Robotic transabdominal retromuscular rectus diastasis (r-TARRD) repair: a new approach.

PURPOSE: The aim of this study is to present our innovative robotic approach for the treatment of rectus diastasis with concurrent primary or incisional ventral hernias. METHODS: We performed 45 r-TARRD repairs for symptomatic rectus diastasis with concomitant associated ventral/incisional umbilical and/or epigastric hernias between January 2019 and January 2020. Data on patient demographics, type of hernia, operative time, complications, recurrence rate, and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1, 6 months, and 1 year after surgery. RESULTS: 45 patients (13 M, 32 F) underwent r-TARRD repair. Mean age was 54.8 years (range 31-68) and mean BMI was 26.74 kg/m2 (range 21.1-31). Mean ASA was 2.2 (range 1-3). In all patients we used a polypropylene mesh 25 × 15 cm, properly shaped. Mean operative time was 192 min (range 115-260). Mean hospital stay 4.2 days (range 2-7). No conversion to laparoscopy or open surgery and no major complications occurred. At 1-month follow-up one mesh infection (2.22%) was observed and it was treated conservatively. Four recurrences (8.88%) were reported at 1-year follow-up. CONCLUSIONS: Robot-assisted TARRD repair is conceived as a novel alternative minimally invasive procedure for RD with concurrent midline defects ensuring a primary fascial defect closure and mesh implantation in a sublay position with a wide overlap. It is important to better evaluate the suture that should be used to perform the repair, and multicenter studies with standardization of patient's demographics, RD characteristics, and long-term follow-up outcomes are mandatory to assess the effectiveness and durability of r-TARDD repair.

Robotic-assisted single site (RASS) TAPP: an advantageous choice? : Outcomes of single site robotic groin hernia repair.

PURPOSE: Laparoscopic transabdominal preperitoneal (TAPP) is a valid option for bilateral primary groin hernia and recurrent cases. Robotic approach for inguinal hernia is still debated. The aim of this study is to investigate the potential role of robotic-assisted single site-TAPP (RASS-TAPP) reporting our experience. METHODS: We performed 44 RASS TAPP in 32 patients from February 2016 to July 2018. Data on patient demographics, type of hernia, operative time, complications, recurrence rate and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1 week, 4 months and 1 year after surgery. RESULTS: Forty-two hernias were treated in 32 patients (27 M). Mean age was 48.6 years (range 20-67), mean BMI was 26.49 kg/m2 (range 16-34.9). Mean operative time was 54.8 min (range 28-150). In two cases (6%) a conversion to laparoscopy was necessary. At 1 week, two scrotal hematomas and four seromas were observed and treated conservatively. At 4 months follow-up, one patient (3.1%) complained temporary pain. No patient had inguinal recurrence or incisional umbilical hernia and chronic pain at 1-year follow-up. CONCLUSION: RASS TAPP is feasible and safe with a high patient satisfaction. However, the surgeon experiences a technical discomfort due to the conflict of the instrumentation which influences negatively the choice of this approach, despite the better vision and augmented dexterity provided by the robot.

[Colorectal carcinoma in the young. Prognostic factors]. / Il carcinoma colo-rettale nel giovane. Fattori prognostici.

Colorectal carcinoma is the third most frequently diagnosed malignant neoplasm. Usually patients affected by this neoplasia belong to VI decade of life. However approximately 2-8% of tumors arise in patients with age under 40 years. Aim of the study was to analyse the results of surgical treatment of colorectal cancer in patients aged under forty. From January 1987 to December 2002, 46 patients under forty years with colorectal cancer underwent surgical procedure. No perioperative mortality was registered, and complications were evidenced in nine patients (20%). Actuarial five years survival was 33%, and overall mean survival was 53 months. Univariate and multivariate analyses identified as prognostic factors the tumor grade, Dukes' stage, nodal status, and length of symptoms.

[Primary adenocarcinoma of the ureter. Case report]. / Adenocarcinoma primitivo dell'uretere: caso clinico.

Primary ureteral adenocarcinoma is an infrequent histological type of urinary neoplasm. Many authors consider intestinal metaplasia the pivotal event of the pathogenetic process, whether it occurs on a pre-existing urothelial carcinoma or on a normal urothelium. Diagnosis is essentially based on case history and clinical findings (hematuria and pain) and on diagnostic imaging. Treatment is surgical and the ideal procedure is nephroureterectomy with excision of a bladder margin adjacent to the ureteral opening and ispilateral para-aortoiliac lymphadenectomy. A 76-year-old man with primary adenocarcinoma of the ureter case is reported.

Clinical significance of serum gastrin levels in patients with colorectal cancer.

AIMS: An association between elevated serum gastrin levels and the presence of human colorectal cancer has been reported, and gastrin has been shown to stimulate the growth of experimentally induced colon neoplasia. The aim of this study was to determine the preoperative and postoperative concentrations of serum gastrin in 53 patients with colorectal cancer and to assess the correlation between gastrin levels and tumor characteristics and prognosis. MATERIALS AND METHODS: A prospective study was performed over a six-year period during which 53 patients received potentially curative surgery for colorectal cancer. The prognostic variables used for the analysis included age, sex, tumor site, stage and degree of differentiation, preoperative and postoperative serum values of carcinoembryonic antigen (CEA) and gastrin, cancer-related mortality, and survival. CEA and gastrin serum values were determined using radioimmunological methods. Follow-up was carried out with clinical and radiological tests. RESULTS: The mean preoperative gastrin concentration was 51.2+/-27.4 pg/mL (range 12-146). Significantly increased serum gastrin concentrations, which returned to normal after surgery, were detected only in patients with well-differentiated cancer (74.2+/-28.3 pg/mL; moderately differentiated, 52.1+/-23.8; poorly differentiated, 29.9+/-12.3, p=0.02). The prognosis was unrelated to serum gastrin level; instead, tumor stage, preoperative CEA value, and degree of differentiation affected patient survival. CONCLUSIONS: This study showed that the serum gastrin concentration is not an appropriate clinical oncogenic factor. Although occurring only in well-differentiated tumors, serum gastrin is unrelated to the prognosis of patients with colorectal cancer.

[Rectal cancer in women]. / Il cancro del retto nella donna.

A retrospective chart review was performed utilizing the First Department of Surgery of the University of Rome "La Sapienza" Medical School database. Ninety-two women who underwent abdominal surgery between 1980 and 1993 for rectal cancer were identified. Data collected included demographics, history, intraoperative findings and complications, cancer histology and stage and follow up. Special attention was focused on intraoperative incidental gynecological findings and follow up. Twenty-two patients being previously submitted to hysterectomy and three with oral intake of hormones were dismitted from the study. Of the remaining 67 patients gynecological procedure was associated to rectal surgery because of a previously undiagnosed gynecological condition. No prophylactic oophorectomies were performed. At follow up 7 patients experienced further surgery for gynecologic disease. The necessity to offer these patients the benefit of a preoperative informed decision about adjunctive gynecologic surgery and indications for bilateral oophorectomy is discussed.

[Use of ileostomy and colostomy as temporal derivation in colorectal surgery]. / L'impiego della ileostomia e della colostomia come derivazioni temporanee in chirurgia colo-rettale.

A retrospective study on 41 patients with primary stoma creation after low anterior resection of the rectum was made. Among the 41 patients 24 had a loop colostomy (Group A) and 17 had a loop ileostomy (Group B). The two groups were well matched for each of the data analysed and there was no significant difference in the rate of complications related to stomas creation and closure. In this study the Authors suggest that loop ileostomy is the best procedure to electively defunctionate colorectal anastomoses.

Unusual breakage of a plastic biliary endoprosthesis causing an enterocutaneous fistula.

OBJECTIVE: The objective of our study was to illustrate a case of endoscopically placed biliary stent breakage. METHODS: A72-year-old woman with a prolonged history of cholangitis following laparoscopic cholecistectomy was referred to our institution 8 years ago. Dilatation of the intra- and extrahepatic biliary tree and a benign stricture at the cystic confluence were observed at US and endoscopic retrograde cholangiopancreatography (ERCP). A 12-F gauge plastic endoprosthesis was placed. In the absence of any symptoms, breakage of the stent was revealed 18 months later at plain radiology. Eight years later an enterocutaneous fistula occurred originating from a jejunal loop containing the indwelled distal part of the stent. Surgery was undertaken and the distal part of the stent removed with the perforated jejunal loop. The proximal part was successively endoscopically removed. CONCLUSIONS: Disruption of a biliary endoprosthesis is observed in patients in whom the stent is kept in situ for a long period or consequent to exchange. The removal and exchange is mandatory when the stent disruption is followed by cholangitis. In the current case, because of the absence of any symptoms the removal of the stent was not attempted. Immediate endoscopic removal of the prosthetic fragments seems to be the treatment of choice for replacement of a new stent.

[Carcinoma of the male breast. Prognostic factors and outcome of surgical treatment]. / Il carcinoma della mammella nell'uomo. Fattori prognostici e criteri di trattamento.

A retrospective study was made on 18 male patients with breast carcinoma treated at the Department of Surgery "Pietro Valdoni" of the University "La Sapienza" of Rome, Medical School. Demographics, pathology, stages, and treatment were determined from clinical reports. All patients but one underwent modified radical mastectomy. The length of follow up averaged 57.5 months. Five years actuarial survival rate was 62%. In the current study the Authors suggest that the clinical, prognostic and treatment features of breast carcinoma in men are similar to those reported in literature for post-menopausal women.

[Ambulatory closed surgery for the treatment of pilonidal sinus]. / Il trattamento chirurgico ambulatoriale del sinus pilonidalis con tecnica chiusa.

Pilonidal disease (PD) is a common chronic disorder of the sacrococcygeal region afflecting young people. Despite several methods for treating PD have been described, the management remains controversial. Recent reports have advocated different surgical approaches such as open or closed technique, but recurrence plagues all forms of therapy. We conducted this case review to evaluate the validity of an outpatient closed technique in the treatment of chronic pilonidal disease. Between January 1997 and July 1999, 65 consecutive patients with quiescent chronic PD were electively treated by surgical excision of the cyst and primary closure. There were 47 men (72%) and 18 women (28%) in this study. Patients ranged in age from 14 to 47 years, the average age being 21 years. The median healing time was 8 days and the median time to return to full work was 20 days (range 10-25). Infection and recurrence rates were 1.5% and 4.6% respectively. There was no correlation among recurrence rate, postoperative infection, or prior surgery. Cyst excision and primary closure is a safe, low cost operation with a very high long-term success rate and a negligible rate of complications. It can successfully be performed under local anaesthesia in an outpatient facility.

Adolescent varicocele: treatment by antegrade sclerotherapy.

BACKGROUND/PURPOSE: The most effective treatment for adolescent varicocele is still debated, although the same treatment methods used for adults have also been used in children. Since 1991 at the Pediatric Surgery Operative Unit of "S. Camillo" Hospital in Rome a multidisciplinary protocol has been established according to which percutaneous retrograde scleroembolization was suggested as the first therapeutic option. Surgery (retroperitoneal ligation) was reserved for select cases. The author now presents his personal experience with alternative-approach antegrade sclerotherapy. METHODS: Since February 1998, as an alternative to percutaneous retrograde sclerosis and surgical ligation, antegrade sclerotherapy has been performed in 92 varicocele patients, 65 of whom were 11 to 19 years of age. In this group, the indication for treatment was grade III varicocele with spontaneous continual reflux, which worsened with the Valsalva maneuver. Twenty patients had recurrent varicocele after other treatments. RESULTS: At a mean follow-up of 9 months, the clinical recovery rate was 92.6%. CONCLUSIONS: Antegrade sclerotherapy is an intermediate treatment because of its invasive nature and success rate compared with more commonly used percutaneous retrograde sclerosis and Palomo procedures in adolescents. In particular, this method is highly effective and well-accepted by patients with recurrent varicocele.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease.

BACKGROUND: Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis. METHODS: One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted. RESULTS: Surgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence. CONCLUSION: Preserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

Late development of bile duct cancer in patients who had biliary-enteric drainage for benign disease: a follow-up study of more than 1,000 patients.

OBJECTIVE: To evaluate the correlation between biliary-enteric surgical drainage and the late development of cholangiocarcinoma of the biliary tract. SUMMARY BACKGROUND DATA: In patients with biliary-enteric drainage, reflux of intestinal contents into the bile duct may occur and cause cholangitis, which is regarded as the most serious complication of these procedures. Lithiasis of the biliary tract and a previous biliary-enteric anastomosis have both been suggested to favor the late onset of cholangiocarcinoma. METHODS: Consecutive patients (n = 1,003) undergoing three different procedures of biliary-enteric anastomosis (transduodenal sphincteroplasty, choledochoduodenostomy, and hepaticojejunostomy) between 1967 and 1997 were included in this study. The postoperative clinical course and long-term outcome were evaluated by a retrospective review of the hospital records and follow-up. Mean follow-up was 129.6 months. RESULTS: Fifty-five (5.5%) cases of primary bile duct cancer were found among the 1,003 patients at intervals of 132 to 218 months from biliary-enteric anastomosis. The incidence of cholangiocarcinoma in the three groups was 5.8% in transduodenal sphincteroplasty patients, 7.6% in choledochoduodenostomy patients, and 1.9% in hepaticojejunostomy patients. The incidence of malignancy related to the different underlying diagnosis was 5.9%, 7.2%, and 1.9% in patients with choledocholithiasis, sphincter of Oddi stenosis, and postoperative benign stricture, respectively. Although only one patient who developed cholangiocarcinoma had previous concurrent lithiasis of the biliary tract, 40 patients had experienced mostly severe, recurrent cholangitis. No case of malignancy occurred in patients scored as having no cholangitis in the early and long-term postoperative outcome. Univariate and multivariate analyses have shown the presence of cholangitis as the only factor affecting the incidence of cholangiocarcinoma. CONCLUSIONS: Chronic inflammatory changes consequent to biliary-enteric drainage should be closely monitored for the late development of biliary tract malignancies.

Clinical significance of normobasemia in early post-operative outcome of hepatic resections.

BACKGROUND: Major hepatic resections are usually followed by acid-base unbalance. Adjustment of the acid-base disorders is considered central when dealing with these critical patients and normobasemia is thought to be a favourable prognostic factor when occurring in the immediate postoperative outcome after major surgery. The present study was undertaken to investigate the influence of acid base balance on the early outcome after hepatic resection. METHODS: A series of fifty-seven cirrhotic patients was submitted to liver resection for hepatocellular carcinoma. Forty-eight patients experienced an uneventful early postoperative outcome (CTR group). Nine died in the postoperative course (HD group). In all patients pulmonary, renal and hepatic functions were monitored pre- and postoperatively. The pH values were detected daily preoperatively and in the course of the first three days after hepatic resection. In the same days acid base balance and arterial ketone body ratio were assessed on arterial blood samples. Data were collected in a data base and statistical analysis was performed. RESULTS: A significantly higher metabolic alkalosis was found to characterize the first and second postoperative days (POD1 and POD2) in the CTR group (pH 7.43+/-0.007 vs pH 7.33+/-0.001; pH 7.45+/-0.006 vs pH 7.35+/-0.009; p<0.05). Lower values of pH and an associated impaired energetic status of the liver were found to characterise the postoperative course of the poor prognosis patients. At POD1 AKBR decreased in both groups but while recovering at POD2 in patients of CTR group maintained significantly lower values in HD group (AKBR 1+/-0.3 vs 0.5+/-0.2; p<0.01). A lower energetic status of the liver is associated with an inadequate tricarboxylic acid cycle and is responsible for an impaired production of HCO3-. CONCLUSIONS: Apparent normobasemia is then expressive of liver failure leading to poor postoperative outcome.

Impact of axillary level I and II lymphnode dissection on the therapy of stage I and II breast cancer.

BACKGROUND: Routine performance of axillary node dissection (AND) in the treatment of stage I and II breast cancer has become controversial because of pretended morbidity of this procedure and progressing consent for sentinel lymphadenectomy. METHODS: Ninety-four consecutive patients who underwent AND for clinical stage I and II breast cancer were evaluated for a range of 48.3 months after surgery for movement and sensory alterations and arm swelling. Arm circumference was measured in all patients at the same four sites on both the operated and non operated sides preoperatively and in the immediate and late postoperative course. Capacity for movement was assessed pre- and postoperatively as active ranging at the shoulder joint. Postoperative numbness and paresthesias were assessed by standard questions. RESULTS: No patient had axillary recurrence. None of the detected differences between the preoperative and postoperative arm circumferences reached statistical significance. No persistent motion limitation was observed. Pain, numbness, paresthesia were detected in almost all patients in the immediate postoperative period but resolved spontaneously in all cases within 6 months. The obese body habit was detected on multivariate analysis as the only significant predictor of edema. CONCLUSIONS: No significant morbidity and no axillary recurrence were observed in current experience to follow AND. These findings suggest that axillary level I and II dissection remains an effective and safe tool for diagnostic, as well therapeutic, purposes in the treatment of stage I and II breast cancer. Further studies are necessary before it can safely be reported that axillary node dissection is an optional part of the treatment of stage I and II breast cancer.

[Acquired abnormalities of the biliary tract. Preoperative diagnosis and surgical risk in the laparoscopic era]. / Le anomalie acquisite della via biliare. Diagnosi preoperatoria e rischio chirurgico nell'era laparoscopica.

Acquired anomalies of the biliary tract are rare. The aim of this work was to examine their frequency and to assess potential associated danger when performing a laparoscopic cholecystectomy. A retrospective analysis of clinical charts of 3.870 patients undergoing elective cholecystectomy between 1959 and 1997 was performed. Eighteen cases of choledoco-duodenal fistula, 9 of cholecysto-duodenal and 12 of cholecysto-choledochal fistulas were observed. Two cases of acquired absence of the cystic duct and one cholecysto-colic fistula were also encountered. The traditional contrastographic radiology showed to be more accurate in defining presence and nature of the acquired anomalies. Etiopathogenesis of the main anomalies and consequent risks in performing laparoscopic cholecystectomy were discussed.

Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences.

HYPOTHESIS: Total mesorectal excision lowers the rate of pelvic recurrence and positively affects the survival after surgical treatment of rectal cancer. DESIGN: Case series. SETTING: Tertiary care university hospital. PATIENTS: Fifty-three consecutive patients were admitted with curative intent to surgery at the First Department of Surgery of the University of Rome "La Sapienza," Rome, Italy, with diagnoses of rectal carcinoma. The mean follow-up was 68.9 months; follow-up was complete for all patients who entered the trial. INTERVENTIONS: Low anterior resection and total mesorectal excision were performed in all cases, regardless of the location of the rectal cancer. A straight mechanical colorectal anastomosis was performed on a rectal stump, never exceeding 5 cm. No kind of adjuvant therapy was given. Mesorectum and open rectum were studied by serial transverse section at 5-mm intervals. A search for depth of penetration and distal intramural extension of the tumor was made. Lymph nodes were detected by clearing method, and nodal metastases (NM) and nonnodal metastases (NNM) were recorded as situated proximally, distally, or at the level of the tumor. RESULTS: There was no postoperative mortality. Clinical and radiologic leaks occurred in 2 and 4 patients, respectively. Mean disease-free survival was 65.9 months. Pelvic recurrence occurred in 5 patients (9%). Overall 5-year survival rate was 75%. Involvement of mesorectum by NM and NNM was detected in 27 and 24 cases, respectively. Both NM and NNM were found to be distal in 33% and 40% of cases, respectively. CONCLUSIONS: Microscopic spread to the distal mesorectum may exceed the intramural spread of rectal cancer. Failure to perform total mesorectal excision leaves a potentially residual disease in the distal mesorectum, thus predisposing the patient to pelvic recurrence.

[Carcinoid of Meckel's diverticulum: presentation of a clinical case]. / Carcinoide del diverticolo del Meckel: presentazione di un caso clinico.

Clinical findings and surgical treatment of a 68 years old man with carcinoid tumor of Meckel's diverticulum are reported. Carcinoids in Meckel's diverticula are rare tumors, commonly discovered incidentally during surgical procedures for different indications. Symptoms are frequently expression of a metastatic disease. Specific diagnostic and therapeutic tools are discussed.

Prospective evaluation of omentoplasty in preventing leakage of colorectal anastomosis.

PURPOSE: The aim of this study was to investigate the role of omentoplasty, by means of intact omentum, in preventing anastomotic leakages after rectal resection. METHODS: Between 1992 and 1997 a total of 112 patients (64 males) with a mean age of 64.7 (range, 39-83) years were randomly assigned to undergo omentoplasty (Group A) or not (Group B) to reinforce the colorectal anastomosis after anterior resection for rectal cancer. The primary end point was anastomotic leakage; the secondary end point included morbidity and mortality related to omentoplasty. RESULTS: The two groups were comparable in terms of preoperative and intraoperative characteristics. Staple-ring disruption at plain abdominal radiographs was detected in seven instances in Group A and in ten in Group B patients (P = not significant). Two leakages were evident clinically in Group A and seven in Group B (P < 0.05). Three leaks were documented radiologically in Group A and eight in Group B (P = not significant). No complications related to omentoplasty were observed in Group A. There were two repeat operations for anastomotic leakage in Group B. At followup, one stricture developed in Group A and three in Group B (P = not significant) CONCLUSIONS: Despite a similar incidence of staple-ring defects, a strikingly lower rate of clinically and radiologically detected leaks developed in patients submitted to omentoplasty. Although not affecting the incidence of anastomotic disruption, omentoplasty seems to contain the severity of anastomotic leakage.