A New Medium (HistoCold) for Surgical Specimens Preserving to Improve the Preanalytic Issues in Histopathological Samples Handling: Morphologic and Antigenic Analysis.

Introduction: The onset of precision medicine has led to the integration of traditional morphologic tissues evaluation with biochemical and molecular data for a more appropriate pathological diagnosis. The preanalytic phase and, particularly, timing of cold ischemia are crucial to guarantee high-quality biorepositories of formalin-fixed paraffin-embedded (FFPE) tissues for patients' needs and scientific research. However, delayed fixation using the gold-standard and carcinogenic fixative neutral-buffered formalin (NBF) can be a significant limitation to diagnosis and biopathological characterization. HistoCold (patented; Bio-Optica Milano S.p.A., Milano, Italy) is a nontoxic, stable, and refrigerated preservative solution for tissue handling. This study examined HistoCold's potential role in improving the preanalytic phase of the pathological diagnostic process. Materials and Methods: Breast, lung, or colorectal cancers (20, 25, and 10 cases, respectively) that were to be surgically resected were recruited between 2019 and 2021. Once specimens were surgically removed, three residual samples for each patient were first promptly immersed into HistoCold for 24, 48, and 72 hours and then FFPE. These were compared with routine specimens regarding morphologic features (hematoxylin and eosin) and tissue antigenicity (immunohistochemical stains). Results: Good concordance regarding both the morphologic characteristics of the neoplasms and their proteins expression between the routine and HistoCold handled tissues were found. The tissue handling with the solution never affected the histopathological diagnosis. Conclusions: The use of HistoCold for samples transporting is easy, allows for improving the management of cold ischemia time, and monitoring the fixation times in NBF, resulting in good quality tissue blocks for biobanking. Moreover, it could be a candidate to eliminate formalin from operating theaters. HistoCold looks very promising for the preanalytic phase of human tissues handling in the era of precision medicine, to provide the best service to patients, and to scientific research.

Management and Outcomes of Pancreatic Resections Performed in High-Volume Referral and Low-Volume Community Hospitals Lead by Surgeons Who Shared the Same Mentor: The Importance of Training.

BACKGROUND: High hospital volume improves outcomes after pancreatic resection. The aim of this study was to assess if practice and outcomes differed between high- and low-volume centers across which chief surgeons shared a similar training and mentoring. METHODS: Data on patients undergoing standard pancreatic resections (2010-2013) at 7 Italian hospitals were collected. Chiefs of pancreatic surgery at each hospital had received the same training, with the same mentor. Two centers were high-volume referral hospitals for pancreatic disease, while 5 were low-volume hospitals. RESULTS: A total of 856 patients were included, with median annual volume of resections 82 at high-volume referral hospitals and 11 at low-volume hospitals. Patients at low-volume hospitals were older, had more comorbidities, and were more often referred from the emergency room. Intraoperative techniques and reconstruction methods were similar. Comparable rates of major postoperative complications (18 vs. 22%; p = 0.236) and pancreatic fistula (29 vs. 32%; p = 0.287) were achieved in both groups, with no significant increases in failure to rescue from grade B-C fistula (6.2 vs. 15.0%; p = 0.108) and mortality (2.4 vs. 4.1%; p = 0.233) in low-volume hospitals. Postoperative length of stay was shorter in high-volume referral hospitals (10 vs. 15 days; p < 0.001). CONCLUSION: Similar postoperative outcomes can be achieved across high- and low-volume centers where chief surgeons shared a similar training and mentoring. However, multidisciplinary postoperative provision more often associated with high-volume centers may also affect outcomes.

Pancreatic tumors imaging: An update.

Currently, ultrasound (US), computed tomography (CT) and Magnetic Resonance imaging (MRI) represent the mainstay in the evaluation of pancreatic solid and cystic tumors affecting pancreas in 80-85% and 10-15% of the cases respectively. Integration of US, CT or MR imaging is essential for an accurate assessment of pancreatic parenchyma, ducts and adjacent soft tissues in order to detect and to stage the tumor, to differentiate solid from cystic lesions and to establish an appropriate treatment. The purpose of this review is to provide an overview of pancreatic tumors and the role of imaging in their diagnosis and management. In order to a prompt and accurate diagnosis and appropriate management of pancreatic lesions, it is crucial for radiologists to know the key findings of the most frequent tumors of the pancreas and the current role of imaging modalities. A multimodality approach is often helpful. If multidetector-row CT (MDCT) is the preferred initial imaging modality in patients with clinical suspicion for pancreatic cancer, multiparametric MRI provides essential information for the detection and characterization of a wide variety of pancreatic lesions and can be used as a problem-solving tool at diagnosis and during follow-up.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected].

BACKGROUND: The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues. METHODS: The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group. RESULTS AND CONCLUSIONS: The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.

Celiac artery compression syndrome managed by laparoscopy.

OBJECTIVE: Celiac artery compression syndrome (CACS) is an unusual condition caused by abnormally low insertion of the median fibrous arcuate ligament and muscular diaphragmatic fiber resulting in luminal narrowing of the celiac trunk. Surgical treatment is the release of the extrinsic compression by division of the median arcuate ligament overlying the celiac axis and skeletonization of the aorta and celiac trunk. The laparoscopic approach has been recently reported for single cases. Percutaneous transluminal angioplasty (PTA) and stenting of the CA alone, before or after the surgical relief of external compression to the celiac axis, has also been used. We report our 7-year experience with the laparoscopic management of CACS caused by the median arcuate ligament. METHODS: Between July 2001 and May 2008, 16 patients (5 men; mean age, 52 years) were treated. Diagnosis was made by duplex ultrasound scan and angiogram (computed tomography [CT] or magnetic resonance). The mean body mass index of the patients was 21.2 kg/m(2). One patient underwent laparoscopic surgery after failure of PTA and stenting of the CA, and two patients after a stenting attempt failed. RESULTS: All procedural steps were laparoscopically completed, and the celiac trunk was skeletonized. The laparoscopic procedures lasted a mean of 90 minutes. Two cases were converted to open surgery for bleeding at the end of the operation when high energies were used. The postoperative course was uneventful. Mean postoperative hospital stay was 3 days. On follow-up, 14 patients remained asymptomatic, with postoperative CT angiogram showing no residual stenosis of the celiac trunk. One patient had restenosis and underwent aortoceliac artery bypass grafting after 3 months. Another patient had PTA and stenting 2 months after laparoscopic operation. All patients reported complete resolution of symptoms at a mean follow-up of 28.3 months. CONCLUSIONS: The laparoscopic approach to CACS appears to be feasible, safe, and successful, if performed by experienced laparoscopic surgeons. PTA and stenting resulted in a valid complementary procedure only when performed after the release of the extrinsic compression on the CA. Additional patients with longer follow-up are needed.

Laparoscopic incisional and ventral hernia repair without sutures: a single-center experience with 200 cases.

BACKGROUND: Laparoscopic incisional and ventral herniorraphy (LIVH), using a mesh, has gained recognition as an effective method and is associated with lower complication and recurrence. Controversies in the operative technique still exist about biomaterial, method of fixation, and overlap of the mesh over the defect. The aim of this study was to evaluate the outcomes achieved with LIVH in 200 consecutive patients treated in a single hospital, using fixation of the mesh with only tacks. Results of the first 100 (group A) and the last 100 (group B) operations were also compared. METHODS: From 2003 through 2007, 200 patients underwent LIVH. Overlap of the mesh was 3-5 cm. The mesh was secured with tacks alone, with the "double crown" technique. In group B, adhesiolysis was performed, avoiding high energies. RESULTS: Mean ventral defect was 107.5 (+/- 95.4) cm2. The recurrent ventral hernia rate was 20%, and the conversion rate was 2.5%. Mean operative time was 77.5 (+/- 33.9) minutes. Mean mesh dimension was 326.4 (+/- 166.8) cm2. The overall morbidity rate was 10.5%. Bowel injuries were 5 (2.5 %). Minor complications were 8.0%. Median postoperative hospital stay was 3 days. Recurrence rate was 3.5%, with a mean follow-up of 22.5 months. Chronic pain was 1%. No difference was seen between groups A and B regarding minor complications, whereas a significant difference was found regarding enterotomies (5 vs. 0; P = 0.024) and recurrences (6 vs. 1; P = 0.056). CONCLUSIONS: Fixation of the mesh with the sole use of tacks was demonstrated to be safe and effective. Avoiding high energies, no case of enterotomy occurred.

Operative and long-term results after one-stage surgery for obstructing colonic cancer.

BACKGROUND/AIMS: To analyze retrospectively the operative results and five-year survival after single-stage resection and primary anastomosis for right- or left-sided colonic malignant obstruction. METHODOLOGY: From 1994 to 2002, 83 patients with acute obstruction due to primary cancer underwent a one-stage procedure, 36 (43.3%) for cancer of the right and 47 (56.7%) of the left colon. Of the 47 patients with left acute obstruction, 45 were treated with intraoperative colonic on-table lavage for decompression and wash-out before resection and anastomosis. Long-term survival was compared with the outcome of 369 patients with colonic cancer without obstruction 144 (39%) right and 225 (61%) left. RESULTS: Overall operative morbidity and mortality were 25.3% and 6%, respectively. Overall anastomotic leakage rate was 6%. Kaplan-Meier curves showed five-year survival rates poorer for patients operated on for obstructing malignancy than those observed for patients without obstruction (p=0.0001, Log-Rank test), obstructing malignancy was associated with more advanced age (p<0.0005) and staging of the cancer. CONCLUSIONS: One-stage resection and primary anastomosis can be applied to the majority of patients with malignant colonic obstruction and it allows achieving excellent operative results. Obstructing colonic cancer proved to be associated to a worse long-term survival.

Laparoscopic central pancreatectomy.

BACKGROUND: The role of mini-invasive surgery in pancreatic surgery is still being debated. Indications and results are still controversial. Only a few centers in the world report on laparoscopic pancreatic resections. With the aim of improving the use of minimally invasive surgery, we have devised a novel laparoscopic procedure for surgical treatment of neuroendocrine tumor of the neck of the pancreas. METHODS: A central laparoscopic pancreatic resection was successfully performed. The pancreatic resection was performed using the harmonic scalpel. The duct was isolated and transected. The proximal duct stump was closed by an endoscopic stitch. The pancreaticojejunostomy was intracorporeally performed using a Roux-en-Y loop. RESULTS: Histologic findings showed a well differentiated neuroendocrine tumor. Operating time was 330 minutes and blood loss 300 mL. The postoperative course was uneventful. CONCLUSIONS: Laparoscopic central pancreatectomy is a feasible and safe procedure. The minimally invasive approach ensures an adequate treatment despite requiring the expertise of highly skilled laparoscopic surgeons.

[Laparoscopic pancreatic resection: preliminary experience]. / Chirurgia laparoscopica del pancreas: esperienza preliminare.

The aim of the study was to evaluate the results of laparoscopic pancreatectomy for pancreatic tumours. Four women and three men underwent laparoscopic pancreatectomy and were recruited into the study retrospectively over the period from June 2002 to February 2004. Pancreaticoduodenectomy (n = 4), intermediate pancreatectomy (n = 1) and distal pancreatic resection with splenectomy (n = 2) were successfully performed. Operative mortality was nil. The postoperative morbidity included two low-output pancreatic leaks. Mean operating time, blood loss and hospital stay were 342 minutes, 289 mL and 14 days, respectively. The pathological diagnosis was ductal adenocarcinoma in one, neuroendocrine tumour in five and metastatic melanoma in one. All patients are still well after a median follow-up of 7 months (range: 1-20 months). The patients appear to benefit from laparoscopic pancreatectomy for pancreatic tumours. The minimally invasive approach ensures adequate treatment but requires the expertise of highly skilled laparoscopic surgeons.

Temperature control and recovery of bowel function after laparoscopic or laparotomic colorectal surgery in patients receiving combined epidural/general anesthesia and postoperative epidural analgesia.

UNLABELLED: We compared the effects of a laparoscopic (n = 23) versus laparotomic (n = 21) technique for major abdominal surgery on temperature control in 44 patients undergoing colorectal surgery during a combined epidural/general anesthesia. A thoracic epidural block up to T4 was induced with 6-10 mL of 0.75% ropivacaine; general anesthesia was induced with thiopental, fentanyl, and atracurium IV and maintained with isoflurane. Core temperature was measured with a bladder probe and recorded every 15 min after the induction. In both groups, core temperature decreased to 35.2 degrees C (range, 34 degrees C-36 degrees C) at the end of surgery. After surgery, normothermia returned after 75 min (60-120 min) in the Laparoscopy group and 60 min (45-180 min) in the Laparotomy group (P = 0.56). No differences in postanesthesia care unit discharge time were reported between the two groups. The degree of pain during coughing was smaller after laparoscopy than laparotomy from the 24th to the 72nd observation times (P < 0.01). Morphine consumption was 22 mg (2-65 mg) in the Laparotomy group and 5 mg (0-45 mg) in the Laparoscopy group (P = 0.02). The time to first flatus was shorter after laparoscopy (24 h [16-72 h]) than laparotomy (72 h [26-96 h]) (P = 0.0005), and the first intake of clear liquid occurred after 48 h (24-72 h) in the Laparoscopy group and after 96 h (90-96 h) in the Laparotomy group (P = 0.0005). Although laparoscopic surgery provides positive effects on the degree of postoperative pain and recovery of bowel function, the reduction in heat loss produced by minimizing bowel exposure with laparoscopic surgery does not compensate for the anesthesia-related effects on temperature control, and active patient warming must also be used with laparoscopic techniques. IMPLICATIONS: This prospective, randomized, controlled study demonstrates that laparoscopic colorectal surgery results in less postoperative pain and earlier recovery of bowel function than conventional laparotomy but does not reduce the risk for perioperative hypothermia. Accordingly, active warming must be provided to patients also during laparoscopic procedures.