Impact of imaging magnification on colorectal surgery: a matched analysis of a single tertiary center.

BACKGROUND: Laparoscopy has been increasingly applied in colorectal surgery, and imaging systems have been improving concurrently. The present study aims to compare outcomes following colorectal surgery with the 4K and traditional high-definition (HD) video systems. METHODS: All consecutive patients undergoing laparoscopic colorectal surgery between April 2016 and June 2020 were retrospectively retrieved from a prospective institutional database. The study population was matched according to the imaging system (4K versus HD groups) through a propensity score matching (PSM) based on perioperative characteristics of 15 patients. A stratified analysis according to surgical procedures (right, left colectomy, and low anterior resection) was also performed. Primary endpoints were intraoperative blood loss and perioperative transfusions. Also, intra- and postoperative morbidity, operative time, lymph node harvest, and length of hospital stay (LOS) were investigated as secondary outcomes. RESULTS: After PSM, 225 patients were included in both 4K and HD groups. The intraoperative blood loss was significantly lower in the 4K group (p = 0.008), although no different volumes of blood transfusion were required. Postoperative complications presented in similar proportions, while significantly higher rates of abdominal collection (p = 0.045), reoperation (p = 0.005), and postoperative urinary disorders occurred in the HD group. After stratification, the right colectomy subgroup shared similar associations with the study population. LOS did not change between groups, although readmissions were significantly lower in the 4K group (p < 0.001). CONCLUSIONS: The 4K imaging system represents a technological advance providing better surgical outcomes, such as the minimization of intraoperative blood loss and postoperative morbidity.

Laparoscopic Appendectomy Performed by junior SUrgeonS: impact of 3D visualization on surgical outcome. Randomized multicentre clinical trial. (LAPSUS TRIAL).

BACKGROUND: The purpose of this study was to evaluate the effect of 3D visualization applied to laparoscopic appendectomy (LA) performed by young surgeons (YS). We considered both operative features and clinical outcomes, aiming to highlight the benefits that this technology could bring to novice surgeons and their laparoscopic training. METHODS: All the surgical procedures were performed by residents who had performed less than 20 appendectomies prior to the beginning of the study under the supervision of an expert surgeon. At the time of enrolment patients were randomized into two arms: Experimental arm (EA): laparoscopic appendectomy performed with laparoscopic 3D vision technology. Control arm (CA): laparoscopic appendectomy performed with the "standard" 2D technology. The primary endpoint was to find any statistically significant difference in operative time between the two arms. Differences in conversion rate, intra-operative complications, post-operative complications and surgeons' operative comfort were considered as secondary endpoints. RESULTS: We randomized 135 patients into the two study arms. The two groups were homogeneous for demographic characteristics, BMI and ASA scores. The characteristics of clinical presentation and anatomical position showed no significant difference. The operative time was longer in the CA (57.5 vs. 49.6 min, p = 0.048, 95% CI). In the subgroup of complicated appendicitis, this trend toward inferior operative time was confirmed without reaching statistical significance (2D = 60 min, 3D = 49.5 min, p = 0.082 95% CI). No intra-operative complications were observed in either group. The conversion rate was 5.6% (4 patients) in the 2D group and 4.6% (3 patients) in 3D group. CONCLUSION: The utilization of 3D laparoscopy was associated with reduction in operative time without influencing other parameters, in particular without altering the safety profile of the procedure.

Enhanced recovery after surgery protocol in patients undergoing esophagectomy for cancer: a single center experience.

This article is about an emerging issue in esophageal surgery: enhanced recovery after surgery (ERAS) Few data are published in literature and its safety and feasibility is still debated. The focus of our paper is on the feasibility of an ERAS protocol for esophagectomy (including both the Ivor-Lewis and McKeown procedure) in a high volume center comparing to a standard perioperative protocol. We introduced a novelty item on this type of surgery: resume of oral feeding in the first postoperative day. We analyzed the dropout rate for each item and the postoperative morbidity. We studied 39 patients operated in the Upper GI division of Verona University Hospital between January 2013 and August 2014; 22 patients (ERAS group) were studied in a perspective way while 17 patients (standard group) were studied retrospectively. The enhanced recovery protocol included intraoperative fluid management, time of extubation after surgery, intensive care unit discharge, drains and nasogastric tube management, mobilization of the patient, oral food intake. We compared the results between the two groups in term of hospital stay, postoperative morbidity and mortality. We also calculated the percentage completion of the protocol, evaluating patient drop-out rates for each of the items. Patients showed an improvement in the ERAS group in terms of earlier extubation, earlier intensive care unit discharge (p < 0.01), earlier thoracic drain, urinary catheter (p < 0.01) and nasogastric tube removal (p = 0.02), earlier mobilization (p < 0.01), and resume of oral feeding (p < 0.01). Median length of hospital stays in the ERAS group was 9 days while in the standard group was 10 days (p = 0.23). Postoperative morbidity and mortality were comparable between the two groups. This study shows the feasibility and safety of an ERAS protocol for esophageal surgery in a high-volume center. These data strengthen the literature results on this argument calling for larger sample size studies.

Tailored treatment for signet ring cell gastric cancer.

Gastric cancer with Laurèn diffuse types is increasing in the West. The raising trend is more evident when considering signet ring cells (SRC) histology. However, to control the biologic potential of this GC subtype, some hypotheses of tailored therapeutic strategies for SRC cancers have been made. A review of the literature was performed using the key words "signet ring cells" AND "gastric cancer". Results of literature review were descriptively reported. Endoscopic submucosal dissection (ESD), according to the Japanese extended criteria, could be a therapeutic option for early SRC tumours. However, according to the evidences from more recent studies, indications for ESD to these tumours types should be carefully considered. Concerning the optimal surgical treatment, considering the high lymphotropism and infiltrating behaviour of SRC histotype, the extension of gastric resection should be wider than for intestinal type cancer and laparoscopic surgery should be performed carefully. Moreover, D3 lymphadenectomy could provide a benefit in diffuse-type and SRC histology. The role of surgery in gastric cancer with peritoneal carcinomatosis is still debated and studies on this topic should stratify the good results according to GC histotype. Finally, despite the evidences of chemoresistance in SRC, ongoing randomized trials suggest that multimodal therapy could be the best treatment. Based on the assumption that SRC tumours have specific features, they deserve a specific multimodal treatment. However, a preliminary step to generate strong evidences in this field is the standardization of terminology used to define signet ring cells carcinoma.

Long-term follow-up of metastatic renal cancer patients undergoing reduced-intensity allografting.

SCT from an HLA-compatible sibling donor is an adoptive immunotherapy for cytokine-refractory, metastatic clear-cell renal cell cancer (RCC). However, the recent introduction of targeted therapy compounds has reduced the interest in this therapeutic strategy. We have reanalyzed our series with the aim to assess long-term benefit from allografting. Twenty-five RCC patients received a reduced-intensity allograft from an HLA-identical sibling donor. All patients received a thiotepa, fludarabine and CY conditioning regimen, and a cyclosporine-based GVHD prophylaxis. Best response to allograft was evaluable in 24 patients: 1 CR, 4 PR, 12 minor response/stable disease, 7 progressive disease. One-year survival was 48%, and five-year survival was 20%. At a median observation time of 65 months, five patients are alive, one in CR, one in PR and three with stable disease. By multivariate analysis, C-reactive protein value before transplant, the number of CD34 + infused cells and disease status at day +90 significantly correlated with survival. Survival of patients at favorable/intermediate-risk according to the MSKCC score that underwent allografting was better in comparison to the survival predicted by historical controls. We conclude that 20% of cytokine-refractory RCC patients are alive long-term after allografting. Transplantation is able to induce long-term disease control in a fraction of relapsed RCC patients.