Laparoscopic versus robotic right colectomy with extra-corporeal or intra-corporeal anastomosis: a systematic review and meta-analysis.

PURPOSE: The aim of the present systematic review and meta-analysis is to compare laparoscopic right colectomy (LRC) versus robotic right colectomy (RRC) using homogeneous subgroup analyses for extra-corporeal anastomosis (EA) and intra-corporeal anastomosis (IA). METHODS: MEDLINE, Scopus, and Web of Science databases were searched up to April 2020 for prospective or retrospective studies comparing LRC versus RRC on at least one short- or long-term outcome. The primary outcome was the length of hospital stay (LOS). The secondary outcomes included operative and pathological results, survival, and total costs. LRC and RRC were compared using three homogeneous subgroups: without distinction by the type of anastomosis, EA only, and IA only. Pooled data analyses were performed using mean difference (MD) and random effects model. RESULTS: Thirty-seven of 448 studies were selected. The included patients were 21,397 for the LRC group and 2796 for the RRC group. Regardless for the type of anastomosis, RRC showed shorter LOS, lower blood loss, lower conversion rate, shorter time to flatus, and lower overall complication rate compared with LRC, but longer operative time and higher total costs. In the EA subgroup, RRC showed similar LOS, longer operative time, and higher costs compared with LRC, the other outcomes being similar. In the IA subgroup, RRC showed shorter LOS and longer operative time compared with LRC, with no difference for the remaining outcomes. CONCLUSIONS: Most included articles are retrospective, providing low-quality evidence and limiting conclusions. The more frequent use of the IA seems to explain the advantages of RRC over LRC.

Safety and Feasibility of Robotic-Assisted Drainage of Symptomatic Pancreatic Pseudocysts: A Case-Series Analysis (with video).

Background: The surgical treatment of pancreatic pseudocysts (PPs) in patients who fail nonoperative management has evolved from aggressive open to a minimally invasive approach. The application of robotic surgery in this setting is scarcely reported. The aim of this study is to analyze the safety and feasibility of the robotic approach to pancreatic pseudocyst drainage. Methods: A single centre retrospective review of consecutive patients undergoing robotic-assisted pancreatic pseudocyst surgeries in an academic tertiary institution was performed. Results: There were 14 patients studied, of whom 10 underwent cystogastrostomy and 4 Roux-En- Y cystojejunostomy. Eight patients had gallstone pancreatitis and 3 patients alcoholic pancreatitis. The mean size of cyst was 8.9 +-1cm and 57.1% located at the pancreatic body. The overall operative time of the procedure was 135 +-34 minutes. There were no open conversions. The overall success rate was 92.8%, while the primary success rate 85.7%. The major morbidity rate was 14.3% and there was no 30-day mortality. The mean post-operative hospital stay was 7 +-3 days with one recurrence of the pancreatic pseudocyst on follow-up requiring endoscopic drainage without further recurrence. Conclusions: The robotic approach for the drainage of symptomatic pancreatic pseudocyst is safe and feasible and can be considered as a viable modality for operative intervention in well-selected patients.

Lymphoscintigraphy with peritumoral injection versus lymphoscintigraphy with subdermal periareolar injection of technetium-labeled human albumin to identify sentinel lymph nodes in breast cancer patients.

BACKGROUND: Preoperative lymphoscintigraphy is without doubt a valid method for the detection of the sentinel lymph node (SLN). There has been considerable debate regarding the optimal site for the introduction of the tracer; various sites include peritumoral (PT), periareolar (PA), subdermal, and intradermal injection. PURPOSE: To evaluate retrospectively the lymphoscintigraphic identification rate of peritumoral (PT) injection versus subdermal periareolar (PA) injection in the detection of SLNs in breast cancer. MATERIAL AND METHODS: Between October 2002 and December 2011, a cohort of 906 consecutive patients with biopsy proven breast cancer underwent 914 SLN biopsy procedures. A total of 339 procedures (Group A) were performed using a PT deep injection of radiotracer while 575 procedures (Group B) adopted a subdermal PA injection of radiotracer towards the upper outer quadrant, regardless of the site of the carcinoma. All the patients underwent synchronous excision of the breast cancer and SLN biopsy. RESULTS: SLNs were identified in the lymphoscintigram in 308/339 cases (90.85%) of Group A (PT injection) and in 537/575 cases (93.39%) of Group B (PA injection). Furthermore, in 2/339 patients (0.58%) of Group A, internal mammary lymph nodes were found at lymphoscintigraphy, whereas no internal mammary sentinel nodes were found in the Group B patients. The intraoperative identification rate of axillary SLNs was 99.41% (337 of 339) in the Group A patients and 99.65% (573 of 575) in the Group B patients. There was no significant difference in the two groups between the incidence of the number of SLNs detected and the incidence of identification of positive SLNs. CONCLUSION: PT versus PA injection of radiotracer showed comparable success rates for axillary SLN identification, and can be considered a rapid and reliable method.

Local neck symptoms before and after thyroidectomy: a possible correlation with reflux laryngopharyngitis.

Local symptoms in the neck such as swallowing and voice disorders, and throat discomfort might be related to a goiter if present, but are also reported by patients suffering from reflux laryngopharyngitis. The aim of our study was to investigate the presence of reflux laryngopharyngitis in patients with nodular goiter before and after uncomplicated total thyroidectomy (TT) using a prospective study in University Hospital setting. We considered 25 patients, affected by non-toxic nodular goiter and candidates for TT, who complained of local symptoms in the neck. All the patients were carefully interviewed, with emphasis on swallowing and voice disorders, throat discomfort and reflux-related symptoms and underwent a videolaryngoscopy (VLS) and a videofluoroscopic swallowing study (VFSS) before and 3 months after TT. Before thyroidectomy, reflux laryngopharyngitis-related alterations were present in 68 and 50% at VLS and VFSS, respectively. After thyroidectomy, the swallowing and voice disorders persisted in 79 and 75%, respectively, while throat discomfort persisted in 91%. The results show that patients with a non-toxic nodular goiter who complain of local neck symptoms, before surgery it is appropriate to see if a reflux laryngopharyngitis is present; VLS and VFSS could be indicated for this and if necessary an antireflux treatment should be administered.

A minor modification of Lichtenstein repair of primary inguinal hernia: postoperative discomfort evaluation.

The aim of this study was to evaluate the usefulness of a modification of the Lichtenstein hernioplasty procedure by evaluating its impact on postoperative discomfort. From December 1999 to May 2006, the Lichtenstein inguinal hernioplasty was performed in 406 patients with noncomplicated unilateral inguinal hernia. During reconstruction, the mesh was fixed to the inguinal canal floor without stitching its upper margin to the internal oblique muscle. Control of postoperative pain proved to be satisfactory; 72 hours after surgery, 26.1 per cent of patients no longer felt any pain, whereas 54.4 per cent had slight pain without the need for painkillers; on Day 7, 92.8 per cent felt no pain at all. After 10 days, 86.7 per cent of those with sedentary jobs were able to return to work, whereas 79.1 per cent of those with heavier jobs resumed work in 11 to 15 days. Our modification of the original Lichtenstein procedure permitted us to obtain satisfactory results with regard to the control of postoperative chronic pain and a rapid reprisal of normal working activity.

The value of intraoperative frozen section examination of sentinel lymph nodes in surgical management of breast carcinoma.

PURPOSE: In breast cancer staging, the need for intraoperative sentinel lymph node (SLN) evaluation has still not been adequately established. This study investigates the impact of intraoperative frozen section (FS) evaluation of SLN to avoid subsequent axillary lymph node dissection (ALND) in patients with positive SLN. METHODS: A retrospective review of 364 breast cancer patients undergoing SLN biopsy with intraoperative FS evaluation of SLN was performed. RESULTS: Sensitivity and accuracy of FS examination of SLN were 76.4% and 94.2%, respectively. The sensitivity was significantly higher in larger tumors (p < 0.01). No significant correlation was found between FS and histologic type. A second intervention was avoided in 83.9% of the patients with positive SLN. CONCLUSIONS: Intraoperative FS examination of the SLN is a useful predictor of axillary lymph node status in breast cancer patients. The majority of SLN-positive patients allows for immediate ALND in a one-stage surgical procedure.

Tangential Venous Resections during Robotic-Assisted Pancreaticoduodenectomy: the Results of a Case Series (with Video).

INTRODUCTION: Despite the potential advantages in terms of microdissection and microsuturing capabilites, the robotic approach for borderline resectable pancreatic cancer is scarcely reported. METHODS: We report our technique for a robotic-assisted pancreaticoduodenectomy with tangential Portal/ Superior Mesenteric Vein resection/reconstruction (RPD PV/SMV).We also compared the surgical outcomes of eight consecutive patients undergoing RPD PV/SMV with that of sixty patients who underwent robotic-assisted pancreaticoduodenectomy (RPD) in the same period of time. RESULTS: A total of eight consecutive patients underwent RPD PV/SMV. We observed an increased estimated blood loss (550 vs 280 mL, p = 0.003) and operative time (438 vs 350 min, p = 0.002) in the RPD PV/SMV group of patients compared with RPD group, whereas the complication rate (28% vs 31%, p = 0.726) was similar. No venous-congestion related complications were observed in the postoperative course. The median length of hospital stay was similar in the RPD group in comparison to that in the RPD PV/SMV group (10 vs 13 range 6-19 days, p = 0.313). CONCLUSION: RPD PV/SMV is a challenging operation. It is associated with higher operative time and increased estimated blood loss in comparison to standard RPD.

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes.

BACKGROUND: Despite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV). METHODS: Since March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics. RESULTS: Mean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004). CONCLUSIONS: RPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.

Minor hepatic resection using heat coagulative necrosis.

Intra- and postoperative bleeding represents an extremely serious and frequent complication of hepatic surgery. In this study, we evaluated the effectiveness of a radiofrequency (RF) device using heat to cause coagulative necrosis of the hepatic parenchyma to control hemostasis in minor hepatic resection. Between December 2005 and November 2007, a study was conducted of 21 patients undergoing 22 hepatic resections with the RF-assisted technique. Sixteen of these were affected by hepatocellular carcinoma and five had liver metastases from colorectal cancer. Intraoperative blood loss, the need for blood transfusion, the complication rates, operating times, and the duration of postoperative hospitalization were evaluated. Four segmentectomies and 18 tumor-ectomies were performed. The average blood loss was of 15.7 mL (range, 0-40 mL); the average operating time was 25.7 minutes (range, 12-43 minutes); the mean postoperative hospital stay was 8.2 days (range, 3-49 days) with a median of 6.0 days. The authors concluded that the RF-assisted technique can be a useful method not only for reducing blood loss and avoiding blood transfusions, but also for reducing operating time and postoperative hospitalization for minor liver resections.

[Focal liver lesions: clinical usefulness of contrast-enhanced ultrasound in the selection of surgical patients]. / Lesioni focali epatiche: utilità clinica dell'ecografia con mezzo di contrasto nella selezione delpaziente chirurgico.

The aim of the study was to evaluate the role of contrast-enhanced ultrasound (CEUS) in the characterisation of focal liver lesions and for the selection of surgical patients. One hundred and thirty-five consecutive patients (71 women, 64 men) with 165 focal liver lesions (mean size: 3.1 cm)--89 benign (10 simple cysts, 26 haemangiomas, 29 focal nodular hyperplasia, 2 hepatocellular adenomas, 11 focal fatty sparing, 3 focal fatty areas, 5 regenerative nodules, 2 hydatid cysts, 1 abscess) and 76 malignant (47 metastases, 26 hepatocellular carcinomas and 3 peripheral cholangiocarcinomas)--underwent CEUS after the administration of SonoVue. Two radiologists reviewed baseline US and CEUS scans obtained 25-30 sec (arterial phase), 55-80 sec (portal-venous phase), and 235-260 sec (late phase) after initiating SonoVue injection, respectively. The radiologists classified each lesion as malignant or benign on the basis of clearly defined diagnostic criteria. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated. CEUS correctly characterised 156/165 focal liver lesions (94.5%), 85 benign and 71 malignant. Five focal liver lesions (3%; 3 haemangiomas and 2 hepatocellular carcinomas) remained undetermined after CEUS and 4 focal liver lesions (2.4%; 3 hepatocellular carcinomas and 1 abscess) were misdiagnosed. CEUS presented sensitivity, specificity, and diagnostic accuracy values of 93.4%, 95.5% and 94.7% respectively. Positive and negative predictive values were 94.7% and 94.4%, respectively. CEUS is a useful tool in the characterisation of focal liver lesions and for selecting surgical patients.

Denosumab for bone health in prostate and breast cancer patients receiving endocrine therapy? A systematic review and a meta-analysis of randomized trials.

Hormonal therapies for receptor positive-breast and prostate cancer patients have shown clinical efficacy but also several side effects including osteoporosis, loss of bone mass and increased fracture risk. Denosumab represents an anti RANKL (receptor activator of nuclear factor-kB ligand) monoclonal anti-body acting as inhibitor of osteoclasts formation, function, and survival, then increasing bone mass. Herein, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the role of Denosumab in saving bone health in prostate and breast cancer patients receiving respectively androgen deprivation therapy and adjuvant endocrine therapy. Moreover, selected patients have to be treated with Denosumab at the dose of 60 mg every six month or placebo. Outcomes studied included the bone mass density (BMD) increase at 24 and 36 months, BMD loss, reduction of fractures risk (in particular vertebral) at 24 and 36 months and safety (overall, serious adverse events - SAEs and discontinuation rate). Our results showed a reduction of the BMD loss up to 36 months both at the lumbar and femoral level and a BMD increase both at 24 and 36 months. It was also found a reduction in the number of new vertebral and femoral fractures at 24 and 36 months. Finally, our pooled analysis showed that Denosumab did not affect both the SAEs and therapy discontinuation risk. In conclusion, Denosumab administration can be considered effective and safe in the prevention and management of the above mentioned adverse events related to hormonal therapies designed for breast and prostate tumors.

Thyroid metastases from renal cell carcinoma. Report of a case and review of the literature.

Metastases to thyroid gland are a rare occurrence in surgical practice. The most frequent primitive tumor is renal cell carcinoma. We report a case of thyroid metastasis from renal cell carcinoma in a 70-year-old man who underwent left nephrectomy ten years earlier, presented with a diagnosis of multinodular goiter, associated with thyroiditis and right laterocervical lymphadenopathy. A total and the surgical excision of laterocervical lymph node were performed. The results, according to the histological examination, were metastases from renal cell carcinoma, involving both the thyroid gland and the lymph node. Therefore, since the delay of presentation and the difficulties of diagnosis, we recommend log-term follow-up of the head and neck region, for those patients with renal cell carcinoma diagnosis.

Validity of needle core biopsy in the histological characterisation of mammary lesions.

Over the last few years, there has been an enormous increase in the use of needle core biopsy (CB) for the histopathological characterisation of suspect lesions of the breast. The aim of this study was to verify the diagnostic reliability of CB by comparing the histological results obtained with the use of this technique with those obtained from the whole of the surgically resected specimen. We studied 198 out of 426 patients with clinically and/or radiologically suspect breast lesions. We found correspondence between the histological examination of the whole of the excised specimen and that of the CB in 94.9% of the cases of infiltrating carcinoma and in 71.4% of those involving ductal carcinomas in situ. The predictive value of CB was 98.9%, sensitivity was 96.1% and specificity 93.3%. These results confirmed that CB is an extremely reliable diagnostic tool in the definition of breast lesions.

Giant hepatic hydatid cyst as a cause of small bowel obstruction.

Today, giant hydatid cysts are fairly rare even in endemic areas. We describe a case of an extremely large hydatid cyst of the liver that was causing massive compression of the neighboring organs, giving rise to a subocclusive syndrome of the intestine. After considering the various approaches available for the treatment of this disease, it was decided that radical surgery was still the best therapeutic choice, especially when extremely large cysts are involved. In particular, in clinical situations where it is difficult to perform radical surgical procedures, less aggressive surgery followed by drug treatment should be the treatment of choice.

Secretory breast carcinoma with metastatic sentinel lymph node.

BACKGROUND: Secretory mammary carcinoma is a rare breast neoplasia originally described in children but sometimes also found in adults. It presents a more favourable outcome than more common histological types of breast carcinoma; published literature in fact reports only a few cases with axillary lymph node metastases and only four cases with distant metastases. CLINICAL PRESENTATION: In this paper we report a rare case of secretory breast carcinoma with axillary lymph node metastases in a 33-year-old woman. To our knowledge, this is the first case of secretory carcinoma involving biopsy of the sentinel lymph node and investigation of the e-cadherin expression. We found positivity for e-cadherin, which would support the hypothesis that this type of tumour is a variant of the infiltrating ductal carcinoma. CONCLUSION: After a careful analysis of reported data, we have come to the conclusion that the treatment of choice for patients with secretory breast carcinoma should be conservative surgery with sentinel lymph node biopsy, followed by accurate follow-up. We are of the opinion that while post-operative radiotherapy is indicated in adult patients who have undergone quadrantectomy, it should not be used in children. Although several cases of secretory carcinoma have been treated with adjuvant chemotherapy, there are still no reliable data regarding the real value of such a choice.

Clinical presentation and treatment of gastrointestinal stromal tumors.

AIMS AND BACKGROUND: Gastrointestinal stromal tumors (GISTs), although rare, are the most common mesenchymal neoplasms affecting the gastrointestinal tract. We present our experience in the treatment of localized and metastatic disease and a review of literature. PATIENTS AND METHODS: Nine patients were observed from April 2002 to July 2004. Eight tumors were in the gastric area and 1 was in the small bowel. In 5 cases, complete surgical removal was performed, and none of these patients underwent adjuvant therapy. The remaining 4 cases, with locally advanced or recurrent disease, were treated with imatinib. RESULTS: The patients with localized disease treated only by surgery did not relapse. In the patients with locally advanced or metastatic disease treated by imatinib, we observed 3 partial responses, and one case was not assessable because he had no measurable disease. In 2 of 3 responders, it was possible to perform a new radical surgery. CONCLUSIONS: Our series is too small to draw any conclusion. According to our review of the literature, surgery remains the standard treatment for non-metastatic GISTs. Imatinib mesylate represents a major breakthrough in the treatment of advanced GISTs and is the first effective systemic therapy for the disease.

Application of a predictive model of axillary lymph node status in patients with sentinel node metastasis from breast cancer. A retrospective cohort study.

BACKGROUND AND OBJECTIVES: The Axillary Lymph Node Dissection (ALND) is the standard treatment in patients with invasive breast cancer and sentinel node metastasis, but in 60% of the cases there is no further axillary neoplastic involvement, so this invasive intervention represents an overtreatment. The purpose of the study is to identify patients with low risk of additional nodal metastases, to omit ALND. METHODS: The MSKCC Additional nodal metastasis nomogram was applied on a sample of 175 patients with invasive breast cancer who underwent ALND after detection of macrometastasis with the extemporaneous examination of the sentinel lymph node. Patients were classified as "low risk" when the result of the nomogram was ≤50%. Sensitivity, specificity, positive and negative predictive values and AUC (Area Under Curve) of the ROC curve of the nomogram were then calculated. RESULTS: A cut-off by 50% yielded 92.3% sensitivity, 81,4% specificity, 80% positive predictive value and 92.9% negative predictive value. The ROC curve AUC in these patients was 0.885. CONCLUSIONS: The MSKCC nomogram has proven to be an effective tool in estimating the axillary lymph node status and it can potentially be used to better select the patients with sentinel node macrometastasis who can actually benefit from ALND.

Hashimoto thyroiditis coexistent with papillary thyroid carcinoma.

Several studies report a higher rate of papillary thyroid carcinomas (PTC) in patients with Hashimoto thyroiditis (HT), indicating a possible correlation between the two diseases. We studied a group of 89 subjects undergoing surgery for thyroid carcinomas compared with a control group of 89 subjects operated on for normofunctioning goiter, and a second group of 47 patients undergoing total thyroidectomy for HT. Association with HT was found in 19 of the 71 PTC subjects (26.7%) and in 8 goiter patients (8.9%), which was a significant difference (P < 0.02). Thirteen of the HT patients, mostly with the nodular form, showed coexistent PTC (27.6%). HT and PTC coexisted in several morphological, immunohistochemical, and biomolecular aspects; increased incidence of PTC in HT patients might therefore indicate that HT is a precursor of thyroid cancer. Further studies are required, however, in order to confirm this hypothesis; until then, HT patients should undergo careful clinical and technical follow-up.

p53 mutations in L3-loop zinc-binding domain, DNA-ploidy, and S phase fraction are independent prognostic indicators in colorectal cancer: a prospective study with a five-year follow-up.

p53 gene alterations are among the most common events observed in colorectal cancer,and are accompanied frequently by DNA aneuploidy and high proliferative activity. The prognostic significance of such mutations remains controversial. We prospectively evaluated the prognostic significance of p53 mutations, DNA-ploidy, and S phase fraction (SPF) in a consecutive series of 160 colorectal cancer patients (median follow-up 71 months). Tumor DNA was screened for p53 mutations by PCR/single-strand conformational polymorphism/sequencing. DNA-ploidy and SPF were assessed by DNA flow cytometry. p53 mutations were detected in 68 of 160 (42.5%) cases. In 56% (38 of 68) of these, p53 mutations were found in conserved areas of the gene and in 44% (30 of 68 cases) outside the conserved regions. Eighteen of the 68 cases (26%) had mutations in the L3 loop, 11 of 68 (16%) in the L1 loop-sheet-alpha helix motif, and 39 of 68 (58%) outside L3 and loop-sheet-alpha helix. Seventy-five percent of the cases (120 of 160) showed DNA aneuploidy, whereas 18% of these (22 of 120) were multiclonal. The major independent predictors for both disease relapse and death were advanced Dukes' stage, p53 mutations affecting L3 loop, DNA-aneuploid tumors, and high SPF (>18.5%). Our results show that mutations in L3 functional domain, more than any mutations, are important biological indicators to predict the outcome of patients indicating that these mutations have biological relevance in terms of colorectal cancer disease course.

[Benign diseases of the thyroid: indications for surgical treatment and the current role of total thyroidectomy]. / Affezioni benigne della tiroide: indicazioni al trattamento chirurgico ed attuale ruolo della tiroidectomia totale.

Total thyroidectomy is the most popular surgical option in a wide range of indications for the treatment of benign disease of the thyroid. The preference for the procedure derives from a long period of observation and clinical experience dating as far back as the early 'seventies and confirms its safety and efficiency. Nevertheless, many doubts still exist as to the indications in the context of benign thyroid disease, as well as the incidence and seriousness of the complications which, though not frequent, are often invalidating. On the basis of the experience gained over the period from January 1994 to November 2002 in 697 patients undergoing surgery for benign disease of the thyroid, the authors analyse the indications for the various different therapeutic options and evaluate the results of total thyroidectomy in terms of therapeutic efficiency, relapse rates and complications. The latter are analysed on the basis of dividing the patients into 2 groups, one comprising 545 patients treated with total thyroidectomy as first-line treatment and the second consisting of 34 patients treated with total thyroidectomy for relapsing goitre after subtotal thyroidectomy. Comparison of the respective incidences of complications reveals a significant difference between the two groups of patients. Total thyroidectomy after subtotal thyroidectomy presented a significantly higher percentage of complications than initial total thyroidectomy. The authors come out in favour of total thyroidectomy with its low incidence of complications and the radical control of the disease it affords, reserving lobectomy-isthmectomy for selected cases of patients with monolateral disease which does not expose the patient to any risk of relapse.