Robotic 8-mm trocar fascial wounds: To close or not to close?

BACKGROUND: The aim of this study was to investigate 8-mm robotic trocar site hernia (TSH) rate over the short and long term, providing aids to manage the related fascial wounds. METHODS: A retrospective analysis of 320 patients undergoing robotic surgery was conducted. The primary outcome was 8-mm TSH rate with a minimum follow-up of 12 months. The secondary outcome was the rate of haematomas and infections related to 8-mm wounds and their association with patient comorbidities and trocar position. RESULTS: One case of TSH was observed (0.31%). There were 15 cases of wound infection (4.68%) and 22 cases of wound haematoma (6.87%). Trocar related complications were significantly associated with patient comorbidities, not with trocar position. CONCLUSIONS: Our results do not justify the 8-mm fascial wound closure. Data concerning the association between trocar-related complications and patient comorbidities strengthen the need to implement the control of metabolic state and correct administration of perioperative therapy in high-risk patients.

Local recurrence risk factors and outcomes in minimally invasive thermal ablation for liver tumors: a single-institution analysis.

BACKGROUND: Minimally Invasive thermal ablation (MITA) of liver tumors is a commonly performed procedure, alone or in combination with liver resection. Despite being a first-option strategy for small lesions, it is technically demanding, and many concerns still exist about local disease control. METHODS: Consecutive patients undergoing MITA from 1-2019 to 12-2022 were retrospectively enrolled. Risk factors of local recurrence were investigated through univariate and multivariable cox regression analysis. RESULTS: At the multivariable analysis of the 207 nodules undergoing MITA, RFA was associated with worse local Recurrence Free Survival (lRFS) than MWA (HR 2.87 [95 % CI 0.96-8.66], p = 0.05), as well as a concomitant surgical resection (HR 3.89 [95 % CI 1.06-9.77], p = 0.02). A concomitant surgical resection showed worse lRFS in the subgroup analysis of both HCC (HR 3.98 [95 % CI 1.16-13.62], p = 0.02) and CRLM patients (HR 2.68 [95 % CI 0.66-5.92], p = 0.04). Interestingly, a tumor size between 30 and 40 mm was not associated to worse lRFS. CONCLUSION: MWA may reduce the risk of local recurrence in comparison to RFA, while MITA associated to liver resection may face an increased risk of local recurrence. Further prospective studies are needed to confirm such results.

Physical activity in elderly kidney transplant patients with multiple renal arteries.

BACKGROUND: Kidney transplantation (KT) is the gold standard for treatment of patients with end-stage-renal disease. To expand the donor reserve, it is necessary to use marginal/suboptimal kidneys. METHODS: We retrospectively evaluated the short/long-term outcome of 34 KT elderly patients who received allografts with vascular abnormalities (MRA group), in comparison with 34 KT patients who received a kidney with a single renal artery (SRA group) pair-matched by age, length of time on dialysis, comorbidity and donor age. RESULTS: All participants completed the International Physical Activity Questionnaire at KT, and then 4, 8, and 12 weeks after transplantation. Our data indicate that kidney with vascular anatomical variants may be successfully transplanted, since the overall rate of surgical complications was 20.6% in the SRA group and 17.6% in the MRA group and that the 5-year survival rate after KT was 100% in both groups. CONCLUSIONS: The data also underlined that individualized physical activity programs induced similar excellent results in both groups, improving physical capacities, arterial pressure, lipid metabolism, insulin sensitivity, quality of life and physical and mental status.

One-stage resection of primary colorectal cancer and hepatic metastases using the Habib Device: analysis of 40 consecutive cases treated in a Unit of general surgery.

BACKGROUND: More than 50% of patients with colorectal cancer (CRC) present or develop hepatic metastases (HM). The intraoperative use of the Habib 4X® radio frequency probe device is safe in resetting HM and allows a one-stage resection of both CRC and HM with a similar mortality rate than a two-stage surgical treatment. METHODS: After an exhaustive residential training at the reference center for hepato-biliary surgery of the Imperial College of London, we treated at our unit of general surgery 40 consecutive patients with CRC and HM with the one-stage resection, using the Habib 4X® intraoperative radiofrequency probe device to reset HM. RESULTS: None of the 40 patients died during the intra-operatory and post-operatory periods, none presented liver failures during the postoperative course nor complication related to the Habib's resection procedure (e.g. bleeding, abscess, bile leak). The amount of intra-operative liver bleeding was minimal. New HM arose in 10 (25%) cases, with a mean disease-free interval of 13 months, but the hepatic tissue close to previous resections remained cancer-free. The 69.7% of patients were disease-free at month 24 of the post-operative follow-up and 5-year rate was about 70%. CONCLUSIONS: The data suggest that surgeons well trained at a reference center for hepato-biliary surgery may perform with excellent results the one-stage CRC and HM resection with the Habib 4X® device even in a Unit of general surgery.

Outcomes of Renal Stone Surgery Performed Either as Predonation or Ex Vivo Bench Procedure in Renal Grafts from Living Donors: A Systematic Review.

AIMS: We aimed to summarize available evidence about intraoperative and postoperative donors' and recipients' outcomes following stone surgery in renal grafts from living donors performed either before donation or as ex vivo bench surgery at the time of living-donor nephrectomy. METHODS: A systematic review of PubMed, ISI Web of Knowledge, and Scopus databases was performed in September 2020. We included full papers that met the following criteria: original research, English language, human studies, and describing the results of stone surgery in renal grafts from living donors performed either before transplantation or as ex vivo bench surgery. RESULTS: We identified 11 studies involving 106 patients aged between 22 and 72 years. Predonation and bench stone surgery was performed in 9 (8.5%) and 96 (90.6%) patients, respectively. Predonation stone surgery involved extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy in 8, 1, and 1 patient, respectively. The overall success rate of predonation stone surgery was 78%, and the complication rate was 0%. Bench stone surgery involved ureteroscopy, pyelolithotomy, or a combination of both in 79 (82.3%), 10 (10.4%), and 7 (7.3%) cases, respectively, with an overall success rate of 95.8% and an overall complication rate of 9.37%. CONCLUSIONS: Predonation and bench stone surgery in grafts from living donors represents efficacious and safe procedures. Further studies on wider series with a longer follow-up are required.

COVID-19 and Living Donor Kidney Transplantation in Naples during the Pandemic.

INTRODUCTION: SARS-CoV-2 is a virus that causes a potentially deadly syndrome that affects especially the respiratory tract. Kidney-transplanted patients are immunosuppressed and more susceptible to viral infections. We have examined our transplantation activity to explore the future role of kidney transplantation from deceased and living donors in COVID-19 era. Patients and Methods. The activity of our transplant center of Naples (one of the two transplant centers in Campania, South Italy) continued during the COVID-19 pandemic. We have analysed the kidney transplants carried out between March 9 and June 9, 2020, comparing these data with the numbers of procedures performed in the two previous years. Moreover, we have considered the possibility of performing living donor transplants during a worldwide pandemic. RESULTS: From March 9, 2020, when the Italian lockdown begun, till June 9, 2020, five kidney transplants have been performed at our transplant center in Naples, all from deceased donors. The donors and the recipients have been screened for COVID-19 infection, and the patients, all asymptomatic, followed strict preventive measures and were fully informed about the risks of surgery and immunosuppression during a pandemic. All the transplanted patients remained COVID negative during the follow-up. The number of transplants performed has been constant compared to the same months of 2018 and 2019. In agreement with the patients, we decided to postpone living donor transplants to a period of greater control of the SARS-CoV-2 spread in Italy. CONCLUSION: Deceased donor kidney transplantation should continue, especially in a region with moderate risk, like Campania, with a more careful selection of donors and recipients, preferring standard donors and recipients without severe comorbidities. Living donor transplantation program, instead, should be postponed to a period of greater control of the SARS-CoV-2 spread, as it is an elective surgery and its delay does not determine additional risks for patients.

Relation Between Wound Complication and Lymphocele After Kidney Transplantation: A Monocentric Study.

INTRODUCTION: Wound complication frequently arises after kidney transplantation and its risk factors are well known. In a previous paper we analyzed these factors, and in this new retrospective study we evaluate the influence of lymphocele in the development of wound complications. PATIENTS AND METHODS: From January 2000 to December 2018, 731 consecutive kidney transplants have been performed in our center. We have analyzed the incidence of wound complication and lymphocele and their risk factors. RESULTS: Out of 731 kidney transplants, we have observed wound complications in 115 patients (15.7%) and lymphocele in 158 patients (21.7%). Of these, 70 patients developed both complications (9.5%), but 6 patients have been excluded because they were in therapy with mammalian target of rapamycin inhibitors. Twenty-nine patients (45.3%) presented a first level and 35 patients (54.7%) showed second level wound complications. Lymphocele was the only present factor in just 3 cases (4.6%). The other patients showed diabetes in 28 cases (43.7%), overweight/obesity in 38 (59.3%), delayed graft function in 17 (26.5%), and 60 years or more in 38 (57.8%). The association has been found in 30 out 64 patients treated with tacrolimus (46.8%) and in 34 with cyclosporine (53.1%); 40 patients did not receive muscular layer's reconstruction (62.5%). CONCLUSION: Our experience shows that lymphocele alone is not a predisposing factor for wound dehiscence after kidney transplantation, and they often coexist because they share the same risk factors, the most important being obesity, diabetes and delayed graft function, older age, and surgical techniques. No relation has been observed with calcineurin inhibitor therapy.

Colorectal Cancer in the Elderly Patient: The Role of Neo-adjuvant Therapy.

BACKGROUND: Neoadjuvant chemoradiotherapy has a significant role in downstaging cancer. It improves the local control of the disease and can make conservative resection of rectal cancer possible. METHODS: We enrolled 114 patients with subperitoneal rectal cancer who underwent neoadjuvant chemoradio-therapy and radical excision with total mesorectal excision (TME). The primary endpoint was oncological outcomes and the secondary endpoint was surgical outcomes.We evaluate the experience of a multidisciplinary team and the role of neoadjuvant chemoradiotherapy in integrated treatment of cancer of the subperitoneal rectum. RESULTS: Surgical procedures performed were abdominal perineal resection in 4 cases (3.5%), anterior resection in 89 cases (78%), Hartmann's procedure in 5 cases (4.4%), and ultralow resection with coloanal anastomosis and diverting stoma in 16 patients (14%).Local recurrence occurred in 6 patients (5.2%), the overall survival was 71.9% at 5 years and disease-free survival was about 60%. CONCLUSIONS: The effect of pathological downstaging amounted to 58.8%, including cPR. The pathologic complete remission occurred in 8.8% of cases.The outcomes of neoadjuvant therapy can be achieved when this treatment is associated with correct surgical technique with TME and the prognosis is defined by an anatomopathological examination performed according to Quirke's protocol.