Early diagnosis of anastomotic leakage after colorectal surgery by the Dutch leakage score, serum procalcitonin and serum C-reactive protein: study protocol of a prospective multicentre observational study by the Italian ColoRectal Anastomotic Leakage (iC.

BACKGROUND: Anastomotic leakage (AL) is a dreaded major complication after colorectal surgery. There is no uniform definition of anastomotic dehiscence and leak. Over the years many risk factors have been identified (distance of anastomosis from anal verge, gender, BMI, ASA score) but none of these allows an early diagnosis of AL. The DUtch LeaKage (DULK) score, C reactive protein (CRP) and procalcitonin (PCT) have been identified as early predictors for anastomotic leakage starting from postoperative day (POD) 2-3. The study was designed to prospectively evaluate AL rates after colorectal resections, in order to give a definite answer to the need for clear risk factors, and testing the diagnostic yeld of DULK score and of laboratory markers. Methods and analysis. A prospective enrollment for all patients undergoing elective colorectal surgery with anastomosis carried out from September 2017 to September 2018 in 19 Italian surgical centers. OUTCOME MEASURES: preoperative risk factors of anastomotic leakage; operative parameters; leukocyte count, serum CRP, serum PCT and DULK score assessment on POD 2 and 3. Primary endpoint is AL; secondary endpoints are minor and major complications according to Clavien-Dindo classification; morbidity and mortality rates; readmission and reoperation rates, length of postoperative hospital stay (Retrospectively registered at ClinicalTrials.gov Identifier: NCT03560180, on June 18, 2018). Ethics. The ethics committee of the "Comitato Etico Regionale delle Marche - C.E.R.M." reviewed and approved this study protocol on September 7, 2017 (protocol no. 2017-0244-AS). All the participating centers submitted the protocol and obtained authorization from the local Institutional Review Board.

Renal cavernous hemangioma: robot-assisted partial nephrectomy with selective warm ischemia. Case report and review of the literature.

Renal hemangioma is a relatively rare benign tumor with a wide range of clinical and radiological presentation, not easy to differentiate preoperatively from a renal cancer. Due to its benign nature complete surgical resection is the recommended therapy and is considered curative. A 73-year old male patient followed-up for a lung carcinoma and a chronic renal failure underwent a CT scan showing a 35-mm mass of the inferior pole of the left kidney. The patient underwent robot-assisted partial nephrectomy with left inferior pole selective warm ischemia. The outcome was favorable and no repercussions on the renal reserve were observed postoperatively. Histopathological characteristics of the surgical specimen were consistent with renal cavernous hemangioma. A robot-assisted operation allows the fine dissection required to carry out a bloodless nephron-sparing surgery without a complete warm ischemia. The use of robot could be noteworthy for nephron-sparing surgery in cases of concomitant chronic renal failure.

Perspective of robotic rectal surgery.

Laparoscopy is widely recognized as a feasible and safe approach to rectal cancer associated with an improved early outcome. Robotic surgery overcomes intrinsic limitation of laparoscopic surgery by a three-dimensional view and wristed instruments, improving its outcome as well. Robot-assisted rectal surgery resulted to be safe and feasible. Prospective studies demonstrated its efficacy in allowing a high rate of negative circumferential resection margins with a consequent reduction in solitary loco-regional recurrences. A better local disease control and a reduced surgical trauma will be the conceivable benefit of this surgery.

Intraoperative and postoperative outcome of robot-assisted and traditional laparoscopic Nissen fundoplication.

BACKGROUND: Robotics has been proposed as a tool to improve laparoscopic Nissen fundoplication. However, a clear benefit of this technology for minimally invasive antireflux surgery has not been demonstrated. MATERIALS AND METHODS: A retrospective review of a prospective database was used to compare the intraoperative and postoperative outcome of 137 patients who underwent conventional laparoscopic fundoplication (CLF) and 45 patients who underwent laparoscopic robot-assisted fundoplication (LRF). Intraoperative outcome measures were: operative time, blood loss and complications. Length of hospital stay, functional results and patient satisfaction were used to compare postoperative outcome. RESULTS: Operative time was significantly shorter in the LRF group (65 min) compared to the CLF group (85 min) (p < 0.0001). The overall complication rate was comparable between the two techniques, even though a higher incidence of liver tears was encountered in the CLF group (p < 0.05). Hospital stay, symptom relief and patient satisfaction did not differ between the groups. CONCLUSION: Robotics improves surgeon dexterity and maneuverability during laparoscopic Nissen fundoplication, but this does not correspond to a better postoperative outcome. LRF should be used only for complex cases and training.

A modified umbilical incision for specimen extraction after laparoscopic abdominal surgery.

BACKGROUND: One advantage of laparoscopic surgery over open surgery is the absence of laparotomic incisions. This advantage is reduced when an auxiliary incision is performed to remove surgical specimens larger than the trocar. METHODS: A special incision was performed at umbilical trocar level that enabled removal of a large surgical specimen as in right hemicolectomy (colic), gastric resection, and splenic surgery. RESULTS: The authors have used this method routinely for 10 years for all cases requiring removal of a surgical specimen too large for the normal incision of a 10-mm trocar. CONCLUSION: The authors maintain that this method avoids the use of auxiliary incisions, which undo the many benefits of laparoscopic surgery.

A prolonged follow-up provides new insights into locally advanced pancreatic cancer treatment.

We report the case of a 64-year-old woman treated for a locally advanced pancreatic adenocarcinoma, which could not undergo radical resection due to encasement of the superior mesenteric artery. After chemoradiotherapy (six weeks), normalization of plasma CA19.9 levels was documented and CT showed shrinkage of the pancreatic mass but persistent encasement of the SMA. Surgical exploration followed by radical resection was performed 18 months later. Resection of the pancreatic head was then performed and the final pathological analysis showed a complete response. This case is unique in terms of the duration of follow-up between chemoradiotherapy and radical resection and raises two main concerns regarding the current standard of care of locally advanced pancreatic tumors; first, the difficulty of assessing the tumor response to chemoradiotherapy, second, the unfeasibility of establishing the timing of surgery, its indications and the survival benefits for patients with an objective response to therapy.

Surgical management of advanced gastric cancer: An evolving issue.

Worldwide, gastric cancer represents the fifth most common cancer and the third leading cause of cancer deaths. Although the overall 5-year survival for resectable disease was more than 70% in Japan due to the implementation of screening programs resulting in detection of disease at earlier stages, in Western countries more than two thirds of gastric cancers are usually diagnosed in advanced stages reporting a 5-year survival rate of only 25.7%. Anyway surgical resection with extended lymph node dissection remains the only curative therapy for non-metastatic advanced gastric cancer, while neoadjuvant and adjuvant chemotherapies can improve the outcomes aimed at the reduction of recurrence and extension of survival. High-quality research and advances in technologies have contributed to well define the oncological outcomes and have stimulated many clinical studies testing multimodality managements in the advanced disease setting. This review article aims to outline and discuss open issues in current surgical management of advanced gastric cancer.

[Minimally invasive treatment of cholelithiasis in the elderly]. / Trattamento mininvasivo della colelitiasi nel paziente anziano.

BACKGROUND: As cholelithiasis has an incidence which is proportional to the age of the patient, it is often detected in the elderly, who have a higher operative risk. Therefore the therapeutic approach should involve low risk and low invasive techniques. The aim of this study is to evaluate the efficacy of combined laparoscopic and endoscopic treatment in biliary tract lithiasis and gallstones. METHODS: One hundred and fifty-seven patients over 60 years old affected by cholelithiasis have been treated with minimally invasive techniques. Mean age was 68+/-5.9 years (range 60-85) and male/female ratio was 1:1.5. All the patients underwent a preoperative screening (abdominal ultrasound, liver functional tests) to evaluate the risk of choledocholithiasis associated to cholelithiasis. An ultrasound examination was performed postoperatively after 15 days and then after 6 months. RESULTS: No death due to cholecystectomy or endoscopic sphincterotomy was registered, while morbility was 5.7%. Mean hospital stay was 2+/-1.67 days which reached 5.3+/-0.7 days in case of endoscopic sphincterotomy with ERCP. CONCLUSIONS: Cholecystectomy and endoscopic sphincterotomy revealed to be low risk techniques and therefore they will to become the gold-standard treatment of cholelithiasis in the elderly.

[Our choice of the method to induce pneumoperitoneum in videolaparoscopic surgery]. / La nostra scelta sul metodo di induzione dello pneumoperitoneo in chirurgia videolaparoscopica.

BACKGROUND: In laparoscopic surgery, pneumoperitoneum may be obtained either by a blind or an open access technique. These two techniques and the advantages of Hasson technique are compared. METHODS: Through January 1998 and May 1999, 262 unselected patients underwent laparoscopic surgery; pneumoperitoneum was obtained with a random technique, while in the patients previously operated on the open technique was always performed. In 161 cases (61.5%) pneumoperitoneum was obtained with Hasson technique and in 101 (38.5%) with Veress technique. All the patients were clinically evaluated after surgery and then after 30-40 days. The complications encountered were always associated with the Veress needle blind access: peritoneal space insufflation in 3 cases, greater omentum insufflation in 3 cases, 4 cases of difficult management and only one case of incisional hernia on the umbilical wound. RESULTS: Our data confirm that Hasson open technique is safer than Veress blind technique as the risk of severe early and late complications is lower. CONCLUSIONS: The open laparoscopic technique with the Hasson trocar is recommended as it showed to be a quicker, safer and superior technique for obtaining pneumoperitoneum.

[Transperitoneal anterior access in video-laparoscopic adrenalectomy]. / Accesso anteriore transperitoneale nella surrenalectomia videolaparoscopica.

BACKGROUND: The more wide spread laparoscopic technique to operate on the adrenal gland is transabdominal approach with a lateral flank adrenalectomy. However, the transabdominal anterior approach can be a sure and safe alternative in selected patients. METHODS: From 1997 to 1999, 18 selected patients underwent laparoscopic anterior adrenalectomy. Mean age was 43 years (range 25-63) with a male/female ratio of 1:1. Indications were Conn's adenoma in 10 patients, pheochromocytoma in 3 cases, Cushing syndrome in 1 and incidentaloma in 4. All the procedures were carried out laparoscopically and only one patient required conversion to an open adrenalectomy for clear signs of malignancy. The mean time for adrenalectomy was 140 minutes and the shorter times were recorded in the right-sided procedures (mean time 84 minute). Estimated blood loss was minimal and no transfusion was done. There were no postoperative complications related to the surgical technique and the hospital stay was 4 days in average. RESULTS: Our data confirm, according with other authors, that this method is feasible in selected patients. Longer times recorded for the left-sided lesions were due to the more difficult dissection required to gain the left adrenal gland. CONCLUSIONS: Transabdominal adrenalectomy with patient in the supine position is feasible, but its use is restricted to the cases with suspect bilateral or multifocal pheochromocytoma, to patients with concomitant abdominal pathologies that can be operated on laparoscopically, to surgeons who prefer to have a frontal view of the operative field.

[The role of laparoscopy in the identification of peritoneal carcinosis from abdominal neoplasms. Analysis of our initial experience]. / Ruolo della laparoscopia nella identificazione della carcinosi peritoneale da neoplasie addominali. Analisi della nostra esperienza iniziale.

BACKGROUND: The authors reviewed the experience on the use of laparoscopy performed since January 1997 in malignant neoplasms at their institution. The aim of the study was to evaluate the real effectiveness of this procedure in the staging of abdominal neoplasms which were considered resectable at preoperative examinations and in particular in the detection of peritoneal metastases not evidenced with traditional imaging techniques. METHODS: Twenty-eight patients with malignant neoplasms: colo-rectum (15), stomach (5), pancreas (4), gallbladder (2), cardias (1), liver (1), were studied. All the patients were preoperatively examined with abdominal computed tomography (CT). In the 2 patients with gallbladder neoplasm a MR cholangiography was also performed. An explorative laparoscopy with peritoneal washing was then performed in all the patients. The diagnostic and therapeutic choices were subsequently done on the basis of laparoscopy results. RESULTS: Therapeutic approach was modified in 21% of cases, as a result of the detection of peritoneal metastases which were not evidenced with imaging examinations. On the contrary, peritoneal washing was not responsible of any preoperative evaluation. CONCLUSIONS: Laparoscopy performed in patients with abdominal neoplasms allows the detection of peritoneal micrometastases not previously evidenced through preoperative CT, thus modifying the therapeutic approach.

[Surgical treatment of diverticular disease of the colon. Our experience in the last decade]. / Il trattamento chirurgico della malattia diverticolare del colon. Nostra esperienza relativa ad un decennio.

The authors analyse their personal experience of diverticular disease of the colon and, comparing it with that of other authors, draw attention to some fundamental data relating to the type of management chosen. Having underlined the high incidence of disease in relation changed living conditions, the authors point out that this pathology is becoming more frequent as a result of the increased average age and that subacute and acute clinical manifestations of the disease are also more common-place. Attention has often been drawn to the presence of non-evolved phlogistic symptoms which it is possible to treat medically thus enabling the operation to be postponed in some cases to a time which is more convenient for the patient, whereas in other cases it has resulted in the remission of symptoms. Surgical therapy need not be used in "silent" cases, but is obligatory in recurring or complicated forms. The authors also affirm that surgery is not burdened by particular postoperative complications which, if present, are linked essentially to peritonitis due to perforation or to other associated pathologies. The use of mechanical staplers has also restricted the number of derivative operations and those performed in several stages.

[Pneumoretroperitoneum due to pneumatosis cystoides intestinalis. An etiopathogenetic and clinico-diagnostic assessment. A clinical case report]. / Pneumoretroperitoneo da pneumatosi cistica intestinale. Valutazioni etiopatogenetiche e clinico-diagnostiche. Presentazione di un caso clinico.

A case of pneumoretroperitoneum which came out to be caused by pneumatosis cystoides intestinalis, after careful and proper diagnostic evaluation, is described. Physiopathology, etiopathogenesis and clinical peculiarities of this infrequent pathology are examined; most useful tests to be performed in diagnostic differential evaluation, and clinical and surgical therapeutic approaches are also described, especially facing rare complications of PCI, such as pneumoperitoneum and pneumoretroperitoneum.

A case of "silent" pheochromocytoma presenting as spontaneous retroperitoneal hematoma.

Pheochromocytoma of the adrenal gland can be the cause of massive and lethal retroperitoneal haemorrhage presenting as acute abdomen. Here we report a case of retroperitoneal hematoma, with concomitant peritoneal spillage, due to the spontaneous rupture of a silent pheochromocytoma. The main clinical findings of this disease will be described. Therapy and prognosis will be also discussed.

[Aberrant pancreas: description of a clinical case and review of the literature]. / Pancreas aberrante: descrizione di un caso clinico e revisione della letteratura.

Aberrant pancreas is a rare finding pathology. Authors reviewed this problem after their personal observation of a specific case, pointing out the behaviour of the disease, particularly the difficult for a careful preoperative diagnosis. They also point out the necessity to make a diagnosis of "suspect" in presence of a symptomatology with the referred characters and when there aren't instrumental findings for evident pathologies.