Intraoperative cholangiography during cholecystectomy in sequential treatment of cholecystocholedocholithiasis: To be, or not to be, that is the question A cohort study.

BACKGROUND: Choledocholithiasis occurs in 10-15% of patients with cholecystolithiasis. Despite the existence of many therapeutic options for the treatment of cholecystocholedocholithiasis, a sequential treatment in which pre-operative ERCP is combined with intraoperative cholangiography (IOC) and laparoscopic cholecystectomy (LC), is the most commonly accepted strategy. However, use of IOC in the "splitting treatment" of cholecystocholedocholithiasis is controversial. The aim of the present study is to investigate the utility of IOC in detecting residual stones in patients undergoing LC in the sequential treatment of common biliary duct or gallbladder stones. METHODS: Patients were recruited retrospectively among those who underwent IOC during LC, performed as second stage in the sequential treatment for cholecystocholedocholithiasis between 2010 and 2016. Demographic and clinical data were obtained from CPT codes at Ospedale Monaldi A.O.R.N dei Colli Naples, Italy. Data obtained from all pre-operative ERCP analyses were recorded, including cholangiogram findings and performance of sphincterotomy. Statistical analysis was carried out using the IBM SPSS Statistic 19.0 software package. RESULTS: Between January 2010 and December 2016 575 patients (343 males, 242 females) underwent IOC during LC for symptomatic cholecystitis due to cholelithiasis. Among patients accrued for the study, 143 underwent preoperative ERCP for suspicion of common biliary duct stones. At the time of pre-operative ERCP, 123 were found to have common biliary duct stones while 20 (15%) presented negative ERCP. Complete removal of stones was accomplished in 119 patients. Among these patients, 13 had residual common biliary duct stones diagnosed by IOC (11%). Two patients underwent laparoscopic bile duct revision and, last, two patients were referred for ERCP at a later point. It is of note that all patients who presented residual stones by IOC had undergone pre-operative sphincterotomy. CONCLUSION: This study demonstrates that IOC is particularly effective in detecting residual stones in patients undergoing LC in sequential treatment of common biliary duct and/or gallbladder stones, and may be used on a routine basis in the sequential treatment of cholecystocholedocholithiasis.

Irreversible electroporation for locally advanced pancreatic cancer through a minimally invasive surgery supported by laparoscopic ultrasound.

INTRODUCTION: Pancreatic cancer is one of the most lethal cancers worldwide, with 5-years survival rate as low as 6%. The majority of pancreatic cancer patients present locally advanced or metastatic disease at diagnosis. Typically, patients affected by locally advanced pancreatic cancer (LAPC) do not undergo radical surgery but are treated with focal ablative therapies. However, a high rate of morbidity due to the heat sink effect has limited the application of ablative techniques on a routine basis in LAPC patients. Irreversible electroporation (IRE) has proved to be a new method of LAPC ablation. PRESENTATION OF THE CASE: A 69-year-old woman affected by LAPC with good response to systemic chemotherapy with FOLFIRINOX and residual 35 mm mass in the neck of the pancreas underwent to IRE through a minimally invasive surgical approach under laparoscopic ultrasound guide. The post-operative course was uneventful and the patient was discharged after 5 days. Six months after surgery she had no evidence of distant or recurrent disease. DISCUSSION: IRE has previously shown promising results in the treatment of LAPC, with relatively acceptable morbidity rates and improvement of survival. We report on the application of IRE through a minimally invasive surgical approach supported by laparoscopic ultrasound. CONCLUSION: In conclusion, we propose a novel technical approach that combines the benefits of IRE on the treatment of patients affected by LAPC with the advantages of laparoscopic surgery.

Laparoscopic spleen-preserving distal pancreatectomy for insulinoma: experience of a single center.

BACKGROUND: Laparoscopic spleen-preserving distal pancreatectomy is gaining acceptance for the treatment of insulinomas of the pancreatic body and tail. The aim of this report is to evaluate the feasibility, safety and outcomes of this procedure in a retrospective series. METHODS: From May 2004 to November 2013, 9 patients underwent laparoscopic spleen-preserving distal pancreatectomy for benign insulinomas in our department. Tumors were single and sporadic in eight patients, while the remaining patient had insulinomas in the setting of multiple endocrine neoplasia type 1. Tumors were located by preoperative imaging in all cases. Laparoscopic ultrasound was always performed to guide the surgical procedure. RESULTS: All the operations were carried out laparoscopically with a mean operative time of 110 min (range 90-210 min) and a mean blood loss of 50 ml (range 30-120 ml). One patient (11.1%) died on the 22nd post-operative day for massive intra-abdominal bleeding associated with pancreatitis of the stump. Two patients (22.2%) developed pancreatic fistula that healed conservatively. Mean postoperative hospital stay was 7.1 days (range 5-18 days). All alive patients were free from recurrence after a mean follow-up of 45 months (range 11-72 months). CONCLUSION: Laparoscopic spleen-preserving distal pancreatectomy is safe and feasible for the management of benign insulinomas. Definition of the tumor with preoperative imaging and laparoscopic ultrasound is essential to achieve high cure rate with minimal conversion.

Laparoscopic total gastrectomy in gastric cancer: our experience in 92 cases.

INTRODUCTION: Laparoscopic total gastrectomy (LTG) is seldom used for gastric cancer because the complex vascularization and lymphatic drainage makes lymphadenectomy and esophagojejunal anastomosis difficult and requires special skills. Our aim was to demonstrate the feasibility and accuracy of LTG in gastric cancer with D2 lymphadenectomy. MATERIAL AND METHODS: Eighty-eight LTG and four laparoscopic remnant gastrectomies (LRGs) were performed over >12 years. The median patient age was 64 years, and the male/female ratio was 1.49/1. Eighty-seven patients had a D2 and only five patients had a D1 lymphadenectomy. We propose the retrospective analysis of intra- and perioperative mortality and morbidity. RESULTS: In only four of 96 cases approached by laparoscopy, a conversion to laparotomy was needed. There were two (2.17%) perioperative deaths in 92 procedures and few complications. Histological data show 79 advanced gastric cancers (AGC), 11 early gastric cancers (EGC), and two gastric diffused lymphomas. The five-year Kaplan-Meier overall survival in patients with EGC and AGC was 100% and 58%, respectively. CONCLUSIONS: The results demonstrate the feasibility of an oncologically correct minimally invasive total gastrectomy. We would like to promote comparisons among different institutions to achieve better standardization of indications and techniques for a laparoscopic approach to gastric cancer.

Iatrogenic colonic perforation: repair using laparoscopic technique.

BACKGROUND: Iatrogenic colonic perforation is a rare complication of colonoscopies. Nowadays, there are still no specific guidelines for the optimal management of these complications (open surgery with colonic resection and anastomosis or colonic diversion, primary repair, endoscopic clips, nonoperative management, and laparoscopic approach). METHODS: A retrospective analysis of 9 patients operated on for iatrogenic colonic perforations (February 2002 to August 2009) is reported. These were treated, in 6 cases, with laparoscopic colorrhaphy, in 2 cases with laparoscopic colonic resection and anastomosis (with 1 temporary ileostomy), and the last patient with laparoscopic Hartmann procedure. RESULTS: All patients underwent successful laparoscopic treatment, with no mortality. CONCLUSIONS: Laparoscopic treatment of iatrogenic colonic perforations is a compromise between risks of nonoperative therapy and invasive surgery. According to our early experience, laparoscopic approach could be used as first choice in the management of these complications. Further studies are necessary for full validation of this approach.

Laparoscopic approach to gastric remnant-stump: our initial successful experience on 3 cases.

INTRODUCTION: Laparoscopic treatment of gastric adenocarcinoma is still a debated issue. In this paper, we retrospectively reviewed 3 cases of laparoscopic treatment of gastric remnant-stump adenocarcinoma. We analyzed the feasibility, the postoperative outcome, and the short-term results. MATERIALS AND METHODS: From January 2003 to September 2005, we carried out 3 laparoscopic completion gastrectomies for cancer of the remnant stomach. All patients were males, between 59 and 73 years old. All of them had a previous history of benign gastric ulcer that required a Billroth II subtotal gastrectomy. We always performed a D2 lymphadenectomy and a Roux an Y side-to-side esophagojejunostomy. RESULTS: No conversion was necessary. Mean operative time was 210 minutes (range: 160 to 260 min). No intraoperative transfusions were applied. We had 1 postoperative bleeding managed conservatively with 2 units of blood transfusion. In 1 case, the esophageal transit study showed a tiny anastomotic leak, not clinically evident, which was managed conservatively. The mean peristalsis was present at 56 hours (range: 48 to 72 h). The mean postoperative stay was 11 days (range: 8 to 18 d). In all cases, histologic examination was positive for adenocarcinoma. The mean number of lymph nodes was 18 (range: 12 to 26). The TNM status was: T2N0M0, T3N0M0, and T3N1M0. Resection margins were negative in all cases (R0). The mean follow-up was 17.6 months (range: 11 to 24 mo). The patient with positive lymph node died 11 months after the operation for metastatic disease. CONCLUSIONS: In our preliminary experience, laparoscopic treatment of gastric remnant-stump adenocarcinoma has been demonstrated to be technically feasible and sure. The histologic examination confirmed a proper surgical dissection. Also, if it is an initial experience, we believe that laparoscopy could be considered a valid opportunity to open surgery.

Liver resection with intraoperative and laparoscopic ultrasound: report of 32 cases : Ultrasonic shears device for liver parenchymal transection.

BACKGROUND: Careful staging of hepatic tumors is mandatory for appropriate selection of patients for liver resection. Number and relationships of liver nodules are issues of utmost importance when evaluating resectability. Sensitivity of preoperative imaging for secondary lesions has been reported between 60-75% with spiral contrast-enhanced computed cosmography (CT), 80-85% with magnetic resonance imaging (MRI), and 90-96% with intraoperative ultrasound (IOUS). Also for primary lesions IOUS has been reported to allow detection of liver nodules in 17% and modify surgical strategy in 10%. The aim of this study was to point out the usefulness of open (IOUS) and laparoscopic (LIOUS) ultrasound in patients undergoing hepatic surgery for liver tumors. METHODS: In the years 2004-2006, 50 patients, mean age 66 years (range 44-76 years) were evaluated for resective surgery at the General Surgery Department of Monaldi Hospital, Naples, Italy. All of them were studied with biphasic CT and transabdominal ultrasound. Eighteen (36%) were judged unresectable. The others were scheduled for laparoscopy and LIOUS, by means of an ALOKA SSD-5500 (Aloka Co. Ltd. Tokyo, Japan), equipped with linear flexible tip laparoscopic probe. RESULTS: Six patients (18.7%) were excluded because of pathology diffusion; 26 (81.3%) were resected, using ultrasonic shears (Harmonic ACE, Ethicon Endo-Surgery, Cincinnati Oh., USA) for parenchymal transection, 3 (11.5%) laparoscopically and 23 (88.5%) after laparotomy. IOUS was repeated in the latter group. LIOUS spared useless laparotomies in six patients (18.7%) and, coupled with IOUS, found undetected nodes in five patients (19.2%), changing surgical strategy in three patients (11.5%). CONCLUSION: In our experience LIUOS and IOUS proved to be of utmost importance both in the selection of patients for resective surgery and in planning surgical approach. Ultrasonic shears device and systematic pedicle clamping sped up resection time and reduced intraoperative bleeding.

The role of echo-laparoscopy in abdominal surgery: five years' experience in a dedicated center.

BACKGROUND: For more than 20 years intraoperative ultrasonography (IOUS) has been considered an important diagnostic tool in abdominal surgery. In the last few years, with the spread of laparoscopic surgery, echo-laparoscopy (LIOUS) has gradually replaced open ultrasonography, aiming to achieve similar results. METHODS: LIOUS was performed using an ALOKA 5.500 device, provided with a linear flexible laparoscopic probe that was compatible with a 10-mm port. IOUS was performed by means of a linear side-view, T-shaped or microconvex probe. The probes were sterilized with hydrogen peroxide. No water bath was used during the surgical examination, but full contact of the probe with the surface of the involved organ was always attempted. From 2001 to 2005, 36 liver resections, 40 pancreas procedures, 203 procedures for suspected common bile duct calculi, 541 colon and 82 stomach resections, and 82 adrenal surgery procedures were performed. IOUS or LIOUS was performed in 432 patients (43.8%). All livers and pancreases underwent intraoperative ultrasound, while biliary, colonic, gastric, and adrenal pathologies were selectively studied when there were doubts about the location and extension of the disease. RESULTS: IOUS and LIOUS were valuable diagnostic procedures, supplying relevant clinical information in 65.1% of the patients and modifying the surgical approach in 17.2%. LIOUS was used instead of cholangiography to study bile ducts when lythiasis was suspected, achieving high diagnostic specificity (98%) and accuracy (100%). Surgical anatomy of the bile ducts was correctly identified by LIOUS in every case. DISCUSSION: In our experience IOUS and LIOUS were of the utmost importance in better defining staging of disease, infiltration of neighboring structures, number and size of nodular lesions, and anatomy of the hepatic pedicle and intrahepatic structures, thus making it possible to more accurately plan surgical procedures.

Laparoscopic treatment of unicentric Castleman's disease with abdominal localization.

We report a case of unicentric Castleman's disease (angiofollicular lymph node hyperplasia) with abdominal localization, that was treated laparoscopically. The patient, a 23-year-old male, was referred to our unit for subtle symptoms of recurrent palpitations and vague abdominal pain. His physician had prescribed an abdominal echtomograph, which showed a mass located at the lower and anterior lower splenic pole. In order to reach a definite diagnosis and prescribe adequate treatment, a diagnostic laparoscopy was performed. Exploration of the abdominal cavity helped detect a well-vascularized solid round mass at the level of the left hypochondrium, with a vascular pedicle; the lesion was detached, and the pedicle sectioned using an Endo-GIA 40. The postoperative course was regular and the patient was discharged on postoperative day 2. The laparoscopic approach enabled the resection of the lesion (with consequent histological diagnosis) and exploration of the peritoneal cavity with the advantages of minimal invasiveness, magnified images, and more rapid recovery). The pathology was totally resolved, with satisfactory results in terms of recovery, postoperative pain, and cosmesis.