Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients.

Although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. A multi-institutional audit was designed, including 92 patients who underwent laparoscopic left colectomy with intracorporeal anastomosis (IA) compared with 89 matched patients who underwent a laparoscopic left colectomy with extracorporeal anastomosis (EA). There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Post-surgical history and stage of disease according to AJCC/UICC TNM were also similar. IA and EA groups demonstrated similar oncologic radicality in terms of the number of lymph nodes harvested (18.5 ± 9 vs. 17.5 ± 8.4; p = 0.48). Recovery after surgery was also better in patients who underwent IA, as confirmed by the shorter time to flatus in the IA group (2.6 ± 1.1 days vs. 3.4 ± 1.2 days; p < 0.001) and higher post-operative pain expressed in the mean VAS Scale in the EA group (1.7 ± 2.1 vs. 3.5 ± 1.6; p < 0.001). Laparoscopic left colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 6.7, 95% CI 2.2-20; p = 0.001). However, when stratifying according to Clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 7.6, 95% CI 2.5-23, p = 0.001) but not for class III, IV, and V complications (OR 1.8, 95% CI 0.1-16.9; p = 0.59). Our results were consistent to hypothesize that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. Further randomized clinical trials are needed to obtain a more definitive conclusion.

Recovery after intracorporeal anastomosis in laparoscopic right hemicolectomy: a systematic review and meta-analysis.

PURPOSE: Although intracorporeal anastomosis (IA) appears to guarantee a faster recovery compared to extracorporeal anastomosis (EA), the data are still unclear. Thus, we performed a systematic review of the literature with meta-analysis to evaluate the recovery benefits of intracorporeal anastomosis. MATERIALS AND METHODS: A systematic search was performed in electronic databases (PubMed, Web of Science, Scopus, EMBASE) using the following search terms in all possible combinations: "laparoscopic," "right hemicolectomy," "right colectomy," "intracorporeal," "extracorporeal," and "anastomosis." According to the pre-specified protocol, all studies evaluating the impact of choice of intra- or extracorporeal anastomosis after right hemicolectomy on time to first flatus and stools, hospital stay, and postoperative complications according to Clavien-Dindo classification were included. RESULTS: Sixteen articles were included in the final analysis, including 1862 patients who had undergone right hemicolectomy: 950 cases (IA) and 912 controls (EA). Patients who underwent IA reported a significantly shorter time to first flatus (MD = - 0.445, p = 0.013, Z = - 2.494, 95% CI - 0.795, 0.095), to first stools (MD = - 0.684, p < 0.001, Z = - 4.597, 95% CI - 0.976, 0.392), and a shorter hospital stay (MD = - 0.782, p < 0.001, Z = -3.867, 95% CI - 1.178, - 0.385) than those who underwent EA. No statistically significant differences in complications between the IA and EA patients were observed in the Clavien-Dindo I-II group (RD = - 0.014, p = 0.797, Z = - 0.257, 95% CI - 0.117, 0.090, number needed to treat (NNT) 74) or in the Clavien-Dindo IV-V (RD = - 0.005, p = 0.361, Z = - 0.933, 95% CI - 0.017, 0.006, NNT 184). The IA procedure led to fewer complications in the Clavien-Dindo III group (RD = - 0.041, p = 0.006, Z = - 2.731, 95% CI - 0.070, 0.012, NNT 24). CONCLUSIONS: Although intracorporeal anastomosis appears to be safe in terms of postoperative complications and is potentially more effective in terms of recovery after surgery, further ad hoc randomized clinical trials are needed, given the heterogeneity of the data available in the current literature.

Blood cell differential count discretisation modelling to predict survival in adults reporting to the emergency room: a retrospective cohort study.

OBJECTIVES: To assess the survival predictivity of baseline blood cell differential count (BCDC), discretised according to two different methods, in adults visiting an emergency room (ER) for illness or trauma over 1 year. DESIGN: Retrospective cohort study of hospital records. SETTING: Tertiary care public hospital in northern Italy. PARTICIPANTS: 11 052 patients aged >18 years, consecutively admitted to the ER in 1 year, and for whom BCDC collection was indicated by ER medical staff at first presentation. PRIMARY OUTCOME: Survival was the referral outcome for explorative model development. Automated BCDC analysis at baseline assessed haemoglobin, mean cell volume (MCV), red cell distribution width (RDW), platelet distribution width (PDW), platelet haematocrit (PCT), absolute red blood cells, white blood cells, neutrophils, lymphocytes, monocytes, eosinophils, basophils and platelets. Discretisation cut-offs were defined by benchmark and tailored methods. Benchmark cut-offs were stated based on laboratory reference values (Clinical and Laboratory Standards Institute). Tailored cut-offs for linear, sigmoid-shaped and U-shaped distributed variables were discretised by maximally selected rank statistics and by optimal-equal HR, respectively. Explanatory variables (age, gender, ER admission during SARS-CoV2 surges and in-hospital admission) were analysed using Cox multivariable regression. Receiver operating curves were drawn by summing the Cox-significant variables for each method. RESULTS: Of 11 052 patients (median age 67 years, IQR 51-81, 48% female), 59% (n=6489) were discharged and 41% (n=4563) were admitted to the hospital. After a 306-day median follow-up (IQR 208-417 days), 9455 (86%) patients were alive and 1597 (14%) deceased. Increased HRs were associated with age >73 years (HR=4.6, 95% CI=4.0 to 5.2), in-hospital admission (HR=2.2, 95% CI=1.9 to 2.4), ER admission during SARS-CoV2 surges (Wave I: HR=1.7, 95% CI=1.5 to 1.9; Wave II: HR=1.2, 95% CI=1.0 to 1.3). Gender, haemoglobin, MCV, RDW, PDW, neutrophils, lymphocytes and eosinophil counts were significant overall. Benchmark-BCDC model included basophils and platelet count (area under the ROC (AUROC) 0.74). Tailored-BCDC model included monocyte counts and PCT (AUROC 0.79). CONCLUSIONS: Baseline discretised BCDC provides meaningful insight regarding ER patients' survival.

Diagnosis and treatment of pancreatic incidentalomas. An overview.

AIM: The aim of this study is to describe the incidence, imaging characteristics and pathological features of pancreatic incidentalomas. Moreover, surgical indications are discussed according to the nature and location of the neoplasms. BACKGROUND: Pancreatic incidental lesions are more commonly diagnosed, due to the widespread of high quality cross sectional imaging. These lesions can be cystic or solid, benign, pre-malignant or already malignant and they cover a wide spectrum of histological diagnosis. Cystic lesions are more commonly benign or at least pre-malignant. Surgery should be reserved in case of unexpected changes in aspect during follow-up or for large cysts (>3 cm). Among solid pancreatic incidentalomas, ductal adenocarcinoma is the most common diagnosis, followed by neuroendocrine tumors. Surgical treatment of pancreatic incidentaloma depends on the location of the tumor: a Whipple's procedure should be performed for neoplasms of the head, while distal pancreatectomy is indicated for body and tail lesions. Pancreatic surgery is still delicate and burdened by serious complications. Both procedures can be performed with minimally-invasive technique which is connected to lower complications rate but, at present, they have shown no advantages in terms of mortality and oncologic outcomes. CONCLUSIONS: Pancreatic incidentalomas are becoming more and more common but when and how to operate them is still subject of debate. Precise criteria about treatment strategy are still lacking and definite guidelines are needed to clarify the best approach. KEY WORDS: Incidentaloma, Laparoscopy, Pancreatic tumors, Surgery.

Small Bowel Intussusception Due to Rare Cardiac Intimal Sarcoma Metastasis: A Case Report.

Background: Intimal sarcomas are rare malignant mesenchymal tumors arising from the heart and large blood vessels. Their intraluminal growth leads to vascular obstructive symptoms and peripheral neoplastic embolization. Direct infiltration of the lungs or metastases to the pulmonary system, occur in 40% of cases and extrathoracic spread is frequent, also in presentation. Intussusception is an unusual event in adults, accounting for <5% of bowel obstructions. In most cases it is caused by a malignancy and requires surgical resection. Case Presentation: We describe a rare case of a 50-year-old man suffering of bowel obstruction due to intussusception sustained by a small bowel metastasis of a primary cardiac intimal sarcoma. One year and a half before the onset of abdominal symptoms, a grade II intimal sarcoma was removed from his left atrium and consequently he followed a chemotherapy protocol. Four months later a CT scan revealed local recurrence. Eighteen months after heart surgery he referred to the ER with abdominal pain. CT scan showed an ileal intussusception and the patient was scheduled for surgery. A tract of 10 cm ileus was removed containing an intramural polypoid solid mass. Histological analyses revealed a grade II intimal sarcoma consistent with his first diagnosis. Conclusion: Primary heart tumors are late found and often partially resected, therefore metastatic pathways are to be expected. Adult small bowel intussusception is a rare event and caused by a malignancy in one third of cases. Therefore, our recommendation is to always resect the tract involved in order to perform a proper diagnosis.

Robotic vs laparoscopic right colectomy - the burden of age and comorbidity in perioperative outcomes: An observational study.

BACKGROUND: Several studies have shown the safety, feasibility and oncologic adequacy of robotic right hemicolectomy (RRH). Laparoscopic right hemicolectomy (LRH) is considered technically challenging. Robotic surgery has been introduced to overcome this technical limitation, but it is related to high costs. To maximize the benefits of such surgery, only selected patients are candidates for this technique. In addition, due to progressive aging of the population, an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities, who are usually more prone to post-operative complications. AIM: To investigate the outcomes of RRH vs LRH with regard to age and comorbidities. METHODS: We retrospectively analyzed 123 minimally invasive procedures (68 LRHs vs 55 RRHs) for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019. The surgical procedures were performed according to standardized techniques. The primary clinical outcome of the study was the length of hospital stay (LOS) measured in days. Secondary outcomes were time to first flatus (TFF) and time to first stool evacuation. The robotic technique was considered the exposure and the laparoscopic technique was considered the control. Routine demographic variables were obtained, including age at time of surgery and gender. Body mass index and American Society of Anesthesiologists physical status were registered. The age-adjusted Charlson Comorbidity Index (ACCI) was calculated; the tumor-node-metastasis system, intra-operative variables and post-operative complications were recorded. Post-operative follow-up was 180 d. RESULTS: LOS, TFF, and time to first stool were significantly shorter in the robotic group: Median 6 [interquartile range (IQR) 5-8] vs 7 (IQR 6-10.5) d, P = 0.028; median 2 (IQR 1-3) vs 3 (IQR 2-4) d, P < 0.001; median 4 (IQR 3-5) vs 5 (IQR 4-6.5) d, P = 0.005, respectively. Following multivariable analysis, the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function; in addition the dichotomous variables of age over 75 years and ACCI more than 7 were significant predictors of hospital stay. No outcomes were significantly associated with Clavien-Dindo grading. Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS (median 6 -IQR 5-8- vs 7 -IQR 6-12- d, P = 0.013) and later TFF (median 2 -IQR 1-3- vs 3 -IQR 2-4- d, P = 0.008), while patients with ACCI more than 7 were only associated with a prolonged hospital stay (median 7 -IQR 5-8- vs 7 -IQR 6-14.5- d, P = 0.036). CONCLUSION: RRH is related to shorter LOS when compared with the laparoscopic approach, but older age and several comorbidities tend to reduce its benefits.

Spontaneous rupture of a non-functioning pancreatic neuroendocrine tumor A case report of a rare cause of acute abdomen.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are a group of rare tumors that account for 2% of all pancreatic malignancies, even though their incidence has been increasing over the past 20 years. Most PNETs are sporadic and tend to affect older individuals. Differently from functional tumors, which present with symptoms resulting from the specific hormone being elaborated, non-functioning pancreatic neuroendocrine tumors (NF-PNETs) typically present with symptoms related to local mass effect or metastatic disease. Today, due to the increasing use of abdominal imaging, NFPNETs are frequently discovered incidentally. CASE REPORT: A 32-year-old woman was admitted to our emergency department for worsening upper abdominal pain radiating to the back. Shortly after the admission, shock and peritoneal signs developed. An abdominal computerized tomography scan showed a solid mass (9 x 12 cm) of the pancreatic tail with severe hemoperitomeum. Exploratory laparotomy and subsequent distal splenopancreasectomy were performed for a bleeding tumor. Histopathological report showed a neuroendocrine, well differentiated tumor (G1). The postoperative course was uneventful and the patient was successfully discharged on 10th postoperative day. CONCLUSION: Spontaneous rupture of solid neuroendocrine neoplasms of the pancreas can cause acute abdomen with potentially devastating effects. KEY WORDS: Abdominal pain, acute abdomen, Hemorrhagic shock, Pancreatic neuroendocrine tumor.

Spontaneous rupture of a non-functioning pancreatic neuroendocrine tumor A case report of a rare cause of acute abdomen.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are a group of rare tumors that account for 2% of all pancreatic malignancies, even though their incidence has been increasing over the past 20 years. Most PNETs are sporadic and tend to affect older individuals. Differently from functional tumors, which present with symptoms resulting from the specific hormone being elaborated, non-functioning pancreatic neuroendocrine tumors (NF-PNETs) typically present with symptoms related to local mass effect or metastatic disease. Today, due to the increasing use of abdominal imaging, NFPNETs are frequently discovered incidentally. CASE REPORT: A 32-year-old woman was admitted to our emergency department for worsening upper abdominal pain radiating to the back. Shortly after the admission, shock and peritoneal signs developed. An abdominal computerized tomography scan showed a solid mass (9 x 12 cm) of the pancreatic tail with severe hemoperitomeum. Exploratory laparotomy and subsequent distal splenopancreasectomy were performed for a bleeding tumor. Histopathological report showed a neuroendocrine, well differentiated tumor (G1). The postoperative course was uneventful and the patient was successfully discharged on 10th postoperative day. CONCLUSION: Spontaneous rupture of solid neuroendocrine neoplasms of the pancreas can cause acute abdomen with potentially devastating effects. KEY WORDS: Abdominal pain, acute abdomen, Hemorrhagic shock, Pancreatic neuroendocrine tumor.

Left colonic metastasis from primary hepatocellular carcinoma: A case report.

BACKGROUND: Hepatocellular carcinoma (HCC) accounts for 5-6% of all human cancers. Considering the extrahepatic metastasis, the main organs involved are lymphnodes, lung, bone and adrenal gland. Usually colon metastasis is very rare, especially on the left sided colon. CASE SUMMARY: We report a case of a 70 years-old man hepatitis B carrier with HCC treated four times with trans-arterial chemoembolization, presented to our surgical department complaining of gastrointestinal bleeding. A colonoscopy revealed a mass of 4 cm of the sigmoid colon with signs of bleeding. The computed tomography showed a mass originated from the sigmoid colon of 3.5 cm, and the presence of HCC in segment VI and VII, without portal vein thrombosis. Due to the large size of the mass and the active bleeding, the patient underwent a left colectomy. The postoperative period was uneventful, and the patient was discharged in fifth post-operative day. Histological examination revealed that the neoplasm was characterized by a diffuse proliferation of epithelial cells with an hepatoid differentiation. So, the presence of a history of HCC of the liver and the histopathological features supported the diagnosis of metastasis from the liver. CONCLUSION: Although rare, colon metastasis from an HCC can be left-sided and can present with acute bleeding.

Treatment of giant condyloma acuminatum of the anus. State of the art.

Giant condyloma acuminatum (GCA) is a rare cauliflower-like lesion, also known as Buschke-L ewenstein tumor (BLT). Although characterized by benign histological features, the local behavior of GCA is extremely aggressive, showing progressive infiltration of the surrounding structures leading to tissue destruction by compression. As the correlation between HPV and GCA development grew stronger, the majority of the Authors came to the conclusion that HPV can not only cause CA but, associated with particular risk factors, it can lead to much more serious conditions such as BLT. Since the treatment of GCA is still not yet standardized, a very accurate pre-operative analysis of the lesions is required to plan the most suitable treatment approach. Based on current knowledge, macroscopic evaluation of local tumor invasion and extensive radical resection appear to be the only valid therapeutic approach, due to its association with longterm survival and minimal recurrence. Looking forward for new techniques and new tissue sparing treatments, at the moment, GCA can be safely treated with radical excision without immediate tissue reconstruction; long-term complications, such as stricture and stenosis, can be prevented by adequate wound healing and by a particularly intense and long- term follow-up program. KEY WORDS: Anus, Giant condyloma acuminatum.

Surgical resection for rectal cancer. Is laparoscopic surgery as successful as open approach? A systematic review with meta-analysis.

BACKGROUND: Recently, it has been questioned if minimally invasive surgery for rectal cancer was surgically successful. We decided to perform a meta-analysis to determine if minimally invasive surgery is adequate to obtain a complete resection for curable rectal cancer. METHODS: A systematic search pertaining to evaluation between laparoscopic and open rectal resection for rectal cancer was performed until 30th November 2016 in the electronic databases (PubMed, Web of Science, Scopus, EMBASE), using the following search terms in all possible combinations: rectal cancer, laparoscopy, minimally invasive and open surgery. Outcomes analyzed were number of clear Distal Resection Margins (DRM or DM), complete Circumferential Resection Margins (CRM) and complete, nearly complete and incomplete Total Mesorectal Excision (TME) and of patients who received laparoscopic or open treatment for rectal cancer. RESULTS: 12 articles were included in the final analysis. The prevalence of successful surgical resection was similar between open and laparoscopic surgery. About distance from distal margin of the specimen, clear CRM and complete TME there were no statistically significant difference between the two groups (MD = -0.090 cm, p = 0.364, 95% CI -0.283, 0.104; OR = 1.032, p = 0.821, 95% CI 0.784, 1.360; OR = 0.933, p = 0.720, 95% CI 0.638, 1.364, respectively). The analysis of nearly complete TME showed a significant difference between the two groups (OR = 1.407, p = 0.006, 95% CI 1.103, 1.795), while the analysis of incomplete TME showed a non-significant difference (OR = 1.010, p = 0.964, 95% CI 0.664, 1.534). CONCLUSIONS: By pooling together data from 5 RCTs and 7 nRCTs, we are able to provide evidence of safety and efficacy of minimally invasive surgery. Waiting for further randomized clinical trials, our results are encouraging to introduce laparoscopic rectal resection in daily practice.