = 0.02) with a pre-COVID mean Breslow of 1.56 mm and post-COVID of 1.84 mm. This meta-analysis concluded that post-COVID ulceration rates significantly surpassed pre-COVID levels. Considering that ulcerated melanomas usually undergo sentinel lymph node biopsy and are more likely to benefit from adjuvant therapies, this indicates important implications, as many patients might have missed the opportunity to start therapy appropriately, regardless of their Breslow thickness status.

Pancreatic Neuroendocrine Tumors: What Is the Best Surgical Option?

Background: Pancreatic neuroendocrine tumors (pNETs) represent a rare subset of pancreatic cancer. Functional tumors cause hormonal changes and clinical syndromes, while non-functional ones are often diagnosed late. Surgical management needs multidisciplinary planning, involving enucleation, distal pancreatectomy with or without spleen preservation, central pancreatectomy, pancreaticoduodenectomy or total pancreatectomy. Minimally invasive approaches have increased in the last decade compared to the open technique. The aim of this study was to analyze the current diagnostic and surgical trends for pNETs, to identify better interventions and their outcomes. Methods: The study adhered to the PRISMA guidelines, conducting a systematic review of the literature from May 2008 to March 2022 across multiple databases. Several combinations of keywords were used ("NET", "pancreatic", "surgery", "laparoscopic", "minimally invasive", "robotic", "enucleation", "parenchyma sparing") and relevant article references were manually checked. The manuscript quality was evaluated. Results: The study screened 3867 manuscripts and twelve studies were selected, primarily from Italy, the United States, and China. A total of 7767 surgically treated patients were collected from 160 included centers. The mean age was 56.3 y.o. Enucleation (EN) and distal pancreatectomy (DP) were the most commonly performed surgeries and represented 43.4% and 38.6% of the total interventions, respectively. Pancreatic fistulae, postoperative bleeding, re-operation, and follow-up were recorded and analyzed. Conclusions: Enucleation shows better postoperative outcomes and lower mortality rates compared to pancreaticoduodenectomy (PD) or distal pancreatectomy (DP), despite the similar risks of postoperative pancreatic fistulae (POPF). DP is preferred over enucleation for the pancreas body-tail, while laparoscopic enucleation is better for head pNETs.

Post-Irradiation Breast Angiosarcoma: All the Possible Treatments and Electrochemotherapy. Case Report and Literature Review.

Breast angiosarcoma is a rare malignancy, accounting for less than 1% of all soft tissue cancers. It comprises primitive and secondary subtypes, such as radiogenic breast angiosarcoma (RAS). Despite multimodal treatment, angiosarcomas represent an incurable disease for many patients and a significant cause of deterioration in their quality of life. Surgery is a cornerstone in management, but high recurrence rates are reported. Electrochemotherapy (ECT) is a practicable locoregional treatment for patients with advanced angiosarcoma as part of a multimodal therapeutic strategy. The palliative benefits of ECT include optimal patient compliance, good local hemostasis control, and positive local responses. Since only 22 cases are described in the literature, we reported a rare case of RAS treated with ECT after a multidisciplinary approach, including Next Generation Sequencing (NGS). A literature review on the feasibility of ECT in RAS management was also performed.

Rare axillary cancer of unknown primary originating from the breast of a 64­year­old male patient: A case report and literature review.

Cancers of unknown primary (CUPs) are a heterogeneous group of tumors characterized by a difficult diagnosis. The primitive tumor remains unknown, whereas metastases are the most common manifestation. Occult male breast cancers are very rare types of CUPs. The present study describes the case of a 64-year-old man affected by a CUP of presumed mammary origin. The aim of the article and the present review was to focus on their management. To the best of our knowledge, only thirteen cases have been reported in the literature. Because no specific guidelines are available, various approaches have been applied, influencing the treatment and the prognosis of patients with CUP.

Large renal lymphoma in a patient with horseshoe kidney: A case report.

Horseshoe kidney (HSK) is the most common renal fusion anomaly. It frequently consists of kidney fusion in the lower pole across the midline and occurs during embryogenesis. The incidence of malignancies in HSKs can be 3-4 times higher than that in normal kidneys. A 69-year-old man with a voluminous right kidney neoplasm in HSK and a single omolateral axillary lymphadenopathy underwent complete excision of right axillary lymphadenopathy and ultrasound-guided percutaneous biopsy of the right kidney expansive lesion. The diagnosis of non-Hodgkin's B cell lymphoma both in HSK and right axilla was made. We report this case to raise awareness among physicians regarding the importance of a correct clinical evaluation and diagnostic workup so as to avoid surgery, which is not easy and without complications, in patients with this kidney anomaly. Primary renal lymphoma should also be included among possible neoplasms of HSK. Renal biopsy should always be recommended in cases where atypical findings are obtained from imaging techniques and when its outcome can impact clinical decision-making. In the present case, biopsy was performed, and thus, nephrectomy was avoided and specific medical therapy was quickly started.

One Anastomosis Gastric Bypass vs. Sleeve Gastrectomy in the Remission of Type 2 Diabetes Mellitus: A Retrospective Analysis on 3 Years of Follow-Up.

Background. Obesity is a prevalent condition associated with various comorbidities, impacting mortality, fertility, and quality of life. Its relationship with type 2 diabetes mellitus (DMII) is well established, with nearly 44% prevalence. Bariatric surgery has proven crucial for treating both obesity and DMII. The comparison between surgical techniques, such as sleeve gastrectomy (SG) and one anastomosis gastric bypass (OAGB), remains controversial in terms of glycemic control efficacy. This retrospective study aimed to assess DMII remission efficacy between SG and OAGB after 36 months. Methods. From January 2016 to September 2020, 201 patients who underwent SG and OAGB for morbid obesity associated with DMII were accurately followed-up with for 36 months, focusing on %HbA1c, DMII remission, anthropometric results, and nutrient deficiency. Results. Although DMII remission did not exhibit statistical significance between the groups (82% vs. 93%, SG vs. OAGB, p = 0.051), OAGB demonstrated a more robust association with glycemic control (Odds Ratio 0.51) throughout the entire follow-up and yielded superior anthropometric outcomes. Notably, nutrient deficiencies, excluding cholecalciferol, iron, and riboflavin, did not show significant intergroup differences. Conclusions. This study contributes valuable insights into the extended-term efficacy of SG and OAGB in DMII remission. The nuanced findings underscore the multifaceted nature of metabolic outcomes, suggesting that factors beyond weight loss influence diabetes resolution. Larger comparative studies are warranted to comprehensively address this issue.

Short- and long-term outcomes of sphincteroplasty for anal incontinence related to obstetric injury: a systematic review.

Anal incontinence is a frequent pathological condition with devastating impact on quality of life. The prevalence is approximately 15% of the population, with higher incidence reported in the elderly and multiparous women, and several factors have a major role in its pathogenesis, such as anatomical sphincter defects (Glasgow and Lowry in Dis Colon Rectum 55(4): 482-490, 2012), delivery injuries, and colorectal, uro-gynecological, and perineal surgery. The direct surgical approach is the gold standard treatment for fecal incontinence, especially through anterior sphincteroplasty, although a permanent defect of continence persists over time. The aim of our study is to evaluate, throughout a systematic review of the literature, the short- and long-term outcomes of sphincteroplasty performed for obstetric injuries anal incontinence. A systematic review of the studies published in the literature from January 2000 to December 2021 was performed in accordance with the PRISMA guidelines. Of the 2543 studies extrapolated, only eight fulfilled the inclusion criteria and were admitted represented by retrospective and prospective studies. The data analyzed from the included studies were number and mean age of the female population, and incontinence improvement with preoperative and postoperative short- and long-term outcomes, as reported by QoL questionaries and incontinence scores. Overall 355 patients with obstetric sphincter damage underwent sphincteroplasty with an anterior external sphincter overlapping procedure. A consistent improvement in fecal incontinence at short-term follow-up with relative improvement in QoL was reported. In 7 of 8 studies, the authors found a progressive worsening of the incontinence symptoms on the long-term follow-up. However, it is not clear whether the decrease in long-term continence results is parallel to a simultaneous decrease in QoL scores. Nevertheless, compared to the preoperative findings, the improvement was maintained in the long-term follow-up. Despite the limited data in the literature, a properly performed sphincteroplasty can guarantee a consistent improvement of the continence in short term with encouraging outcomes, especially for solid stool continence, in long time. We believe that anterior sphincteroplasty, as a low cost, feasible, and safe procedure, still has a role in the treatment of fecal incontinence for obstetric injury. Further large cohort randomized clinical trials are necessary to validate these results.

Prognosis of Adrenal Oncocytic Neoplasms (AONs): Literature Review of 287 Cases and Presentation of the Oldest Patient.

INTRODUCTION: The adrenocortical oncocytic neoplasms (AONs) are rare tumors of the adrenal gland, classified as oncocytoma (AO), oncocytic neoplasm of uncertain malignant potential (AONUMP) and oncocytic carcinoma (AOC). The aim of this study was to perform a review of the literature, in order to evaluate the prognosis of these rare cancers. We also reported the oldest patient with AON. METHODS: A comprehensive literature review using as key words "adrenal oncocytoma", "adrenal oncocytic neoplasm", and "adrenal oncocytic carcinoma" was performed. REPORT OF THE CASE: We report the case of an 88-year-old woman receiving a left open adrenalectomy for an AON (15 × 10 × 8 cm). The considerable size and weight together with the presence of necrosis were indicative for a lesion with an uncertain potential for malignancy, according to Weiss modified criteria. After two years, the patient was free from any sign of recurrence. RESULTS: Only 287 AONs were detected in the scientific literature, exploring OVID, MEDLINE, PubMed and SCOPUS as dataset. These tumors are usually incidentalomas with an unpredictable malignant potential. Surgical resection remains the mainstay of treatment for AON. CONCLUSION: AO and AONUMP have an excellent prognosis and a low mortality rate, with only three cases of recurrence reported in the literature and one metastatic case four years after first adrenal surgery. In contrast, AOC carries a high risk of local relapses, distant metastasis, and a significantly higher mortality rate (30%). Surgical resection remains the primary treatment for adrenal oncocytic neoplasms.

Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study.

BACKGROUND: Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure. METHODS: From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152). CONCLUSIONS: In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.

Impact of Current Technology in Laparoscopic Adrenalectomy: 20 Years of Experience in the Treatment of 254 Consecutive Clinical Cases.

BACKGROUND: Laparoscopic adrenalectomy (LA), which avoids large abdomen incisions, is considered the gold standard technique for the treatment of benign small- and medium-size adrenal masses (<6 cm) and weighing < 100 g. A trascurable mortality and morbidity rate, short hospitalization and patient rapid recovery are the main advantages compared to traditional surgery. During the past decade, a new surgical technology has been developed that expedites a "clipless" adrenalectomy. Here, the authors analyze a clinical series of 254 consecutive patients who were affected by adrenal gland neoplasms and underwent LA by the transabdominal lateral approach over the two last decades. A literature review is also presented. METHODS: Preoperative, intraoperative and postoperative data from 254 patients who underwent LA between January 2003 and December 2022 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in the case of pheochromocytoma (PCC) while spironolactone and potassium were employed to treat Conn's disease. The same surgeon (CG) performed all the LA and utilized the same laparoscopic transabdominal lateral approach. Different dissection tools-ultrasonic, bipolar or mixed scissors-and hemostatic agents were used during this period. The following results were obtained: 254 patients were included in the study; functioning tumors were diagnosed in 155 patients, 52 patients were affected by PCCs, 55 by Conn's disease, 48 by Cushing's disease. Surgery mean operative time was 137.33 min (range 100-180 min) during the learning curve adrenalectomies and 98.5 min (range 70-180) in subsequent procedures. Mean blood loss was respectively 160.2 mL (range 60-280) and 96.98 mL (range 50-280) in the first 30 procedures and the subsequent ones. Only three conversions (1.18%) to open surgery occurred. No mortality or postoperative major complications were observed, while minor complications occurred in 19 patients (3.54%). In 153 out of 155 functioning neoplasms, LA was effective in the normalization of the endocrine profile. According to our experience, a learning curve consisting of 30 cases was identified. In fact, a lower operative time and a lower complication rate was reported following 30 LA. CONCLUSIONS: LA is a safe procedure, even for masses larger than 6 cm and PCCs. Undoubtedly, the development of surgical technology has made it possible reducing operative times, performing a "clipless" adrenalectomy and extending the indications in the treatment of more complex patients. A multidisciplinary team, in referral high-volume centers, is recommended in the management of adrenal pathology. A 30-procedure learning curve is necessary to improve surgical outcomes.