Navigator nurse implementation within a fast track program of liver resections: How to improve the healthcare service and perioperative results.

BACKGROUND: The introduction into the clinical practice of the navigator nurse (NaNu) to address the task of counseling and short term follow-up help the effective implementation of the fast track protocol. The aim of the present study was to investigate the impact of the standardization of the NaNu's role in patients undergoing liver surgery. METHODS: Patients undergoing elective liver surgery for all diagnosis and approach, from 2015, received counseling and postoperative follow-up by NaNu and constituted the study group (n = 890). This group was compared with the control group (n = 712) including patients treated in the era before the implementation of the NaNu role (2011-2014). Outcome was evaluated in terms of discrepancy between functional recovery and discharge, number of ER accesses, number of readmissions. RESULTS: Preoperative characteristics of patients and disease, as well as type of resection and postoperative outcomes were similar between the two groups. The proportion of laparoscopic cases was higher in the study group (51.2% vs. 32% in the control). Time for discharge, interval between functional recovery and discharge, number of ER accesses and number of readmissions were reduced in the study group. Benign diagnosis, absence of complications, laparoscopic approach and presence of NaNu were independent predictors of shorter length of stay. The positive effect of NaNu's activation was recorded in patients with complications and undergoing open surgery. CONCLUSION: The implementation of NaNu's role has allowed to us optimize the level of healthcare service offered to patients. The wider benefit was offered in the setting of complex patients.

Safety of laparoscopic cholecystectomy performed by trainee surgeons with different cholangiographic techniques (SCOTCH): a prospective non-randomized trial on the impact of fluorescent cholangiography during laparoscopic cholecystectomy performed by trainees.

AIMS: The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST. METHODS: This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction. RESULTS: Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences. CONCLUSIONS: These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.

Robo-Lap Approach Optimizes Intraoperative Outcomes in Robotic Left and Right Hepatectomy.

Background: The aim of the present study is to evaluate the possible advantages of the Robo-Lap (parenchymal transection by laparoscopic ultrasonic dissector and robotic bipolar forceps and scissors) compared with pure robotic technique (parenchymal transection by use of robotic bipolar forceps and scissors) in major anatomical liver resections with specific focus on intraoperative outcomes. Methods: Major liver resections performed by robotic approach between February 1, 2021 and March 31, 2023 were stratified into two groups according to the approach used to address the phase of liver transection; Pure Robotic Group (n = 21) versus Robo-Lap Group (n = 48). The two groups were compared in terms of intra- and postoperative outcomes and in terms of rate of achievement of intraoperative textbook outcomes. Results: Conversion rate was similar between the two groups while incidence of adverse intraoperative events (according to Satava classification) was higher in the Pure Robotic compared with the Robo-Lap group (85.7% vs 39.6%, p < 0.001). Time to perform parenchymal transection was significantly shorter in the Robo-Lap group (180 min) compared with the Pure Robotic Group (240 min), p = 0.003. Intraoperative textbook outcomes were achieved in a lower proportion of patients in the Pure Robotic compared with the Robo-Lap group. Conclusion: Outcomes of the present study suggest a favorable role of the Robo-Lap approach in robotic major resections as it allows an improvement of the intraoperative results, a greater probability of an uneventful conduction of the procedure, and therefore, better management of the operating room time.

Pituitary T1 signal intensity at magnetic resonance imaging is reduced in patients with obesity: results from the CHIASM study.

BACKGROUND: Despite obesity being well known to be associated with several pituitary hormone imbalances, pituitary appearance in magnetic resonance imaging (MRI) in patients with obesity is understudied. OBJECTIVE: To evaluate the pituitary volume and signal intensity at MRI in patients with obesity. METHODS: This is a prospective study performed in an endocrine Italian referral center (ClinicalTrial.gov Identifier: NCT03458533). Sixty-nine patients with obesity (BMI > 30 kg/m2) and twenty-five subjects without obesity were enrolled. Thirty-three patients with obesity were re-evaluated after 3 years of diet and lifestyle changes, of whom 17 (51.5%) achieved a > 5% loss of their initial body weight, whereas the remaining 16 (48.5%) had maintained or gained weight. Evaluations included metabolic and hormone assessments, DEXA scan, and pituitary MRI. Pituitary signal intensity was quantified by measuring the pixel density using ImageJ software. RESULTS: At baseline, no difference in pituitary volume was observed between the obese and non-obese cohorts. At the 3-year follow-up, pituitary volume was significantly reduced (p = 0.011) only in participants with stable-increased body weight. Furthermore, a significant difference was noted in the mean pituitary intensity of T1-weighted plain and contrast-enhanced sequences between the obese and non-obese cohorts at baseline (p = 0.006; p = 0.002), and a significant decrease in signal intensity was observed in the subgroup of participants who had not lost weight (p = 0.012; p = 0.017). Insulin-like growth factor-1 levels, following correction for BMI, were correlated with pituitary volume (p = 0.001) and intensity (p = 0.049), whereas morning cortisol levels were correlated with pituitary intensity (p = 0.007). The T1-weighted pituitary intensity was negatively correlated with truncal fat (p = 0.006) and fibrinogen (p = 0.018). CONCLUSIONS: The CHIASM study describes a quantitative reduction in pituitary intensity in T1-weighted sequences in patients with obesity. These alterations could be explained by changes in the pituitary stromal tissue, correlated with low-grade inflammation.

Long-Term Oncological Results After Laparoscopic Sigmoidectomy for Adenocarcinoma.

Purpose: Sigmoidectomy is performed in most cases for benign pathologies and mainly in cases of diverticulitis. Few studies in the literature report oncological results after sigmoidectomy for adenocarcinoma. The aim of this study was to report the long-term oncological outcomes after elective laparoscopic sigmoidectomy (LS) for adenocarcinoma. Methods: This study is a retrospective analysis of prospectively collected data. From January 2003 to February 2021, 173 patients underwent elective LS for adenocarcinoma. Twenty-four patients with a diagnosis of preoperative distant metastases were excluded (13.9%). Results: Seven postoperative complications were observed (7.1%). Of these, 2 (2%) anastomotic leakages were treated surgically by the Hartmann procedure (Clavien-Dindo grade III-b). The mean number of harvested lymph nodes with the specimen was 14.2 ± 7.1. At a median follow-up of 115 months (interquartile range 133.8), 2 (2%) and 9 patients (9.2%) had developed recurrence and metastases, respectively. During follow-up, 6 patients (6.1%) with metastases died due to disease progression and 6 other patients (6.1%) died due to causes other than cancer related. At the 5- and 10-year follow-ups, the overall survival rates were 90.5% ± 3.4% and 83.8% ± 4.5%, respectively, while the disease-free survival rates were 87.1% ± 4.1% and 83.5% ± 4.7%, respectively. Conclusion: LS is a safe and feasible technique both in terms of the number of harvested lymph nodes and oncological results. The possibility of sparing the colon without mobilizing the splenic flexure and dividing the left colic artery could reduce intra- and postoperative complications. Further studies with larger samples of patients are required to confirm these data.

Surgical site infections in patients undergoing breast oncological surgery during the lockdown: An unexpected lesson from the COVID-19 pandemic.

Background: The present study aims to evaluate how the measures to contain the SARS-CoV-2 spreading affected the surgical site infections (SSIs) rate in patients who underwent nondeferrable breast cancer surgery (BCS). Methods: This study is a retrospective analysis of prospectively collected data from a consecutive series of patients underwent nondeferrable BCS in a regional Italian Covid-free hub during two different period: March to April 2020 (pandemic cohort [PC]) and March till April 2019 (control cohort [CC]). SSIs were defined according to the criteria established by the Center for disease control and prevention (CDC) and additional treatment, serous discharge, erythema, purulent exudate, separation of deep tissues, isolation of bacteria, and stay (ASEPSIS) scoring systems. Results: One hundred ninety-nine patients were included in the present study: 100 and 99 patients who underwent nondeferrable BCS from March to April 2020 (PC) and from March to April 2019 (CC), respectively. The overall SSIs rate in this series was 9.1% according to CDC criteria and 6.5% according to ASEPSIS criteria. The SSIs incidence decreased during the pandemic period. Moreover, the SSIs rate according to ASEPSIS criteria was statistically lower in the PC than in the CC. We observed significant evidence of higher SSIs, both in terms of CDC and ASEPSIS score, in patients having undergone breast reconstruction compared with patients not undergoing immediate reconstruction. Conclusions: The restrictive measures issued during the lockdown period seemed to lower the SSIs rates in patients undergoing nondeferrable BCS.

Indocyanine Green Fluorescence Angiography During Laparoscopic Bariatric Surgery: A Pilot Study.

Aims: Indocyanine green (ICG) fluorescence angiography (FA) is used for several purposes in general surgery, but its use in bariatric surgery is still debated. The objective of the present pilot study is to evaluate the intraoperative utility of ICG-FA during bariatric surgery in order to focus future research on a reliable tool to reduce the postoperative leak rate. Methods: Thirteen patients (4 men, 30.8%, 9 women, 69.2%) with median age of 52 years (confidence interval, CI, 95% 46.2-58.7 years) and preoperative median body mass index of 42.6 kg/m2 (CI, 95% 36 to 49.3 kg/m2) underwent bariatric surgery with ICG-FA in our center. Three mL of ICG diluted with 10 cc sterile water were intravenously injected after gastric tube creation during laparoscopic sleeve gastrectomy (LSG) and after the gastric pouch and gastro-jejunal anastomosis creation during laparoscopic gastric by-pass (LGB). For the ICG-FA, Karl Storz Image 1S D-Light system (Karl Storz Endoscope GmbH & C. K., Tuttlingen, Germany) placed at a fixed distance of 5 cm from the structures of interest and zoomed vision modality were used to identify the vascular supply. The perfusion pattern was assessed by the surgical team according to a score. The score ranged from 1 (poor vascularization) to 5 (excellent vascularization) based on the intensity and timing of fluorescence of the vascularized structures. Results: Fom January 2021 to February 2022, six patients underwent LSG (46.2%), three patients underwent LGB (23.1%), and four patients underwent re-do LGB after LSG (30.8%). No adverse effects to ICG were observed. In 11 patients (84.6%) ICG-FA score was 5. During two laparoscopic re-do LGB, the vascular supply was not satisfactory (score 2/5) and the surgical strategy was changed based on ICG-FA (15.4%). At a median follow-up of five months postoperatively, leaks did not occur in any case. Conclusions: ICG-FA during bariatric surgery is a safe, feasible and promising procedure. It could help to reduce the ischemic leak rate, even if standardization of the procedure and objective fluorescence quantification are still missing. Further prospective studies with a larger sample of patients are required to draw definitive conclusions.

Complications after bowel resection for inflammatory bowel disease associated cancer: a systematic literature review.

INTRODUCTION: Inflammatory bowel disease (IBD) associated colorectal cancer represents the 1-2% of all patients affected by colorectal carcinoma, but it is frequent responsible for death in these patients. Aim of this systematic review was to report the complications after bowel resection in patients with IBD associated cancer. EVIDENCE ACQUISITION: A systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The search was carried out in PubMed, Embase, Cochrane and Web of Science databases. A total of 54,084 articles were found. Of these 38,954 were eliminated because were duplicates between the searches. Of the remaining 15,130 articles, 14,888 were excluded after screening title and abstract. EVIDENCE SYNTHESIS: Two-hundred-forty-two articles were fully analyzed, and 239 further articles were excluded. Finally, three articles were included for a total of 63 patients. Overall, 38 early postoperative complications (60.3%) were observed. Of these, anastomotic leakage occurred in 13 patients (20.6%). The indication for surgery was ulcerative colitis in 52 patients (82.5%), Crohn's disease in 8 patients (12.7%) and indeterminate colitis in 3 patients (4.8%). Intraoperative complications, readmission and postoperative mortality were not observed. CONCLUSIONS: Complication rate after bowel resection for IBD associated cancer is not different from complication rate after colorectal surgery for other diseases. Given the high probability of developing a cancer and the time correlated occurrence of malignancy in IBD patients, it should be debated if a surgical resection should be performed as soon as dysplasia is detected in IBD patients or earlier in their life.

Does Sleeve Gastrectomy Worsen Gastroesophageal Reflux Disease in Obese Patients? A Prospective Study.

BACKGROUND: To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LGB) on gastroesophageal reflux disease (GERD). METHODS: GERD was evaluated by the Modified Italian Gastroesophageal reflux disease-Health-Related Quality of Life (MI-GERD-HRQL) questionnaire, pH-manometry, endoscopy, and Rx-esophagogram, before and 12 months after surgery. Based on these exams, patients without GERD underwent LSG, and patients with GERD underwent LGB. RESULTS: Thirteen and six patients underwent LSG and LGB, respectively. After LSG, the only statistically significant difference observed at pH-manometry was the median DeMeester score, from 5.7 to 22.7 (P = .0026). De novo GERD occurred in 6 patients (46.2%), with erosive esophagitis in one. The median MI-GERD-HRQL score improved from 3 to 0. Overall, nine patients underwent LGB, but three were lost to follow-up. Preoperative pH-manometry changed the surgical indication from LSG to LGB in 7 out of 9 patients (77.8%). Six patients who underwent LGB completed the study, and at pH-manometry, statistically significant differences were observed in the percentage of total acid exposure time, with the number of reflux episodes lasting >5 minutes and DeMeester score (P = .009). The median MI-GERD-HRQL score improved from 6.5 to 0. Statistically significant differences were not observed at endoscopy and Rx-esophagogram findings in both groups. CONCLUSIONS: LSG has a negative impact on GERD, even in patients without preoperative GERD. LGB confirmed to be the intervention of choice in patients with GERD. Preoperative pH-manometry may identify patients with silent GERD, to candidate them to LGB rather than LSG. pH-manometry should be used more liberally to establish the correct surgical indication on objective grounds.

Cancer risk in adrenalectomy: are adrenal lesions equal or more than 4 cm a contraindication for laparoscopy?

BACKGROUND: Some authors consider adrenal lesions size of less than 4 cm as a positive cut-off limit to set the indications for minimally invasive surgery due to a lower risk of malignancy. Aim of this study is to report the risk of cancer for adrenal lesions measuring 4 cm or more in diameter, assessed as benign at preoperative workup (primary outcome), and to evaluate the feasibility and safety of laparoscopic adrenalectomy (LA) in these cases (secondary outcome). METHODS: From January 1994 to February 2019, 579 patients underwent adrenalectomy. Fifty patients with a preoperative diagnosis of primary adrenal cancer or metastases were excluded. The remaining 529 patients were included and divided in five subgroups based on adrenal lesion size at definitive histology: group A, 4-5.9 cm (137 patients); group B, 6-7.9 cm (64 patients); group C, 8-9.9 cm (13 patients); group D, ≥ 10 cm (11 patients); group E, < 4 cm (304 patients). Each group was further divided based on diagnosis of benign or malignant lesions at definitive histology. RESULTS: Four (2.9%) malignant lesions were observed in group A, 5 (7.8%) in group B, 2 (15.4%) in Groups C and D (18.2%) and 13 (4.3%) in Group E. Comparing the cancer risk among the groups, no statistically significant differences were observed. Operative time increased with increasing lesion size. However, no statistically significant differences were observed between benign and malignant lesions in each group comparing operative time, conversion and complication rates, postoperative hospital stay and mortality rate. CONCLUSIONS: Adrenal lesions measuring 4 cm or more in diameter are not a contraindication for LA neither in terms of cancer risk nor of conversion and morbidity rates, even if the operative time increases with increasing adrenal lesion diameter. Further prospective studies with a larger number of patients are required to draw definitive conclusions.

Manometric and pH-monitoring changes after laparoscopic sleeve gastrectomy: a systematic review.

PURPOSE: Aim of this systematic review is to assess the changes in esophageal motility and acid exposure of the esophagus through esophageal manometry and 24-hours pH-monitoring before and after laparoscopic sleeve gastrectomy (LSG). METHODS: Articles in which all patients included underwent manometry and/or 24-hours pH-metry or both, before and after LSG, were included. The search was carried out in the PubMed, Embase, Cochrane, and Web of Science databases, revealing overall 13,769 articles. Of these, 9702 were eliminated because they have been found more than once between the searches. Of the remaining 4067 articles, further 4030 were excluded after screening the title and abstract because they did not meet the inclusion criteria. Thirty-seven articles were fully analyzed, and of these, 21 further articles were excluded, finally including 16 articles. RESULTS: Fourteen and twelve studies reported manometric and pH-metric data from 402 and 547 patients, respectively. At manometry, a decrease of the lower esophageal sphincter resting pressure after surgery was observed in six articles. At 24-hours pH-metry, a worsening of the DeMeester score and/or of the acid exposure time was observed in nine articles and the de novo gastroesophageal reflux disease (GERD) rate that ranged between 17.8 and 69%. A meta-analysis was not performed due to the heterogeneity of data. CONCLUSIONS: After LSG a worsening of GERD evaluated by instrumental exams was observed such as high prevalence of de novo GERD. However, to understand the clinical impact of LSG and the burden of GERD over time further long-term studies are necessary.

Endo-SPONGE pulley system for the treatment of chronic anastomotic leakage after rectal resection. A case report.

AIM: Anastomotic leakage (AL) after anterior rectal resection unresponsive to diverting ileostomy is difficult to manage. Endoscopic vacuum-assisted (E-VAC) wound closure system is a new approach based on co-axial sponge positioning under endoscopic control. If the abscess is not co-axial, however, endoscopic positioning is not feasible. Aim is to report an original method of sponge positioning. CASE EXPERIENCE: A 62-year-old woman with chronic AL after anterior rectal resection for cancer was referred. AL had been treated with diverting ileostomy without healing. Due to the peri-rectal abscess anatomy, standard E-VAC positioning was not possible. A combined endoscopic-interventional radiology procedure for Endo-SPONGE® (B. Braun Aesculap AG, Germany) positioning was thus employed. Under general anesthesia, a guidewire was passed after small counter-incision on the left gluteus and through the left levator muscle, reaching the anastomotic dehiscence and rectal lumen through the chronic abscess. The guidewire was retrieved through the anus and connected to a long silk thread. By retracting the trans-gluteal guidewire, the silk thread was pulled through the abscess to exit from the gluteal skin incision. A tailored Endo-SPONGE® was then connected to the trans-anal silk thread. By pulling on the gluteal silk thread, the sponge was positioned inside the abscess. The silk thread remained in place under a medication for sponge replacements. DISCUSSION AND RESULTS: Twelve Endo-SPONGE replacements under sedation were required until AL completely resolved after 35 days. CONCLUSION: When traditional endoscopic sponge insertion into AL is not possible, this original "pulley system" proved effective for sponge introduction and replacement. KEY WORDS: Anastomotic leakage (AL), Anterior rectal resection, Endo-SPONGE, Endoscopic-Interventional radiology, Pulley system.

One-stage laparoscopic bilateral adrenalectomy, cholecystectomy and choledochotomy by a transperitoneal anterior approach Case report of a combined management for a challenging condition.

Laparoscopic adrenalectomy (LA) is the treatment of choice for management of adrenal tumors. Several approaches are proposed, including the transperitoneal one with patient in lateral or supine position, and the retroperitoneal one, with patient in lateral or prone position. The best approach, however, has yet to be defined. In patients with gallstones and common bile duct (CBD) stones, available options are one-stage [including laparoscopic cholecystectomy (LC) with CBD exploration (LC-LCBDE) and LC with endoscopic rendez-vous (LC-ERV)], or two-stage management [LC and pre or postoperative Endoscopic-Retrograde-Cholangio-Pancreatography (ERCP) with endoscopic sphincterotomy (ES)]. Both are safe and effective, with lower hospital stay after one-stage option. The decision for one or the other depends on local resources and patient conditions. We report the case of a hypertensive 53-years-old man with Cushing's disease from pituitary ACTH-secreting adenoma, after three failed trans-sphenoidal pituitary gland surgical resection procedures, and recurrent biliary symptoms from gallstones and CBD stones. The patient underwent laparoscopic transperitoneal bilateral adrenalectomy in supine position (anterior approach on the right, submesocolic approach on the left) together with LC, intraoperative cholangiography, choledochotomy, CBD exploration, T-tube drainage. In this challenging case, laparoscopic transperitoneal bilateral adrenalectomy with patient in supine position together with one-stage laparoscopic management of gallstones and CBD stones, offered the patient the opportunity to solve both adrenal and biliary problems in the same session, reducing hospital stay and costs. In experienced hands, the transperitoneal combination of different surgical approaches during the same anesthesia with patient in supine position may provide safe and effective patient management. KEY WORDS: Bilateral adrenalectomy, Laparoscopic adrenalectomy (LA), Choledochotomy, Common bile duct (CBD) stones, Laparoscopic cholecystectomy (LC) Laparoscopic common bile duct exploration (LCBDE), Submesocolic approach, Transperitoneal anterior approach.

Are Adrenal Lesions of 6 cm or More in Diameter a Contraindication to Laparoscopic Adrenalectomy? A Case-Control Study.

BACKGROUND: The aim of this case-control study is to compare the surgical outcomes of laparoscopic adrenalectomy (LA) for lesions measuring ≥6 cm versus ≤5.9 cm in diameter. METHODS: Eighty-one patients with adrenal gland lesions ≥6 cm in diameter (intervention group) were identified. Patients were matched to 81 patients with adrenal gland ≤5.9 cm in diameter (control group) based on disease (Conn-Cushing syndrome, pheochromocytoma, primary or secondary adrenal cancer or other disease), lesion side (right, left), surgical technique (anterior transperitoneal approach for right and left LA or anterior transperitoneal submesocolic for left LA) and body mass index class (18-24.9, 25-29.9, 30-34.9, 35-39.9, ≥40 kg/m2). Surgical outcomes were compared between the intervention and control groups. RESULTS: Mean operative time was statistically significantly longer in the interventional arm (101.4 ± 52.4 vs. and 85 ± 31.6 min, p = 0.0174). Eight conversions were observed in the intervention group (9.8%) compared to four in the control group (4.9%) (p = 0.3690). Five (6.1%) and three (3.7%) postoperative complications were observed in the intervention and control groups, respectively (p = 0.7196). Mean postoperative hospital stay was 4.6 ± 2.4 and 4.1 ± 2.3 days in the intervention and control groups, respectively (p = 0.1957). CONCLUSIONS: Operative time was statistically significantly longer in adrenal gland lesions ≥6 cm in diameter (vs. ≤5.9 cm). Conversion and complication rates were also higher, but the difference was not statistically significant. Based on the present data, adrenal gland lesions ≥6 cm in diameter are not an absolute contraindication to the laparoscopic approach.

Results after laparoscopic left anterior transperitoneal submesocolic adrenalectomy for the treatment of pheochromocytoma.

AIM: Minimally invasive adrenalectomy is the treatment of choice for benign adrenal lesions including pheocromocytoma (PHE) and in selected patients with malignant lesions. The aim of the present study is to evaluate the authors' results after laparoscopic left anterior transperitoneal submesocolic adrenalectomy (LLATSA) for unilateral PHE. MATERIAL OF STUDY: This study is a retrospective analysis of prospectively collected data. From 1994 to 2018, 552 patients underwent laparoscopic adrenalectomy (LA). Of these, 34 patients (14 men, 20 women, mean age 52.8 years) underwent LLATSA for PHE. RESULTS: Mean operative time was 93.1 ± 44.9 minutes. Conversion to open surgery occurred in two patients due to difficult identification of the anatomy. Intraoperative blood pressure and heart rate instability were observed in four cases, but with no need for conversion. Postoperative morbidity was nil. One American Society of Anesthesiologists (ASA) III patient died on postoperative day 4 from acute myocardial infarction. Mean postoperative hospital stay was 3.8 ± 1.8 days (range 2 - 8). DISCUSSION: The main advantage of this approach is the early ligation of the main adrenal vein prior to any gland manipulation. This reduces the risk of catecholamines' spread and consequently the risk of hemodynamic instability. Intraperitoneal dissection is limited and there is no need to mobilize the colon or pancreas, with a lower risk of complications from organ manipulation. CONCLUSIONS: LLATSA is feasible and safe for the treatment of PHE. A randomized trial design and a larger cohort of patients would be required to confirm these conclusions. KEY WORDS: Adrenal tumors, Adrenal lesions, Laparoscopic adrenalectomy, Pheochromocytoma, Transperitoneal anterior approach, Laparoscopic left anterior transperitoneal submesocolic adrenalectomy (LLATSA).

Quality of life and anorectal function after transanal surgery for rectal cancer. A literature review.

AIM: The aim of the study is analyze the results after Transanal Endoscopic Microsurgery (TEM) and Trans-Anal Minimally Invasive Surgery (TAMIS) for rectal cancer in terms of Quality of Life (QoL) and anorectal function. MATERIAL OF STUDY: The authors have conducted a review of the literature through the PubMed database using the following keywords: "quality of life", "rectal cancer", "transanal surgery", "TEM" and "TAMIS". RESULTS: Six and five studies were included on TEM and TAMIS, respectively, for a total of 619 patients with a follow up of up to five years. QoL and anorectal function were evaluated by questionnaires and anorectal manometry in four out of eleven studies. At postoperative evaluation, patients reported temporary changes (from 3 weeks to 36 months) but no long-term effects on anorectal function and QoL. There were no differences in the postoperative functional outcome between surgery with rigid (TEM) or soft (TAMIS) devices. Some of the studies reported postoperative changes at manometry that were not clinically confirmed by the questionnaires. DISCUSSION: During TEM and TAMIS the risk of pelvic autonomic nerves damage, that may compromise urinary and sexual function and the risk of permanent sphincter damage with the need to perform a stoma, are very low. CONCLUSIONS: Quality of life and anorectal function after TEM or TAMIS for the treatment of rectal tumors are good with no postoperative sequelae at mid-term follow up. KEY WORDS: Quality of Life (QoL), Rectal cancer, Transanal surgery, Transanal Endoscopic Microsurgery (TEM), Trans-Anal Minimally Invasive Surgery (TAMIS).

Laparoscopic bilateral anterior transperitoneal adrenalectomy: 24 years experience.

BACKGROUND: The aim of this study is to evaluate the feasibility, safety, advantages and surgical outcomes of laparoscopic bilateral adrenalectomy (LBA) by an anterior transperitoneal approach. METHODS: From 1994 to 2018, 552 patients underwent laparoscopic adrenalectomy, unilateral in 531 and bilateral in 21 patients (9 females and 12 males). All patients who underwent LBA were approached via a transperitoneal anterior route and form our study population. Indications included: Cushing's disease (n = 11), pheochromocytoma (n = 6), Conn's disease (n = 3) and adrenal cysts (n = 1). RESULTS: Mean operative time was 195 ± 86.2 min (range 55-360 min). Conversion was necessary in one case for bleeding. Three patients underwent concurrent laparoscopic cholecystectomy with laparoscopic common bile duct exploration and ductal stone extraction in one. Three postoperative complications occurred in one patient each: subhepatic fluid collection, intestinal ileus and pleural effusion. Mean hospital stay was 6.1 ± 4.7 days (range 2-18 days). CONCLUSIONS: In our experience, transperitoneal anterior LBA was feasible and safe. Based on our results, we believe that this approach leads to prompt recognition of anatomical landmarks with early division of the main adrenal vein prior to any gland manipulation, with a low risk of bleeding and without the need to change patient position. Unlike the lateral approach, there is no need to mobilize the spleno-pancreatic complex on the left or the liver on the right. The ability to perform associated intraperitoneal procedures, if required, is an added benefit.