A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group).

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Laparoscopic right hemicolectomy: a SICE (Società Italiana di Chirurgia Endoscopica e Nuove tecnologie) network prospective study on the approach to right colon lymphadenectomy in Italy: is there a standard?-CoDIG 2 (ColonDx Italian Group).

BACKGROUND: Colon cancer is a disease with a worldwide spread. Surgery is the best option for the treatment of advanced colon cancer, but some aspects are still debated, such as the extent of lymphadenectomy. In Japanese guidelines, the gold standard was D3 dissection to remove the central lymph nodes (203, 213, and 223), but in 2009, Hoenberger et al. introduced the concept of complete mesocolic excision, in which surgical dissection follows the embryological planes to remove the mesentery entirely to prevent leakage of cancer cells and collect more lymph nodes. Our study describes how lymphadenectomy is currently performed in major Italian centers with an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH). METHODS: CoDIG 2 is an observational multicenter national study that involves 76 Italian general surgery wards highly specialized in colorectal surgery. Each center was asked not to modify their usual surgical and clinical practices. The aim of the study was to assess the preference of Italian surgeons on the type of lymphadenectomy to perform during RH and the rise of any new trends or modifications in habits compared to the findings of the CoDIG 1 study conducted 4 years ago. RESULTS: A total of 788 patients were enrolled. The most commonly used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%), side-to-side (98.7%), or isoperistaltic (96.0%) anastomosis. The lymph nodes at the origin of the vessels were harvested in an inferior number of cases (203, 213, and 223: 42.4%, 31.1%, and 20.3%, respectively). A comparison between CoDIG 1 and CoDIG 2 showed a stable trend in surgical techniques and complications, with an increase in the robotic approach (7.7% vs. 12.3%). CONCLUSIONS: This analysis shows how lymphadenectomy is performed in Italy to achieve oncological outcomes in RH, although the technique to achieve a higher lymph node count has not yet been standardized. Trial registration (ClinicalTrials.gov) ID: NCT05943951.

The Impact of Social Determinants of Health on Presentation, Treatment, and Outcomes in Branch Retinal Vein Occlusion With Cystoid Macular Edema.

BACKGROUND AND OBJECTIVE: To investigate the impact of social determinants of health on the presentation, treatment, and outcomes of branch retinal vein occlusion (BRVO) with cystoid macular edema (CME). PATIENTS AND METHODS: A retrospective chart review was conducted of patients with BRVO and CME treated with anti-vascular endothelial growth factor (anti-VEGF) injections at Atrium Health Wake Forest Baptist from 2013 to 2021. Patients' baseline characteristics including visual acuity (VA), age, sex, race, Area Deprivation Index (ADI), insurance status, baseline central macular thickness (CMT), treatment details, final VA, and final CMT were recorded. The primary outcome measure was final VA comparing more and less deprived groups, and White and non-White groups. RESULTS: Two hundred forty-four eyes of 240 patients were included. Patients with higher socioeconomic deprivation scores had thicker final CMT (P = 0.05). Non-White patients had worse presenting (P = 0.01) and final VA (P = 0.02). CONCLUSION: This study demonstrated disparities in presentation and outcomes based on socioeconomic status and race in patients with BRVO and CME treated with anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina 2023;54:411-416.].

Systematic review of economic evaluations in pediatric ophthalmology and strabismus.

BACKGROUND: Economic evaluations in health care quantitatively compare interventions using cost and outcomes data. These evaluations can aid in the adoption of new surgical or medical treatments and inform policy decisions regarding healthcare spending. Several common types of economic analysis exist (cost-benefit, cost-analysis, cost-effectiveness, and cost-utility). We review all English-language economic evaluations in strabismus surgery and pediatric ophthalmology. METHODS: An electronic literature search of the PubMed and Health Economic Evaluations databases was conducted. Two reviewers independently reviewed the search string yield and assessed articles against inclusion and exclusion criteria. Outcome measures included journal of publication, year of publication, domain of ophthalmology, region/country of study, and type of economic evaluation. RESULTS: We identified 62 articles. Cost-utility studies comprised 30% of evaluations. The most studied domain was retinopathy of prematurity (33%), followed by amblyopia and vision screening (24%) and cataracts (14%). The Journal of the American Association for Pediatric Ophthalmology and Strabismus published the most economic evaluations (15%) followed by Ophthalmology and Pediatrics. The number of published economic evaluations did not increase over time. CONCLUSIONS: Economic evaluations in pediatric ophthalmology and strabismus have not increased over time. A minority (30%) of studies used cost utility-analysis, limiting comparisons to other domains of medicine. This suggests the need to alert pediatric ophthalmologists to the benefits of economic analysis, and cost-utility methodology specifically, to better inform and influence policy decisions regarding healthcare spending.

Waardenburg syndrome-associated neurotrophic keratopathy in a child treated with neurotization surgery.

Waardenburg syndrome (WS) is a congenital developmental disorder characterized by congenital sensorineural hearing loss and pigmentary deficiencies in the iris, hair, and skin. Ocular associations of WS include choroidal and iris hypopigmentation and foveal hypoplasia. Possible associations include cataracts and retinal vein occlusion. We report the first case of neurotrophic cornea and relate our experience with neurotization surgery.

Right hemicolectomy with complete mesocolic excision is safe, leads to an increased lymph node yield and to increased survival: results of a systematic review and meta-analysis.

BACKGROUND: The introduction of complete mesocolic excision (CME) for right colon cancer has raised an important discussion in relation to the extent of colic and mesenteric resection, and the impact this may have on lymph node yield. As uncertainty remains regarding the usefulness of and indications for right hemicolectomy with CME and the benefits of CME compared with a traditional approach, the purpose of this meta-analysis is to compare the two procedures in terms of safety, lymph node yield and oncological outcome. METHODS: We performed a systematic review of the literature from 2009 up to March 15th, 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two hundred eighty-one publications were evaluated, and 17 met the inclusion criteria and were included. Primary endpoints analysed were anastomotic leak rate, blood loss, number of harvested lymph nodes, 3- and 5-year oncologic outcomes. Secondary outcomes were operating time, conversion, intraoperative complications, reoperation rate, overall and Clavien-Dindo grade 3-4 postoperative complications. RESULTS: In terms of safety, right hemicolectomy with CME is not inferior to the standard procedure when comparing rates of anastomotic leak (RR 0.82, 95% CI 0.38-1.79), blood loss (MD -32.48, 95% CI -98.54 to -33.58), overall postoperative complications (RR 0.82, 95% CI 0.67-1.00), Clavien-Dindo grade III-IV postoperative complications (RR 1.36, 95% CI 0.82-2.28) and reoperation rate (RR 0.65, 95% CI 0.26-1.75). Traditional surgery is associated with a shorter operating time (MD 16.43, 95% CI 4.27-28.60) and lower conversion from laparoscopic to open approach (RR 1.72, 95% CI 1.00-2.96). In terms of oncologic outcomes, right hemicolectomy with CME leads to a higher lymph node yield than traditional surgery (MD 7.05, 95% CI 4.06-10.04). Results of statistical analysis comparing 3-year overall survival and 5-year disease-free survival were better in the CME group, RR 0.42, 95% CI 0.27-0.66 and RR 0.36, 95% CI 0.17-0.56, respectively. CONCLUSIONS: Right hemicolectomy with CME is not inferior to traditional surgery in terms of safety and has a greater lymph node yield when compared with traditional surgery. Moreover, right-sided CME is associated with better overall and disease-free survival.

Could fluorescence-guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary.

BACKGROUND: Indocyanine green fluorescence vision is an upcoming technology in surgery. It can be used in three ways: angiographic and biliary tree visualization and lymphatic spreading studies. The present paper shows the most outstanding results from an health technology assessment study design, conducted on fluorescence-guided compared with standard vision surgery. METHODS: A health technology assessment approach was implemented to investigate the economic, social, ethical, and organizational implications related to the adoption of the innovative fluorescence-guided view, with a focus on minimally invasive approach. With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaires and self-reported interviews, considering the dimensions resulting from the EUnetHTA Core Model. RESULTS: From a systematic search of literature, we retrieved the following studies: 6 on hepatic, 1 on pancreatic, 4 on biliary, 2 on bariatric, 4 on endocrine, 2 on thoracic, 11 on colorectal, 7 on urology, 11 on gynecology, 2 on gastric surgery. Fluorescence guide has shown advantages on the length of hospitalization particularly in colorectal surgery, with a reduction of the rate of leakages and re-do anastomoses, in spite of a slight increase in operating time, and is confirmed to be a safe, efficacious, and sustainable vision technology. Clinical applications are still presenting a low evidence in the literature. CONCLUSION: The present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an HTA approach, sustains the use of fluorescence-guided vision in minimally invasive surgery, in the fields of general, gynecologic, urologic, and thoracic surgery, as an efficient and economically sustainable technology.

Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study.

INTRODUCTION: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. MATERIALS AND METHODS: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. RESULTS: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). CONCLUSIONS: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Treatment of Colorectal Cancer: a Multidisciplinary Approach.

BACKGROUND: Colorectal cancer is the third most prevalent cancer in the world, preceded by prostate and lung cancers in men (10%) and breast and lung cancers in women (9.4%). Colorectal cancer is the fourth leading cause of death in men (7.6%) and the third in women (8.6%). A multidisciplinary approach has radically changed the way we deal with this disease among all specialist fields. PURPOSE: In this study, we propose comparing the multidisciplinary experience group (started in 2012) of S. Anna Hospital (University of Ferrara) with the previous approach to rectal cancer before the advent of the multidisciplinary program. RESULTS: We find that more study depth of neoplastic disease as well as of each individual patient leads to more accurate staging and to a weighted therapy based on the needs of the individual. All the studies were performed in accordance with the guidelines established by the European and Italian associations.

Focus on the diagnostic problems of primary adenocarcinoma of the third and fourth portion of the duodenum. Case report.

Although the small intestine constitutes over 75% of the length and 90% of the mucosal surface of the gastrointestinal tract, small intestine cancer is rare and accounts for only 1% of gastrointestinal malignancies. Adenocarcinoma together with carcinoid tumours are the most common histological types of primary malignant tumours of the small bowel but others, including lymphoma and leiomyosarcoma, may less frequently be encountered. Adenocarcinomas are predominantly located in the duodenum. Primary adenocarcinoma of the duodenum is a rare malignant tumor, accounting for 0.3-0.5% of all gastroenteral malignancies. The diagnosis of primary adenocarcinoma of duodenum is often delayed because its symptoms and signs are nonspecific. In this work we want to focus on the diagnostic and therapeutic problems of duodenal adenocarcinoma, reporting a case report.

Seasonal and weekly patterns of hospital admissions for acute diverticulitis.

OBJECTIVE: Onset and hospitalization of acute diseases do not occur randomly, but exhibit preferred high-risk temporal periods. The aim of this study, based on the database of hospital admissions of the Emilia-Romagna region of Italy, was to evaluate the possible existence of a seasonal or weekly pattern of hospitalization for acute diverticulitis (AD), and different rates of complications between weekend (WE) vs. weekday (WD) admissions. PATIENTS AND METHODS: The study included all emergency hospital admissions in Emilia Romagna Region for AD between 1999 and 2011 (ICD-9-CM codes: 562.11-562.13). Day of admission was categorized, respectively, into four 3-month intervals, twelve 1-month intervals, seven 1-day intervals for statistical analysis, performed by c2 test goodness of fit and partial Fourier series on total number of cases, males and females, nonfatal or fatal cases, without and with hemorrhage. RESULTS: The database contained records of 29,428 events of AD, relative to 24,843 different patients (mean age: 71.2 ± 13.8 years; 40.5% males). Chronobiological analysis yielded a biphasic rhythmic pattern in AD admissions, characterized by two peaks in Autumn and Spring. As for day of admission, a progressive decrease of frequency during the week was observed. In turn, a slight increase of admissions on WE was observed for hemorrhagic events. CONCLUSIONS: An excess burden of hospitalization for AD is observed in the region Emilia-Romagna of Italy, with demonstration of a biphasic cyclical pattern with peaks in Autumn and Spring. Again, a decreasing number of Monday to Friday admissions was observed. Further studies are needed to identify possible underlying causes.

Appendicular mucocele: two case reports and literature review.

The classification of mucinous tumors of the vermiform appendix is quite controversial, and includes a spectrum of neoplastic lesions ranging from benign proliferations, intraluminal, to invasive adenocarcinomas. Among the complications of appendicular mucinous neoplasms we should mention the "pseudomyxoma peritonei", a condition caused by cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelationous ascites. Mucinous neoplasms of the appendix are rare diseases of unknown etiology. The diagnosis is difficult because of poorly specific clinical, biochemical and imaging parameters, and their detection can be occasional. Most of the reported cases involving women of reproductive age (with a history of endometriosis, abdominal surgery or pelvic inflammatory disease). The definitive diagnosis requires histology and immunohistochemistry. Cytoredutive surgery combined with hyperthermic intraperitoneal chemoterapy (HIPEC) is now considered the best treatment for this disease. We present two cases treated with surgery and HIPEC.

Isolated splenic metastasis of ovaric cancer. Case report and literature review.

Splenic metastasis is extremely rare and are usually found in conjunction with metastasis of other organs. In addition, late recurrence even after 10 years of operation is very unusual. The most common sources of splenic metastasis are lung, colonrectal, melanoma, breast and ovarian carcinoma. We present a case of 67 year old woman who was admitted to our department with a solitary splenic metastases after hysterectomy with bilateral salpingo-oophorectomy for ovaric carcinoma 10 years ago. In conclusion, solitary splenic metastasis are very rare and the incidence of the reported cases in the medical literature is increasing. The treatment of choice is laparoscopic splenectomy that must be followed by chemotherapy in order to prevent the development of other possible micrometastases.

Complications of diverticular disease: surgical laparoscopic treatment.

Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of our study was to evaluate the outcome of laparoscopic colon resection in patients with diverticulitis and with complications like colon-vescical fistula, peridiverticular abscess, perforation or stricture. All patients underwent laparoscopic colectomy within 8 years period. Main data recorded were age, sex, return of bowel function, operation time, duration of hospital stay, ASA score, body mass index (BMI), early and late complications. During the study period, 33 colon resections were performed for diverticulitis and complications of diverticulitis. We performed 5 associated procedures. We had 2 postoperative complications; 1 of these required a redo operation with laparotomy for anastomotic leak and 3 patients required conversion from laparoscopic to open colectomy. The most common reasons for conversion were related to the inflammatory process with a severe adhesion syndrome. Mean operative time was 229 minutes, and average postoperative hospital stay was 9,8 days. Laparoscopic surgery for complications of diverticular disease is safe, effective and feasible. Laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis in our institution.

Laparoscopic resection of a jejunal mesenteric pseudocyst: case report.

Mesenteric cysts are rare and can occur at any age. They can manifest with abdominal pain or compressive mass effect. The exact etiology is unknown. Ultrasonography, computed tomography and laparoscopy are used in diagnosing mesenteric cysts. Laparoscopic excision of a mesenteric cyst is possible and should be considered as the treatment of choice. We present a case of mesenteric pseudocyst of small bowel treated by laparoscopic excision.

Sigmoid volvulus: is it a possible complication after stapled transanal rectal resection (STARR)?

We report a case of sigmoid volvulus post-stapled transanal rectal resection (STARR) for obstructed defecation. The patient, a 68-yearold woman with chronic constipation and dolichosigma, two days post-STARR presented severe abdominal pain. CT revealed sigmoid ischemia. The patient underwent resection of the sigmoid colon with end colostomy (Hartmann's procedure). Can STARR procedure produce a serious complication as sigmoid volvulus in patient with dolichosigma and obstructed defecation syndrome?

Totally laparoscopic resection of a very large gastric GIST.

Laparoscopic approach was safely performed for the diagnosis and treatment of the submucosal tumors of the stomach because it is associated with low morbidity, mortality, and sound oncologic outcomes. However, no report on the long-term safety and efficacy of this surgery for large sized gastric GISTs has been published to date. We present a 63-year-old female case of a large gastric GIST of 19 cm removed by laparoscopic wedge resection.

One-stage laparoscopic procedure for a patient with bilateral colorectal tumours and renal carcinoma.

We describe a case of a patient with synchronous bilateral colorectal tumours and renal carcinoma who underwent one-stage laparoscopic surgery procedure with right transperitoneal nefrectomy, right hemicolectomy and sigmoidectomy. One-stage laparoscopic procedure can be used safely and successfully for a patient with multiple primary tumours.