Role of Indocyanine Green Fluorescence Imaging in Minimally Invasive Resection of Colorectal Liver Metastases.

Indocyanine green (ICG) fluorescence imaging is an easy and reproducible method to detect hepatic lesions, both primary and metastatic. This review reports the potential benefits of this technique as a tactile mimicking visual tool and a navigator guide in minimally invasive liver resection of colorectal liver metastases (CRLM). PubMed and MEDLINE databases were searched for studies reporting the use of intravenous injection of ICG before minimally invasive surgery for CLRM. The search was performed for publications reported from the first study in 2014 to April 2021. The final review included 13 articles: 6 prospective cohort studies, 1 retrospective cohort study, 3 case series, 1 case report, 1 case-matched study, and 1 clinical trial registry. The administered dose ranged between 0.3 and 0.5 mg/kg, while timing ranged between 1 and 14 days before surgery. CRLM detection rate ranged between 30.3% and 100% with preoperative imaging (abdominal computed tomography/magnetic resonance imaging), between 93.3 and 100% with laparoscopic ultrasound, between 57.6% and 100% with ICG fluorescence, and was 100% with combined modalities (ICG and laparoscopic ultrasound) with weighted averages of 77.42%, 95.97%, 79.03%, and 100%, respectively. ICG fusion imaging also allowed to detect occult small-sized lesions, not diagnosed preoperatively. In addition, ICG is effective in real-time assessment of surgical margins by evaluating the integrity of the fluorescent rim around the CRLM.

Bottom-up suprapubic approach for robotic right colectomy: technical aspects and preliminary outcomes.

BACKGROUND: Complete mesocolic excision (CME) for right colectomy increase the technical complexity of a laparoscopic approach especially when an intracorporeal anastomosis (IA) is associated. The robotic platform, with its intrinsic technical advantages, could potentially overcome the limitations of conventional laparoscopy. This study aimed to describe the robotic bottom-up technique and to evaluate short-terms outcomes of robotic right colectomy (RRC) with CME and IA. METHODS: Data from patients who underwent RRC for cancer with bottom-up suprapubic approach from October 2016 to April 2020 were prospectively collected and retrospectively analyzed. Intraoperative outcomes and complications, conversion rate, 30-day postoperative outcomes, incisional hernia rate and pathological outcomes were the variables assessed. RESULTS: A total of 109 patients were submitted to bottom-up suprapubic approach for RRC with CME and IA during the study period. Mean operative time was 179 min, no intraoperative complications were observed, and the conversion rate was 3.6%. Mean postoperative stay was 4.6 days and the overall 30-day complication rate was 15.6%. Thirteen patients (12%) had minor complications, while major postoperative complications occurred in 4 patients (3.6%). Anastomotic leak was recorded in 1 patient (0.9%) and the 30-day re-admission rate was 0.9%. Mean number of harvested lymph nodes was 22.6. Incisional hernia rate at the specimen extraction site was 0.9%. CONCLUSIONS: Bottom-up approach for RRC with CME and IA carries a low rate of conversions, intraoperative and short-term postoperative complications.

Correction to: Robotic Versus Laparoscopic Right Colectomy with Complete Mesocolic Excision for the Treatment of Colon Cancer: Perioperative Outcomes and 5-Year Survival in a Consecutive Series of 202 Patients.

Dario Ribero's affiliation is corrected as reflected here.

Structured training program in colorectal surgery: the robotic surgeon as a new paradigm.

BACKGROUND: One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young surgeons without prior experience in both open and laparoscopic colorectal surgery, who were autonomous in basic minimally-invasive surgical procedures. Right colectomy with intracorporeal anastomosis has been chosen as a model. METHODS: Between May 2015 and December 2017 two junior attending surgeons were trained through a STP. Right colectomy was divided into three main learning modules (colonic mobilization, vascular control, intracorporeal anastomosis) and each one was carried out by the trainees for at least two times under direct supervision of the senior surgeon. After the initial robotic cases completely performed under formal proctoring, they were privileged to perform robotic right colectomy independently without a mentor (20 procedures). Operative time, conversion rate, intra- and postoperative complications, length of stay and pathological outcomes were the variables analyzed to assess the effectiveness of the STP. RESULTS: The mean operative time was 200 minutes and no conversion was required. Neither intraoperative nor major postoperative complications were recorded and the mean length of hospital stay was 6 days. Mean nodal yield was 21. CONCLUSIONS: A STP in robotic colorectal surgery is feasible and effective. Right colectomy represents a good model as first step of the program in order to develop multiple technical skills. Previous experience in open or laparoscopic colorectal surgery may not be necessary.

Robotic Versus Laparoscopic Right Colectomy with Complete Mesocolic Excision for the Treatment of Colon Cancer: Perioperative Outcomes and 5-Year Survival in a Consecutive Series of 202 Patients.

BACKGROUND: During the past decade, the concept of complete mesocolic excision (CME) has emerged as a possible strategy to minimize recurrence for right colon cancers. The purpose of this study was to compare robotic versus laparoscopic CME in performing right colectomy for cancer. METHODS: Pertinent data of all patients who underwent robotic or laparoscopic right colectomy with CME using a Pfannenstiel incision and intracorporeal anastomosis performed between October 2005 and November 2015 were entered in a prospectively maintained database. RESULTS: A total of 202 patients underwent robotic (n = 101) or laparoscopic (n = 101) right colectomy within the study period. Patient characteristics were equivalent between groups. The robotic group showed a statistically significant reduction in conversion rate (0% vs. 6.9%, p = 0.01) but a longer operative time (279 min vs. 236 min, p < 0.001) compared with the laparoscopic group. There were no other differences in perioperative clinical or pathological outcomes. Five-years overall survival was 77 versus 73 months for the robotic versus laparoscopic groups (p = 0.64). The disease-free survival (DFS) rates were 85% and 83% for the robotic versus laparoscopic groups (p = 0.58). Among UICC stage III patients, there was a slight but not significant difference in 5-year DFS for the robotic group (81 vs. 68 months; p = 0.122). CONCLUSIONS: Both approaches for right colectomy with CME were safe and feasible and resulted in excellent survival. Robotic assistance was beneficial for performing intracorporeal anastomosis and dissection as evidenced by the lower conversion rates. Further robotic experience may shorten the operative time.

Minimally invasive versus open pancreatic enucleation. Systematic review and meta-analysis of surgical outcomes.

Parenchymal sparing procedures are gaining interest in pancreatic surgery and recent studies have reported that minimally invasive pancreatic enucleation may be associated with enhanced outcomes when compared with traditional surgery. By meta-analyzing the available data from the literature, minimally invasive surgery is not at higher risk of pancreatic fistula and offers a number of advantages over conventional surgery for pancreatic enucleation.

The Impact of pelvimetry on anastomotic leakage in a consecutive series of open, laparoscopic and robotic low anterior resections with total mesorectal excision for rectal cancer. .

BACKGROUND/AIMS: Recently, pelvic anatomy has been taken into consideration and related to surgical outcome indicators after low anterior resection (LAR). Several pelvimetric parameters have been matched with conversion rate, postoperative complications and duration of surgery in laparoscopic series, and with the quality of specimen and pathologic outcomes in further open surgical series. METHODOLOGY: In 97 consecutive patients submitted to sphincter-saving LAR with total mesorectal excision (TME) five pelvic dimensions were measured by abdominal computed tomography scan: anteroposterior and transverse diameters in the pelvic inlet (IAP and ITRA), anteroposterior and transverse diameters in the pelvic outlet (OAP and OTRA), and the pelvic depth. The endpoint evaluated was anastomotic leakage (AL) rate. RESULTS: There were 51 open, 12 laparoscopic and 34 robotic LARs. The sum of IAP OAP and OTRA (Pelvic Index) significantly predicted AL showing that starting from the cut-point of 290 mm down to a PI of 278 mm the odds-ratio of having an AL increased from 2.63 (95% CI: 1.10,5.47) to 5.07 (95% CI: 1.35,8.02). CONCLUSIONS: The sum of the 3 pelvic dimensions which we termed "Pelvic Index" was associated to AL following sphinctersaving LAR. This may be considered in planning the surgical strategy for rectal cancer patients.

Experience with robotic lobectomy for lung cancer.

OBJECTIVE: In this study, we analyze our experience so far with robotic pulmonary lobectomy, compare it with published data, and suggest a learning curve for the operation. METHODS: Ninety-one patients with suspected or proven clinical stage I-III lung cancer underwent robotic lobectomy. Selection criteria included lesion <5 cm and normal respiratory function. One surgeon performed the operations using the da Vinci system with three ports and a 3-cm utility thoracotomy. RESULTS: Median duration of operation was 239 (range 85-411) minutes, 260 minutes in the first 18 patients and 221 minutes in the remaining 73 cases (P=0.01). Median hospitalization declined from 6 days in the first 18 cases to 5 days in the remaining cases (P=0.002). Conversion rate and number of complications reduced nonsignificantly from the initial to later series. Major complications occurred in 11% of the first 18 cases and 4% of the later cases. The number of lymph nodes removed did not change over the two series. There was no 30-day postoperative mortality. After a median follow-up of 24 months, 80 of 91 patients were alive with no sign of disease. CONCLUSIONS: Our data suggest that about 20 operations are required to achieve surgical competence. Robotic lobectomy appears safe, oncologically radical, and associated with shorter postoperative hospitalization than open surgery.

Laparoscopic rectal resection for cancer: effects of conversion on short-term outcome and survival.

BACKGROUND: Laparoscopic rectal resection (LRR) is an oncologically safe procedure. The impact of conversion to open surgery on outcomes has not been fully elucidated. The aim of the study is to compare short- and long-term outcomes of converted (CR) and not converted (NCR) patients undergoing LRR. METHODS: Data were drawn from a prospective database of LRR performed between 1999 and 2008. Statistical analysis employed the chi-squared or Wilcoxon test and Kaplan-Meier estimation. RESULTS: Of 173 patients undergoing LRR, 26 (15%) required conversion. No differences in age, gender, American Society of Anesthesiologists (ASA) score, and T and N stages were observed between CR and NCR patients. Conversion was associated with higher body mass index (BMI) (27.3 versus 24.9 kg/m(2), P < 0.001) and American Joint Committee on Cancer (AJCC) stage IV (26.9% versus 4.8%, P < 0.001), and resulted in longer operative time (342 versus 285 min, P = 0.006) and increased intraoperative complication rate (31% versus 5%, P < 0.001). No differences were observed in postoperative outcome between CR and NCR patients. After a mean follow-up of 46 and 36 months, 5-year disease-free survival was 55.7% in CR group and 79.2% in NCR group (P = 0.007). After exclusion of stage IV patients from the analysis, 5-year disease-free survival was 71.1% in CR group and 85.3% in NCR group (P = 0.17), while the overall recurrence rate was 26.3% in CR patients and 11.4% in NCR patients (P = 0.07). CONCLUSIONS: Our study suggests that conversion to open surgery does not affect postoperative outcome, but could have a negative impact on long-term overall recurrence rate. LRR should be performed by experienced surgeons in selected patients.

Metachronous Colon Metastases from Gastric Adenocarcinoma: A Case Report.

The colon is a very rare metastatic localization. Here we report a case of colonic metastases from gastric adenocarcinoma whose clinical presentation was suggestive of a de novo adenocarcinoma of the ascending colon. The authors discuss that in the presence of a previous history of gastric cancer, immunohistochemical analysis on endoscopic biopsies may help in the definition of a differential diagnosis. Furthermore, this rare metastatic localization might suggest a poor prognosis and a more accurate diagnostic work-up.

[Laparoscopic surgery of colon cancer. State of art and literature review]. / La chirurgia laparoscopica nel tumore del colon. Stato dell'arte e revisione della letteratura.

Over the past decade advances in laparoscopic surgery have revolutionized the surgical approach to many diseases. Although the first case series on laparoscopic segmental colectomy in patient with sigmoid cancer was described in 1991, this technique has not been readily accepted. Despite reduced morbidity and improved convalescence after laparoscopic surgery for benign disorders, surgeons have been sceptical about similar advantages of laparoscopic colectomy for cancer. The safety of the procedure has been questioned because of early reports of port-site metastases and there has been uncertainty about whether minimally invasive surgery for colonic malignancies would achieve adequate oncologic resection. Open surgical resection of the primary tumor, until just recently, has been widely considered the most effective treatment of colon cancer. The adherence to the principles of complete abdominal exploration, high ligation of mesenteric vessels, lymphnodal clearance and adequate bowel resection margins is essential. Several randomized trials were initiated in the early 1990s to compare the short- and long-term outcomes of patients undergoing minimally invasive and conventional open surgery for colon cancer. Today the results of this large multiinstitutional randomized trials have been reported. This review examines recent data from randomized, controlled trials and meta-analysis, that report the short- and long-term outcomes after laparoscopic colectomy for cancer.

Endoscopic ultrasonography and magnetic resonance in preoperative staging of rectal cancer: comparison with histologic findings.

The development of new surgical techniques and use of neoadjuvant therapy have increased the need for accurate preoperative staging of rectal cancer. We compared the ability of endoscopic ultrasonography (EUS) and two magnetic resonance imaging (MRI) coils to locally stage rectal carcinoma before surgery. Forty-nine patients with histologically proven rectal carcinoma were T and N staged by EUS and either body coil MRI or phased-array coil MRI. After radical surgery, the preoperative findings were compared with histologic findings on the surgical specimen. For T stage, accuracies were 70% for EUS, 43% for body coil MRI, and 71% for phased-array coil MRI. For N stage, accuracies were 63% for EUS, 64% for body coil MRI, and 76% for phased-array coil MRI. For T stage, EUS had the best sensitivity (80%) and the same specificity (67%) as phased-array coil MRI. For N stage, phased-array coil MRI had the best sensitivity (63%) and the same specificity (80%) as the other methods. EUS and phased-array coil MRI provided similar results for assessing T stage. No method provided satisfactory assessments of local N stage, although phased-array coil MRI was marginally better in assessing this important parameter. Although none of the results differed significantly, phased-array coil MRI seems to be the best single method for the preoperative staging of rectal cancer.