Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort

BACKGROUND

Current evidence concerning bowel preparation before elective colorectal surgery is still controversial. This study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation.

METHODS

A prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). Twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. The primary endpoints were AL, SSIs, and OM. All the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI).

RESULTS

Compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23-2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10-1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25-0.79; p = .008).

CONCLUSIONS

MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP.

Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort

BACKGROUND

In Italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. The aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery.

METHODS

A database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. The primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. The results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i.

RESULTS

A total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). Group A versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). A mean postoperative duration of stay difference of 0.86 days was detected between groups. No difference was recorded between the two groups for all the other endpoints.

CONCLUSION

This study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery.

Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts

Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.

Preservation of the inferior mesenteric artery VS ligation of the inferior mesenteric artery in left colectomy: evaluation of functional outcomes-a prospective non-randomized controlled trial

Vascular approach during elective laparoscopic left colectomy impacts post-operative outcomes. The aim of our study was to evaluate how different approaches impact positively defecatory, urinary and sexual functions and quality of life during elective laparoscopic left colectomy. A prospective non-randomized controlled trial at two tertiary center was conducted. All patients who underwent elective laparoscopic left colonic resection from January 2019 to July 2022 were analyzed. They were divided into two groups based on Inferior Mesenteric Artery (IMA) preservation with distal ligation of sigmoid branches close to a colonic wall for complicated diverticular disease and IMA high tie ligation for oncological disease. Patients were asked to fulfil standardized, validated questionnaires to evaluate pre and post-operative defecatory, urinary and sexual functions and quality of life. Defecatory disorders were assessed by high-resolution anorectal manometry preoperatively and six months after surgery. A total of 122 patients were included in the study. The 62 patients with IMA preservation showed a lower incidence of defecatory disorders also confirmed by manometer data, minor incontinence and less lifestyle alteration than the 60 patients with IMA high tie ligation. No urinary disorders such as incomplete emptying, frequency, intermittence or urgency were highlighted after surgery in the IMA preservation group. Evidence of any sexual disorders remained controversial. The IMA-preserving vascular approach seems to be an effective strategy to prevent postoperative functional disorders. It is a safe and feasible technique especially for diverticular disease. New prospective randomized and highly probative studies are needed to confirm the effectiveness in specific clinical situations.

Blood Transfusions and Adverse Events after Colorectal Surgery: A Propensity-Score-Matched Analysis of a Hen-Egg Issue

Blood transfusions are considered a risk factor for adverse outcomes after colorectal surgery. However, it is still unclear if they are the cause (the hen) or the consequence (the egg) of adverse events. A prospective database of 4529 colorectal resections gathered over a 12-month period in 76 Italian surgical units (the iCral3 study), reporting patient-, disease-, and procedure-related variables, together with 60-day adverse events, was retrospectively analyzed identifying a subgroup of 304 cases (6.7%) that received intra- and/or postoperative blood transfusions (IPBTs). The endpoints considered were overall and major morbidity (OM and MM, respectively), anastomotic leakage (AL), and mortality (M) rates. After the exclusion of 336 patients who underwent neo-adjuvant treatments, 4193 (92.6%) cases were analyzed through a 1:1 propensity score matching model including 22 covariates. Two well-balanced groups of 275 patients each were obtained: group A, presence of IPBT, and group B, absence of IPBT. Group A vs. group B showed a significantly higher risk of overall morbidity (154 (56%) vs. 84 (31%) events; OR 3.07; 95%CI 2.13-4.43; p = 0.001), major morbidity (59 (21%) vs. 13 (4.7%) events; OR 6.06; 95%CI 3.17-11.6; p = 0.001), and anastomotic leakage (31 (11.3%) vs. 8 (2.9%) events; OR 4.72; 95%CI 2.09-10.66; p = 0.0002). No significant difference was recorded between the two groups concerning the risk of mortality. The original subpopulation of 304 patients that received IPBT was further analyzed considering three variables: appropriateness of BT according to liberal transfusion thresholds, BT following any hemorrhagic and/or major adverse event, and major adverse event following BT without any previous hemorrhagic adverse event. Inappropriate BT was administered in more than a quarter of cases, without any significant influence on any endpoint. The majority of BT was administered after a hemorrhagic or a major adverse event, with significantly higher rates of MM and AL. Finally, a major adverse event followed BT in a minority (4.3%) of cases, with significantly higher MM, AL, and M rates. In conclusion, although the majority of IPBT was administered with the consequence of hemorrhage and/or major adverse events (the egg), after adjustment accounting for 22 covariates, IPBT still resulted in a definite source of a higher risk of major morbidity and anastomotic leakage rates after colorectal surgery (the hen), calling urgent attention to the implementation of patient blood management programs.

A combined system for asbestos-cement waste degradation by dark fermentation and resulting supernatant valorization in anaerobic digestion

The use of biological processes for the treatment of asbestos cement waste (ACW) has gained interest in recent years. Nevertheless, this methodology is not yet consolidated because of the incomplete ACW conversion during the biological treatment and the consequent need for further treatments that generally require a high amount of energy and chemicals. In this study, the efficiency of both mesophilic and thermophilic dark fermentation (DF) fed with glucose in fed-batch conditions was assessed for ACW biological treatment. Both thermophilic and mesophilic DF of glucose resulted in a partial conversion of glucose into organic acids that successfully degraded all the asbestos fibers contained in an ACW sample. A hydrogen-rich biogas was produced as well: at the end of the mesophilic DF treatment 0.14 L_H2 g_glucose^-1 were obtained. In addition, the anaerobic digestion (AD) of the DF supernatants led to the production of 0.38 L_CH4 g_COD^-1.

ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study

BACKGROUND

Enhanced recovery after surgery (ERAS) programs influence morbidity rates and length of stay after colorectal surgery (CRS), and may also impact major complications and anastomotic leakage rates. A prospective multicenter observational study to investigate the interactions between ERAS program adherence and early outcomes after elective CRS was carried out.

METHODS

Prospective enrolment of patients submitted to elective CRS with anastomosis in 18 months. Adherence to 21 items of ERAS program was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints [major morbidity (MM) and anastomotic leakage (AL) rates] were identified through logistic regression analyses including all significant variables, presenting odds ratios (OR).

RESULTS

Institutional ERAS protocol was declared by 27 out of 38 (71.0%) participating centers. Median overall adherence to ERAS program items was 71.4%. Among 3830 patients included in the study, MM and AL rates were 4.7% and 4.2%, respectively. MM rates were independently influenced by intra- and/or postoperative blood transfusions (OR 7.79, 95% CI 5.46-11.10; p < 0.0001) and standard anesthesia protocol (OR 0.68, 95% CI 0.48-0.96; p = 0.028). AL rates were independently influenced by male gender (OR 1.48, 95% CI 1.06-2.07; p = 0.021), intra- and/or postoperative blood transfusions (OR 4.29, 95% CI 2.93-6.50; p < 0.0001) and non-standard resections (OR 1.49, 95% CI 1.01-2.22; p = 0.049).

CONCLUSIONS

This study disclosed wide room for improvement in compliance to several ERAS program items. It failed to detect any significant association between institutionalization and/or adherence rates to ERAS program with primary endpoints. These outcomes were independently influenced by gender, intra- and postoperative blood transfusions, non-standard resections, and standard anesthesia protocol.

Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases

Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.

Microsatellite Status Detection in Gastrointestinal Cancers: PCR/NGS Is Mandatory in Negative/Patchy MMR Immunohistochemistry

Simple Summary

Microsatellite instability (MSI) detection has a high impact on eligibility for immune checkpoint inhibitors in gastrointestinal cancers. The appropriate detection of MSI represents the major critical issue in clinical practice, thus a better understanding of the limits related to MSI testing is needed to avoid misinterpretations. This study addresses the discordance between IHC and PCR/NGS testing in a large retrospective series of colorectal and gastric cancers in order to improve diagnosis. Our findings show a disagreement between negative/patchy expression IHC and PCR/NGS results, suggesting that molecular testing is mandatory in this subset of tumors.

Abstract

Background: Microsatellite instability (MSI) is a predictive biomarker for immune checkpoint inhibitors. The main goal was to investigate the discordance between IHC and PCR/NGS for MSI testing in gastrointestinal cancers. Methods: Two series were analyzed through IHC for mismatch-repair-system proteins (MMRP) and PCR, with one series of 444 colorectal cancers (CRC) and the other of 176 gastric cancers (GC). All cases with discordant results between IHC and PCR were analyzed by NGS. IHC staining was evaluated as follows: proficient MMR (pMMR), with all MMR positive; deficient MMR (dMMR), with the loss of one heterodimer; and cases with the loss/patchy expression of one MMR (lo-paMMR). Cases with instability in at least two markers by PCR were MSI-high (MSI-H) and with instability in one marker, MSI-low (MSI-L). Cases without instability were evaluated as microsatellite-stable (MSS). Results: In the CRC cohort, 15 out of 444 cases were dMMR and 46 lo-paMMR. Among the 15 dMMR, 13 were MSI-H and 2 MSS. Among the 46 lo-paMMR, 13 were MSI-H and 33 were MSS. In the GC cohort, 13 out of 176 cases were dMMR and 6 cases lo-paMMR. Among the 13 dMMR, 12 were MSI-H and only 1 was MSS. All six lo-paMMR cases were MSS. All NGS results were in agreement with PCR. Conclusions: In clinical practice, MMR–IHC could be used as a screening test and additional molecular analysis is mandatory exclusively in cases carrying loss/patchy MMR-IHC.

Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: A multi-institutional propensity score-matched study

Background and Objectives

In the setting of a minimally invasive approach, we aimed to compare short and long‐term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population.

Methods

All consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score‐matching, postoperative morbidity and oncologic outcomes were investigated.

Results

After matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease‐free‐survival (p = 0.34) was found between groups.

Conclusions

NAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short‐term outcomes are more evident in patients over 60 years old receiving NAT.

ICG fluorescence imaging in colorectal surgery: a snapshot from the ICRAL study group

Background

Fluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date.

Methods

This survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire.

Results

Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future.

Conclusion

The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

Laparoscopic segmental resection for tumours of the Angle of Treitz: a challenging but feasible surgical option. Results from a retrospective case-series analysis

Tumours of the small intestine are rare and account for about 5% of gastrointestinal tract neoplasms. The angle of Treitz (AT) could be defined as the intestinal loop comprised between the third duodenal portion and the first 10 cm of jejunum. A gold standard surgical treatment for AT neoplasm has not yet been well defined. This paper is focused on a very rare disease and at the best of our knowledge this is the largest case series in the literature about the Laparoscopic Segmental Resection (LSR) of AT tumours. Using a prospectively collected database, all data of consecutive patients, from January 2007 to May 2019, who underwent LSR for AT tumours at two different institutions were analysed. Patients’ demographics, intra and post-operative data, 30-day mortality and overall survival were collected. A total of 16 patients were retrieved from our database. The mean operative time was 206,5 ± 79 min. Conversion to open surgery was needed in two cases due to tumor size and, respectively, invasion of the transverse colon which required a multivisceral resection. The mean distal and proximal resection margins were 7.4 ± 2.2 and 3.9 ± 1.2 cm. The median number of harvested nodes was 9 ± 3. Pathological diagnosis was GIST in 11 cases, adenocarcinoma in 4 and sarcoma in 1 case. In conclusion, in experienced hands, LSR appears to be a safe and effective treatment option for tumours of the AT. Prospective studies are needed to confirm these findings.

Current emerging SARS-CoV-2 pandemic: Potential direct/indirect negative impacts of virus persistence and related therapeutic drugs on the aquatic compartments

The purpose of the present work is to provide a complete overview of possible direct/indirect implications on the quality of aquatic compartments due to the recent SARS-CoV-2 outbreak. With this aim, the environmental impacts are mainly related to i) the virus persistence in sewage and wastewaters, and ii) possible fate in aquatic compartments of drugs tested and administered to SARS-CoV-2 infected patients. Because SARS-CoV-2 spread is very recent, and there is a lack of specific studies on this strain, the virus persistence in wastewaters, the parameters influencing the persistence, as well as the detection methodologies are referenced to the general coronaviruses group. However, the present detailed report of up-to-date knowledge on this topic can provide a useful source for further studies focusing on more deepened investigations of SARS-CoV-2 behaviour in the environment. Such a perspective is significant not only for the control of virus diffusion but also represents a crucial point for the identification of produced alteration to the environmental quality.

Simultaneous removal of Cr(III) from high contaminated soil and recovery of lactic acid from the spent solution

It is proposed a closed-loop treatment cycle for Cr(III) removal from contaminated soils (2080 mg/kg). The treatment includes the use of lactic acid as washing agent, and the recovery of both Cr(II) and lactic acid from the spent solution. Results indicate that Cr(III) removal efficiency can be very high, passing 70% in all tested operative conditions. The metal forms strong complexes with lactic acid, and therefore cannot be eliminated through direct precipitation simply increasing the pH value. Therefore, lactic acid is preliminarily extracted from the solution using n-butanol at very acidic pH. The obtained extraction degree is generally high, varying between 0.5 and 1 according to the amount of used n-butanol solution. After lactic acid extraction, almost 100% of chromium can be recovered through precipitation in alkaline conditions. Lactic acid, in turns, can be purified and reused for a new washing treatment, separating it from n-butanol solution through water extraction. The extraction efficiency is once more satisfying (around 0.5), and not dependent on the operative pH.

Colorectal surgery in Italy during the Covid19 outbreak: a survey from the iCral study group

BACKGROUND

The COVID19 pandemic had a deep impact on healthcare facilities in Italy, with profound reorganization of surgical activities. The Italian ColoRectal Anastomotic Leakage (iCral) study group collecting 43 Italian surgical centers experienced in colorectal surgery from multiple regions performed a quick survey to make a snapshot of the current situation.

METHODS

A 25-items questionnaire was sent to the 43 principal investigators of the iCral study group, with questions regarding qualitative and quantitative aspects of the surgical activity before and after the COVID19 outbreak.

RESULTS

Two-thirds of the centers were involved in the treatment of COVID19 cases. Intensive care units (ICU) beds were partially or totally reallocated for the treatment of COVID19 cases in 72% of the hospitals. Elective colorectal surgery for malignancy was stopped or delayed in nearly 30% of the centers, with less than 20% of them still scheduling elective colorectal resections for frail and comorbid patients needing postoperative ICU care. A significant reduction of the number of colorectal resections during the time span from January to March 2020 was recorded, with significant delay in treatment in more than 50% of the centers.

DISCUSSION

Our survey confirms that COVID19 outbreak is severely affecting the activity of colorectal surgery centers participating to iCral study group. This could impact the activity of surgical centers for many months after the end of the emergency.

Does a 3D laparoscopic approach improve surgical outcome of mininvasive right colectomy? A retrospective case-control study

Laparoscopy has gained wide acceptance due its benefits for patients. However, advanced laparoscopic procedures are still challenging. One critical issue is lack of stereoscopic vision. Despite its diffusion, the totally laparoscopic approach for right hemicolectomy (TLRC) is still debated due to its difficulty, particularly for fashioning of the ileocolic anastomosis. The aim of this multicenter study is to investigate whether 3D vision offers any advantages on surgical performance over 2D vision during TLRC. All data of consecutive patients who underwent elective TLRC for cancer at three Italian surgical centers with either 2D or 3D technology from January 2013 to December 2018 were retrieved from a computer-maintained database. A case-matched analysis using the Mantel-Haenszel method was performed. After matching, a total of 106 patients were analyzed with 53 patients in each group. Mean operative time was significantly longer for 2D-TLRC than for 3D-TLRC (153.2 ± 52.4 vs. 131 ± 51 min, p = 0.029) and a statistically significant difference in anastomosing time (p = 0.032, 19.2 ± 5.9 min vs. 21.7 ± 6.2 min for 3D and 2D group, respectively) was also recorded. No difference in the median number of harvested nodes (23 ± 11 vs. 21 ± 7 for 3D and 2D group, respectively; p = 0.48) was found. Neither intraoperative complications nor conversions occurred in the two groups. In conclusion, 3D vision appears to improve the performance of a TLRC by reducing operative time and making intracorporeal anastomosis easier. Prospective randomized studies are required to determine the real beneficial effects.

Enhanced recovery pathways in colorectal surgery: a consensus paper by the Associazione Chirurghi Ospedalieri Italiani (ACOI) and the PeriOperative Italian Society (POIS)

Enhanced Recovery After Surgery (ERAS) pathway is a multi-disciplinary, patient-centered protocol relying on the implementation of the best evidence-based perioperative practice. In the field of colorectal surgery, the application of ERAS programs is associated with up to 50% reduction of morbidity rates and up to 2.5 days reduction of postoperative hospital stay. However, widespread adoption of ERAS pathways is still yet to come, mainly because of the lack of proper information and communication. Purpose of this paper is to support the diffusion of ERAS pathways through a critical review of the existing evidence by members of the two national societies dealing with ERAS pathways in Italy, the PeriOperative Italian Society (POIS) and the Associazione Italiana Chirurghi Ospedalieri (ACOI), showing the results of a consensus development conference held at Matera, Italy, during the national ACOI Congress on June 10, 2019.

Genetic determinants of telomere length and risk of pancreatic cancer: A PANDoRA study

Telomere deregulation is a hallmark of cancer. Telomere length measured in lymphocytes (LTL) has been shown to be a risk marker for several cancers. For pancreatic ductal adenocarcinoma (PDAC) consensus is lacking whether risk is associated with long or short telomeres. Mendelian randomization approaches have shown that a score built from SNPs associated with LTL could be used as a robust risk marker. We explored this approach in a large scale study within the PANcreatic Disease ReseArch (PANDoRA) consortium. We analyzed 10 SNPs (ZNF676-rs409627, TERT-rs2736100, CTC1-rs3027234, DHX35-rs6028466, PXK-rs6772228, NAF1-rs7675998, ZNF208-rs8105767, OBFC1-rs9420907, ACYP2-rs11125529 and TERC-rs10936599) alone and combined in a LTL genetic score ("teloscore", which explains 2.2% of the telomere variability) in relation to PDAC risk in 2,374 cases and 4,326 controls. We identified several associations with PDAC risk, among which the strongest were with the TERT-rs2736100 SNP (OR = 1.54; 95%CI 1.35-1.76; p = 1.54 × 10-10 ) and a novel one with the NAF1-rs7675998 SNP (OR = 0.80; 95%CI 0.73-0.88; p = 1.87 × 10-6 , ptrend = 3.27 × 10-7 ). The association of short LTL, measured by the teloscore, with PDAC risk reached genome-wide significance (p = 2.98 × 10-9 for highest vs. lowest quintile; p = 1.82 × 10-10 as a continuous variable). In conclusion, we present a novel genome-wide candidate SNP for PDAC risk (TERT-rs2736100), a completely new signal (NAF1-rs7675998) approaching genome-wide significance and we report a strong association between the teloscore and risk of pancreatic cancer, suggesting that telomeres are a potential risk factor for pancreatic cancer.

Droplet digital PCR quantification of miR-1290 as a circulating biomarker for pancreatic cancer

Droplet digital PCR was used to validate miR-1290 as circulating biomarker for pancreatic cancer (PC). The diagnostic performance of miR-1290 was evaluate in 167 PC patients and 267 healthy subjects at clinical risk of developing the disease (HS). MiR-1290 plasma levels were compared to CA 19-9 determinations, and the combination of the two biomarkers was also taken into account. Plasma levels of miR-1290 were higher in PC patients compared to HS (p = 2.55 × 10⁻¹⁶). A similar trend was observed for CA 19-9 determinations (p = 1.03 × 10⁻⁴⁷). ROC curve analysis revealed that miR-1290 in combination with CA 19-9 was effective for discriminating between PC patients and HS (AUC = 0.956, 95% CI = 0.933–0.979) than the two biomarkers tested alone (miR-1290: AUC = 0.734, 0.678–0.789; CA 19-9: AUC = 0.914, 0.877–0.951). The discriminating ability was higher when only PC patients with low or slightly increased CA 19-9 levels were compared with HS. MiR-1290 concentrations were not able to differentiate between PC patients with single or multiple risk factors for developing PC. Our data suggest that the absolute quantification of circulating miR-1290 levels does not allow to select patients at clinical risk of PC for entry into a surveillance program, and underline the methodological challenges still existing in utilizing circulating miRNAs as new promising biomarkers for PC.

Effect of light intensity and nutrients supply on microalgae cultivated in urban wastewater: Biomass production, lipids accumulation and settleability characteristics

Microalgae cultivation systems fed with wastewater as source of nutrients represents the principal sustainable condition to produce microalgal biomass to be converted conveniently to biofuels. In order to optimize microalgae growth and their lipid content, the effect of light intensity and nutrients load in real wastewater was investigated through batch microalgal cultivation tests. A microalgal polyculture was used as inoculum and grown for 10 days in batch at different conditions of light intensity (i.e. 20, 50 and 100 μmol s^-1m^-2) and nutrients concentration in wastewater. Experimental results showed that biomass productivity decreased for rich nutrients conditions and increased for high light intensities. The highest lipid mass content (29%) was found for high light intensity condition (100 μmol s^-1m^-2). Furthermore, microalgae settleability tests, conducted at the end of the cultivation time, resulted in the highest biomass recovery efficiency (72%) for low light intensity and nutrients supply conditions.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Combined yeast and microalgal cultivation in a pilot-scale raceway pond for urban wastewater treatment and potential biodiesel production

A mixed culture of oleaginous yeast Lipomyces starkeyi and wastewater native microalgae (mostly Scenedesmus sp. and Chlorella sp.) was performed to enhance lipid and biomass production from urban wastewaters. A 400 L raceway pond, operating outdoors, was designed and used for biomass cultivation. Microalgae and yeast were inoculated into the cultivation pond with a 2:1 inoculum ratio. Their concentrations were monitored for 14 continuous days of batch cultivation. Microalgal growth presented a 3-day initial lag-phase, while yeast growth occurred in the first few days. Yeast activity during the microalgal lag-phase enhanced microalgal biomass productivity, corresponding to 31.4 mgTSS m^-2 d^-1. Yeast growth was limited by low concentrations in wastewater of easily assimilated organic substrates. Organic carbon was absorbed in the first 3 days with a 3.7 mgC L^-1 d^-1 removal rate. Complete nutrient removal occurred during microalgal linear growth with 2.9 mgN L^-1 d^-1 and 0.96 mgP L^-1 d^-1 removal rates. Microalgal photosynthetic activity induced high pH and dissolved oxygen values resulted in natural bactericidal and antifungal activity. A 15% lipid/dry weight was measured at the end of the cultivation time. Fatty acid methyl ester (FAME) analysis indicated that the lipids were mainly composed of arachidic acid.

Treatments of asbestos containing wastes

Since the second half of the twentieth century, many studies have indicated inhalation of asbestos fibers as the main cause of deadly diseases including fibrosis and cancer. Consequently, since the beginning of the 80s, many countries started banning production and use of asbestos containing products (ACP), although still present in private and public buildings. Due to some extraordinary catastrophic events and/or the aging of these products, people's health and environmental risk associated with the inhalation of asbestos fibers keeps being high even in those countries where it was banned. For these reasons, many communities are developing plans for an environmental and sanitary safe asbestos removal and management. Asbestos containing wastes (ACW) are usually disposed in controlled landfills, but this practice does not definitively eliminate the problems related with asbestos fiber release and conflicts with the ideas of sustainable land use, recycling, and closing material cycles. Consequently, many scientific papers and patents proposed physical, chemical, and biological treatments aimed to the detoxification of ACW (or the reduction of their health effects) and looking for the adoption of technologies, which allow the reuse of the end-products. By including recent relevant bibliography, this report summarizes the status of the most important and innovative treatments of ACW, providing main operating parameters, advantages, and disadvantages.

Lack of Association for Reported Endocrine Pancreatic Cancer Risk Loci in the PANDoRA Consortium

Background: Pancreatic neuroendocrine tumors (PNETs) are rare neoplasms for which very little is known about either environmental or genetic risk factors. Only a handful of association studies have been performed so far, suggesting a small number of risk loci.Methods: To replicate the best findings, we have selected 16 SNPs suggested in previous studies to be relevant in PNET etiogenesis. We genotyped the selected SNPs (rs16944, rs1052536, rs1059293, rs1136410, rs1143634, rs2069762, rs2236302, rs2387632, rs3212961, rs3734299, rs3803258, rs4962081, rs7234941, rs7243091, rs12957119, and rs1800629) in 344 PNET sporadic cases and 2,721 controls in the context of the PANcreatic Disease ReseArch (PANDoRA) consortium.Results: After correction for multiple testing, we did not observe any statistically significant association between the SNPs and PNET risk. We also used three online bioinformatic tools (HaploReg, RegulomeDB, and GTEx) to predict a possible functional role of the SNPs, but we did not observe any clear indication.Conclusions: None of the selected SNPs were convincingly associated with PNET risk in the PANDoRA consortium.Impact: We can exclude a major role of the selected polymorphisms in PNET etiology, and this highlights the need for replication of epidemiologic findings in independent populations, especially in rare diseases such as PNETs. Cancer Epidemiol Biomarkers Prev; 26(8); 1349-51. ©2017 AACR.

3D Vision Provides Shorter Operative Time and More Accurate Intraoperative Surgical Performance in Laparoscopic Hiatal Hernia Repair Compared With 2D Vision

Background. The aim of this study is to evaluate if 3-dimensional high-definition (3D) vision in laparoscopy can prompt advantages over conventional 2D high-definition vision in hiatal hernia (HH) repair. Study design. Between September 2012 and September 2015, we randomized 36 patients affected by symptomatic HH to undergo surgery; 17 patients underwent 2D laparoscopic HH repair, whereas 19 patients underwent the same operation in 3D vision. Results. No conversion to open surgery occurred. Overall operative time was significantly reduced in the 3D laparoscopic group compared with the 2D one (69.9 vs 90.1 minutes, P = .006). Operative time to perform laparoscopic crura closure did not differ significantly between the 2 groups. We observed a tendency to a faster crura closure in the 3D group in the subgroup of patients with mesh positioning (7.5 vs 8.9 minutes, P = .09). Nissen fundoplication was faster in the 3D group without mesh positioning ( P = .07). Conclusions. 3D vision in laparoscopic HH repair helps surgeon’s visualization and seems to lead to operative time reduction. Advantages can result from the enhanced spatial perception of narrow spaces. Less operative time and more accurate surgery translate to benefit for patients and cost savings, compensating the high costs of the 3D technology. However, more data from larger series are needed to firmly assess the advantages of 3D over 2D vision in laparoscopic HH repair.

Laparoscopic Deloyers procedure for tension-free anastomosis after extended left colectomy: technique and results

BACKGROUND

The Deloyers procedure, which includes inversion of the right colon around the axis of the ileocolic vessels, can be used to achieve a well vascularized, tension-free colorectal anastomosis after extended left colectomy. The aim of this study is to report our technique and outcome in a series of ten consecutive patients who underwent right colonic transposition by laparoscopic approach.

METHODS

Charts were retrospectively reviewed to analyze postoperative outcome and bowel function. A video was recorded to demonstrate the procedure.

RESULTS

Conversion was required in one (10%) patient due to extensive adhesions. No intraoperative complications were recorded. Anastomotic leakage occurred in one (10%) case and was managed with peritoneal lavage and ileostomy. Six months after surgery, all patients reported a median number of 2.5 (range 2-3) bowel movements per day with solid stool consistency. Neither anastomotic stricture nor bowel ischemia was found at 1-year endoscopic follow-up.

CONCLUSION

Our experience shows that laparoscopic right colonic transposition is a safe and feasible procedure and provides good functional outcomes.

Biodegradation, ecotoxicity and UV254/H2O2 treatment of imidazole, 1-methyl-imidazole and N,N'-alkyl-imidazolium chlorides in water

Imidazole-based compounds are used as reagents for the manufacturing of other compounds including imidazolium-based ionic liquids, which have been recently proposed as a green alternative to conventional solvents. Since some imidazole-based compounds have been demonstrated to be harmful to aquatic organisms, the removal of imidazole, 1-methylimidazole, 1-ethyl-3-methyl-imidazolium chloride and 1-butyl-3-methyl-imidazolium chloride from aqueous solutions was attempted by biological oxidation, direct UV₂₅₄ photolysis, and UV₂₅₄/H₂O₂ process at pH 5.5 and 8.5. Results showed that UV₂₅₄/H₂O₂ treatment is an effective tool for the removal of the selected compounds at both pHs. In fact, the kinetic constants of the reaction between the photogenerated HO radicals and the four target compounds, estimated by means of both numerical and competition kinetic method, range between 2.32·10⁹ M^-1 s^-1 and 5.52 ·10⁹ M^-1 s^-1. Moreover, an ecotoxicity assessment of the contaminated water before and after initial treatment without further processing was assessed by using two living aquatic organisms: Raphidocelis subcapitata and Daphnia magna. The results of this assessment not only corresponded closely to previous findings (in terms of EC₅₀ values) reported in the literature, but also indicated that, in some cases, UV₂₅₄/H₂O₂ oxidation by-products could be even more toxic than parent compounds.

Laparoscopic 3D high-definition Deloyers procedure: when, how, why?

After extensive mobilization and resection of the left colon, colorectal anastomosis may result impossible due to the distance between the remaining colon and the rectal stump. The Deloyers procedure represents an interesting alternative to total colectomy with ileorectal anastomosis. In this manuscript, we describe when and how to perform this technique with a mini-invasive approach. We also report the case of a patient who underwent Deloyers procedure, due to early ischemia of the descending colon after left colectomy.

Effect of the concentration of essential oil on orange peel waste biomethanization: Preliminary batch results

The cultivation of orange (Citrus×sinensis) and its transformation is a major industry in many countries in the world, it leads to the production of about 25-30Mt of orange peel waste (OPW) per year. Until now many options have been proposed for the management of OPW but although they are technically feasible, in many cases their economic/environmental sustainability is questionable. This paper analyse at lab scale the possibility of using OPW as a substrate for anaerobic digestion. Specific objectives are testing the possible codigestion with municipal biowaste, verifying the effect on methane production of increasingly high concentration of orange essential oil (EO, that is well known to have antioxidant properties that can slower or either inhibit biomass activity) and obtaining information on the behaviour of d-limonene, the main EO component, during anaerobic digestion. The results indicate that OPW can produce up to about 370LnCH4/kgVS in mesophilic conditions and up to about 300LnCH4/kgVS in thermophilic conditions. The presence of increasingly high concentrations of EO temporary inhibits methanogenesis, but according to the results of batch tests, methane production restarts while d-limonene is partially degraded through a pathway that requires its conversion into p-cymene as the main intermediate.

Single-layer versus double-layer closure of the enterotomy in laparoscopic right hemicolectomy with intracorporeal anastomosis: a single-center study

BACKGROUND

The aim of our study was to evaluate the short-term outcomes of totally laparoscopic right colectomy, in particular to compare the incidence of leakage of the ileocolic anastomosis after either single-layer (SL) or double-layer (DL) enterotomy closure.

METHODS

From March 2010 to July 2014, 162 patients underwent laparoscopic right colectomy with intracorporeal ileocolic anastomosis. The enterotomy was closed with either SL (77 patients) or DL technique (85 patients). Short-term outcomes in both groups were retrospectively analyzed.

RESULTS

Median time to perform the ileocolic anastomosis was similar in the two groups (17 min in SL versus 20 min in DL, p = 0.109). DL closure was associated with a significantly lower incidence of anastomotic leakage (1.2 % in DL vs 7.8 % in SL, p = 0.044). Shorter hospital stay was also observed in the DL group.

CONCLUSIONS

Adoption of DL closure of the enterotomy resulted in significantly improved outcome. We strongly recommend a double-layer closure technique when performing an intracorporeal enterocolic anastomosis.

Relaparoscopy for management of postoperative complications following colorectal surgery: ten years experience in a single center

BACKGROUND

Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant disease. On the basis of this growing experience, there is now an expanded role for laparoscopic approach to postoperative complications after primary colorectal resection. However, there is little literature specific to this topic. We report a ten-year experience with laparoscopic treatment of early complications following laparoscopic colorectal surgery.

METHODS

From January 2003 to December 2012, a total of 1,292 patients underwent elective laparoscopic colorectal surgery in our department. One hundred and two (7.9%) patients required reoperation for a postoperative complication. Laparoscopy has been also adopted as the preferred procedure for management of postoperative complications. A retrospective review of 84 patients who had relaparoscopy (RL) for postoperative complications, including peritonitis, ureteral injury, bowel obstruction, and bleeding, was performed.

RESULTS

Reoperation was carried out laparoscopically in 79 (94.0%) patients. Five (6.0%) conversions were necessary because of massive colonic ischemia, generalized fecal peritonitis, and lack of working space. The most common finding at RL was anastomotic leakage (57.1%) that was managed by peritoneal lavage and ileostomy in 91.7% of cases. Six percent of patients had negative RL. Overall morbidity rate was 25.0%. Five patients required additional surgery: four (5.1%) after RL and one after a converted procedure. There were five (6.0%) deaths from septic shock, myocardial infarction, and pulmonary embolism.

CONCLUSIONS

Laparoscopy is a safe and effective tool for management of complications following laparoscopic colorectal surgery. In this setting, RL represents the first step of re-exploration and treatment, with no delay to conversion to open procedure even in skilled laparoscopic hands.

Effect of arsenic on nitrification of simulated mining water

Mining and mineral processing of gold-bearing ores often release arsenic to the environment. Ammonium is released when N-based explosives or cyanide are used. Nitrification of simulated As-rich mining waters was investigated in batch bioassays using nitrifying cultures enriched in a fluidized-bed reactor (FBR). Nitrification was maintained at 100mg AsTOT/L. In batch assays, ammonium was totally oxidized by the FBR enrichment in 48 h. As(III) oxidation to As(V) occurred during the first 3h attenuating arsenic toxicity to nitrification. At 150 and 200mg AsTOT/L, nitrification was inhibited by 25%. Candidatus Nitrospira defluvii and other nitrifying species mainly colonized the FBR. In conclusion, the FBR enriched cultures of municipal activated sludge origins tolerated high As concentrations making nitrification a potent process for mining water treatment.

Robotic single-access splenectomy using the Da Vinci Single-Site® platform: a case report

BACKGROUND

Single-access laparoscopic splenectomy can offer patients some advantages. It has many difficulties, such as instrument clashing, lack of triangulation, odd angles and lack of space. The Da Vinci Single-Site® robotic surgery platform could decrease these difficulties. We present a case of single-access robotic splenectomy using this device.

METHODS

A 37 year-old female with idiopathic thrombocytopenic purpura was operated on with a single-site approach, using the Da Vinci Single-Site robotic surgery device.

RESULTS

The procedure was successfully completed in 140 min. No intraoperative and postoperative complications occurred. The patient was discharged from hospital on day 3.

CONCLUSIONS

Single-access robotic splenectomy seems to be feasible and safe using the new robotic single-access platform, which seems to overcome certain limits of previous robotic or conventional single-access laparoscopy. We think that additional studies should also be performed to explore the real cost-effectiveness of the platform.

Standardization of laparoscopic left hemicolectomy: a single-center experience of 484 cases

AIM

Laparoscopic surgery has become recognized as an established technique for colon diseases and many different surgical techniques have been described. The aim of our study is to show the results of a single institution where a standardized operative and perioperative procedure for laparoscopic left hemicolectomy (LLH) has been used.

METHODS

Between January 2005 and April 2011, 484 patients underwent LLH for colon diseases. Data collected included age, indication for surgery, ASA class, body mass index, operating time, intra and post-operative complications, conversion rate, length of hospital stay, tumor stage, number of lymph nodes harvested, mortality, and a 30-day readmission rate.

RESULTS

We found 299 cancer, 29 large dysplastic polyps and 156 complicated diverticular diseases. Average operation time was 120 minutes. The average hospital stay was 5.7 days. In the cancer group, the average number of lymph nodes harvested was 12.7. The intraoperative and early postoperative complications were 3.3% and 10.7 % respectively. The conversion rate was 3.7%. The 30-day readmission rate was 3%. The 30-day mortality rate was 0.4%. CONCLUSION. The standardization of the LLH technique might reduce the technical difficulties and complications. Its potential benefits include the standardization of surgical instrument sets, the definition of benchmarks for conversion before making any inappropriate investment in time and equipment, low rates of complications and readmission rate.

Standardization of laparoscopic left hemicolectomy: a single-center experience of 484 cases

Aim: Laparoscopic surgery has become recognized as an established technique for colon diseases and many different surgical techniques have been described. The aim of our study is to show the results of a single institution where a standardized operative and perioperative procedure for laparoscopic left hemicolectomy (LLH) has been used. Methods: Between January 2005 and April 2011, 484 patients underwent LLH for colon diseases. Data collected included age, indication for surgery, ASA class, body mass index, operating time, intra and post-operative complications, conversion rate, length of hospital stay, tumor stage, number of lymph nodes harvested, mortality, and a 30-day readmission rate. Results: We found 299 cancer, 29 large dysplastic polyps and 156 complicated diverticular diseases. Average operation time was 120 minutes. The average hospital stay was 5.7 days. In the cancer group, the average number of lymph nodes harvested was 12.7. The intraoperative and early postoperative complications were 3.3% and 10.7 % respectively. The conversion rate was 3.7%. The 30-day readmission rate was 3%. The 30-day mortality rate was 0.4%. Conclusion: The standardization of the LLH technique might reduce the technical difficulties and complications. Its potential benefits include the standardization of surgical instrument sets, the definition of benchmarks for conversion before making any inappropriate investment in time and equipment, low rates of complications and readmission rate.

Biological inverse fluidized-bed reactors for the treatment of low pH- and sulphate-containing wastewaters under different COD/SO4(2-) conditions

The feasibility of removing sulphate using low-density polypropylene pellets as carrier material in two lactate-fed sulphidogenic inverse fluidized-bed reactors was investigated. Two different COD/sulphate ratios and two different feed-sulphate concentrations were used for the operation of the reactors. During the 242 days of operation, the robustness of the system was studied by suddenly decreasing the feed pH to 3.00. A 10% fluidization degree was used since the carrier material adopted showed not to be adequate to attain a satisfactory immobilization of the biomass with higher fluidization degrees. This resulted in a failure of the process when the feed pH was intentionally decreased to 3.00 in reactor 2, operated with a COD/sulphate ratio of 4.00. On the contrary, when a slightly acidic feed solution was fed to reactor 2, a 97% sulphate reduction efficiency was obtained. In reactor 1, operated with a COD/sulphate ratio of 0.67 throughout the experiment, COD removal and sulphate reduction efficiencies reached the highest values of 75% and 35%, respectively. Higher efficiencies were not achieved also due to the accumulation of acetate and the most likely presence of microbial competition between sulphate reducers and other microorganisms.

Laparoscopic pancreaticoduodenectomy: experience of 22 cases

BACKGROUND

Laparoscopic pancreatic surgery has gradually expanded its applications to include pancreaticoduodenectomy. However, the benefits of the laparoscopic approach are still debated. This article aims to present data regarding the efficacy of laparoscopic pancreaticoduodenectomy in a single center.

METHODS

From March 2003 to June 2010, a total of 22 patients underwent pancreaticoduodenectomy with a totally laparoscopic approach, using a five-trocar technique. Reconstruction of the digestive tract was adapted to the aspect of the pancreatic stump, with 6 patients having Wirsung duct occlusion and 16 patients pancreaticodigestive anastomosis. Patient selection, short-term outcomes, oncologic results, and technical issues were retrospectively reviewed.

RESULTS

Mean operative time was 392 (range, 327-570) min. Conversion was required in 2 patients (9.1 %) as a result of bleeding and difficult dissection. Major intraoperative complications included an injury to the right hepatic artery (4.5 %). Postoperative mortality was 4.5 %. Surgery-related morbidity occurred in 14 patients (63.6 %) and included bleeding (n = 5), pancreatic fistula (n = 6), biliary fistula (n = 2), and dumping syndrome (n = 1). Pancreatic fistulas occurred in 4 patients with duct occlusion and in 2 patients with pancreaticojejunostomy, and they all healed with conservative treatment. Mean hospital stay was 23 (range, 12-35) days. Pathologic diagnoses were pancreatic ductal adenocarcinoma (n = 11), ampullary adenocarcinoma (n = 8), and duodenal adenocarcinoma (n = 3). The resection margins were all free from disease; the mean number of collected lymph nodes was 15 (range, 14-20).

CONCLUSIONS

The complexity of pancreaticoduodenectomy entails some issues, including patient selection and management of the pancreatic stump, that are not related to the approach used. Laparoscopic pancreaticoduodenectomy is feasible, safe, and oncologically adequate, but only if performed in selected cases by highly skilled laparoscopic surgeons. Laparoscopy does not provide any significant advantage over traditional surgery, but it may improve postoperative outcomes in the so-called excellence centers, once the learning curve has been overcome. Multicenter randomized trials are needed.

Laparoscopic total gastrectomy in gastric cancer: our experience in 92 cases

INTRODUCTION

Laparoscopic total gastrectomy (LTG) is seldom used for gastric cancer because the complex vascularization and lymphatic drainage makes lymphadenectomy and esophagojejunal anastomosis difficult and requires special skills. Our aim was to demonstrate the feasibility and accuracy of LTG in gastric cancer with D2 lymphadenectomy.

MATERIAL AND METHODS

Eighty-eight LTG and four laparoscopic remnant gastrectomies (LRGs) were performed over >12 years. The median patient age was 64 years, and the male/female ratio was 1.49/1. Eighty-seven patients had a D2 and only five patients had a D1 lymphadenectomy. We propose the retrospective analysis of intra- and perioperative mortality and morbidity.

RESULTS

In only four of 96 cases approached by laparoscopy, a conversion to laparotomy was needed. There were two (2.17%) perioperative deaths in 92 procedures and few complications. Histological data show 79 advanced gastric cancers (AGC), 11 early gastric cancers (EGC), and two gastric diffused lymphomas. The five-year Kaplan-Meier overall survival in patients with EGC and AGC was 100% and 58%, respectively.

CONCLUSIONS

The results demonstrate the feasibility of an oncologically correct minimally invasive total gastrectomy. We would like to promote comparisons among different institutions to achieve better standardization of indications and techniques for a laparoscopic approach to gastric cancer.

Laparoscopic pancreas-preserving subtotal duodenectomy for gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GISTs) of the duodenum are rare neoplasms. The optimal surgical procedure is debated and several options ranging from limited resections to pancreaticoduodenectomy have been reported. The laparoscopic approach has been validated for gastric GISTs, but it does not yet represent a standard technique for tumors of the duodenum. We report the case of a localized duodenal GIST that was successfully treated by totally laparoscopic pancreas-preserving subtotal duodenectomy. This procedure may represent a feasible and effective treatment option for localized GISTs of the duodenum. Large series with long-term follow-up are needed.

Laparoscopic splenectomy: experience of a single center in a series of 300 cases

BACKGROUND

Laparoscopic splenectomy (LS) has gradually become the technique of choice for surgical removal of the spleen. The aim of this study was to evaluate the efficacy of LS in a large cohort of patients from a single center.

METHODS

From March 1992 to June 2010, 300 patients underwent LS at our hospital for predominantly hematologic disorders. The first 92 cases were performed using an anterior approach, whereas in the remaining 208 cases a lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed.

RESULTS

Spleen volume was similar between the anterior (350 ml) and the lateral (370 ml) approaches. The lateral approach was associated with shorter operative time (60 vs. 80 min), less blood loss (30 vs. 110 ml), and no conversion (0 vs. 2.2 %) compared to the anterior approach. Reoperations were required in three patients (1.0 %) because of bleeding, subphrenic abscess, and intestinal ischemia. Postoperative complications were significantly fewer for the lateral (4.8 %) than for the anterior (31.5 %) approach and the hospital stay was shorter (3.1 vs. 5.2 days) and there was less postoperative pain. Splenectomy for hematologic malignancies resulted in a higher morbidity rate, more postoperative pain, and longer hospital stay. Overall mortality rate was 0.3 %. No late complications were observed during the 1-5-year follow-up.

CONCLUSIONS

LS using the lateral approach with the placement of four trocars can be considered the procedure of choice for both benign and malignant diseases affecting the spleen. Extensive experience and technical standardization help to avoid surgical pitfalls, providing an adequate control of hemostasis, the excision of accessory spleens (AS), and the avoidance of parenchymal rupture.