Robotic subtotal D2-gastrectomy for gastric cancer after right hemiliver transplantation: case report and literature review.

BACKGROUND: With the progress achieved in transplant surgeries an improved long-term survival of patients is obtained due to more effective immunosuppressant therapy. De novo malignancy (DNM) has gained interest in this group of patients. DNM is a major cause of late mortality after liver transplantation. METHODS: We report the case of a patient who underwent orthotopic liver transplantation with right hemiliver (right split) 18 years ago who came to our attention for gastric cancer. We performed a robotic subtotal gastrectomy D2 lymphadenectomy with manual latero lateral trans mesocolic BII gastro jejunal anastomosis using da Vinci robotic surgery system at our hospital. RESULTS: The operation was successful, the operative time was 230 min, the intraoperative blood loss was 100 ml. The patient was discharged on day 8 after surgery, and no complications occurred. Postoperative pathological stages were pT2 N0 (0/25). During the follow-up period, the patient was in good health without long-term complications. CONCLUSION: Robotic approach is feasible in patients after liver transplantation.

Pancreatic Ducts Obliteration With Controlled Injection of Onyx®: A Proposal of New Onyx® Pancreatic Ducts Obliteration Scoring System.

BACKGROUND: The aim of this study was confirm the efficacy and feasibility of Onyx injection for pancreatic stump management after pancreaticoduodenectomy (PD) and investigate a new Onyx® Pancreatic Ducts Obliteration (OPDO) scoring system of pancreatic duct obliteration (PDOb) in patients with high risk of Post-Operative Pancreatic Fistula (POPF). STUDY DESIGN: We enrolled ten patients undergoing PDOb with Onyx® intraoperative controlled injection after elective PD. RESULTS: PDOb with Onyx® controlled injection was classified according to the OPDO scoring system in three degrees: complete 5/10 (50%), medium 2/10 (20%) and bad 3/10 (30%). Increased amylase in abdominal drainage was identified in two patients (20%) with a degree II and III, and resolved spontaneously within a week. A "clinically relevant" POPF (CR-POPF) was observed in one patient (10%) with a degree III and none in the patients with degree I and II. DISCUSSION: We confirm that intraoperative injection of Onyx® is a valid solution in high-risk POPF patients and our OPDO scoring system allows obtain an intraoperative classification of the degree of PDO to prevent the CR-POPOF; furthermore, it may be suggested that the viscosity of the injected product (Onyx®) reduce parenchymal fibrosis.

Transanal Inspection and Management of Low Colorectal Anastomosis Performed With a New Technique: the TICRANT Study.

BACKGROUND: Anastomotic leakage is one of the most serious complications after rectal cancer surgery. METHOD: A prospective multicenter interventional study to assess a newly described technique of creating the colorectal and coloanal anastomosis. The primary outcome was to access the safety and efficacy of this technique in the reduction of anastomotic leak. RESULT: Fifty-three patients with rectal cancer who underwent low or ultra-low anterior resection were included in the study. There were 35 males and 18 females, with a median age of 68 years (range = 49-89 years). The median tumor distance from the anal verge was 8 cm (range = 4-12 cm), and the median body mass index was 24 kg/m2 (range = 20-35 kg/m2). Thirty patients underwent open, 16 laparoscopic, and 7 robotic surgeries. Multiple firing (2-charges) was required in 30 patients to obtain a complete rectal division. Forty-five patients had colorectal anastomosis, and 8 patients had coloanal anastomosis. The protective ileostomy was created in 40 patients at the time of initial surgery. There was no mortality in the first 30 days postoperatively, and only 10 (19%) patients developed complications. There were 3 anastomotic leakages (6%); 2 of them were subclinical with ileostomy created at initial operation and both were treated conservatively with transanal drainage and intravenous antibiotics. One patient required reoperation and ileostomy. The median length of hospital stay was 10 days (range = 4-20 days). CONCLUSION: Our technique is a safe and efficient method of creation of colorectal anastomosis. It is also a universal method that can be used in open, laparoscopic, and robotic surgeries.

Prognosis of Adrenal Oncocytic Neoplasms (AONs): Literature Review of 287 Cases and Presentation of the Oldest Patient.

INTRODUCTION: The adrenocortical oncocytic neoplasms (AONs) are rare tumors of the adrenal gland, classified as oncocytoma (AO), oncocytic neoplasm of uncertain malignant potential (AONUMP) and oncocytic carcinoma (AOC). The aim of this study was to perform a review of the literature, in order to evaluate the prognosis of these rare cancers. We also reported the oldest patient with AON. METHODS: A comprehensive literature review using as key words "adrenal oncocytoma", "adrenal oncocytic neoplasm", and "adrenal oncocytic carcinoma" was performed. REPORT OF THE CASE: We report the case of an 88-year-old woman receiving a left open adrenalectomy for an AON (15 × 10 × 8 cm). The considerable size and weight together with the presence of necrosis were indicative for a lesion with an uncertain potential for malignancy, according to Weiss modified criteria. After two years, the patient was free from any sign of recurrence. RESULTS: Only 287 AONs were detected in the scientific literature, exploring OVID, MEDLINE, PubMed and SCOPUS as dataset. These tumors are usually incidentalomas with an unpredictable malignant potential. Surgical resection remains the mainstay of treatment for AON. CONCLUSION: AO and AONUMP have an excellent prognosis and a low mortality rate, with only three cases of recurrence reported in the literature and one metastatic case four years after first adrenal surgery. In contrast, AOC carries a high risk of local relapses, distant metastasis, and a significantly higher mortality rate (30%). Surgical resection remains the primary treatment for adrenal oncocytic neoplasms.

Minimally invasive colorectal surgery learning curve.

The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon's experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.

Intravascular leiomyomatosis with intracardiac extension: a toraco-abdominal approach.

Intravenous leiomyomatosis is a rare nonmalignant tumor, which originates from the uterine smooth muscle cells and is usually confined to the pelvic venous system. Sometimes it can extend from the pelvis through the veins into the right side of the heart; this condition is named intracardiac leiomyomatosis (ICLM). To date few cases of these conditions have been described, the treatment is surgical, often challenging and usually multidisciplinary. In this paper are described the clinical presentation, the full radiologic study and surgical treatment of a case of ICLM that authors treated at their institution with thoraco-abdominal approach. Surgical removal of the ICLM is strongly recommended, because no recurrence has been reported, in our case at 7 years we did not observe recurrence of the disease.

Sentinel Lymph Node Analysis in Colorectal Cancer Patients Using One-Step Nucleic Acid Amplification in Combination With Fluorescence and Indocyanine Green.

PURPOSE: Analysis of the sentinel lymph node (SLN) in colorectal cancer (CRC) patients was proposed for more accurate staging and tailored lymphadenectomy. The aim of this study was to assess the ability to predict lymph node (LN) involvement through analysis of the SLN with a one-step nucleic acid (OSNA) technique in combination with peritumoral injection of indocyanine green (ICG) and near-infrared (NIR) lymphangiography in CRC patients. METHODS: A total of 34 patients were enrolled. Overall, 51 LNs were analyzed with OSNA. LNs of 17 patients (50%) were examined simultaneously with hematoxylin and eosin (H&E) and OSNA. RESULTS: SLN analysis of 17 patients examined with H&E and OSNA revealed that OSNA had a higher sensitivity (1 vs. 0.55), higher negative predictive value (1 vs. 0.66) and higher accuracy (100% vs. 76.4%) in predicting LN involvement. Overall, OSNA showed a sensitivity of 0.69, specificity of 1, accuracy of 88.2%, and stage migration of 8.8%. Compared to those who were OSNA (-), OSNA (+) patients had a greater number of LN metastases (4.8 vs. 0.16, P = 0.04), higher G3 rate (44.4% vs. 4%, P = 0.01), more advanced stage of disease (stage III: 77.8% vs. 16%; P = 0.00) and were more rapidly subjected to adjuvant chemotherapy (39.1 days vs. 50.2 days, P = 0.01). CONCLUSION: SLN analysis with OSNA in combination with ICG-NIR lymphangiography is feasible and can detect LN involvement in CRC patients. Furthermore, it allows for more accurate staging reducing the delay between surgery and adjuvant chemotherapy.

Merkel cell carcinoma: extended lymphadenectomy and reconstruction with biosynthetic prosthesis.

INTRODUCTION: Merkel cell carcinomas (MCC) is an aggressive neuroendocrine carcinoma originating from the Merkel cell in the dermo-epidermal junction. Only 10% of MCC occur on the skin of the trunk. CASE REPORT: We report a case of Merkel's abdominal carcinomas treated with extensive inguinal lymphadenectomy and reconstruction of the abdominal wall and inguinal canal using prosthesis GORE® BIO-A®. DISCUSSION: Immunohistochemical analysis by tumor-specific markers is crucial for diagnosis and permits differentiation from other tumors of the skin. MCC is an aggressive tumor with poor prognosis. CONCLUSIONS: For primary tumors without indications of the presence of organ metastases complete surgical excision is the gold standard. Gore BIO-A is a biosynthetic prosthesis with manageable structure that allows it to be positioned and shaped according to needs, its strength provides for excellent support for the reconstruction of the inguinal canal wall.

How to prevent the postoperative pancreatic fistula with an ethylene vinyl alcohol copolymer (Onyx®): A proposal of a new technique.

BACKGROUNDS/AIMS: Despite the advances in identifying risk factors, improving operative technique, and postoperative patient care, pancreatic leakage after pancreatic resection remains a highly debated topic. The aim of this study is to describe our technique and our initial experience with the intraoperative embolization of the main pancreatic duct with an Ethylene Vinyl Alcohol Copolymer (Onyx®). METHODS: Two patients of 63 and 64 years underwent pancreaticoduodenectomy for a cholangiocarcinoma of the extrahepatic bile duct and a pancreatic adenocarcinoma, respectively. At the time of pancreatic parenchyma resection, a Wirsung duct was identified and catheterized. A wirsungography was done and then, embolization with Onyx® was carried out under fluoroscopic control. RESULTS: Neither of the patients developed a postoperative pancreatic fistula. They were discharged to home on the 17th and 18th postoperative day, respectively. At the last follow-up, no recurrence was found. The two patients became diabetics; both needed the support of supplementary pancreatic enzymes. CONCLUSIONS: To our knowledge, we are the first to describe this technique, which seems safe and reliable. Studies on this subject with more patients are needed to confirm the validity of this procedure.

Partial splenectomy: A case series and systematic review of the literature.

BACKGROUNDS/AIMS: Partial splenectomy (PS) is a surgical option for splenic mass, in order to reduce postoperative complications and preserve the splenic function. Despite this, data in literature is still scarce. The present study aimed to reveal our recent experience and provide a comprehensive overview of the feasibility and complications related to various surgical approaches. METHODS: Data of patients who underwent PS, between 2014 and 2017 were retrospectively reviewed. Literature was searched for studies reporting all types of PS in adult or adolescent patients. RESULTS: Five PS were performed in our department: two (40%) by laparoscopy and three (60%) by laparotomy. Two (40%) postoperative complications were detected, and in one of them, total splenectomy (TS) by laparotomy was finally required. There were no deaths or complications at last follow-up. Twenty studies including 213 patients were identified in the literature search. The rate of conversion from laparoscopic to open surgery was 3% (range, 5-50%) and in 3% of cases (range, 7-10%) PS was converted into total TS and the overall morbidity rate was 8% (range, 5-25%). In comparison to laparotomy, the conversion rate of laparoscopic approach to TS was 3.5% (vs. 1.4%) and a morbidity rate of 9.8% (vs. 4.3%). CONCLUSIONS: The present review shows that PS is a viable procedure in selected cases. The mini-invasive approach seemed to be feasible despite the presence of higher rate of complications than the open technique. In future, further studies on this topic are needed by involving more patients. Furthermore, it is proposed that the development of robotic surgery could make this approach the new gold-standard technique for spleen-preserving surgery.

[Bilirubin removal with Coupled Plasma Filtration and Adsorption in patients affected by hilar cholangiocarcinoma]. / Rimozione della bilirubina con Coupled Plasma Filtration and Adsorption in pazienti con colangiocarcinoma ilare.

BACKGROUND: Patients affected by hilar cholangiocarcinoma are eligible for surgery only in the 20-30% of the cases and postoperative mortality is 40-50%. Many specialists are involved in the treatment of this disease, like surgeons, gastroenterologists, oncologists and radiotherapists. Recent studies have shown that preoperative bilirubinaemia is a predictor of morbidity and mortality after surgery. Coupled Plasma Filtration and Adsorption (CPFA) is a blood purification extracorporeal therapy recommended for sepsis and able to reduce bilirubinaemia. METHODS: We treated 10 patients referred to our centre affected by hilar cholangiocarcinoma complicated by obstructive jaundice with 34 CPFA sessions to test its ability to reduce preoperative bilirubin levels and we checked for mortality at 90 days. RESULTS: CPFA reduced preoperative bilirubin of 30% for session; it also improved others inflammation and coagulation tests. Mortality at 90 days was 40%. CONCLUSIONS: CPFA is an effective therapy for hyperbilirubinaemia. Lowering preoperative bilirubinaemia and improvement of coagulation tests subsidized the management of the patients but in our study did not affect postoperative mortality. Further studies to evaluate the indications for treatments that remove bilirubin in this setting are needed.