Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort.

BACKGROUND: In Italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. The aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery. METHODS: A database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. The primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. The results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i. RESULTS: A total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). Group A versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). A mean postoperative duration of stay difference of 0.86 days was detected between groups. No difference was recorded between the two groups for all the other endpoints. CONCLUSION: This study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery.

Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts.

Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. METHODS: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. RESULTS: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. CONCLUSIONS: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Clear Cell Hidradenocarcinoma: a Rare Identity Difficult to Recognize - Case Report and Review of the Literature.

Hidradenocarcinoma (HC) is a malignant and aggressive sweat gland tumour. It is a rare occurrence, accounting for about 6% of malignant eccrine cancers and less than 1% of all cutaneous neoplasms. It is a malignant tumor which can manifest itself in any area of the body, including the anterior surface of the trunk, the torso, scalp, face, and extremities. It is apparent that HC has a high propensity for lymphatic metastasis. The suggested treatment approach for HC implies making a wide surgical excision with negative margins. Nevertheless, such tumours are aggressive and recur locally in 50% of cases; they also produce metastases in 60% of cases. The overall five-year survival rate is 30%. Here, we present the case of a 68-year-old Caucasian male with unknown diagnosis of malignant neoplasm of inguinal cutaneous skin of sweat gland called hydrocarcinoma.

[Structured implementation and high adherence to the ERAS program in colorectal surgery in two operating units of the ASUR Marche.] / Implementazione strutturata ed elevata aderenza al programma ERAS in chirurgia colorettale in due unità operative dell'ASUR Marche.

BACKGROUND: An Enhanced Recovery After Surgery (ERAS) program in colorectal surgery is able to significantly reduce the morbidity rates and postoperative hospital stay (LOS) related to the intervention. However, it is not clear what modalities and levels of implementation are necessary to achieve these results. The purpose of this work is to analyze the methods and results of the first year of implementation of the program in two centers of the Agenzia Sanitaria Unica Regionale (ASUR) Marche. MATERIALS: After a structured implementation pathway, characterized by the creation of a core team, field training, internal courses and coaching, the details of 196 consecutive cases of patients submitted to colorectal resection over a one-year period in two surgical units of the ASUR Marche were prospectively loaded in a database, considering over 50 variables including adherence to the individual items of the ERAS program. The primary outcomes were: overall and major morbidity, mortality and anastomotic dehiscence rates; secondary outcomes were: LOS, re-admission and re-intervention rates. The results of primary endpoints were evaluated by univariable and multivariable analyses with logistic regression and, thereafter, according to ERAS item adherence rate. RESULTS: After a median (interquartile range, IQR) follow-up of 40 (32-94) days, we recorded complications in 72 patients (overall morbidity 36.7%), major morbidity in 14 patients (7.1%), 6 deaths (mortality 3.1%), an anastomotic dehiscence in 9 cases (4.9%), median (IQR) overalll LOS 5 (3-7) days, 10 readmissions (5.1%) and 13 reoperations (6.7%). The mean adherence rate to the items of the ERAS program was 85.4%, showing a significant dose-effect curve for overall morbidity, major morbidity, anastomotic leakage and for overall LOS. DISCUSSION: The ERAS implementation methods in this project led to a high adherence (>80%) to the program items. All the results showed a significant improvement compared to the previous pre-implementation period and according to the adherence to program items rate.

ERAS pathway in colorectal surgery: structured implementation program and high adherence for improved outcomes.

Although there is clear evidence that an Enhanced Recovery After Surgery (ERAS) program in colorectal surgery leads to significantly reduced morbidity rates and length of hospital stay (LOS), it is still unclear what modalities and levels of implementation of the program are necessary to achieve these results. The purpose of this study is to analyze the methods and results of the first year of structured implementation of a colorectal ERAS program in two surgical units of the Azienda Sanitaria Unica Regionale (ASUR) Marche in Italy. A two-center observational study on a prospectively maintained database was performed on 196 consecutive colorectal resections (excluding emergencies and American Society of Anesthesiologists class > III cases) over a 1-year period. More than 50 variables including adherence to the individual items of the ERAS program were considered. Primary outcomes were overall morbidity, major morbidity, mortality and anastomotic leakage rates; secondary outcomes were LOS, re-admission and re-operation. The results were evaluated by univariate and multivariate analyses through logistic regression. After a median follow-up of 39.5 days, we recorded complications in 72 patients (overall morbidity 36.7%), major complications in 14 patients (major morbidity 7.1%), 6 deaths (mortality 3.1%), anastomotic dehiscence in 9 cases (4.9%), mean overall LOS of 6.6 days, 10 readmissions (5.1%) and 13 reoperations (6.7%). The mean adherence rate to the items of the ERAS program was 85.4%, showing a significant dose-effect curve for overall and major morbidity rates, anastomotic leakage rates and LOS. The implementation methods of a colorectal ERAS program in this study led to a high adherence (> 80%) to the program items. High adherence had significant effects also on major morbidity and anastomotic leakage rates.

Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery.

PURPOSE: To analyze different types of management and one-year outcomes of anastomotic leakage (AL) after elective colorectal resection. METHODS: All patients with anastomotic leakage after elective colorectal surgery with anastomosis (76/1,546; 4.9%), with the exclusion of cases with proximal diverting stoma, were followed-up for at least one year. Primary endpoints were as follows: composite outcome of one-year mortality and/or unplanned intensive care unit (ICU) admission and additional morbidity rates. Secondary endpoints were as follows: length of stay (LOS), one-year persistent stoma rate, and rate of return to intended oncologic therapy (RIOT). RESULTS: One-year mortality rate was 10.5% and unplanned ICU admission rate was 30.3%. Risk factors of the composite outcome included age (aOR = 1.08 per 1-year increase, p = 0.002) and anastomotic breakdown with end stoma at reoperation (aOR = 2.77, p = 0.007). Additional morbidity rate was 52.6%: risk factors included open versus laparoscopic reoperation (aOR = 4.38, p = 0.03) and ICU admission (aOR = 3.63, p = 0.05). Median (IQR) overall LOS was 20 days (14-26), higher in the subgroup of patients reoperated without stoma. At 1 year, a stoma persisted in 32.0% of patients, higher in the open (41.2%) versus laparoscopic (12.5%) reoperation group (p = 0.04). Only 4 out of 18 patients (22.2%) were able to RIOT. CONCLUSION: Mortality and/or unplanned ICU admission rates after AL are influenced by increasing age and by anastomotic breakdown at reoperation; additional morbidity rates are influenced by unplanned ICU admission and by laparoscopic approach to reoperation, the latter also reducing permanent stoma and failure to RIOT rates. TRIAL REGISTRATION: ClinicalTrials.gov # NCT03560180.

Colorectal surgery in Italy during the Covid19 outbreak: a survey from the iCral study group.

BACKGROUND: The COVID19 pandemic had a deep impact on healthcare facilities in Italy, with profound reorganization of surgical activities. The Italian ColoRectal Anastomotic Leakage (iCral) study group collecting 43 Italian surgical centers experienced in colorectal surgery from multiple regions performed a quick survey to make a snapshot of the current situation. METHODS: A 25-items questionnaire was sent to the 43 principal investigators of the iCral study group, with questions regarding qualitative and quantitative aspects of the surgical activity before and after the COVID19 outbreak. RESULTS: Two-thirds of the centers were involved in the treatment of COVID19 cases. Intensive care units (ICU) beds were partially or totally reallocated for the treatment of COVID19 cases in 72% of the hospitals. Elective colorectal surgery for malignancy was stopped or delayed in nearly 30% of the centers, with less than 20% of them still scheduling elective colorectal resections for frail and comorbid patients needing postoperative ICU care. A significant reduction of the number of colorectal resections during the time span from January to March 2020 was recorded, with significant delay in treatment in more than 50% of the centers. DISCUSSION: Our survey confirms that COVID19 outbreak is severely affecting the activity of colorectal surgery centers participating to iCral study group. This could impact the activity of surgical centers for many months after the end of the emergency.

Esophagojejunal Anastomosis Leakage after Total Gastrectomy: Special Tretament with Thoracic Minimal Invasive Management. Case Report and Review.

Background:Esophagojejunal leakage is one of the most serious complication in gastric surgery for cancer Case presentation:We report the case of a 74-year-old woman with severe leakage after d2 total gastrectomy that was treated without re-surgery. Conclusion:a multidisciplinary approach is the best choice for decision making leakage treatment demonstrating inferior morbidity and mortality then re-surgery.

A 23 year experience with laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endo-laparoscopic treatment, but with shorter hospital stay, lower cost and recurrent stone rate. Aim of this paper was to report the authors' experience with LCBDE during LC. METHODS: A retrospective analysis of patients who underwent LCBDE for ductal stones was performed. Recurrent stones were defined as CBD stones detected beyond 6 months from the procedure. Postoperative biliary stricture was defined as a symptomatic reduction of CBD diameter. RESULTS: Out of 3444 patients who underwent LC, 384 (11%) had CBD stones treated by trans-cystic duct exploration [214 (6%) patients, TCD-CBDE] or choledochotomy [170 (5%) patients, C-CBDE]. For TCD-CBDE and C-CBDE, mean operative time was 127 ± 69 and 191 ± 74 min, respectively. Major morbidity rate was 3% (n = 6) in TCD-CBDE and 6% (n = 11) in C-CBDE. The incidence of residual stones was 5% (n = 20) and complete ductal clearance rate was 95% (n = 364). After long-term follow-up (mean 189 ± 105 months) the recurrent stone rate was 2%. DISCUSSION: In expert centers, LCBDE during LC is safe and effective with low short and long term morbidity rates.

Inferior Vena Cava Duplication: Incidental Case in a Young Woman.

A case of a double inferior vena cava (IVC) with retroaortic left renal vein, azygos continuation of the IVC, and presence of the hepatic portion of the IVC drained into the right renal vein is reported and the embryologic, clinical, and radiological significance is discussed. The diagnosis is suggested by multidetector computed tomography (MDCT), which reveals the aberrant vascular structures. Awareness of different congenital anomalies of IVC is necessary for radiologists to avoid diagnostic pitfalls and they should be remembered because they can influence several surgical interventions and endovascular procedures.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones.

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

Totally robotic vs 3D laparoscopic colectomy: A single centers preliminary experience.

AIM: To compare robotic and three-dimensional (3D) laparoscopic colectomy based on the literature and our preliminary experience. METHODS: This retrospective observational study compared operative measures and postoperative outcomes between laparoscopic 3D and robotic colectomy for cancer. From September 2013 to September 2014, 24 robotic colectomies and 23 3D laparoscopic colectomy were performed at our Department. Data were analyzed and reported both by approach and by colectomy side. Robotic left colectomy (RL) vs laparoscopic 3D left colectomy (LL 3D) and Robotic right colectomy (RR) vs laparoscopic 3D (LR 3D). Rectal cancer procedures were not included. RESULTS: There were 18 RR and 11 LR 3D, 6 RL and 12 LL 3D. As regards LR 3D, extracorporeal anastomosis (EA) was performed in 7 patients and intracorporeal anastomosis (IA) in 4; the RR group included 14 IA and 4 EA. There was no mortality. Median operative time was higher for the robotic group while conversion rate (12.5% vs 13%) and lymph nodes removed (14 vs 13) were similar for both. First flatus time was 1 d for RR and 2 d the other patient groups. Oral intake was resumed in 1 d by LR and in 2 d by the other patients (P = 0.012). Overall cost was €4950 and €1950 for RL and LL 3D, and €4450 and €1450 for RR and LR 3D, respectively. CONCLUSION: There were no differences between RR and LR 3D, except that IA was easier with RR, and probably contributed with the learning curve to the longer operative time recorded. Both techniques offer similar advantages for the patient with significantly different costs. In left colectomies robotic colectomy provided better outcomes, especially in resections approaching the rectum.

Laparoscopic transperitoneal anterior adrenalectomy in pheochromocytoma: experience in 62 patients.

BACKGROUND: Aim was to evaluate the results in 62 patients undergoing laparoscopic adrenalectomy (LA) for the treatment of pheochromocytoma (PHE), with a transperitoneal anterior approach for lesions on the right side, and with a transperitoneal anterior submesocolic approach in case of left-sided lesions. METHODS: Sixty-two patients underwent LA for the treatment of PHE at two centers in Rome and Ancona (Italy). Two patients had bilateral lesions, for a total of 64 adrenalectomies. Sporadic PHE occurred in 57 patients (91.9 %) and in 5 (8.0 %) it was familiar. Thirty-six patients (58.0 %) underwent right adrenalectomy, 24 (38.7 %) left adrenalectomy, and in 2 cases (3.2 %) LA was bilateral. In 38 cases of right adrenalectomy (59.3 %) and in 5 cases of left adrenalectomy (7.8 %), the approach was a transperitoneal anterior one. A transperitoneal anterior submesocolic approach was used in 21 left adrenalectomy cases (32.8 %). RESULTS: Mean operative time for right and left transperitoneal anterior LA was 101 min (range 50-240) and 163 min (range 50-190), respectively. Mean operative time for left transperitoneal anterior submesocolic LA was 92 min (range 50-195). For bilateral adrenalectomy, mean operative time was 210 min (range 200-220). Conversion to open surgery occurred in 2 cases (3.22 %) due to extensive adhesions (1) and hemorrhage (1). One major and three minor complications were observed. Mobilization occurred on the first postoperative day. Hospitalization was 4.8 days (range 2-19). The lesions had a mean diameter of 4.5 cm (range 0.5-10). CONCLUSIONS: Early identification with no gland manipulation prior to closure of the adrenal vein is the main advantages of the transperitoneal anterior approach. PHE may be treated safely and effectively by a laparoscopic transperitoneal anterior approach for right-sided lesions and with a transperitoneal anterior submesocolic approach for left-sided ones.

Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy.

BACKGROUND AND PURPOSE: There is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3 years. METHODS: The subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; n = 164) or laparoscopic surgery (LS group; n = 126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0 months after OS and LS, respectively. RESULTS: There were 10 (6.1 %) versus 9 (7.1 %) deaths unrelated to cancer, 15 (9.1 %) versus 5 (4 %) cases of local recurrence, 7 (4.2 %) versus 5 (4 %) cases of peritoneal carcinosis, and 37 (22.5 %) versus 14 (11.1 %) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8 %). The OS group had a significantly higher probability of local recurrence and metastases (p < 0.001) with a significant higher probability of cancer-related death (p = 0.001) than the LS group. CONCLUSIONS: These findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.

Laparoscopic colectomy is a reliable option for colon cancer treatment.

AIMS: To report oncological results in a remarkable single institution series of laparoscopic colectomy for cancer. METHODS: 340 not selected patients with adenocarcinoma of colon underwent laparoscopic colonic resection in a five years period (2004-2008). Of the 340 patients, there were 185 male and 155 female. The mean age was 68 years (31-92). Of the 340 procedures, 175 were laparoscopic right colectomy and 165 laparoscopic left colectomy. No tumor touch technique, ligation at vascular origin, adequate lymphadenectomy and minilaparotomy protection against cells implant was the main landmarks of all cases. RESULTS: There was no intraoperative mortality. Twenty patients (5.8%) were converted to open surgery. Two patients (0,58%) died in the postoperative period. Five major complications occurred (1,5%) in the postoperative period. The average hospital stay for patients who underwent right colectomy was 6.7 days (4-27) and 6.9 for patients underwent left hemicolectomy (4-23). The average number of lymph nodes removed was 15.6. In a mean 38 months follow-up (25-78) there were 16 incisional hernias, 12 after right colectomy and 4 after left. Eight patients (4,5%) who underwent laparoscopic right colectomy and ten (6%) of the left colectomy group developed a metastatic disease. The overall mortality rate was 10.8%; 14.3% for patients who underwent resection of the right colon and 7.2% for the left colectomy series. CONCLUSIONS: Laparoscopic colectomy for cancer is feasible, safe and not encumbered by an higher complications rate compared to open colectomy. If the oncological criteria are respected, the results are at least noniferior to the open access.

Transanal endoscopic microsurgery for 135 patients with small nonadvanced low rectal cancer (iT1-iT2, iN0): short- and long-term results.

BACKGROUND: Local excision of rectal cancer as an alternative to radical resection for patients with small nonadvanced low rectal cancer (SNALRC) (iT1-iT2, iN0) is debated. This study aimed to analyze the short- and long-term results for a series of 135 patients with SNALRC who underwent local excision by transanal endoscopic microsurgery (TEM). METHODS: According to the study protocol, 135 patients classified by endorectal ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) imaging as having iT1 iN0 iM0 (n = 51) or iT2 iN0 iM0 (n = 84) low rectal cancer were enrolled in the study. All the patients with iT2 rectal cancer underwent neoadjuvant therapy. The definitive histologic findings showed 24 pT0 patients (17.8%), 66 pT1 patients (48.8%), and 45 pT2 patients (33.4%). RESULTS: Minor complications were observed in 12 patients (8.8%) and major complications in 2 patients (1.5%). During a median follow-up period of 97 months (range, 55-139 months), local recurrences occurred for four patients and distant metastases for two patients. The patients who experienced a recurrence had been preoperatively staged as iT2 and were low or nonresponders to neoadjuvant treatment (ypT2). At the end of the follow-up period, the disease-free survival rates were 100% for the iT1 patients and 93% for the iT2 patients CONCLUSIONS: The long-term results for adequate local excision by TEM with or without neoadjuvant radiochemotherapy in the treatment of SNALRC based on the current study protocol are not inferior to those reported in the literature for radical surgery with total mesorectal excision (TME).

Primary adrenal hypercortisolism: minimally invasive surgical treatment or medical therapy? A retrospective study with long-term follow-up evaluation.

BACKGROUND: Because the most suitable management of subclinical Cushing syndrome (SCS, which involves hypersecretion of cortisol without clinically evident disease) still is undefined, the current study aimed to compare retrospectively the outcome for a cohort of patients treated by medical therapy or laparoscopic adrenalectomy (LA). METHODS: Over a 12-year period, 47 patients with SCS have been treated by means of LA (19 patients, group A) or medical therapy (28 patients, group B). Group A consisted of 15 women and 4 men with a mean age of 54.8 years. Eight patients had a left adrenal mass, whereas nine had a right adrenal mass, and one patient had bilateral lesion. Group B was composed of 18 women and 10 men with a mean age of 57.8 years. Of these patients, 14 had a left adrenal lesion, 12 had a right adrenal lesion, and 1 had bilateral lesion. The patients were followed up for a mean 4 years (range, 1-11 years) by both an endocrinologist and a surgeon. RESULTS: In group A, hypertension improved for 66.3% of the patients; body mass index (BMI) decreased for 47.4%; and hyperlipidemia based on high-density lypoproteins (HDL) cholesterol, total cholesterol ratio, and triglyceridemic concentration improved for 63.2% of the patients. No changes in bone parameters were seen after surgery in SCS patients with osteoporosis. Some patients in group B, during their long-term medical therapy, experienced worsening hypertension (14.2%), hyperlipidemia (17.8%), and diabetes mellitus (8%). CONCLUSIONS: This retrospective study focused on a cohort of patients with SCS. Their medium long-term follow-up evaluation showed that LA is better than medical therapy for treating this condition, especially by reducing the cardiovascular risk (hypertension-hyperlipidemia).

[Laparoscopic surgery of rectal cancer: state of art and long-term results]. / Chirurgia laparoscopica del cancro del retto. Stato dell'arte e risultati a lungo termine.

BACKGROUND: From the first laparoscopic colectomy that we performed 18 years ago, several studies showed equivalent oncologic results of this technique compared to open surgery Despite this evidence traditional surgeons remain skeptical in the use of this technique, although it may favor an early return of bowel function and therefore a shorter hospitalization, as reported in recent comparative studies. Many colorectal surgeons, who have appreciated the advantages of laparoscopic colectomy, extended this approach also in rectal cancer, finding a better view in the pelvis during dissection. METHOD: From 1992 to july 2009 we performed more than 400 laparoscopic resection and amputation for rectal cancer. One hundreds eighteen patients (TNM stage I-III) with a 36 month minimum follow-up were enrolled in this analysis. Converted patients to open surgery and patients staged as iT1N0 are not present in this series because we treat with local excision by TEM. RESULTS: Mean operative time was 160 minutes (90-265). Mortality was 1% in 186 patients and conversion rate was 1.5%. Major complications occurred in 10.7%, including anastomotic leakage in 14 patients (7.5%) and mean hospital stay was 7.7 days. With a mean follow up of 96.8 (36-175) months in the stage I-III, the local recurrence rate was 12.5%. Systematic recurrence occurred in 13.1%. CONCLUSION: Laparoscopic resection in rectal cancer would allow the use of the same Heald's technique, respecting the Heald's principle of meticulous dissection during total mesorectal excision, furthermore we are waiting 5 years data from randomized trials (COLOR II and CLASICC).