Endoscopic or combined management of post-surgical biliary leaks: a two-center recent experience.

BACKGROUND AND AIMS: Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree. METHODS: A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes. RESULTS: 65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005). CONCLUSIONS: ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.

The Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colonproctologia) guidelines for the management of acute and chronic hemorrhoidal disease.

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

Rectal Sparing Approach after preoperative Radio- and/or Chemo-therapy (ReSARCh): a prospective, multicenter, observational study.

BACKGROUND: Rectal-sparing approaches for patients with rectal cancer who achieved a complete or major response following neoadjuvant therapy constitute a paradigm of a potential shift in the management of patients with rectal cancer; however, their role remains controversial. The aim of this study was to investigate the feasibility of rectal-sparing approaches to preserve the rectum without impairing the outcomes. METHODS: This prospective, multicenter, observational study investigated the outcomes of patients with clinical stage II-III mid-low rectal adenocarcinoma treated with any neoadjuvant therapy, and either transanal local excision or watch-and-wait approach, based on tumor response (major or complete) and patient/surgeon choice. The primary endpoint of the study was rectum preservation at a minimum follow-up of 2 years. Secondary endpoints were overall, disease-free, local and distant recurrence-free, and stoma-free survival at 3 years. RESULTS: Of the 178 patients enrolled in 16 centers, 112 (62.9%) were managed with local excision and 66 (37.1%) with watch-and-wait. At a median (interquartile range) follow-up of 36.1 (30.6-45.6) months, the rectum was preserved in 144 (80.9%) patients. The 3-year rectum-sparing, overall survival, disease-free survival, local recurrence-free survival, and distant recurrence-free survival was 80.6% (95% CI 73.9-85.8), 97.6% (95% CI 93.6-99.1), 90.0% (95% CI 84.3-93.7), 94.7% (95% CI 90.1-97.2), and 94.6% (95% CI 89.9-97.2), respectively. The 3-year stoma-free survival was 95.0% (95% CI 89.5-97.6). The 3-year regrowth-free survival in the watch-and-wait group was 71.8% (95% CI 59.9-81.2). CONCLUSIONS: In rectal cancer patients with major or complete clinical response after neoadjuvant therapy, the rectum can be preserved in about 80% of cases, without compromising the outcomes.

Outcomes of Laparoscopic Surgery in Very Elderly Patients with Colorectal Cancer: A Survival Analysis and Comparative Study.

(1) Background: Colorectal cancer (CRC) is a global health concern, particularly among the elderly population. This study aimed to assess the impact of laparoscopic surgery on CRC patients aged ≥80 years. (2) Methods: We conducted a retrospective analysis of prospectively collected data from consecutive CRC patients who underwent surgery at our institution between July 2018 and July 2023. The patients were categorized into three groups: those aged over 80 who underwent laparoscopic surgery (Group A), those aged over 80 who underwent open surgery (Group B), and those under 80 who underwent laparoscopic surgery (Group C). We examined various clinical and surgical parameters, including demographic data, medical history, surgical outcomes, and survival. (3) Results: Group A (N = 113) had shorter hospital stays than Group B (N = 23; p = 0.042), with no significant differences in complications or 30-day outcomes. Compared to Group C (N = 269), Group A had higher comorbidity indices (p < 0.001), more emergency admissions, anemia, low hemoglobin levels, colonic obstruction (p < 0.001), longer hospital stays (p < 0.001), and more medical complications (p = 0.003). Laparotomic conversion was associated with obstructive neoplasms (p < 0.001), and medical complications with ASA scores (p < 0.001). Both the medical and surgical complications predicted adverse 30-day outcomes (p = 0.007 and p < 0.001). Survival analysis revealed superior overall survival (OS) in Group A vs. Group B (p < 0.0001) and inferior OS vs. Group C (p < 0.0001). After a landmark analysis, the OS for patients aged 80 or older and those under 80 appeared to be similar (HR 2.55 [0.75-8.72], p = 0.136). (4) Conclusions: Laparoscopic surgery in very elderly CRC patients shows comparable oncological outcomes and surgical complications to younger populations. Survival benefits are influenced by age, comorbidities, and medical complications. Further prospective multicenter studies are needed in order to validate these findings.

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure.

INTRODUCTION: The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature. METHODS: A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology. CONCLUSIONS: In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Right colectomy with intracorporeal anastomosis for cancer: a prospective comparison between robotics and laparoscopy.

Robotics in right colectomy are still under debate. Available studies compare different techniques of ileocolic anastomosis but results are non-conclusive. Our study aimed to compare intraoperative outcomes, and short-term postoperative results between robotic and standard laparoscopic right colectomies for cancer with intracorporeal anastomosis (ICA) fashioned with the same technique. All consecutive patients scheduled for laparoscopic or robotic right hemicolectomies with ICA for cancer in two hospitals, one of which is a tertiary care centre, were prospectively enrolled in our prospective observational study, from April 2018 to December 2019. ICA was fashioned with the same stapled hand-sewn technique. Continuous and categorical variables were analysed using t test and chi-squared test as required. Statistical significance was set at p < 0.05. Forty patients underwent laparoscopic surgery, and 48 underwent robotic right colectomy and were included in the intention-to-treat analysis. Operative time was not statistically different between the two groups (robotic group 265.9 min vs laparoscopic group 254.2 min, p = 0.29). The robotic group had a significantly shorter time for stump oversewing (ileum reinforcement: robotic group 9.3 min vs laparoscopic group 14.2 min, p < 0.001; colon reinforcement: robotic 7.7. min, laparoscopy 13.9 min, p < 0.001) and for ICA (robotic 31.6 min vs laparoscopy 43.0, p < 0.001). One patient underwent extracorporeal anastomosis in the robotic group. The short-term outcomes were comparable between standard laparoscopic and robotic right colectomies with ICA. The limitation of the study is its small sample size and the fact that it was done in two institutions under the supervision of one person. Our data demonstrate that intracorporeal ileocolic anastomosis is safe, and faster and easier with robotic systems. Robotics can facilitate more challenging ICA in minimally invasive surgery.

Long-Standing Ulcerative Colitis May Trigger a Multilineage Cancerization Field.

Longstanding/relapsing inflammation characterizing ulcerative colitis (UC) has been associated to an increased risk of colon mucosa neoplastic transformation. We describe the clinicopathological features of a UC-related poorly-differentiated neuroendocrine carcinoma coexisting with a conventional adenocarcinoma. This case supports UC as a multilineage cancerization field.

Diagnostic flexible laparoscopy: a single incision procedure.

A novel, minimally invasive diagnostic laparoscopy procedure is described in this report. After positioning a percutaneous trocar and inducing CO2 pneumoperitoneum, a flexible endoscope is introduced through the trocar to inspect intra-abdominal organs, including the surface of the liver, the gallbladder, the stomach, the intestine, the pelvic organs, and free intraperitoneal fluid. Simple procedures such as gathering histological or cytological samples, intraperitoneal lavage, collecting peritoneal fluid for culture, removing adhesions and cyst puncturing are carried out at the endoscopic surgeon's discretion through 1 or 2 working channels. Only a single incision is necessary and, unlike Natural Orifice Translumenal Endoscopic Surgery, visceral iatrogenic perforations are unnecessary.

Selection criteria for surgery in patients with obstructed defecation, rectocele and anorectal prolapse.

The aim of this study was to evaluate the impact of applying strict selection criteria to patients with symptoms of obstructed defecation, rectocele and rectal prolapse who were candidates for surgery. From June 2001 to September 2003, 20 patients underwent surgery in our clinic for symptomatic rectocele and anorectal prolapse. They were evaluated prospectively using a dedicated questionnaire (KESS), a proctological and gynaecological examination, colpo-cysto-defecography and anorectal manometry before surgery and 6 months postoperatively. Strict selection criteria were used for surgery. After 6 months the questionnaire showed an important improvement in symptoms. The symptoms of obstructed defecation and vaginal bulging improved significantly. The average KESS score dropped from 17.65 preoperatively to 5.8 six months after surgery. In the treatment of pelvic floor disease, it is important to evaluate both the uro-gynaecological and the proctological symptoms with the utmost care, obtaining an accurate clinical picture with the aid of dedicated questionnaires and a thorough clinical examination. Evaluation of the effectiveness of surgery for constipation necessarily includes assessing the strength of the indications for surgery, irrespective of the surgical technique adopted, but there is currently no standardised test method for recording and comparing the symptoms of constipation.

Colitis cystica profunda of the rectum: report of a case and review of the literature.

Colitis cystica profunda is a rare intestinal lesion. Because of its clinical expression (rectorrhagia, mucorrhea and abdominal pain) and the way it appears to current imaging techniques this disease presents features which can be associated with colon neoplasm. Its diagnosis has to be confirmed histologically, and its etiology remains unclear. The following is a case report of colitis cystica profunda recurring 20 years after a first episode in a white woman, who had had an anterior resection of the sigmoid colon and upper rectum to deal with a colitis cystica profunda-induced stenosis of the sigmoid colon and at 41 underwent the transanal removal of a polypoid lesion. A review of 20 cases in the literature showed that colitis cystica profunda has a predilection for the male and generally affects the medial and lower rectum and the sigmoid colon. The literature also confirmed the association with ulcerative rectocolitis, Crohn's disease and rectal prolapse. The type of treatment varies from surgical, medical, and endoscopic to no treatment at all.

Insertion of prolonged venous access device: a comparison between surgical cutdown and percutaneous techniques.

The use of totally implantable prolonged venous access devices (TIPVAD) in chemotherapy for oncological patients is now consolidated practice, whereas the choice between surgical cutdown and the percutaneous technique is still a controversial matter. The aim of this study was to retrospectively evaluate the validity and safety of the surgical approach by comparison with percutaneous techniques. Over a period of 17 months, 106 patients (mainly oncological cases) underwent surgical cutdown for TIPVAD placement in the cephalic vein. During a mean follow-up of 8 months (range 1-21), we evaluated the surgical and management complications and compared them with reported results obtained with the percutaneous technique. We observed a lower incidence of pneumothorax, 2 cases of malfunction due to kinking, and no catheter fractures, while management complications were similar to the findings in the literature. In expert hands, the surgical approach is a fast, safe technique with a lower rate of intraoperative complications than the percutaneous approach and less discomfort for the patient. Adequate training of medical and paramedical staff is the most important factor in making TIPVAD reliable and safe in the long term.

Role of transperineal Doppler and ultrasound in evaluating anal sphincter injury after stapled haemorrhoidopexy.

The stapler treatment first described by Longo is considered by some authors to be a good technical solution for mucohaemorrhoidectomy. The aim of the present prospective study was to assess the function and morphology of the internal and external anal sphincters preoperatively and one month after surgery by means of a clinical examination, anorectal manometry and transperineal ultrasound. Ten patients (6 M, 4 F) underwent rectal mucosal prolapsectomy according to Longo. Anoscopy, anorectal manometry and transperineal ultrasound were performed in all patients preoperatively and again one month after surgery. The thickness and integrity of the internal and external anal sphincters were ascertained and colour Doppler was performed to assess the presence, quantity and size of any haemorrhoid swellings. All anatomical specimens underwent histological examination in search of smooth muscle fibres. Anorectal manometry revealed no postoperative sphincter tone defects. Transperineal ultrasound detected no postoperative sphincter lesions and the presence of venous swellings (always present at preoperative colour Doppler) never persisted at postoperative follow-up. The mean follow-up was 52.7 days (range: 31-151). Transperineal ultrasound proved useful in demonstrating the lifting of the mucohaemorrhoid prolapse within the ampulla of the rectum one month after surgery. The Longo procedure, in our albeit limited experience, caused no sphincter lesions.

Giant condyloma acuminatum of the anorectum (Buschke-Lowenstein tumour): a case report of conservative surgery.

Giant condyloma acuminatum of the anorectum (Buschke-Lowenstein tumour) is a rare interesting infectious disease caused by the papillomavirus serotypes 16 and 18. In January 2002 a 47-year-old heterosexual male presented with Buschke-Lowenstein tumour and reported having had the disease for 12 years. The patient underwent thorough screening for sexually-transmitted diseases (which proved negative), abdominal CT, transanal US-endoscopy, inguinal ultrasound, chest X-ray and anorectal manometry, which revealed only localized disease. He was treated conservatively with radical local excision of the lesions. No postoperative complications were observed. Twelve months after surgery, there has been no local or remote recurrence and faecal continence is normal. The treatment of choice for Buschke-Lowenstein tumour is controversial; there is no evidence to support the need for demolitive surgery or chemo- and/or radiotherapy. The majority of authors prefer abdominoperineal amputation, but in our opinion conservative surgery is the best choice, especially in terms of the patient's quality of life.

Laparoscopic-assisted resection is safe and effective for colorectal malignancies: a single-centre experience.

The aim of the study was to evaluate laparoscopic-assisted colorectal resection for malignancies in terms of effectiveness, safety and medium-term survival, comparing our results with those reported in literature. From November 2000 to March 2004, 78 patients with colorectal malignancies underwent laparoscopic-assisted resection. All anastomoses were performed extracorporeally. Where indicated, patients underwent pre- or post-operative chemo-radiotherapy. All patients were followed up at regular intervals for a mean period of 18 months (2-42). The conversion rate was 14.1% and mean intraoperative blood loss was 120 cc. The post-operative morbidity rate was 15.3%. The mean number of lymph nodes removed was 12 (3-38) and all resection margins were clear and adequate. The observed overall and "disease-free" survival rates were similar to those reported in literature. Although the body of evidence needs to be increased, our findings and the data in the literature suggest that laparoscopic-assisted resection for colorectal malignancies is safe and effective, also in the medium and long term.

[Advantages of surgical treatment of hemorrhoids with mechanical sutures]. / Vantaggi del trattamento chirurgico della malattia emorroidaria con suturatrice meccanica.

The use of circular staplers for the treatment of haemorrhoids is a new technique that makes for better correction of the physiopathology of the condition, affords greater patient comfort and reduces health-care expenditure. This technique, which was invented by A. Longo in 1993, pulls up the haemorrhoidal cushions into their anatomical position, reduces or avoids postoperative pain, sparing the sensitive fibres of the anal canal, avoids anal canal stenosis and is not complicated by faecal incontinence. The authors present their experience in 41 patients affected by symptomatic haemorrhoidal prolapse and treated with a mucosal rectal prolapsectomy using a circular stapler. Each patient was followed up for 6 months to assess the incidence of complications and the degree of patient satisfaction. The results were compared with those reported in the literature, obtained using the Milligan-Morgan procedure. The Longo technique, which can be performed in the one-day surgery setting, allows very good relief of postoperative pain, rapid functional recovery and an early return to work, with a saving in health-care expenditure as compared with conventional treatment.