Special Use of Intraoperative Endoscopy in Sleeve Gastrectomy: A Case Report.

Sleeve gastrectomy is the most frequently performed operation for the treatment of morbid obesity. Even though sleeve gastrectomy is now widely standardized, it may still benefit from the use of certain devices and procedures such as intraoperative endoscopy. The use of an endoscope offers numerous advantages that can considerably reduce the morbidity and mortality of patients who undergo laparoscopic sleeve gastrectomy. This paper describes our experience with a case in which the information obtained by endoscopy allowed us to perform a real-time assessment of the location of two large gastric polyps to control the staple-line.

Gastric Leaks after Sleeve Gastrectomy: Focus on Pathogenetic Factors.

As reported by The International Federation for the Surgery of Obesity (IFSO) worldwide survey on bariatric surgery, sleeve gastrectomy has become the second most performed bariatric/metabolic procedure in the world just after gastric bypass. If we consider complications, despite a recent systematic review and meta-analysis that reported a substantial decrease in sleeve gastrectomy complication rates, leaks after sleeve gastrectomy still rate between 0 and 18%. Unlike the leaks of other types of gastrointestinal surgery, leaks after sleeve gastrectomy are challenging in diagnosis and treatment and can lead to sepsis, multiple organ failure, and even death. A standardized algorithm of diagnosis and management is still lacking. Current classification of gastric leaks is based on the time of onset and clinico-pathological aspects. Nonetheless, none of the largest series in literature report the pathogenesis of gastric leaks. Given this paucity of evidence-based data and the lack of defined guidelines, we try to examine and consider the pathogenetic factors of gastric leak to implement better treatments and predict outcomes.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): From A to Z.

We depict the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Patient selection criteria are (1) ultrasonographically (US) estimated thyroid diameter no larger than 10cm, (2) US estimated gland volume ≥45mL, (3) nodule size ≥5mm, (4) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (5) follicular neoplasm, and (6) papillary microcarcinoma without evidence of metastasis. TOETVA is carried out through a three-port technique placed at the oral vestibule, one 10mm port for 30° endoscope and two additional 5mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscles bilaterally. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments. Intraoperative neuromonitoring is used for identification and dissecting and monitoring both the superior and inferior laryngeal nerves.

Topographical Variations between Splenic Flexure and Spleen: A Study with CT Image-Based Reconstruction.

INTRODUCTION: An issue that is seldom seen in the literature relates the detailed relationship of the splenic flexure (SF) and the spleen-both carefully examined-with a prospective approach in patients undergoing computer tomography (CT) scan. MATERIALS AND METHODS: SF localization has been searched and examined in 120 consecutive CT scans. Several different variables (age, gender, BMI, indication of CT scan, etc.) have been considered. In cooperation with the Radiology Division, we brought to completion a dedicated topographic outline, with the purpose of providing a detailed classification for SF localization. RESULTS: The SF lies, in 52% of cases, in what we called the inferior (I) position, below the spleen. Other categories of our classification were anterior (A) and posterior (P) positions, which were found respectively in 42% and 8% of analyzed cases. Considering all the variables given, we did not find any significant statistical correlation (p > 0.05). CONCLUSIONS: This study was carried out to classify types of SF in terms of its positional relationship with the spleen. We investigated 120 CT scans and classified the SF into three types, according to its localization: inferior (I), anterior (A), and posterior (P) types. A better understanding of the anatomic variability in SF may be useful for minimizing complications and performing an accurate surgical dissection.

Self-Retaining Retractor Widox® for Thyroid Surgeries: Technical Note.

During a thyroidectomy, perfect exposure of the vascular nerve structures, parathyroid gland, trachea, larynx, esophagus, and lymphnodes is crucial to facilitate the surgeon in the meticulous dissection. WIDOX® (MOSS Spa, Lesa, Italy) is an atraumatic self-retaining thyroidectomy retractor specifically designed for thyroid surgeries with an octagonal shape and six retractors (Fig. 1). It is a sterile, single-use device which keeps the surgical wound and the neck muscles retracted allowing the proper exposure of the operatory field. The device substitutes the manual retractors held by the surgeon's assistants. In our institute, we started using the self-retaining retractor WIDOX® from May 2015 for a total of 50 patients. From our preliminary experience, the self-retaining retractor WIDOX® is simple and practical and can be adapted to each patient. The use of energy-based devices and the neuromonitoring is not prevented by the presence of this retractor.

Spontaneous bowel evisceration through umbilical hernia in an adult non-cirrhotic patient.

Few cases of spontaneous bowel evisceration (SBE) through umbilical hernias (UHs) in adult patients have been reported in the literature. Interestingly, the spontaneous rupture of the hernia sac is a rare complication usually seen in adult cirrhotic patients with persistent ascites or in patients with congenital wall defects. A man in his early 50s was admitted to our emergency department with SBE through a long-standing acquired UH. He was not clinically cirrhotic, although being HCV positive. Surgeons performed an urgent laparotomy with ileal resection, latero-lateral ileal anastomosis and direct hernioplasty without mesh. Given the rarity of this presentation, we reported it and reviewed the available literature on this subject. Elective hernioplasty is currently suggested to lower the risk of complications. Mesh placement should be preferred, but only if comorbidities and infectious risks do not contraindicate its use. In emergency situations, a direct hernia repair is preferred.

Neoadjuvant Chemotherapy in Breast Cancer: Evaluation of the Impact on Surgical Outcomes and Prognosis.

The correlation between TNM staging and histology variations in a sample of patients who underwent neoadjuvant chemotherapy demonstrates a positive impact on both increasing conservative surgery and achieving pCR, resulting in better outcomes in terms of disease-free survival (DFS) and the risk of relapse. Benefits have also been highlighted in terms of cosmetic outcomes, postoperative complications, and psychological benefits. However, the overall outcomes must be evaluated according to the subtype and individual characteristics of the patients.

Non-recurrent Laryngeal Nerve During Intraoperative Neuromonitoring Thyroidectomy: A Case Report and Literature Review.

Complete and precise knowledge of the neck anatomy and its eventual anomalies is crucial while performing a safe thyroid and parathyroid surgery. Embryo-genetic malformations of the IV branchial arch can lead to an uncommon anatomical alteration known as non-recurrent inferior laryngeal nerve. Its prevalence varies between 0.7% for the dextral branch and 0.04% for the sinistral. In these cases, the inferior laryngeal nerve branches originate directly from the cervical vagus nerve, entering the larynx without hooking, on the right side around the subclavian artery or on the left around the aortic arch. The presence of a non-recurrent laryngeal nerve is challenging, due to the increased risks of iatrogenic damage to the nerve, which results in hoarseness, dysphagia, glottal obstruction, vocal cords palsy, and serious airway impairment. We present the case of a 58-year-old woman. The patient was admitted to our department for a nodule classified as Bethesda IV in the right thyroid lobe. Through the use of intraoperative neuromonitoring (IONM), surgeons detected intraoperatively a non-recurrent laryngeal nerve. A subsequent computed tomography scan confirmed an anomalous right subclavian artery branching from the left aortic arch, the Lusoria Artery. Anatomical variants represent pitfalls in this case and an accurate knowledge of the neck region is imperative while performing thyroid surgery. Devices such as IONM are useful for detecting abnormalities that may lead to iatrogenic damages.

Open Renal Transplantation in Obese Patients: A Correlation Study between BMI and Early and Late Complications with Implementation of a Prognostic Risk Score.

BACKGROUND: Obesity is a global epidemic that affects millions worldwide and can be a deterrent to surgical procedures in the population waiting for kidney transplantation. However, the literature on the topic is controversial. This study evaluates the impact of body mass index (BMI) on complications after renal transplantation, and identifies factors associated with major complications to develop a prognostic risk score. METHODS: A correlation analysis between BMI and early and late complications was first performed, followed by a univariate and multivariate logistic regression analysis. The 302 included patients were divided into obese (BMI ≥ 30 kg/m2) and non-obese (BMI ≤ 30 kg/m2) groups. Correlation analysis showed that delayed graft function (DGF) was the only obesity-associated complication (p = 0.044). Logistic regression analysis identified female sex, age ≥ 57 years, BMI ≥ 25 and ≥30 kg/m2, previous abdominal and/or urinary system surgery, and Charlson morbidity Score ≥ 3 as risk factors for significant complications. Based on the analyzed data, we developed a nomogram and a prognostic risk score. RESULTS: The model's area (AUC) was 0.6457 (95% IC: 0.57; 0.72). The percentage of cases correctly identified by this model retrospectively applied to the entire cohort was 73.61%. CONCLUSIONS: A high BMI seems to be associated with an increased risk of DGF, but it does not appear to be a risk factor for other complications. Using an easy-to-use model, identification, and stratification of individualized risk factors could help to identify the need for interventions and, thus, improve patient eligibility and transplant outcomes. This could also contribute to maintaining an approach with high ethical standards.

Meckel's Diverticulum Causing Ileal Volvulus and Peritonitis after a Recent Appendectomy: A Case Report and Literature Review-We Should Likely Resect an Incidental MD.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract with a 1-3% prevalence in the general population. The surgical management of symptomatic MD is well described in the literature, but there is still no consensus on the indication for prophylactic resection of incidental asymptomatic MD. To address this issue, we extensively reviewed the current literature and report our experience with laparoscopic management of an unusual case of MD causing ileal volvulus and acute peritonitis two weeks after a laparoscopic appendectomy for acute gangrenous appendicitis performed in another hospital. A 50-year-old man presented to the emergency department with acute and severe abdominal pain, vomiting, and constipation. He had undergone a laparoscopic appendectomy for acute appendicitis two weeks before in another hospital. The patient was apyretic, distressed, and seeking an antalgic position. The abdomen was mildly distended and tender, and the Blumberg sign was mildly positive in the central quadrants. The clinical picture deteriorated with fever, peritonismus, and leukocytosis. A CT scan showed an ileo-ileal adhesion near the ileocolic junction and dilatation of the upstream loops with the air-fluid levels. Through an urgent laparoscopy, a necrotic mass, the MD, was wedge-resected, and the surrounding ileal volvulus derotated. The postoperative course was uneventful. There is no definitive consensus on the appropriate management of incidental asymptomatic MD, although several studies have attempted to identify guiding criteria. Features of the MD, the patient's risk factors, clinical presentation, and surgical approach need to be considered to establish definitive guidelines for the management of incidental asymptomatic MD. In the absence of definitive guidelines, personal expertise and judgement are the main resources for the surgeon approaching an incidental asymptomatic MD.

Multicellular Liver Organoids: Generation and Importance of Diverse Specialized Cellular Components.

Over 40,000 patients in the United States are estimated to suffer from end-stage liver disease and acute hepatic failure, for which liver transplantation is the only available therapy. Human primary hepatocytes (HPH) have not been employed as a therapeutic tool due to the difficulty in growing and expanding them in vitro, their sensitivity to cold temperatures, and tendency to dedifferentiate following two-dimensional culture. The differentiation of human-induced pluripotent stem cells (hiPSCs) into liver organoids (LO) has emerged as a potential alternative to orthotropic liver transplantation (OLT). However, several factors limit the efficiency of liver differentiation from hiPSCs, including a low proportion of differentiated cells capable of reaching a mature phenotype, the poor reproducibility of existing differentiation protocols, and insufficient long-term viability in vitro and in vivo. This review will analyze various methodologies being developed to improve hepatic differentiation from hiPSCs into liver organoids, paying particular attention to the use of endothelial cells as supportive cells for their further maturation. Here, we demonstrate why differentiated liver organoids can be used as a research tool for drug testing and disease modeling, or employed as a bridge for liver transplantation following liver failure.

Indocyanine Green Angiography for Quality Assessment of Renal Graft Before Transplantation: A Pilot Study.

OBJECTIVES: Criteria for donation have been expanded to meet the great demand for organ transplant, resulting in different tools and classifications to help physicians to better assess the quality of the transplanted kidney. In this study, we evaluated the use of indocyanine green angiography as an additional tool to evaluate the renal microcirculation and the quality of the potential kidney graft. MATERIALS AND METHODS: All kidneys from extended criteria donors or donors after cardiac death available for transplant underwent indocyanine green angiog-raphy before implantation and after reconditioning, when hypothermic perfusion was required. We performed fluorescent angiography with a 10-mm-view laparoscope connected to a high-definition camera system while a solution of indocyanine green and Celsior was injected into the renal artery. We compared fluorescence intensities with postoperative graft function and then analyzed increases in fluorescence intensity before and after hypothermic machine perfusion treatment. RESULTS: In transplanted kidneys preserved in traditional cold storage, we found a statistically significant difference in fluorescence intensity values between groups with early graft function and delayed graft function. Fluorescence intensity increased significantly in all perfused kidneys after hypothermic machine perfusion treatment, indicating that intensity was directly proportional to improved renal microcirculation. Among 21 kidneys retrieved for transplant that adhered to the inclusion criteria, 11 were examined histopathologically, with a Karpinski score ranging from 2 to 7. The kidney that scored 7 was immediately discarded. Five underwent hypothermic pulsatile perfusion since they came from donors after cardiac death. Fluorescence intensity increased significantly in all perfused kidneys (4/5 were closest to doubling). Histopathological evaluations and Karpinski scores of the grafts indicated that all 5 were considered suitable for transplant. CONCLUSIONS: Indocyanine green angiography can be used in the future as an additional useful tool to help physicians to assess graft quality before implantation.

Liver Trauma: Until When We Have to Delay Surgery? A Review.

Liver involvement after abdominal blunt trauma must be expected, and in up to 30% of cases, spleen, kidney, and pancreas injuries may coexist. Whenever hemodynamics conditions do not contraindicate the overcoming of the ancient dogma according to which exploratory laparotomy should be performed after every major abdominal trauma, a CT scan has to clarify the liver lesions so as to determine the optimal management strategy. Except for complete vascular avulsion, no liver trauma grade precludes nonoperative management. Every attempt to treat the injured liver by avoiding a strong surgical approach may be considered. Each time, a nonoperative management (NOM) consisting of a basic "wait and see" attitude combined with systemic support and blood replacement are inadequate. Embolization should be considered to stop the bleeding. Percutaneous drainage of collections, endoscopic retrograde cholangiopancreatography (ERCP) with papilla sphincterotomy or stent placement and percutaneous transhepatic biliary drainage (PTBD) may avoid, or at least delay, surgical reconstruction or resection until systemic and hepatic inflammatory remodeling are resolved. The pathophysiological principle sustaining these leanings is based on the opportunity to limit the further release of cell debris fragments acting as damage-associated molecular patterns (DAMPs) and the following stress response associated with the consequent immune suppression after trauma. The main goal will be a faster recovery combined with limited cell death of the liver through the ischemic events that may directly follow the trauma, exacerbated by hemostatic procedures and surgery, in order to reduce the gross distortion of a regenerated liver.

Dental Prosthesis in Esophagus: A Right Cervicotomic Approach.

Foreign body ingestion in the upper digestive tract is a relatively common emergency. Less than 1% have to be treated surgically. We report the case of a 68-year-old man who ingested a dental prosthesis, probably during a seizure, and thus unknowingly, and presented two days later to the emergency department complaining of a mild dysphagia. A chest radiograph showed the presence of a removable dental prosthesis in the upper esophageal tract. The patient was brought to the operating room where a multidisciplinary equipe was assembled. Two attempts of retrieval with a flexible and a rigid endoscope failed because the removable dental prosthesis was stuck in the right pyriform sinus. Therefore, the surgeon performed an uncommon right cervicotomy and retrieved the foreign body through a right-side esophagotomy. The surgical approach depends on the nature and location of the foreign body. Urgent treatment is required whenever the patient develops dyspnea or dysphagia because of the high risk of inhalation and asphyxia. Removal of any esophageal foreign body has to be performed within 12-24 h. Repeated attempts to retrieve large dental prosthesis using an endoscope may result in esophageal perforation therefore when such risk of complication is too high, a surgical approach becomes inevitable. In our opinion, surgery remains the extrema ratio after a failed endoscopic retrieval attempt but can be lifesaving despite high risk of complications.

Intestinal metastasis from breast cancer: Presentation, treatment and survival from a systematic literature review.

BACKGROUND: Intestinal metastases from breast cancer (BC) arerare; available data depend mainly on case reports and case series. AIM: To conduct a review of the literature regarding presentation, diagnosis, treatment and survival of patients with intestinal metastasis from BC. METHODS: We identified all articles that described patients with intestinal metastasis (from duodenum to anum) from BC using MEDLINE (1975 to 2020) and EMBASE (1975 to 2020) electronic databases. RESULTS: We found 96 cases of intestinal metastasis of BC. Metastasization involved large bowel (cecum, colon, sigmoid, rectum) (51%), small bowel (duodenum, jejunum, ileum) (49%), and anum (< 1%). Median age of patients was 61-years. The most frequent histology was infiltrating lobular carcinoma followed by infiltrating ductal carcinoma. In more than half of patients, the diagnosis was made after the diagnosis of BC (median: 7.2 years) and in many cases of emergency, for bowel obstruction, bleeding or perforation. Diagnosis was achieved through endoscopy, radiological examination or both. In most of the cases, patients underwent surgery with or without systemic therapies. Survival of patients included in this review was available in less than 50% of patients and showed an overall median of 12 mo since diagnosis of the intestinal metastasis. CONCLUSION: Although, intestinal metastases of BC are considered a rare condition, clinicians should consider the possibility of intestinal involvement in case of abdominal symptoms even in acute setting and many years after the diagnosis of BC, especially in patients with a histology of lobular carcinoma.

Risk factors for complications after robotic adrenalectomy: a review.

The application of adrenal surgery has been spreading steadily in recent years. With the increased use of robotics in surgery, robotic adrenalectomy (RA), especially for the posterior retroperitoneoscopic approach, has been taken on by many high-volume institutions as a good option over the standard laparoscopic approach (LA). This paper reviews the recent literature from May 2010 up to November 2019 with the aim of analyzing RA complications in order to identify risk factors for complications after RA. We analyzed 7 principal risk factors for complication: body mass index (BMI), age, tumor size, tumor side, pathology, previous surgery, and surgeon experience. In the review, some studies identified tumor size, malignancy type, completion of learning curve and, and less clearly, previous ipsilateral upper mesocolic or retroperitoneal surgery, as risk factors for postoperative complications and failure of robotic surgery. Whether RA is meaningfully superior to the standard minimally invasive approach is still a subject of discussion. RA appears safer by virtue of its reduction in hospital stay, lower blood loss, and equivalent complication rates, and surgeons should prefer adrenalectomy over the LA. Despite these advantages, the operative time and the overall cost of the robotic procedure are higher than the LA. Further high-quality trials, especially those analyzing the specific risk factors for complications in robotic surgery, should be conducted in order to optimize the stratification of patients eligible for robotic surgery.

Lessons Learned From a Faulty Transoral Endoscopic Thyroidectomy Vestibular Approach.

BACKGROUND: Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is currently considered the most promisingly scarless approach to the thyroid and has gained more acceptance. MATERIALS AND METHODS: We described a case of faulty TOETVA. RESULTS: The faulty TOETVA resulted in pneumomediastinum, diffuse subcutaneous emphysema, prolonged surgery, and anesthesia. CONCLUSIONS: The important technical considerations during TOETVA, including the use of external retraction, the identification of the subplatysmal plane of dissection, CO2 insufflation settings, the learning curve, and patient selection, were described and discussed.

Lymphadenectomy in elderly/high risk patients: should it be different?

The global aging of population will lead a greater number of elderly patients to undergo surgical procedure in a near future. Concerning gastric cancer, the impact of lymphadenectomy on survival has been demonstrated in RCTs, and extended lymphadenectomy is now considered as gold standard of treatment in non-early tumors. However, the role of age as a prognostic factor and the benefit of extended surgery in elderly/high-risk patients are not clearly defined yet. From our revision of literature, it seems that surgery for gastric cancer may have a further tailorization, considering not only the stage of disease, but also patients' age and comorbidities.

Transoral endoscopic thyroidectomy: preliminary experience in Italy.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a feasible novel surgical procedure that does not need visible incisions. We describe our initial experience with TOETVA. We recruited 15 patients who were willing to undergo TOETVA. Inclusion criteria were (a) patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 10 cm; (b) US estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (e) follicular neoplasm; (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. All TOETVA procedures were performed successfully with no conversions. The mean operative time was 87.6 (59-118) min for lobectomy and 107.6 (99-135) min for bilateral procedure. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients. This is the first case series of TOETVA in Italy. TOETVA may provide a method for ideal cosmetic results. The results are encouraging, and we are optimistic about the future expansion of its applicability.

Thyroidectomy in elderly patients aged ≥70 years.

Worldwide, the indications for thyroid surgery have been continuously extended among elderly patients in the last 20 years. The balance between treatment indication and surgical risk is certainly an interesting topic for every thyroid surgeon. This paper is a review of recent literature from January 2005 up to April 2017. We analyzed three principal subjects: indications for surgical treatment, medical complications and surgical complications. We can summarize the conclusions of our analysis, stating that age could not be considered as an absolute factor, but in relation to the comorbidities and the general clinical condition of the patient. Special risk indices dedicated to geriatric patients could be very useful in order to facilitate the decision-making process; however, relying on the current knowledge, we could state that there is value in providing surgery to geriatric patients in highly specialized and high-volume centers, where access to technology and its systematic use, coupled with surgeons' experience, could certainly avail the geriatric patient management.