Laparoscopic Welti's Maneuver: A Single-Center Experience.

Purpose: Left hemicolectomy is the standard surgical operation for a variety of colonic diseases, both benign and malignant. When colonic resection is extended, relocation of the small bowel loops can be difficult. Several techniques have been described to reposition the small intestine. Welti's technique consists in the passage of the entire small bowel to the left side of the abdomen, below the descending colon that is positioned on the right side. Methods: We retrospectively evaluated 23 patients who underwent extended left hemicolectomy and reconstruction according to the Welti's technique at our hospital. We assessed the recovery of intestinal function and the length of hospital stay; in the mid-term follow-up we searched for episodes of acute or chronic intestinal obstruction. Results: Median operative time was 215 minutes; median resumption of gas and stool emission were, respectively, 3 days (interquartile range [IQR]: 2-6) and 4 days (IQR: 2-9) after surgery. Median hospital stay was 8 (IQR: 5-37) day. After a median follow-up of 15 months (IQR: 3-132) we did not observe any episode of acute or chronic bowel obstruction. Conclusions: Welti's technique is safe and does not cause a delay in resumption of bowel functions or a delayed hospital discharge; it is a useful technique that the colorectal surgeon can use when needed.

Effect of Age and Comorbidities on Short- and Long-Term Results in Patients Undergoing Laparoscopic Curative Resection for Rectal Cancer.

BACKGROUND AND AIM: Conflicting findings have been reported in older patients undergoing laparoscopic surgery for rectal cancer. The aim of this study was to evaluate the effects of age and comorbidities on short- and long-term results of patients undergoing laparoscopic curative resection for rectal cancer (LCRRC). MATERIALS AND METHODS: We retrospectively evaluated all 173 consecutive patients undergoing LCRRC at our unit (June 2005-September 2015). They were divided into two age groups as follows: <75 (n = 122) and ≥75 (n = 51) years. Comorbidities were evaluated using American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), and age-related Charlson Comorbidity Index (ACCI). RESULTS: Tumor characteristics were similar in the two groups. Comorbidity status (ASA, CCI, ACCI) was worse in elderly patients. Type of surgery performed was similar in the two groups. Medical complications were significantly higher in elderly (10.7% versus 29.4%, P = .006), while surgical complications were similar. Postoperative stay was longer in older patients (13 days versus 9 days, P = .0007). Multivariable analysis identified older age, higher CCI, and longer operative time as independent predictors of morbidity. Five years overall survival and disease-free survival were 49% and 43% in older and 84% and 77% in younger group (P < .0001). Multivariable analysis identified age, CCI, tumor, node, metastasis stage, and postoperative morbidity as independent risk factors for overall and disease-free survival. CONCLUSIONS: LCRRC achieves excellent short- and long-term results, but age and comorbidities may significantly affect postoperative morbidity and survival.

Laparoscopic Curative Resection for Rectal Cancer: A Cohort Study on Long-term Outcome.

The aim of the present study was to evaluate the long-term results of laparoscopic curative resection for rectal cancer. We included all patients who underwent laparoscopic curative resection for rectal cancer from June 2005 to September 2015. A total of 159 patients were included; 33.9% received neoadjuvant chemoradiotherapy. Thirty-day mortality and morbidity rates were 0.6% and 26.4%, respectively. Pathologic stage was 0 in 12%, I in 39%, II in 24.5%, and III in 24.5%. The median number of lymph nodes harvested was 16. In 5% of patients, mesorectal excision was incomplete. Median follow-up was 59 months. Overall 5-year survival was 80%. Multivariable analysis identified older age, higher Charlson Comorbidity Index, advanced tumor stage, and postoperative morbidity as independent risk factors for overall/disease-free survival. Local/distant recurrence rate was 4.4%/17.6%. Deaths during follow-up were 33/159 (20.8%): cancer related 54.6% and non cancer related 45.4% of patients. Laparoscopic curative resection for rectal cancer can yield prolonged survival and low recurrence.

Platelet-to-Lymphocyte Ratio and Neutrophil-to-Lymphocyte Ratio Are Not Prognostic Biomarkers in Rectal Cancer Patients with Curative Resection.

BACKGROUND: Actual predictors of survival and recurrence for rectal cancer patients undergoing curative resection mostly come from pathological data of surgical specimen. Recently, novel blood biomarkers have been proposed as useful tools in cancer patient management, but few and conflicting data have been reported in rectal cancer. We evaluated the prognostic relevance of preoperative platelet-to-lymphocyte (P/L) ratio and neutrophil-to-lymphocyte (N/L) ratio on survival and recurrence in patients undergoing laparoscopic curative resection for rectal cancer. METHODS: All consecutive patients who referred for primary rectal disease to the Department of General Surgery in Cittadella (Italy) from June 2005 to September 2015 were retrospectively evaluated. Patients with metastatic disease at surgery were excluded. P/L and N/L ratios were calculated. For patients undergoing neoadjuvant chemo-radiotherapy, pre-treatment data were considered. Follow-up data were updated at December 2016. RESULTS: One hundred fifty-two patients were included in the study, 49 (32%) received neoadjuvant chemo-radiotherapy. Both P/L and N/L ratios showed poor discriminative performance on 5-year OS and DFS. Time-dependent ROC curves showed no improvements in discriminative performance of P/L and N/L ratios when considering different time endpoints. Multivariable analysis identified CEA-rather than P/L or N/L ratios-as independent predictor of OS and DFS, adjusting for age, tumor stage, and postoperative morbidity. CONCLUSION: Neither P/L nor N/L ratios were associated with survival after rectal cancer surgery. Further studies on large series might provide insights on the role of these inexpensive blood biomarkers in rectal cancer.

Splenic flexure colon cancers: minimally invasive treatment.

Optimal treatment of splenic flexure (SF) colon cancer-less than 10% of all colorectal cancers is a matter of debate, in particular with regard to the optimal extent of radical surgery, according to the oncological principles of curative resection. Aims of this study were to assess the clinicopathological characteristics and report operative data and survival of patients with SF colon cancers. Short- and mid-term outcome of patients undergoing laparoscopic curative resection for SF colon cancer between June 2005 and September 2011 was assessed. The analysis considered 16 patients: 10 underwent segmental resection, 4 left hemicolectomy and 2 subtotal colectomy. There were no intraoperative deaths or major morbidity. The median operative time was 185 min. The median number of lymph nodes harvested was 17. Disease-free survival rate at 30-month follow-up was 75%. Laparoscopic resection of SF cancer is feasible and safe. Oncological principles of disease-free margins and minimum node harvest can be respected even with segmental resection.

Laparoscopic reversal of Hartmann's procedure.

Reestablishing continuity after a Hartmann's procedure is considered a major surgical procedure with high morbidity/mortality. The aim of this study was to assess the short-/long-term outcome of laparoscopic restoration of bowel continuity after HP. A prospectively collected database of colorectal laparoscopic procedures (>800) performed between June 2005 and June 2013 was used to identify 20 consecutive patients who had undergone laparoscopic reversal of Hartmann's procedure (LHR). Median age was 65.4. Ten patients (50 %) had undergone surgery for perforated diverticulitis, 3 (15 %) for cancer, and 7 (35 %) for other reasons (volvulus, posttraumatic perforation, and sigmoid perforation from foreign body). Previous HP had been performed laparoscopically in only 3 patients. Median operative time was 162.5 min. All the procedures were completed laparoscopically. Intraoperative complication rate was nil. Post-operative mortality and morbidity were respectively 0 and 10 % (1 pneumonia, 1 bowel obstruction from post-anastomotic stenosis which required resection and redo of the anastomosis). Median time to first flatus was 3 days, to normal diet 5 days. Median hospital stay was 9 days without readmissions. We followed up the patients for a median of 44 months: when asked, all 20 (100 %) said they would undergo the operation (LHR) again; 3 (15 %) had been re-operated of laparoscopic mesh repair for incisional hernia. When performed by experienced surgeons, LHR is a feasible, safe, reproducible operation, which allows early return of bowel function, early discharge and fast return to work for the patient. It has a low morbidity rate.

Laparoscopic-assisted total gastrectomy for adenocarcinoma in a western country: safety and oncological issues.

BACKGROUND: Laparoscopic total gastrectomy for adenocarcinoma is a widely diffused operation in eastern countries, but there are only a few reports from western centers. We assessed a single surgeon's experience at a single, nonacademic, community hospital. METHODS: Short-term outcome of patients undergoing laparoscopic total gastrectomy for adenocarcinoma (June 2005-March 2010) was assessed. RESULTS: Fourteen patients (5 males, 9 females; median age, 66.8 years [interquartile range, 59.7-71.8]) underwent laparoscopic total gastrectomy. The median operative time was 240 min. There were five stage 1 patients, five stage 2, and four stage 3; R0 resection was obtained in all 14 patients, and the median number of lymph nodes retrieved was 38. Mortality and overall morbidity rates were 0% and 35.7%, respectively. CONCLUSIONS: The outcomes of laparoscopic total gastrectomy for adenocarcinoma performed by a well-trained laparoscopic surgeon working in a community hospital are good in terms of safety for the patients and response to the oncological criteria used in open surgery.

Laparoscopic repair of intrathoracic liver herniation after traumatic rupture of the diaphragm.

Right diaphragmatic hernia after abdominal trauma is a rare injury. Most patients can be asymptomatic, and the diagnosis may be delayed for several years. The treatment of choice involves surgical repair via laparotomy. The authors treated a young patient with transdiaphragmatic herniation of the right hepatic lobe and delayed diagnosis using a laparoscopic approach and accomplished a successful complete repair. The 6-month radiologic follow-up assessment confirmed good results.

Spontaneous rupture of middle thoracic esophagus: thoracoscopic treatment.

Spontaneous rupture of the esophagus (so-called Boerhaave's syndrome) is considered a medical emergency. It carries a significant mortality rate and requires prompt treatment. The treatment of choice involves surgical repair of the esophageal defect, usually accomplished via laparotomy, thoracotomy, or both to accomplish esophageal repair and mediastinal debridement. We have treated an elderly patient with severe comorbidities with a minimally invasive approach, achieving a successful complete repair. Long-term endoscopic and radiologic follow-up confirm the good results.

Laparoscopic resection of colorectal cancer in elderly patients.

AIMS AND BACKGROUND: Aging of the population and a longer life expectancy have led to an increased number of elderly patients presenting with colorectal cancer and searching for treatment. The aim of the study was to assess the effects of age on the outcome of laparoscopic colorectal surgery for cancer at a single department. METHODS: Perioperative outcome of patients > or =75 years old undergoing laparoscopic colorectal surgery between June 2005 and January 2009 for colorectal cancer were compared with findings in younger patients. RESULTS: The analysis considered 134 patients <75 years and 82 patients > or =75 years of age. There was a significant difference in perioperative risk factors, as reflected by different ASA scores and a significantly higher postoperative 'medical' morbidity, but 'surgical' morbidity was similar in the two groups and remained low. DISCUSSION: Surgical morbidity rate was not affected by age. Cardiovascular and pulmonary comorbid conditions were mainly responsible for the higher morbidity rate reported in the elderly patients, although advanced age, per se, should not be considered a contraindication to laparoscopic colorectal surgery for cancer.

Spontaneous rupture of giant gastric GIST presenting as hemoperitoneum and mimicking cavernous liver angioma.

Spontaneous rupture of gastrointestinal stromal tumor (GIST) with hemoperitoneum is an extremely rare clinical presentation of this mesenchymal tumor. We report the unusual case of a 68-year-old man who was admitted to the hospital with abdominal pain. While waiting for the results of his laboratory tests the patient became pale and tachycardic and his abdomen distended with generalized rebound tenderness. A CT scan suggested rupture of a cavernous angioma of the liver and the patient was brought to the operating room for an explorative laparoscopy, which revealed hemoperitoneum from a ruptured giant gastric GIST. After conversion to laparotomy, the tumor was excised: it was 11 x 10 x 5 cm in size, with massive necrosis and clotted blood inside. Immunohistochemical examination revealed reactivity to c-KIT and CD34, consistent with the diagnostic criteria for GIST, with low mitotic activity (< 5/50 HPF). The postoperative course was uneventful, and the clinical and radiological follow-up at 6 months is negative for recurrence.

Thoracoscopic repair of lung herniation following minimally invasive cardiothoracic surgery.

Pulmonary hernias--defined as protrusions of the lung parenchyma and pleural membranes through a defect in the thoracic wall--are rare. They are usually congenital, spontaneous or traumatic iatrogenic lung herniations are extremely rare and secondary to thoracoscopic procedures or minimally invasive cardiothoracic surgery. There are very few reports of surgical repair of this iatrogenic condition and, to date, no reports of thoracoscopic repair of such defects of the thoracic wall have been reported. We present a case of a young patient with iatrogenic lung herniation in which a thoracoscopic approach was attempted and complete repair successfully accomplished.

Laparoscopic colon resection by a single general surgeon in a community hospital: a review of 200 consecutive cases.

BACKGROUND: We assessed a single surgeon's experience on laparoscopic colorectal surgery (LCR) at a single non academic, community hospital. The surgeon was trained in minimally-invasive techniques and robotic surgery with >500 procedures at another non-university hospital, either as operating surgeon or as assistant. METHODS: Short-term outcome of patients undergoing LCR for benign/neoplastic disease (June 2005-September 2007) was assessed. RESULTS: A total of 208 patients (104 males, 104 females; median age 69.1 years, Interquartile Range (IQR):59.3-76.6) underwent LCR. Over 70% of the operations were performed for cancer. Left hemicolectomy was performed in 102 patients (49.1%), right hemicolectomy in 50 (24%), anterior resection in 40 (19.2%), other procedures in 16 (7.7%). One-hundred-ninety (91.3%) operations were elective. The median operative time was 180 min (IQR:150-210). Conversion rate was 4.8%: 3.4% for benign and 5.4% for neoplastic disease (p = n.s.). The median lymph node harvest in cancer patients was 16 (IQR:12-20). Mortality and overall morbidity rates were 0.5% and 13%, with no significant difference between benign and malignant disease, colon and rectum, elective and non elective operations. CONCLUSIONS: The outcomes of LCR surgery performed by a well-trained laparoscopic surgeon working in a community hospital are comparable with results from academic health science centers.

Successful minimally invasive repair of spontaneous esophageal perforation.

Esophageal perforations with a mediastinal abscess are medical emergencies with a significant mortality rate. Prompt management is mandatory, and a variety of treatment strategies have been advocated. In the case of a spontaneous rupture of the esophagus (the so-called Boerhaave's syndrome), the treatment of choice involves the surgical repair of the esophageal defect, usually accomplished through a laparotomy or thoracotomy. In this paper, we present a case of an elderly patient with severe comorbidities, in which a minimally invasive approach was attempted and a complete repair was successfully accomplished.

Pathophysiology of giant incisional hernias with loss of abdominal wall substance.

Incisional hernia represents the most common wound complication after abdominal surgery. The repair of large incisional hernias requires an accurate knowledge of the interactions between the tissues of the abdominal wall, the prosthetic materials and the bowel. At the same time a careful attention must be placed on the physiopathology of abdominal hypertension. Repair of giant incisional hernias with heavy loss of substance may take to a sudden increase of intra-abdominal pressure and, sometimes, to Abdominal Compartment Syndrome (ACS). The aim of preventing recurrences very often requires the use of a prosthesis, which must be placed on a low-tension environment to avoid early failures and excessive increase of intra-abdominal pressure. It is also necessary to employ as much parietal tissues as possible to prevent visceral adhesions and lesions and to pay attention to an appropriate employment of prosthesis. Utilization of composite materials, absorbable prosthesis or of combinations of mesh and flaps looks promising in preventing endoabdominal hypertension without increasing the rate of recurrences, infections and adhesive complications.