Laparoscopic Inferior Mesenteric Artery Peeling: An Alternative to High or Low Vascular Ligation for Sigmoid Colon Cancer Resection.

BACKGROUND: In sigmoid cancer, both inferior mesenteric artery high or low ligations are accepted for curative purposes. Since inferior mesenteric artery ligation could compromise blood flow to the anastomosis, potentially increasing anastomotic leakage onset, real oncological benefits and possible disadvantages related to vascular transection level are still on debate. We introduce totally laparoscopic inferior mesenteric artery peeling technique to release from the concept of lymph nodal harvesting linked to arterial transection level. METHODS: Over a period of 24 months, 31 patients presenting with sigmoid cancer were submitted to laparoscopic sigmoidectomy associated with inferior mesenteric artery peeling. Data on intraoperative and postoperative outcomes have been prospectively collected. RESULTS: Mean operative time was 180 min (range 110-330 min); mean intraoperative blood loss was 60 ml (range 30-150 ml), and mean postoperative hospitalization was 6.2 days (range 4-11 days). Mean number of lymph node harvested was 16.7 (range 12-28). CONCLUSIONS: Given a proper selection of patients, laparoscopic sigmoidectomy comprehensive of sub-adventitial IMA skeletonization from its aortic origin could provide good oncological outcomes and recanalization rate. Further data are advocated to confirm these preliminary results.

Synchronous totally laparoscopic management of colorectal cancer and resectable liver metastases: a single center experience.

PURPOSE: The simultaneous management of primary colorectal cancer and synchronous liver metastases has been reported extensively in open surgery. Data regarding feasibility, safety, and outcomes of the laparoscopic procedure is emerging from the experience of a few surgical centers. This paper aims at discussing the technique and results of a one-step laparoscopic approach for colorectal cancer and liver metastases resection on a series of 35 patients. METHODS: Between January 2008 and December 2013, 18 males and 17 females (median age 71 years) underwent colorectal and hepatic laparoscopic resection for colorectal metastatic cancer. RESULTS: Thirty-five colorectal resections and 66 liver resections were performed; no conversion to open surgery has been indicated. Median blood loss was 200 ml, median operative time 240 min, and median hospital stay was 8 days (range 4-30). According to Clavien-Dindo classification, two class II complications, two class IIIb complications, and one class IV complication were recorded. Two high-risk patients died within 30 days from surgery. CONCLUSIONS: This series confirms the feasibility of synchronous laparoscopic colorectal and hepatic resections. To ensure the best outcomes, a careful selection of patients is needed. However, most patients can benefit from this surgical approach.

Adult pulmonary blastoma: Report of an unusual malignant lung tumor.

Pulmonary blastoma is an uncommon lung malignancy, usually presenting itself as a large chest mass causing pain, hemoptysis, cough and dyspnea; however, it is asymptomatic in up to 40% of patients. We present the case and suggestive images of a 37-year-old non-smoking lady with a monophasic pulmonary blastoma located in the lower lobe of the left lung who underwent a left posterolateral thoracotomy with lower lobectomy, hilar and mediastinal node dissection, followed by chemo and radiation therapy. After 36 mo, there is no disease progression and the patient is in good health, clinically stable and without significant chest pain.

Use of bovine pericardium graft for abdominal wall reconstruction in contaminated fields.

AIM: To employ, in such conditions, a biological graft such as bovine pericardium that offers resistance to infection. METHODS: In our surgical department, from January 2006 to June 2010, 48 patients underwent abdominal wall reconstruction using acellular bovine pericardium; of these 34 patients had a contaminated wound due to diffuse peritonitis (complicated diverticulitis, bowel perforation, intestinal infarction, strangled hernia, etc.) and 14 patients had hernia relapse on infected synthetic mesh. RESULTS: In our series, one patient died of multi-organ failure 3 d after surgery. After placement of the pericardium mesh four cases of hernia relapse occurred. CONCLUSION: Recurrence rate is similar to that of prosthetic mesh repair and the application of acellular bovine pericardium (Tutomesh(®), Tutogen Medical Gmbh Germany) is moreover a safe and feasible option that can be employed to manage complicated abdominal wall defects where prosthetic mesh is unsuitable.

Managing acute colorectal obstruction by "bridge stenting" to laparoscopic surgery: Our experience.

AIM: To verify the clinical results of the endoscopic stenting procedure for colorectal obstructions followed by laparoscopic colorectal resection with "one stage anastomosis". METHODS: From March 2003 to March 2009 in our surgical department, 48 patients underwent endoscopic stenting for colorectal occlusive lesion: 30 males (62.5%) and 18 females (37.5%) with an age range from 40 years to 92 years (median age 69.5). All patients enrolled in our study were diagnosed with an intestinal obstruction originating from the colorectal tract without bowel perforation signs. Obstruction was primitive colorectal cancer in 45 cases (93.7%) and benign anastomotic stricture in 3 cases (6.3%). RESULTS: Surgical resection was totally laparoscopic in 69% of cases (24 patients) while 17% (6 patients) of cases were video-assisted due to the local extension of cancer with infiltrations of surrounding structures (urinary bladder in 2 cases, ileus and iliac vessels in the others). In 14% of cases (5 patients), resection was performed by open surgery due to the high American Society of Anesthesiologists score and the elderly age of patients (median age of 89 years). We performed a terminal stomy in only 7 patients out of 35, 6 colostomies and one ileostomy (in a total colectomy). In the other 28 cases (80%), we performed bowel anastomosis at the same time as resection, employing a temporary ileostomy only in 5 cases. CONCLUSION: Colorectal stenting transforms an emergency operation in to an elective operation performable in a totally laparoscopic manner, limiting the confection of colostomy with its correlated complications.

Hemostatic step-by-step procedure to control presacral bleeding during laparoscopic total mesorectal excision.

BACKGROUND: A new procedure of hemostasis during laparoscopic total mesorectal excision is described. METHODS: In our surgical department, from January 2004 to December 2007, 128 patients underwent laparoscopic total mesorectal excision. Among them, 47 patients underwent laparoscopic anterior resection after preoperative radiotherapy, 68 patients underwent laparoscopic anterior resection without preoperative radiotherapy, and 13 patients underwent laparoscopic abdominal perineal amputation. RESULTS: In seven laparoscopic rectal surgery cases, we encountered unstoppable presacral bleeding, not amenable by conventional hemostatic solutions. In these cases we applied a simple staging hemostatic procedure. We first performed local compression: tamponing with a small gauze or absorbable fabric hemostat. If bleeding did not stop, we localized an epiploic or omental scrap and excised it by using bipolar forceps and use it as a plug on the tip of a grasping forceps. This plug is then put on the bleeding source and monopolar coagulation is applied by electrified dissecting forceps through the interposed grasping forceps. If bleeding did not stop, we used a little scrap of bovine pericardium graft and tacked it to the bleeding site using endoscopic helicoidal protack. CONCLUSIONS: Our experience suggests that this hemostatic step-by-step procedure is a valid option to control persistent presacral hemorrhages.

A rare case of Bouveret's syndrome presenting with upper gastrointestinal bleeding.

We report a case of duodenal obstruction caused by a large gallstone wedged in the duodenal bulb (Bouveret's syndrome), presenting with acute upper gastrointestinal bleeding and successfully treated by surgery following a failed attempt at endoscopic retrieval of the stone. Haemorrhage is a very rare form of presentation. After an extensive review of the literature, the therapeutic options and surgical strategies (one-stage and two-stage procedure) are critically discussed.

[Laparoscopic versus mini-cholecystectomy: analysis of hospital costs and social costs in a prospective randomized study]. / Video-colecistectomia versus mini-colecistectomia: analisi dei costi ospedalieri e dei costi sociali in uno studio prospettico randomizzato.

The aim of the study was to calculate the hospital and social costs in relation to efficacy of clinical outcome, hospital stay and time off work in two groups of patients randomly treated with laparoscopic or mini-cholecystectomy. One hundred and eighty-one patients with simple, symptomatic gallstone disease were included in the study; of these, 9 cases were excluded because of conversion to conventional cholecystectomy. Eighty-six cases underwent laparoscopic cholecystectomy and 86 mini-cholecystectomy. Operative time (median time: 35 minutes) and hospital stay (median stay: 3 days) were the same for both surgical procedures. The median time off work was 10 days for laparoscopic cholecystectomy and 20 days for mini-cholecystectomy (P = 0.007). Hospital expenses showed a saving of 820.48 euros for each patient undergoing mini-cholecystectomy. Since laparoscopic cholecystectomy is associated with a shorter period off work, it seems to be cheaper with a daily saving of 164.96 and 146.51 Euros per patient, according to cost/effectiveness and cost/utility analyses, respectively. Consequently, although laparoscopic cholecystectomy shows a better outcome in terms of socioeconomic aspects and patient compliance, in an attempt to rationalize hospital expenditure, we would advocate mini-cholecystectomy for those patients who do not need to return to work early.

Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial.

AIMS: This paper aims to evaluate the diagnostic efficacy and costs of follow-up tailored according to risk of recurrence compared with minimal surveillance. METHODS: A total of 358 patients treated by surgery alone for colorectal cancer were prospectively divided into two groups of 200 and 158 patients considered at high and low risk of recurrence respectively, according to prognostic factors. They were further randomized into two subgroups: group 1, 192 patients undergoing risk-adapted follow-up, intensive and low-intensity; group 2, 145 patients undergoing minimal surveillance. Twenty-one cases dropped out. Median follow-up was 61.5 months and 42 months for cases at high risk (intensive follow-up) and at low risk (low-intensity follow-up) respectively. RESULTS: At the end of the study, 52.6% of patients undergoing risk-adapted follow-up and 57.2% undergoing minimal follow-up had developed recurrence. In patients at high risk, a significant difference in the incidence of curative re-operations was observed between the subgroups undergoing risk-adapted follow-up and subgroups undergoing minimal surveillance (P<0.05). The actuarial 5 year survival of patients at high and at low risk of recurrence undergoing risk-adapted follow-up is significantly better than that of cases undergoing minimal follow-up. The economic costs for 34 patients in the intensive follow-up group and for the 57 patients in the low-intensity follow-up group who were free from disease after primary surgery was very similar. CONCLUSIONS: Risk-adapted follow-up has significantly improved the targeting of curative re-operations and overall survival of patients independently of risk of recurrence and has allowed a reduction in the costs of following up of disease-free patients.