Laparoscopic gastrectomy for stage II and III advanced gastric cancer: long­term follow­up data from a Western multicenter retrospective study.

INTRODUCTION: There has been an increasing interest for the laparoscopic treatment of early gastric cancer, especially among Eastern surgeons. However, the oncological effectiveness of Laparoscopic Gastrectomy (LG) for Advanced Gastric Cancer (AGC) remains a subject of debate, especially in Western countries where limited reports have been published. The aim of this paper is to retrospectively analyze short- and long-term results of LG for AGC in a real-life Western practice. MATERIALS AND METHODS: All consecutive cases of LG with D2 lymphadenectomy for AGC performed from January 2005 to December 2019 at seven different surgical departments were analyzed retrospectively. The primary outcome was diseases-free survival (DFS). Secondary outcomes were overall survival (OS), number of retrieved lymph nodes, postoperative morbidity and conversion rate. RESULTS: A total of 366 patients with stage II and III AGC underwent either total or subtotal LG. The mean number of harvested lymph nodes was 25 ± 14. The mean hospital stay was 13 ± 10 days and overall postoperative morbidity rate 27.32%, with severe complications (grade ≥ III) accounting for 9.29%. The median follow-up was 36 ± 16 months during which 90 deaths occurred, all due to disease progression. The DFS and OS probability was equal to 0.85 (95% CI 0.81-0.89) and 0.94 (95% CI 0.92-0.97) at 1 year, 0.62 (95% CI 0.55-0.69) and 0.63 (95% CI 0.56-0.71) at 5 years, respectively. CONCLUSION: Our study has led us to conclude that LG for AGC is feasible and safe in the general practice of Western institutions when performed by trained surgeons.

Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: A multi-institutional propensity score-matched study.

BACKGROUND AND OBJECTIVES: In the setting of a minimally invasive approach, we aimed to compare short and long-term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population. METHODS: All consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score-matching, postoperative morbidity and oncologic outcomes were investigated. RESULTS: After matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease-free-survival (p = 0.34) was found between groups. CONCLUSIONS: NAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short-term outcomes are more evident in patients over 60 years old receiving NAT.

Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery.

PURPOSE: To analyze different types of management and one-year outcomes of anastomotic leakage (AL) after elective colorectal resection. METHODS: All patients with anastomotic leakage after elective colorectal surgery with anastomosis (76/1,546; 4.9%), with the exclusion of cases with proximal diverting stoma, were followed-up for at least one year. Primary endpoints were as follows: composite outcome of one-year mortality and/or unplanned intensive care unit (ICU) admission and additional morbidity rates. Secondary endpoints were as follows: length of stay (LOS), one-year persistent stoma rate, and rate of return to intended oncologic therapy (RIOT). RESULTS: One-year mortality rate was 10.5% and unplanned ICU admission rate was 30.3%. Risk factors of the composite outcome included age (aOR = 1.08 per 1-year increase, p = 0.002) and anastomotic breakdown with end stoma at reoperation (aOR = 2.77, p = 0.007). Additional morbidity rate was 52.6%: risk factors included open versus laparoscopic reoperation (aOR = 4.38, p = 0.03) and ICU admission (aOR = 3.63, p = 0.05). Median (IQR) overall LOS was 20 days (14-26), higher in the subgroup of patients reoperated without stoma. At 1 year, a stoma persisted in 32.0% of patients, higher in the open (41.2%) versus laparoscopic (12.5%) reoperation group (p = 0.04). Only 4 out of 18 patients (22.2%) were able to RIOT. CONCLUSION: Mortality and/or unplanned ICU admission rates after AL are influenced by increasing age and by anastomotic breakdown at reoperation; additional morbidity rates are influenced by unplanned ICU admission and by laparoscopic approach to reoperation, the latter also reducing permanent stoma and failure to RIOT rates. TRIAL REGISTRATION: ClinicalTrials.gov # NCT03560180.

Laparoscopic resection with complete mesocolic excision for splenic flexure cancer: long-term follow-up data from a multicenter retrospective study.

BACKGROUND: Splenic flexure cancer (SFC), identified as tumors raised in the distal transverse colon and proximal descending colon, accounts for 2 to 5% of all surgically treated colorectal cancers. Despite the fact that the laparoscopic approach has become the gold standard for many colorectal procedures, it has never been extensively investigated in SFC due to lack of an agreed consensus on the appropriate operative procedure. The aim of this multicenter retrospective study is to evaluate the oncologic value of laparoscopic segmental resection with complete mesocolic excision (CME) for cancer located in the splenic flexure. METHODS: All data of consecutive patients who had undergone laparoscopic resection with CME for SFC from January 2005 to December 2017 at five different tertiary centers were retrospectively analyzed. The Kaplan-Meier (KM) test was used to assess the overall survival (OS) and the disease-free survival (DFS) rates after surgery. Univariate Cox regression was used to explore the association between OS and other independent factors. RESULTS: Recurrence was observed in 13 (11.6%) patients and a significant association between disease stage and recurrence (P < 0.001) was found with a higher proportion of stage IV patients in the recurrence group (46.1% vs. 7.1%). During a median follow-up of 43 months (range 12-149), 13 deaths occurred, all of them due to disease progression. KM curves for all stages showed an estimated survival rate of 51% at 148 months. CONCLUSION: Laparoscopic segmental resection with CME appears to be an oncologically safe and effective procedure for treatment of SFC and may be considered as a standard surgical method for elective management of the disease. In the future, routine lymph node mapping could be used to confirm this hypothesis.

Is robotic right colectomy economically sustainable? a multicentre retrospective comparative study and cost analysis.

BACKGROUND: Following the Food and Drug Administration approval, robot-assisted colorectal surgery has gained more acceptance among surgeons. One of the open issues about robotic surgery is the economic sustainability. The aim of our study is to evaluate the economic sustainability of robotic as compared to laparoscopic right colectomy for the Italian National Health System. METHODS: We performed a retrospective multicentre case-matched study including 94 patients for each group from four different Italian surgical departments. An economic evaluation gathered from a real-world data was performed to assess the sustainability of the robotic approach for right colectomy in the Italian National Health System. In particular, a differential cost analysis between the two procedures was performed. RESULTS: No statistical differences were found between the two groups for postoperative outcomes. After a careful review of the literature on the cost assessment for the operative room, medical devices and hospital stay according with our data, we estimated the followings: (a) the mean operative room cost for robotic group was 2179 ± 476 € vs. 1376 ± 322 € for laparoscopic group; (b) the mean hospital stay cost for robotic group was 3143 ± 1435 € vs. 3292 ± 1123 € for laparoscopic group; and (c) the mean cost for instruments was 6280 € for robotic group vs. 1504 € for laparoscopic group. The total mean cost of robotic right colectomy was 11,576 ± 1915 € vs. 6196 ± 1444 € for laparoscopic right colectomy. CONCLUSION: In conclusion, to date, robotic right colectomy with intracorporeal anastomosis does not provide any significant clinical advantages, which may justify the additional costs, as compared to its laparoscopic counterpart. Further evolution of robotic technology and experience may lead to a reduction of costs, especially if the robotic platform is used in an appropriate healthcare setting.

Oncologic outcomes following laparoscopic colon cancer resection for T4 lesions: a case-control analysis of 7-years' experience.

BACKGROUND: According to many Societies' guidelines, patients presenting with clinical T4 colorectal cancer should conventionally be approached by a laparotomy. Results of emerging series are questioning this attitude. METHODS: We retrospectively analysed the oncologic outcomes of 147 patients operated on between June 2008 and September 2015 for histologically proven pT4 colon cancers. All patients were treated with curative intent, either by a laparoscopic or open "en bloc" resection. RESULTS: Median operative time, blood loss and hospital length of stay were significantly reduced in the laparoscopic group. Postoperative surgical complication rate and 30-day mortality did not significantly differ between the two groups ( p = 0.09 and p = 0.99, respectively). R1 resection rate and lymph nodes harvest, as well, did not remarkably differ when comparing the two groups. In the laparoscopic group, conversion rate was 19%. Long-term outcomes were not affected in patients who had undergone conversion. Five-year overall survival and disease-free survival did not significantly differ between the two groups (44.6% and 40.3% vs. 39.4% and 38.9%). Locally advanced stages (IIIB-IIIC) and R1 resections were detected as independent prognostic factors for overall survival. CONCLUSION: Laparoscopic approach might be safe and acceptable for locally advanced colon cancer and does not jeopardize the oncologic results. Conversion to open surgery should be a part of a strategy as it does not seem to adversely affect perioperative and long-term outcomes. We consider laparoscopy, in expert hands, the last diagnostic tool and the first therapeutic approach for well-selected locally advanced colon cancers. Larger prospective studies are needed to widely assess this issue.

Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant.

BACKGROUND: Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication. METHODS: From January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction. RESULTS: Among the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect. CONCLUSION: In our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.

3D Vision Provides Shorter Operative Time and More Accurate Intraoperative Surgical Performance in Laparoscopic Hiatal Hernia Repair Compared With 2D Vision.

BACKGROUND: The aim of this study is to evaluate if 3-dimensional high-definition (3D) vision in laparoscopy can prompt advantages over conventional 2D high-definition vision in hiatal hernia (HH) repair. STUDY DESIGN: Between September 2012 and September 2015, we randomized 36 patients affected by symptomatic HH to undergo surgery; 17 patients underwent 2D laparoscopic HH repair, whereas 19 patients underwent the same operation in 3D vision. RESULTS: No conversion to open surgery occurred. Overall operative time was significantly reduced in the 3D laparoscopic group compared with the 2D one (69.9 vs 90.1 minutes, P = .006). Operative time to perform laparoscopic crura closure did not differ significantly between the 2 groups. We observed a tendency to a faster crura closure in the 3D group in the subgroup of patients with mesh positioning (7.5 vs 8.9 minutes, P = .09). Nissen fundoplication was faster in the 3D group without mesh positioning ( P = .07). CONCLUSIONS: 3D vision in laparoscopic HH repair helps surgeon's visualization and seems to lead to operative time reduction. Advantages can result from the enhanced spatial perception of narrow spaces. Less operative time and more accurate surgery translate to benefit for patients and cost savings, compensating the high costs of the 3D technology. However, more data from larger series are needed to firmly assess the advantages of 3D over 2D vision in laparoscopic HH repair.

Relaparoscopy for management of postoperative complications following colorectal surgery: ten years experience in a single center.

BACKGROUND: Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant disease. On the basis of this growing experience, there is now an expanded role for laparoscopic approach to postoperative complications after primary colorectal resection. However, there is little literature specific to this topic. We report a ten-year experience with laparoscopic treatment of early complications following laparoscopic colorectal surgery. METHODS: From January 2003 to December 2012, a total of 1,292 patients underwent elective laparoscopic colorectal surgery in our department. One hundred and two (7.9%) patients required reoperation for a postoperative complication. Laparoscopy has been also adopted as the preferred procedure for management of postoperative complications. A retrospective review of 84 patients who had relaparoscopy (RL) for postoperative complications, including peritonitis, ureteral injury, bowel obstruction, and bleeding, was performed. RESULTS: Reoperation was carried out laparoscopically in 79 (94.0%) patients. Five (6.0%) conversions were necessary because of massive colonic ischemia, generalized fecal peritonitis, and lack of working space. The most common finding at RL was anastomotic leakage (57.1%) that was managed by peritoneal lavage and ileostomy in 91.7% of cases. Six percent of patients had negative RL. Overall morbidity rate was 25.0%. Five patients required additional surgery: four (5.1%) after RL and one after a converted procedure. There were five (6.0%) deaths from septic shock, myocardial infarction, and pulmonary embolism. CONCLUSIONS: Laparoscopy is a safe and effective tool for management of complications following laparoscopic colorectal surgery. In this setting, RL represents the first step of re-exploration and treatment, with no delay to conversion to open procedure even in skilled laparoscopic hands.

Laparoscopic pancreaticoduodenectomy: experience of 22 cases.

BACKGROUND: Laparoscopic pancreatic surgery has gradually expanded its applications to include pancreaticoduodenectomy. However, the benefits of the laparoscopic approach are still debated. This article aims to present data regarding the efficacy of laparoscopic pancreaticoduodenectomy in a single center. METHODS: From March 2003 to June 2010, a total of 22 patients underwent pancreaticoduodenectomy with a totally laparoscopic approach, using a five-trocar technique. Reconstruction of the digestive tract was adapted to the aspect of the pancreatic stump, with 6 patients having Wirsung duct occlusion and 16 patients pancreaticodigestive anastomosis. Patient selection, short-term outcomes, oncologic results, and technical issues were retrospectively reviewed. RESULTS: Mean operative time was 392 (range, 327-570) min. Conversion was required in 2 patients (9.1 %) as a result of bleeding and difficult dissection. Major intraoperative complications included an injury to the right hepatic artery (4.5 %). Postoperative mortality was 4.5 %. Surgery-related morbidity occurred in 14 patients (63.6 %) and included bleeding (n = 5), pancreatic fistula (n = 6), biliary fistula (n = 2), and dumping syndrome (n = 1). Pancreatic fistulas occurred in 4 patients with duct occlusion and in 2 patients with pancreaticojejunostomy, and they all healed with conservative treatment. Mean hospital stay was 23 (range, 12-35) days. Pathologic diagnoses were pancreatic ductal adenocarcinoma (n = 11), ampullary adenocarcinoma (n = 8), and duodenal adenocarcinoma (n = 3). The resection margins were all free from disease; the mean number of collected lymph nodes was 15 (range, 14-20). CONCLUSIONS: The complexity of pancreaticoduodenectomy entails some issues, including patient selection and management of the pancreatic stump, that are not related to the approach used. Laparoscopic pancreaticoduodenectomy is feasible, safe, and oncologically adequate, but only if performed in selected cases by highly skilled laparoscopic surgeons. Laparoscopy does not provide any significant advantage over traditional surgery, but it may improve postoperative outcomes in the so-called excellence centers, once the learning curve has been overcome. Multicenter randomized trials are needed.

Laparoscopic pancreas-preserving subtotal duodenectomy for gastrointestinal stromal tumor.

Gastrointestinal stromal tumors (GISTs) of the duodenum are rare neoplasms. The optimal surgical procedure is debated and several options ranging from limited resections to pancreaticoduodenectomy have been reported. The laparoscopic approach has been validated for gastric GISTs, but it does not yet represent a standard technique for tumors of the duodenum. We report the case of a localized duodenal GIST that was successfully treated by totally laparoscopic pancreas-preserving subtotal duodenectomy. This procedure may represent a feasible and effective treatment option for localized GISTs of the duodenum. Large series with long-term follow-up are needed.

Preservation of the inferior mesenteric artery VS ligation of the inferior mesenteric artery in left colectomy: evaluation of functional outcomes-a prospective non-randomized controlled trial.

Vascular approach during elective laparoscopic left colectomy impacts post-operative outcomes. The aim of our study was to evaluate how different approaches impact positively defecatory, urinary and sexual functions and quality of life during elective laparoscopic left colectomy. A prospective non-randomized controlled trial at two tertiary center was conducted. All patients who underwent elective laparoscopic left colonic resection from January 2019 to July 2022 were analyzed. They were divided into two groups based on Inferior Mesenteric Artery (IMA) preservation with distal ligation of sigmoid branches close to a colonic wall for complicated diverticular disease and IMA high tie ligation for oncological disease. Patients were asked to fulfil standardized, validated questionnaires to evaluate pre and post-operative defecatory, urinary and sexual functions and quality of life. Defecatory disorders were assessed by high-resolution anorectal manometry preoperatively and six months after surgery. A total of 122 patients were included in the study. The 62 patients with IMA preservation showed a lower incidence of defecatory disorders also confirmed by manometer data, minor incontinence and less lifestyle alteration than the 60 patients with IMA high tie ligation. No urinary disorders such as incomplete emptying, frequency, intermittence or urgency were highlighted after surgery in the IMA preservation group. Evidence of any sexual disorders remained controversial. The IMA-preserving vascular approach seems to be an effective strategy to prevent postoperative functional disorders. It is a safe and feasible technique especially for diverticular disease. New prospective randomized and highly probative studies are needed to confirm the effectiveness in specific clinical situations.

Laparoscopic splenectomy: experience of a single center in a series of 300 cases.

BACKGROUND: Laparoscopic splenectomy (LS) has gradually become the technique of choice for surgical removal of the spleen. The aim of this study was to evaluate the efficacy of LS in a large cohort of patients from a single center. METHODS: From March 1992 to June 2010, 300 patients underwent LS at our hospital for predominantly hematologic disorders. The first 92 cases were performed using an anterior approach, whereas in the remaining 208 cases a lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed. RESULTS: Spleen volume was similar between the anterior (350 ml) and the lateral (370 ml) approaches. The lateral approach was associated with shorter operative time (60 vs. 80 min), less blood loss (30 vs. 110 ml), and no conversion (0 vs. 2.2 %) compared to the anterior approach. Reoperations were required in three patients (1.0 %) because of bleeding, subphrenic abscess, and intestinal ischemia. Postoperative complications were significantly fewer for the lateral (4.8 %) than for the anterior (31.5 %) approach and the hospital stay was shorter (3.1 vs. 5.2 days) and there was less postoperative pain. Splenectomy for hematologic malignancies resulted in a higher morbidity rate, more postoperative pain, and longer hospital stay. Overall mortality rate was 0.3 %. No late complications were observed during the 1-5-year follow-up. CONCLUSIONS: LS using the lateral approach with the placement of four trocars can be considered the procedure of choice for both benign and malignant diseases affecting the spleen. Extensive experience and technical standardization help to avoid surgical pitfalls, providing an adequate control of hemostasis, the excision of accessory spleens (AS), and the avoidance of parenchymal rupture.

Bile leaks after videolaparoscopic cholecystectomy: duct of Luschka. Endoscopic treatment in a single centre and brief literature review on current management.

BACKGROUND: Laparoscopic cholecystectomy (LC) for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity (0.2-2%). The bile ducts of Luschka (DL)are small ducts which originate from the right hepatic lobe, course along the gallbladder bed, and usually drain in the extrahepatic bile ducts. Injuries to these ducts are the second most frequent cause of bile leaks after cholecystectomy. Aim of our study is build a literature review starting from our experience. PERSONAL EXPERIENCE: Forty four patients with abdominal bile collections post-cholecystectomy by suspected bile leak under-went endoscopic retrograde cholagio-pancreatography (ERCP). A complete cholangiogram was obtained in 42 patients(95.5%). In according to the magnitude of bile leak daily, we subdivided the patients in two groups: a) < 180 ml/daily,and b) > 180 ml/daily. The most common site of the leak was the cystic duct stump (94.5%), followed by DL (2 patient = 5.5%). 10 Fr stent insertion after endoscopic sphincterotomy (ES) was the most common intervention. In 6 patients (14%) a 7 Fr naso-biliary drainage was inserted. On an intention-to-treat basis, endoscopic intervention at ERCP had 100% success rate for resolution of the leak. The median time for resolution of the leak was 8 and 12 days in the first and second group respectively. No mortality ERCP-related were recorded. Early minor complications occurred in 7/42 (16.5%) patients. METHODS: A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles.Cross-references from these articles were also used. RESULTS: ERCP is the most common diagnostic and therapeutic method used in bile leaks post-cholecystectomy. Most patients with DL leaks are symptomatic, and most leaks are detected postoperatively during the first postoperative week. Reduction of intra-ductal pressure with ES and stent or naso-biliary tube insertion will lead to preferential flow of bile through the papilla, thus permitting DL injuries to heal. This is the most common treatment modality used. In a minority of patients,re-laparoscopy is performed. In such cases, the leaking DL is visualized directly and ligation usually is sufficient treatment.Simple drainage is adequate treatment for a small number of asymptomatic patients with low-volume leaks. CONCLUSIONS: DL leaks occur after cholecystectomy regardless of gallbladder pathology or urgency of operation. They have been encountered more frequently in the era of LC Intraoperative cholangiography does not detect all such leaks. ERCP with ES and stent placement are the most common effective diagnostic and therapeutic methods used. Intraoperative and perioperative adjunctive measures, such as fibrin glue instillation and pharmacologic relaxation of the sphincter of Oddi,can potentially be used in lowering the incidence and in the treatment of DL leaks.

MDCT Findings in Gastrointestinal Perforations and the Predictive Value according to the Site of Perforation.

Background: Gastrointestinal perforations are a frequent cause of acute abdominal symptomatology for patients in the emergency department. The aim of this study was to investigate the findings of multidetector-row computed tomography of gastrointestinal perforations and analyze the impact of any imaging signs on the presurgical identification of the perforation site. Methods: We retrospectively reviewed emergency MDCT findings of 93 patients submitted to surgery for gastrointestinal perforation at two different institutions. Two radiologists separately reviewed the emergency MDCT examinations performed on each patient, before and after knowing the surgical diagnosis of the perforation site. A list of findings was considered. Positive predictive values were estimated for each finding with respect to each perforation site, and correspondence analysis (CA) was used to investigate the relationship between the findings and each of the perforation types. Results: We did not find inframesocolic free air in sigmoid colorectal perforations, and in rare cases, only supramesocolic free fluid in gastroduodenal perforations was found. A high PPV of perivisceral fat stranding due to colonic perforation and general distension of upstream loops and collapse of downstream loops were evident in most patients. Conclusions: Our data could offer additional information on the perforation site in the case of doubtful findings to support surgeons, especially in planning a laparoscopic approach.

Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases.

Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.

Machine Learning and Clinical-Radiological Characteristics for the Classification of Prostate Cancer in PI-RADS 3 Lesions.

The Prostate Imaging Reporting and Data System (PI-RADS) classification is based on a scale of values from 1 to 5. The value is assigned according to the probability that a finding is a malignant tumor (prostate carcinoma) and is calculated by evaluating the signal behavior in morphological, diffusion, and post-contrastographic sequences. A PI-RADS score of 3 is recognized as the equivocal likelihood of clinically significant prostate cancer, making its diagnosis very challenging. While PI-RADS values of 4 and 5 make biopsy necessary, it is very hard to establish whether to perform a biopsy or not in patients with a PI-RADS score 3. In recent years, machine learning algorithms have been proposed for a wide range of applications in medical fields, thanks to their ability to extract hidden information and to learn from a set of data without previous specific programming. In this paper, we evaluate machine learning approaches in detecting prostate cancer in patients with PI-RADS score 3 lesions via considering clinical-radiological characteristics. A total of 109 patients were included in this study. We collected data on body mass index (BMI), location of suspicious PI-RADS 3 lesions, serum prostate-specific antigen (PSA) level, prostate volume, PSA density, and histopathology results. The implemented classifiers exploit a patient's clinical and radiological information to generate a probability of malignancy that could help the physicians in diagnostic decisions, including the need for a biopsy.

Laparoscopic segmental resection for tumours of the Angle of Treitz: a challenging but feasible surgical option. Results from a retrospective case-series analysis.

Tumours of the small intestine are rare and account for about 5% of gastrointestinal tract neoplasms. The angle of Treitz (AT) could be defined as the intestinal loop comprised between the third duodenal portion and the first 10 cm of jejunum. A gold standard surgical treatment for AT neoplasm has not yet been well defined. This paper is focused on a very rare disease and at the best of our knowledge this is the largest case series in the literature about the Laparoscopic Segmental Resection (LSR) of AT tumours. Using a prospectively collected database, all data of consecutive patients, from January 2007 to May 2019, who underwent LSR for AT tumours at two different institutions were analysed. Patients' demographics, intra and post-operative data, 30-day mortality and overall survival were collected. A total of 16 patients were retrieved from our database. The mean operative time was 206,5 ± 79 min. Conversion to open surgery was needed in two cases due to tumor size and, respectively, invasion of the transverse colon which required a multivisceral resection. The mean distal and proximal resection margins were 7.4 ± 2.2 and 3.9 ± 1.2 cm. The median number of harvested nodes was 9 ± 3. Pathological diagnosis was GIST in 11 cases, adenocarcinoma in 4 and sarcoma in 1 case. In conclusion, in experienced hands, LSR appears to be a safe and effective treatment option for tumours of the AT. Prospective studies are needed to confirm these findings.

Does a 3D laparoscopic approach improve surgical outcome of mininvasive right colectomy? A retrospective case-control study.

Laparoscopy has gained wide acceptance due its benefits for patients. However, advanced laparoscopic procedures are still challenging. One critical issue is lack of stereoscopic vision. Despite its diffusion, the totally laparoscopic approach for right hemicolectomy (TLRC) is still debated due to its difficulty, particularly for fashioning of the ileocolic anastomosis. The aim of this multicenter study is to investigate whether 3D vision offers any advantages on surgical performance over 2D vision during TLRC. All data of consecutive patients who underwent elective TLRC for cancer at three Italian surgical centers with either 2D or 3D technology from January 2013 to December 2018 were retrieved from a computer-maintained database. A case-matched analysis using the Mantel-Haenszel method was performed. After matching, a total of 106 patients were analyzed with 53 patients in each group. Mean operative time was significantly longer for 2D-TLRC than for 3D-TLRC (153.2 ± 52.4 vs. 131 ± 51 min, p = 0.029) and a statistically significant difference in anastomosing time (p = 0.032, 19.2 ± 5.9 min vs. 21.7 ± 6.2 min for 3D and 2D group, respectively) was also recorded. No difference in the median number of harvested nodes (23 ± 11 vs. 21 ± 7 for 3D and 2D group, respectively; p = 0.48) was found. Neither intraoperative complications nor conversions occurred in the two groups. In conclusion, 3D vision appears to improve the performance of a TLRC by reducing operative time and making intracorporeal anastomosis easier. Prospective randomized studies are required to determine the real beneficial effects.