Efficacy of Cathelicidin LL-37 in an MRSA Wound Infection Mouse Model.

BACKGROUND: LL-37 is the only human antimicrobial peptide that belongs to the cathelicidins. The aim of the study was to evaluate the efficacy of LL-37 in the management of MRSA-infected surgical wounds in mice. METHODS: A wound on the back of adult male BALB/c mice was made and inoculated with Staphylococcus aureus. Two control groups were formed (uninfected and not treated, C0; infected and not treated, C1) and six contaminated groups were treated, respectively, with: teicoplanin, LL-37, given topically and /or systemically. Histological examination of VEGF expression and micro-vessel density, and bacterial cultures of wound tissues, were performed. RESULTS: Histological examination of wounds in the group treated with topical and intraperitoneal LL-37 showed increased re-epithelialization, formation of the granulation tissue, collagen organization, and angiogenesis. CONCLUSIONS: Based on the mode of action, LL-37 has a potential future role in the management of infected wounds.

Association of Delayed Surgery With Oncologic Long-term Outcomes in Patients With Locally Advanced Rectal Cancer Not Responding to Preoperative Chemoradiation.

Importance: Extending the interval between the end of neoadjuvant chemoradiotherapy (CRT) and surgery may enhance tumor response in patients with locally advanced rectal cancer. However, data on the association of delaying surgery with long-term outcome in patients who had a minor or poor response are lacking. Objective: To assess a large series of patients who had minor or no tumor response to CRT and the association of shorter or longer waiting times between CRT and surgery with short- and long-term outcomes. Design, Setting, and Participants: This is a multicenter retrospective cohort study. Data from 1701 consecutive patients with rectal cancer treated in 12 Italian referral centers were analyzed for colorectal surgery between January 2000 and December 2014. Patients with a minor or null tumor response (ypT stage of 2 to 3 or ypN positive) stage greater than 0 to neoadjuvant CRT were selected for the study. The data were analyzed between March and July 2020. Exposures: Patients who had a minor or null tumor response were divided into 2 groups according to the wait time between neoadjuvant therapy end and surgery. Differences in surgical and oncological outcomes between these 2 groups were explored. Main Outcomes and Measures: The primary outcomes were overall and disease-free survival between the 2 groups. Results: Of a total of 1064 patients, 654 (61.5%) were male, and the median (IQR) age was 64 (55-71) years. A total of 579 patients (54.4%) had a shorter wait time (8 weeks or less) 485 patients (45.6%) had a longer wait time (greater than 8 weeks). A longer waiting time before surgery was associated with worse 5- and 10-year overall survival rates (67.6% [95% CI, 63.1%-71.7%] vs 80.3% [95% CI, 76.5%-83.6%] at 5 years; 40.1% [95% CI, 33.5%-46.5%] vs 57.8% [95% CI, 52.1%-63.0%] at 10 years; P < .001). Also, delayed surgery was associated with worse 5- and 10-year disease-free survival (59.6% [95% CI, 54.9%-63.9%] vs 72.0% [95% CI, 67.9%-75.7%] at 5 years; 36.2% [95% CI, 29.9%-42.4%] vs 53.9% [95% CI, 48.5%-59.1%] at 10 years; P < .001). At multivariate analysis, a longer waiting time was associated with an augmented risk of death (hazard ratio, 1.84; 95% CI, 1.50-2.26; P < .001) and death/recurrence (hazard ratio, 1.69; 95% CI, 1.39-2.04; P < .001). Conclusions and Relevance: In this cohort study, a longer interval before surgery after completing neoadjuvant CRT was associated with worse overall and disease-free survival in tumors with a poor pathological response to preoperative CRT. Based on these findings, patients who do not respond well to CRT should be identified early after the end of CRT and undergo surgery without delay.

Laparoscopic repair of giant Morgagni hernia by direct suturing with V-Loc.

BACKGROUND: Morgagni hernias present technical challenges. The laparoscopic approach for repair was first described in 1992; however, as these hernias are uncommon in adult life, few data exist on the optimal method for surgical management. The purpose of this study was to analyze a method for laparoscopic repair of Morgagni giant hernias using laparoscopic primary closure with V lock (Medtronic, Covidien). METHODS: This case series describes a method of laparoscopic Morgagni hernia repair using primary closure. In all patients, a laparoscopic transabdominal approach was used. The content of the hernia was reduced into the abdomen, and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. Clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. Demographic data such as BMI and operative and postoperative data were collected. RESULTS: Retrospectively collected data for 9 patients were analyzed. There were 1 (11.1%) males and 8 (88.8%) females. The median BMI was 29.14±52 kg/m2. The median operative time was 80±25 minutes. There were no intraoperative complications or conversions to open surgery. Patients began a fluid diet on the first postoperative day and were discharged after a median hospital stay of 3±1.87 days. In a median follow-up of 36 months, we did not observe any recurrences. CONCLUSIONS: Transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for the repair of Morgagni hernia. In our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs.

Transanal endoscopic microsurgery: indications, tips and long-term results. A single center experience.

BACKGROUND: Transanal endoscopic microsurgery (TEM) was introduced to combine the curativeness of full thickness excision with minimum morbidity, while traditional rectal surgery is burdened by high morbidity and mortality rates. However, while it is still a matter of considerable debate whether local excision is an adequate approach for curative resection of rectal cancer, new minimally invasive operative techniques have been introduced. The purpose of this paper was to show the indications, the tips and long term results of this technique through the review of the largest single-center database available to date. The showed results derived from the single center experience of the Clinica Chirurgica of Polytechnic University of Marche. METHODS: We retrospectively reviewed a 25-year database from May 1992 to May 2017. We divided the patients into three different groups of patients according to the preoperative diagnosis: rectal cancers, adenomas and other rectal lesions. Rectal adenomas were divided into two groups according to their diameter (> or <5 cm). Rectal cancer patients were divided into two groups according to the preoperative staging: early rectal cancer and irradiated rectal cancer. RESULTS: Among the 1324 patients who had rectal tumors excised with TEM at our institution, preoperative histology was rectal adenoma in 729 (55%) patients, adenocarcinoma in 536 (40.5%) patients and other lesions in the remaining 59 (4.4%) patients. 5 years overall survival (OS) and Recurrence free survival (RFS) were 93.3% and 98.6% for patients with rectal adenomas and 86.8% and 70.9% for patients with rectal cancer. CONCLUSIONS: TEM can be a valid alternative for the treatment of both benign and malignant rectal lesions, further studies are needed to define more specific indications to justify the survival of this technique in the future.

Erratum: Correction of Affiliation.

This corrects the article "Anastomotic healing in a rat model of peritonitis after non-steroidal anti-inflammatory drug administration " in volume 64(1):3085 In the published article "Anastomotic healing in a rat model of peritonitis after non-steroidal anti-inflammatory drug administration" Eur J Histochem 2020;64(1):3085, https://doi.org/10.4081/ejh.2020.3085," one affiliation was published incorrectly. The authors apologize for any inconvenience that it may have caused. Roberto Ghiselli,1 Guendalina Lucarini,2 Monica Ortenzi,1 Eleonora Salvolini,3 Stefania Saccomanno,2 Fiorenza Orlando,4 Mauro Provinciali,4 Fabio Casciani,1 Mario Guerrieri1 1Clinic of Surgery, Marche Polytechnic University, Ancona 2Department of Clinical and Molecular Sciences, Marche Polytechnic University, Ancona 3Department of Odontostomatologic and Specialized Clinical Sciences, Marche Polytechnic University, Ancona 4Experimental Animal Models for Aging Units, Research Department, Italian National Institute on Aging (INRCA) IRCCS, Ancona, Italy The affiliation should be corrected as follows: 4Experimental Animal Models for Aging Units, Scientific Technological Area, IRCCS INRCA, Ancona, Italy.

Anastomotic healing in a rat model of peritonitis after non-steroidal anti-inflammatory drug administration.

The tissue inflammatory response can influence the outcome of anastomotic healing. Anastomotic leakage represents a dreadful complication after gastrointestinal surgery, in particular sepsis and intra-abdominal infections impair the restorative process of colic anastomoses. It has been debated whether the administration of non-steroidal anti-inflammatory drugs (NSAIDs) is a risk factor for dehiscence, since many patients receive NSAIDs in the early postoperative period. Our aim was, for the first time, to analyze the morpho-functional effects of postoperative administration of two commonly used NSAIDs, Diclofenac and Ketorolac, on the healing process of colo-colic anastomoses constructed under condition of fecal peritonitis in a rat model. Sixty adult male rats underwent two surgical procedures: peritonitis induction and colo-colic anastomosis, and were divided into three groups: 20 rats received saline; 20 rats 4 mg/kg Diclofenac and 20 rats 5 mg/kg Ketorolac. We assessed anastomosis strength, morphological features of tissue wound healing, immunohistochemical metalloproteinase 9 (MMP9) expression and collagen deposition and content by Sirius red staining and hydroxyproline level. We found no significant difference in bursting pressure, collagen content and organization and morphological features between the groups, except a significantly reduced presence of inflammatory cells and MMP9 expression in the groups treated with NSAIDs. Our findings showed that Diclofenac and Ketorolac administration did not affect post-surgical healing and did not increase the leakage risk of colo-colic anastomoses during peritonitis.

Minimally invasive approach to the adrenal gland in obese patients with Cushing's syndrome.

Introduction: The combination of Cushing's syndrome and obesity, one of the most common manifestations of the syndrome itself, may be associated with the worsening of post-operative outcomes in case of laparoscopic adrenalectomy. This study focused on the laparoscopic treatment of Cushing's syndrome with the purpose to identify any relevant difference between morbidly obese, mildly obese and non-obese patients.Material and methods: Patients were retrospectively divided into three groups according to their Body Mass Index (BMI). Demographic characteristics, operative and post-operative data were collected. Data about different hemostatic devices were also collected and compared. Differences were analyzed with the Fisher's exact test for categorical variables, and the Mann-Whitney test for continuous variables.Results: No differences were found in operative time (101.5 ± 50.9 min; p = .919), conversion rate (2.6%; p = .655) or length of stay (4.3 ± 2.9 days; p = .886). Complication rate was 3% (p = .32), without any mortality. 95% of patients showed a complete resolution of hypercotisolyism-related symptoms, and a mean BMI reduction of 5 ± 3.2 kg/m2 (follow up = 6.3 ± 4.2 years). Conclusions: Laparoscopic adrenalectomy is safe and feasible in obese patients affected with Cushing's disease and it can lead to the resolution of the related symptoms.

In vitro and in vivo activity of fosfomycin alone and in combination with rifampin and tigecycline against Gram-positive cocci isolated from surgical wound infections.

Complicated skin and soft tissue infections constitute a heterogeneous group of severe disorders, with surgical site infections being the most common hospital-acquired ones. The aim of our study was to investigate the synergistic and bactericidal activities of antimicrobial combinations of fosfomycin with rifampicin and tigecycline against Enterococcus faecalis, Enterococcus faecium and methicillin-resistant Staphylococcus aureus (MRSA) clinical isolates, and also to evaluate their in vivo effects in a mouse wound infection model. In in vitro studies, the combinations of fosfomycin with rifampicin and tigecycline were both synergistic. These synergies were confirmed in in vivo studies: the drug combinations showed the highest antimicrobial effects compared to monotherapy. In conclusion, the efficacy of fosfomycin combinations, also confirmed in our in vivo model, may suggest new directions in the treatment of infected skin and a possible alternative way to control bacterial skin infection.

Is the bipolar vessel sealer device an effective tool in robotic surgery? A retrospective analysis of our experience and a meta-analysis of the literature about different robotic procedures by investigating operative data and post-operative course.

BACKGROUND: The latest robotic bipolar vessel sealing tools have been described to be effective allowing to perform procedures with reduced blood loss and shorter operative times. The aim of this study was to assess the efficacy and reliability of these devices applied in different robotic procedures. MATERIAL AND METHODS: All robotic operations, between 2014 and 2016, were performed using the EndoWrist One VesselSealer (EWO, Intuitive Surgical, Sunnyvale, CA), a bipolar fully wristed device. Data, including age, gender, body mass index (BMI), were collected. Robot docking time, intraoperative blood loss, robot malfunctioning and overall operative time were analyzed. A meta-analysis of the literature was carried out to point the attention to three different parameters (mean blood loss, operating time and hospital stay) trying to identify how different coagulation devices may affect them. RESULTS: In 73 robotic procedures, the mean operative time was 118.2 minutes (75-125 minutes). Mean hospital stay was four days (2-10 days). There were two post-operative complications (2.74%). CONCLUSIONS: The bipolar vessel sealer offers the efficacy of bipolar diathermy and the advantages of a fully wristed instrument. It does not require any change of instruments for coagulation or involvement of the bedside assistant surgeon. These characteristics lead to a reduction in operative time.

Effect of omiganan on colonic anastomosis healing in a rat model of peritonitis.

BACKGROUND: This study investigates the effects of the antimicrobial cationic peptide omiganan-alone and combined with the antibiotic imipenem-on colonic anastomosis healing in presence of intraperitoneal sepsis induced in a rodent model of cecal ligation and puncture (CLP). METHODS: Forty male Wistar rats were divided into 5 groups of 8 animals. Group 1 (control group) underwent laparotomy and cecal mobilization and the next day received left colon anastomosis. In group 2 (CLP without treatment), group 3 (CLP + imipenem), group 4 (CLP + omiganan), and group 5 (CLP + omiganan + imipenem), the left colon anastomosis was performed the day after CLP. Imipenem and omiganan were administered by intraperitoneal injection immediately before anastomosis construction and subsequently at 24 h intervals until the 7th postoperative day, when rats were sacrificed. Anastomotic bursting pressure was measured in situ. Tissue samples were collected for determination of hydroxyproline content and histological characteristics. RESULTS: Only rats receiving omiganan + imipenem displayed re-epithelialization, reduced neovascularization of granulation tissue, and a bursting pressure that was similar to that of controls. Omiganan-alone and combined with imipenem-was associated with a better control of inflammatory parameters than imipenem alone. In addition omiganan, like imipenem, counteracted the collagen depletion typical of sepsis. CONCLUSIONS: This experimental study demonstrates the efficacy of the new antimicrobial agent omiganan, alone and in combination with imipenem, in delaying the effects of intraperitoneal sepsis on colonic anastomosis healing and provides evidence of the value of omiganan as a therapeutic agent.

Increase of n-NOS and i-NOS in Rat Colon After Sacral Neuromodulation.

OBJECTIVE: Sacral neuromodulation (SNM) is proposed to treat different anorectal dysfunctions but its mechanism of action is not yet known. Our previous study demonstrated how SNM can significantly increase neuronal nitric oxide synthase NOS (n-NOS) and inducible NOS (i-NOS) expression in the anus and rectum of rats. There are no reports regarding the relation between SNM and NOS in colonic cells: our aim was to assess NOS expression in colonic rat model after SNM. MATERIALS AND METHODS: Twenty-six female Sprangue-Dawley rats were considered: group I, normal control rats; group II, sham treatment rats, in whom electrodes for electrical stimulation were placed in S1 foramen bilaterally and left in place, without performing neuromodulation; group III, rats in whom SNM was performed. After 14 days, the rats were sacrificed and we evaluated n-NOS and i-NOS in colonic specimens by immunohistochemistry and Western Blot analysis. RESULTS: Western Blot analysis showed that levels of n-NOS and i-NOS were higher in colon of the III group rats respect to the others; in particular, immunohistochemistry revealed that, after neuromodulation, n-NOS expression in the muscle cells and i-NOS expression in glandular epithelium and nervous cells were highly represented (p < 0.05). CONCLUSION: Our study showed that in colon, SNM is able to influence NO synthesis, activating n-NOS expression in muscle cells and i-NOS expression in glandular epithelium and nervous cells. Our study showed a complex colonic response to SNM. This experimental model could be applied to better understand the mechanism of action of SNM in bowel dysfunction.

Role of Daptomycin on Burn Wound Healing in an Animal Methicillin-Resistant Staphylococcus aureus Infection Model.

Prolonged hospitalization and antibiotic therapy are risk factors for the development of methicillin-resistant Staphylococcus aureus (MRSA) infections in thermal burn patients. We used a rat model to study the in vivo efficacy of daptomycin in the treatment of burn wound infections by S. aureus, and we evaluated the wound healing process through morphological and immunohistochemical analysis. A copper bar heated in boiling water was applied on a paraspinal site of each rat, resulting in two full-thickness burns. A small gauze was placed over each burn and inoculated with 5 × 107 CFU of S. aureus ATCC 43300. The study included two uninfected control groups with and without daptomycin treatment, an infected control group that did not receive any treatment, and two infected groups treated, respectively, with intraperitoneal daptomycin and teicoplanin. The main outcome measures were quantitative culture, histological evaluation of tissue repair, and immunohistochemical expression of wound healing markers: epidermal growth factor receptor (EGFR) and fibroblast growth factor 2 (FGF-2). The highest inhibition of infection was achieved in the group that received daptomycin, which reduced the bacterial load from 107 CFU/ml to about 103 CFU/g (P < 0.01). The groups treated with daptomycin showed better overall healing with epithelialization and significantly higher collagen scores than the other groups, and these findings were also confirmed by immunohistochemical data. In conclusion, our results support the hypothesis that daptomycin is an important modulator of wound repair by possibly reducing hypertrophic burn scar formation.

Surgical treatment of gastric stromal tumors: laparoscopic versus open approach.

AIM: Gastrointestinal stromal tumors (GIST) are quite rare tumors, but yet they are the most common mesenchymal lesions of gastrointestinal tract. Their outmost frequent origin site is stomach and presently surgical resection is the mainstay in the treatment of gastric non metastatic GIST. Their peculiar characteristic of growth and poor metastatic tendency make this tumors particularly prone to be managed by minimally invasive technique. Presenting our experience we want show the feasibility and safeness of laparoscopic approach for gastric GIST and its benefits versus traditional open surgery and pointing out short term and long terms outcomes. PATIENTS AND METHODS: In our series we included 60 patients who underwent surgery for gastric GIST from 2004 to 2014 at Clinica Chirurgica of Università Politecnica delle Marche. Patients were divided in two group according with surgical approach (open or laparoscopic). Criteria of exclusion were metastatic disease and palliative purpose of surgical resection. All patients underwent endoscopic ultrasonography, fine needle aspiration, TC/MRI or PET before surgery. However most of the definitive diagnosis were postoperative. CD117 and CD34 immunohistochemical positivity were considered suggestive for GIST. Tumors were classified in four different prognostic groups according with pathological findings (size and mitotic count) as reported in Fletcher classification. None of the patients received Imatinib before surgery. All patients underwent follow-up with Computerized Tomography (TC) and/or Magnetic Resonance (MRI) repeated every year (mean 51.98 ± 35.68 months). RESULTS: We performed open surgery on 22 patients (36.7%) and laparoscopic wedge resection on 38 patients (63.33%); one of these underwent robotic wedge resection by da the da Vinci® surgical system. The median age at diagnosis was 64 years (range= 45-71). Patients with gastric GIST presented with various symptoms, including fatigue secondary to anemia, intraluminal gastrointestinal bleeding, abdominal pain, abdominal mass, vomiting and syncope. In 26 patients (43.3%) gastric GISTs were detected incidentally during abdominal exploration, endoscopy, or radiologic imaging. Tumor dimensional difference between the two groups was not significant (mean 4.75 cm, range= 2-13). Operation time was significantly lower in laparoscopic approach (82.4 versus 117.8 min). We did not experience of intraoperative or post-operative complications in laparoscopic group. Conversely 4 patients of open group were transfused for anemia. In our series we didn't observe recurrence or metastasis at mean follow up period of (range= 49-120 months). CONCLUSIONS: Laparoscopic surgery is a minimally invasive approach to the treatment of GISTs and offers many advantages such as short hospital stay and low morbidity. In the meantime oncological outcomes of laparoscopy for gastric GIST, assessed as tumor free resection margins and recurrence rate, are comparable to traditional open strategy. KEY WORDS: Gastrointestinal stromal tumors, Laparoscopy, Minimally invasive surgery, Stomach.

Functional outcomes after TEM in patients with complete clinical response after neoadjuvant chemoradiotherapy.

BACKGROUND: In patients who exhibit a complete clinical response after radio-chemotherapy for rectal cancer, the standard surgical approach might constitute overtreatment. The aim of this study is to analyse the outcomes of anorectal function and quality of life after transanal endoscopic microsurgery (TEM) in irradiated patients with complete clinical response. PATIENTS AND METHODS: Between 2007 and 2014, 84 patients who were diagnosed with stage T2-T3-T4 N0 rectal cancer before chemoradiotherapy showed a complete clinical response to neoadjuvant therapy and underwent TEM. All patients were evaluated before and 1 year after TEM using the Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS) questionnaire to determine the impact of this surgical technique on the degree of faecal continence. To assess the quality of life of patients after surgery, we administered the Fecal Incontinence Quality of Life Scale. RESULTS: Twenty-three patients exhibited a worse incontinence status after surgical intervention (27.4; 95% CI 18.2-38.2). These patients experienced a median positive absolute variation in the CCF-FIS of four points (95% CI 3.5-4.5; p < 0.001). Female sex and age showed a significant correlation with the worsening of continence status. Scores on the Fecal Incontinence Quality of Life Index Scale did not show a significant difference before and after TEM. CONCLUSIONS: TEM may be an alternative treatment for patients with rectal cancer who exhibit a complete clinical response to neoadjuvant chemoradiotherapy because it offers the possibility to achieve a full thickness excision of the rectal wall. TEM also allows the identification of any residual disease and provides optimal quality of life and functional results.

Transanal endoscopic microsurgery in the treatment of large rectal adenomas.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique allowing to excise large rectal adenomas by local approach. This study shows the feasibility and results of a long term experience of TEM applied in this field. METHODS: A retrospective investigation was performed in patients affected by rectal adenomas (5-11 cm in diameter) who had undergone transanal endoscopic microsurgery from 1992 to 2015. A series of 207 patients met the inclusion criteria and were analyzed for characteristics, intraoperative and postoperative results and long-term follow-up. RESULTS: Median age was 71 years (52-83 years). Of the 207 total patients, 77 were women (37.2%) and 130 men (62.8%). Median distance from the anal verge was 8 cm (4-20 cm). Median size was 6 cm, with lesion ranging from 5 to 11 cm in diameter. Median operative time was 57 minutes (42-90 minutes). We observed 17 (8.2%) minor complications and 2 (0.9%) major complication according to the Clavien-Dindo classification. We did not observe any intraoperative or post-operative mortality. Histological examination showed preoperative undiagnosed cancer in 8 (3.8%) cases in which the pathologist revealed adenocarcinoma staged as T1 Sm1 according to the Kikuchi classification. The median follow-up was 115 months (12-288 months). Six recurrences (2.9%), we observed with a median time for recurrence of 14 months. CONCLUSIONS: TEM provides excellent oncological outcomes in the treatment of large benign rectal lesions, ensuring a minimal risk of resection margin infiltration at pathological examination, and is associated with low risk of complications.

Colistin enhances therapeutic efficacy of daptomycin or teicoplanin in a murine model of multiresistant Acinetobacter baumannii sepsis.

We investigated the efficacy of colistin combined with teicoplanin or daptomycin in an experimental mouse model of multiresistant Acinetobacter baumannii infection. Animal received intraperitoneally 1ml saline containing 2×1010CFU of A. baumannii. Colistin, daptomycin, teicoplanin, and colistin plus daptomycin or teicoplanin were given by intraperitoneal administration 2h after bacterial challenge. A control group received sodium chloride solution. In the in vitro study A. baumannii showed to be susceptible only to colistin with MIC of 2mg/l. In the in vivo study, colistin alone showed a good antimicrobial efficacy. When combined with teicoplanin or daptomycin, colistin produced the lowest bacterial and the best survival rates. In immunological studies, when colistin was associated to daptomycin or teicoplanin, both the number and the cytotoxic activity of NK cells increased. In conclusion, colistin combined with teicoplanin or daptomycin may improve the therapy of multiresistant A. baumannii infection.

Transanal endoscopic microsurgery as optimal option in treatment of rare rectal lesions: A single centre experience.

AIM: To analyze the outcomes of transanal endoscopic microsurgery (TEM) in the treatment of rare rectal condition like mesenchymal tumors, condylomas, endometriosis and melanoma. METHODS: We retrospectively reviewed a twenty-three years database. Fifty-two patients were enrolled in this study. The lesions were considered suitable for TEM if they were within 20 cm from the anus. All of them underwent an accurate preoperative workup consisting in clinical examination, total colonoscopy with biopsies, endoscopic ultrasonography, and pelvic computerized tomography or pelvic magnetic resonance imaging. Operative time, intraoperative complications, rate of conversion, tumor size, postoperative morbidity, mortality, the length of hospital stay, local and distant recurrence were analyzed. RESULTS: Among the 1328 patients treated by TEM in our department, the 52 patients with rectal abnormalities other than adenoma or adenocarcinoma represented 4.4%. There were 30 males (57.7%) and 22 females (42.3%). Mean age was 55 years (median = 60, range = 24-78). This series included 14 (26.9%) gastrointestinal stromal tumors, 21 neuroendocrine tumors (40.4%), 1 ganglioneuroma (1.9%), 2 solitary ulcers in the rectum (3.8%), 6 cases of rectal endometriosis (11.5%), 6 cases of rectal condylomatosis (11.5%) and 2 rectal melanomas (3.8%). Mean lesion diameter was 2.7 cm (median: 4, range: 0.4-8). Mean distance from the anal verge was 9.5 cm (median: 10, range: 4-15). One patient operated for rectal melanoma developed distant metastases and died two years after the operation. We experienced 2 local recurrences (3.8%) with an overall survival equal to 97.6% (95%CI: 95%-99%) at the end of follow-up and a disease free survival of 98% (95%CI: 96%-99%). CONCLUSION: We could conclude that TEM is an important therapeutical option for rectal rare conditions.

Robotic versus laparoscopic right colectomy for cancer: short-term outcomes and influence of Body Mass Index on conversion rate.

BACKGROUND: It is still controversial if the robotic colorectal surgery provides any advantage compared to conventional laparoscopy. We compared the short-term outcomes of robotic right colectomy (RRC) and laparoscopic right colectomy (LRC) and the influence of Body Mass Index (BMI) on each one. METHODS: Between September 2013 and April 2015, 60 LRC and 30 RRC were performed for colorectal cancer in our institution. Comparison was based on quality of surgical procedure, postoperative and oncological outcomes. The BMI was evaluated as a conversion risk factor. RESULTS: A higher surgery time (P<0.001), a higher operative room setting (P<0.001), a lower time of first flatus (P<0.035) and oral feeding recovery (P<0.034) resulted in RRC group. The probability of conversion to open colectomy was higher for LRC group, but not significantly (P=0.659). The conversion rate was higher in obese patients for both procedures (P<0.001). No difference between the two techniques was reported in the obese class with regard to the conversion rate (P=0.282). Both procedures proved acceptable oncological safety. CONCLUSIONS: RRC offers slightly advantages to the LRC with extracorporeal anastomosis, even if it still requests increased time and costs. This study suggested that this difference increases when BMI rises.