Abdominal wall endometriosis misdiagnosed as a desmoid tumor: A case report.

INTRODUCTION: Abdominal wall masses have different aetiologies. Diagnosis includes desmoid tumors (DTs) and other benign and malignant lesions, among which abdominal wall endometriosis (AWE). Diagnosis is challenging if symptoms are aspecific, and the contribution of imaging may be weak. We present a case of AWE that according to clinical history and imaging was misdiagnosed as DT. PRESENTATION OF CASE: A healthy 35-year-old female presented, 4 years after a cesarean delivery, a rapidly growing painless subumbilical mass within the right rectus abdominis muscle. Ultrasound and magnetic resonance imaging suspected a DT. The patient underwent complete resection of the mass and pathological examination revealed foci of endometriosis in the muscle. Patient's post-operative course was uneventful and at 18-month follow-up, no recurrence has been detected. DISCUSSION: The current case highlights differences in clinical presentation and imaging in case of AWE and DTs, underlining possible pitfalls in diagnosis. In young women with previous gynaecological abdominal surgery, AWE is the most likely disease when a mass in the region of the scar appears. Differential diagnosis is complex and rare entities like DTs should nevertheless be taken into consideration. A complete surgical resection with negative margins is considered the primary treatment for AWE and for selected DTs. Final pathology of the tumor can state the precise diagnosis. CONCLUSION: Since AWE and DTs share similar clinical signs and aspecific imaging exams, both diseases should be considered in case of abdominal wall mass in female patients of childbearing age and history of uterine-related surgery.

Prospective, randomised, multicentre, open-label trial, designed to evaluate the best timing of closure of the temporary ileostomy (early versus late) in patients who underwent rectal cancer resection and with indication for adjuvant chemotherapy: the STOMAD (STOMa closure before or after ADjuvant therapy) randomised controlled trial.

INTRODUCTION: Temporary ileostomy is a valuable aid in reducing the severity of complications related to rectal cancer surgery. However, it is still unclear what is the best timing of its closure in relation to the feasibility of an adjuvant treatment, especially considering patient-reported outcomes and health system costs. The aim of the study is to compare the results of an early versus late closure strategy in patients with indication to adjuvant chemotherapy after resection for rectal cancer. METHODS AND ANALYSIS: This is a prospective multicentre randomised trial, sponsored by Rete Oncologica Piemonte e Valle d'Aosta (Oncology Network of Piedmont and Aosta Valley-Italy). Patients undergone to rectal cancer surgery with temporary ileostomy, aged >18 years, without evidence of anastomotic leak and with indication to adjuvant chemotherapy will be enrolled in 28 Network centres. An early closure strategy (between 30 and 40 days from rectal surgery) will be compared with a late one (after the end of adjuvant therapy). Primary endpoint will be the compliance to adjuvant chemotherapy with and without ileostomy. Complications associated with stoma closure as well as quality of life, costs and oncological outcomes will be assessed as secondary endpoints. ETHICS AND DISSEMINATION: The trial will engage the Network professional teams in a common effort to improve the treatment of rectal cancer by ensuring the best results in relation to the most correct use of resources. It will take into consideration both the patients' point of view (patient-reported outcome) and the health system perspective (costs analysis). The study has been approved by the Ethical Review Board of Città della Salute e della Scienza Hospital in Turin (Italy). The results of the study will be disseminated by the Network website, medical conferences and peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT04372992.

Anastomosis configuration and technique following ileocaecal resection for Crohn's disease: a multicentre study.

A limited ileocaecal resection is the most frequently performed procedure for ileocaecal CD and different anastomotic configurations and techniques have been described. This manuscript audited the different anastomotic techniques used in a national study and evaluated their influence on postoperative outcomes following ileocaecal resection for primary CD. This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing elective ileocaecal resection for primary CD from June 2018 May 2019. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. 427 patients were included. The side to side anastomosis was the chosen configuration in 380 patients (89%). The stapled anastomotic (n = 286; 67%), techniques were preferred to hand-sewn (n = 141; 33%). Postoperative morbidity was 20.3% and anastomotic leak 3.7%. Anastomotic leak was independent of the type of anastomosis performed, while was associated with an ASA grade ≥ 3, presence of perianal disease and ileocolonic localization of disease. Four predictors of LOS were identified after multivariate analysis. The laparoscopic approach was the only associated with a reduced LOS (p = 0.017), while age, ASA grade ≥ 3 or administration of preoperative TPN were associated with increased LOS. The side to side was the most commonly used anastomotic configuration for ileocolic reconstruction following primary CD resection. There was no difference in postoperative morbidity according to anastomotic technique and configuration. Anastomotic leak was associated with ASA grade ≥ 3, a penetrating phenotype of disease and ileo-colonic distribution of CD.

Robotic versus laparoscopic right colectomy within a systematic ERAS protocol: a propensity-weighted analysis.

The purpose of this study is to compare the early postoperative and pathological outcomes of robotic right colectomy (RRC) to those of laparoscopic right colectomy (LRC) with intracorporeal anastomosis (IA) within the systematic application of an enhanced recovery after surgery (ERAS) program. A single-institution prospective database of patients who underwent elective RRC or LRC with IA for neoplastic lesions between April 2010 and June 2018 was retrospectively reviewed. The patients' demographic characteristics, and perioperative and pathological outcomes were analyzed. Propensity-weighted analysis was employed to address potential selection biases of treatment allocation. A total of 216 patients (46 RRC, 170 LRC) were included. RRC demonstrated a significantly longer operative time (mean 242.43 min, SD 47.51) compared to LRC (mean 187.60 min, SD 56.60) (p = 0.001), confirmed by the propensity-weighted analysis (Coefficient 50.65; p < 0.001). Conversion rate between the two groups was comparable (p = 0.99). Median length of hospital stay (LOS) was the same in the RRC and the LRC group (4 days, p = 0.35). Readmission rate within 30 days in the RRC and LRC group was 2.2% and 2.4%, respectively (p = 0.99). Overall 30-day morbidity and 30-day mortality was 32.6% versus 27.1% (p = 0.46), and 0% versus 1.2% (p = 0.99) in the robotic and laparoscopic groups, respectively. No difference was found in the number of harvested lymph nodes (p = 0.75). In an ERAS environment, without the bias of mixed techniques of anastomosis, RRC had similar postoperative and pathological outcomes compared to the laparoscopic approach, but was associated with a longer operative time.

Robotic approach to large tailgut cyst with malignant transformation: A case report.

INTRODUCTION: Tailgut cysts (TGC) are rare congenital retrorectal lesions deriving from vestiges of the hindgut. The risk of malignant transformation is relatively high. Thus early diagnosis and a complete removal of the mass are of paramount importance. We present a case of successful robotic exeresis of a large TGC adenocarcinoma. PRESENTATION OF CASE: A healthy 35-year-old woman was found to have a retrorectal TGC with suspected malignant transformation. The patient underwent complete robotic resection of the mass and pathology confirmed a TGC adenocarcinoma. The patient's post-operative course was unremarkable. At 24 months, the patient has not experienced any recurrence nor complained functional disorders. DISCUSSION: The current case highlights the importance of TGC as a differential diagnosis of presacral masses, underscoring that malignant transformation can occur and may result in mortality and morbidity if radical surgery is not performed. Diagnosing TGC adenocarcinoma can be challenging because of its relatively low incidence. Biopsy is not recommended while magnetic resonance imaging (MRI) is indispensable in the evaluation of this lesion as the presence of intracystic vegetations could indicate a malignant transformation. Surgery is the mainstay of treatment and minimally invasive techniques have the potential to minimize morbidity and enhance recovery. Amongst these, the robotic approach can make the dissection of large lesions easier, reducing their manipulation and preventing nerve injuries. CONCLUSION: Robot-assisted resection of a TGC adenocarcinoma is safe and feasible. This approach can be particularly useful in the pelvis providing acceptable functional and oncological outcomes.

Management of Peritonitis After Minimally Invasive Colorectal Surgery: Can We Stick to Laparoscopy?

BACKGROUND: Although laparoscopy is becoming the standard of care for the treatment of colorectal disease, its application in case of postoperative peritonitis is still not widespread. The objective of this article is to evaluate the role of laparoscopy in the management of postoperative peritonitis after elective minimally invasive colorectal resection for malignant and benign diseases. MATERIALS AND METHODS: Between April 2010 and May 2016, 536 patients received primary minimally invasive colorectal surgery at our Department. Among this series, we carried out a retrospective study of those patients who, having developed signs of peritonitis, were treated with a laparoscopic reintervention. Patient demographics, type of complication and of the main relaparoscopic treatment, and main outcomes of reoperation were recorded. RESULTS: A total of 20 patients (3.7%) underwent relaparoscopy for the management of postoperative peritonitis, of which exact causes were detected by laparoscopy in 75% as follows: anastomotic leakage (n = 8, 40%), colonic ischemia (n = 2, 10%), iatrogenic bowel tear (n = 4, 20%), and other (n = 1, 5%). The median time between operations was 3.5 days (range, 2-8). The laparoscopic reintervention was tailored case by case and ranged from lavage and drainage to redo anastomosis with ostomy fashioning. Conversion rate was 10% and overall morbidity was 50%. No cases required additional surgery and 30-day mortality was nil. Three patients (15%) were admitted to intensive care unit for 24-hour surveillance. CONCLUSION: Our experience suggests that in experienced hands and in hemodynamically stable patients, a prompt laparoscopic reoperation appears as an accurate diagnostic tool and an effective and safe option for the treatment of postoperative peritonitis after primary colorectal minimally invasive surgery.