Iatrogenic biliary leak treated by performing exploratory laparoscopic using indocyanine green (ICG) fluorescence. A case report and review of literature.

INTRODUCTION: Cholangiography with indocyanine green fluorescence (ICG) is increasingly used to visualize the bile duct anatomy during laparoscopic cholecystectomy. Biliary leaks are rare complications after laparoscopic cholecystectomy, result could be lethal. Lesion's site is not always visible. We present an interesting case of a patient with biloma due to an iatrogenic lesion of the biliary tract, treated in urgency using ICG fluorescence. To our knowledge, this is the only case in the literature. CASE PRESENTATION: A 62-years-old patient after 7 days from laparoscopic cholecystectomy presented abdominal pain and fever. Blood tests showed an increase of inflammation indexes. Abdominal US and abdominal CT revealed a conspicuous right sub-hepatic fluid. We performed a laparoscopy using ICG fluorescence to find the biliary leak. Operative time of surgery was 60 min. There were no complications during this procedure. CONCLUSIONS: ICG is a safe and effective procedure that enables real-time visualization of the biliary system. In some cases, it can also be used in urgent surgery, where the biliary anatomy is much more complex. KEY WORDS: Biloma, Indocyanine green fluorescence, Iatrogenic biliary leaks, Urgent surgery.

The Role of Intraoperative Indocyanine Green (ICG) and Preoperative 3-Dimensional (3D) Reconstruction in Laparoscopic Adrenalectomy: A Propensity Score-matched Analysis.

BACKGROUND: Laparoscopic adrenalectomy (LA) is considered the "gold standard" treatment of adrenal lesions that are often coincidentally diagnosed during the radiologic workup of other diseases. This study aims to evaluate the intraoperative role of indocyanine green (ICG) fluorescence associated with preoperative 3-dimensional reconstruction (3DR) in laparoscopic adrenalectomy in terms of perioperative outcomes. To our knowledge, this is the first prospective case-controlled report comparing these techniques. MATERIALS AND METHODS: All consecutive patients aged≥18 and undergoing laparoscopic transperitoneal adrenalectomy for all adrenal masses from January 1, 2019 to January 31, 2022 were prospectively enrolled. Patients undertaking standard LA and those undergoing preoperative 3D reconstruction and intraoperative ICG fluorescence were matched through a one-on-one propensity score matching analysis (PSM) for age, gender, BMI, CCI score, ASA score, lesion histology, tumor side, and lesion diameter. Differences in operative time, blood loss, intraoperative and postoperative complications, conversion rate, and length of stay were analyzed. RESULTS: After propensity score matching analysis, we obtained a cohort of 36 patients divided into 2 groups of 18 patients each. The operative time and intraoperative blood loss were shorter in patients of the 3DR group ( P =0,004 and P =0,004, respectively). There was no difference in terms of length of stay, conversion rate, and intraoperative and postoperative complications between the 2 groups. CONCLUSIONS: The use of intraoperative ICG in LA and preoperative planning with 3DR images is a safe and useful addition to surgery. Furthermore, we observed a reduction in terms of operating time and intraoperative blood loss.

Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience.

Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p < 0.05 is the criterion for statistical significance. Statistical analyses were performed with the Number Cruncher Statistical System (NCSS) 2020 data analysis version 20.0.1 (Utah, USA). The operation time was higher in robotic left (p = 0.003, mean time 249.6 vs 211.7 min) and right (p = 0.004, mean time 238.5 vs 183.5 min) hemicolectomy and similar for procedures on rectosigmoid and rectum when compared to laparoscopic technique. In terms of length of hospital stay and recovery of bowel function, these values were significantly lower for robotic group in left hemicolectomy (p = 0.004), rectum (p = 0.003) and rectosigmoid (p = 0.003), while right hemicolectomy was similar in two groups (p = 0.26). There was no statistically significant difference between the groups regarding conversion rate, postoperative complications, length of specimen, number of lymph nodes encountered and oncological results. Colorectal robotic surgery in elderly patients appears as a feasible and safe surgical approach when compared to the laparoscopic one, showing a shorter recovery and a reduction of length of stay with similar oncological outcomes even if with an increase of operating times.

Laparoscopic left nephro-adrenalectomy for renal vein leiomyosarcoma using (ICG) fluorescence and 3D-CT reconstruction: A case report.

INTRODUCTION: Leiomyosarcoma is a rare malignant mesenchymal cancer of smooth muscle and about 50-60 % of cases are from inferior vena cava. Recently, preoperative reconstruction of three-dimensional (3D) images from computed tomography (CT) and intraoperative indocyanine green (ICG) are being developed. We present a case of laparoscopic left nephro-adrenalectomy using ICG fluorescence associated with 3D-CT reconstruction:n. CASE REPORT: A 72-years-old female patient presented pain in left side from two months. Contrast computed tomography and magnetic resonance imaging showed a solid mass between left-adrenal gland and upper renal pole. After multidisciplinary evaluation, a laparoscopic left nephno-adrenalectomy was performed. DISCUSSION: The surgery was without intra and postoperative complications. The patient was discharged in the 3rd postoperative day without complications and with oral steroid replacement therapy. Histology confirmed leiomysarcoma of renal vein. CONCLUSION: In this case, use intraoperative ICG fluorescence associated with preoperative 3D-CT was a valuable support for surgery. KEY WORDS: Endocrine surgery, Indocyanine green fluorescence, Laparoscopic Nephro-Adrenalectomy, Leiomyosarcoma, Three-dimensional computed tomography reconstruction, Video surgery.

Management of pheochromocytoma during pregnancy from diagnosis to laparoscopic adrenalectomy. A case report and review of literature.

INTRODUCTION: Pheochromocytoma is an endocrine tumour of chromaffin cells. It can be diagnosed either sporadically or in the context of hereditary syndromes (e.g. Von Hippel Lindau, Neurofibromatosis type 1 and multiple neuroendocrine neoplasia type 2). During pregnancy, its frequency is very low (about 0,007%). This tumour causes paroxysmal hypertension in 0,1-0,6% pregnant women, because of an overproduction of catecholamines. If undiagnosed and nontreated, it's associated with high maternal and fetal mortality (40-50%). We report the case of a 30-year-old female diagnosed with pheochromocytoma during pregnancy at week 31 of gestation. In a multidisciplinary team made of surgeons, gynaecologists, anaesthetists, geneticists and endocrinologists we evaluated the case and according to literature, we choose a surgical approach after childbirth: performing a laparoscopic right adrenalectomy. DISCUSSION: In pregnancy, pheochromocytoma is a rare clinical condition. Gold standard treatment is laparoscopic adrenalectomy. However, the optimum timing of surgery is a challenge. CONCLUSION: Timely diagnosis of pheochromocytoma in pregnant women with hypertension and appropriate therapeutic management can lead to improve maternal, fetal and neonatal outcomes. The multidisciplinary team is necessary to recognize the symptoms and to adopt the right pre - and post - operative treatment. Laparoscopic adrenalectomy after delivery is safe and feasible even though the surgical procedure should be performed by an experienced surgeon. KEY WORDS: Pheochromocytoma, Pregnancy, Laparoscopic adrenalectomy and pregnancy, Management of pheochromocytoma, Laparoscopic adrenalectomy, Adrenalectomy, Pregnancy and pheochromocytoma.

Impact of SARS-Cov-2 pandemic on Emergency General Surgery. A single-center observational study.

INTRODUCTION: Several articles have been published on impact COVID-19 infection about reduction of surgical activity. We have focused on the differences between our surgical activity in an Emergency General Surgery department in "Cardarelli" Hospital in Naples. METHODS: This retrospective study compared the patients treated from March 9, 2020 to April 27, 2020 (Italian lockdown time) and the patients treated in the same period of 2019. We recruited 75 patients in Group A (2020) and 165 patients in Group B (2019). RESULTS: There was a reduction in hospitalizations for non-trauma disease (69 in group A and 122 in group B with p: 0.001), a reduction in transfers from other hospitals (2 patients in group A and 17 in group B with p. 0.04) and a reduction in hospitalizations for trauma disease (6 in group A and 43 in group B with p: 0.001). The severity of the disease in 2020 was greater than in the same period in 2019 and there was a higher rate of high-grade complications CONCLUSION: From data analysis, we conclude that there has been a reduction in hospitalizations and surgical interventions in our emergency surgery department. The patients, however, had a much more severe disease that resulted in a greater number of complications in the peri and post-operative time. KEY WORDS: COVID-19, Lockdown, Emergency Surgery, Severity of disease.

Telemedicine in Patients With an Ostomy During the COVID-19 Pandemic: A Retrospective Observational Study.

BACKGROUND: Italy instituted a lockdown from March 10 to May 3, 2020, due to the coronavirus disease-19 pandemic. All nonessential businesses were closed during this time, and health care services were reorganized. On March 11, the Stoma Care Center started providing telehealth services for patients with a stoma. PURPOSE: This retrospective observational study describes the experience of the Stoma Care Center of the University Hospital Federico II, Naples, Italy, before and during the lockdown. METHODS: Consultation records from January 1 through April 29 were retrieved, patient demographics and reasons for consultation abstracted, and pre-lockdown (January 1 to February 29) and lockdown (March 1 to April 29) information was compared. Patients who used telehealth services were also asked to rate their satisfaction with these services on a scale of 0 (extremely dissatisfied) to 4 (extremely satisfied). The authors analyzed all consultations provided from January to April 2020 and evaluated the use of telemedicine services for patients with an ostomy. Consultations were divided into 2 groups. Group A included consultations provided from January 1 to February 29. Group B included consultations provided from March 1 to April 29, which included the lockdown period. Group B included both in-person and telemedicine consultations. RESULTS: During the pre-lockdown period, 240 in-person consultations were provided. During the lockdown period, 181 in-person and 99 telemedicine consultations were provided. The number of in-person consultations for mechanical bowel preparation and transanal irrigation system training was lower (12.5% vs 6.6% [P = .046] and 3.3% vs 0% [P = .03]), whereas the number of consults for stoma care follow-up and stoma complications was higher (202 [84.1%] vs 266 [95%]). Of the 65 patients who completed the questionnaire, 82% indicated being extremely satisfied. CONCLUSIONS: The reorganization of stoma care services, including the availability of telemedicine, did not result in a decrease in the number of consultations provided. The results suggest that stoma care services using telemedicine may provide valid support for patients with an ostomy in the future.

Endoscopic Approach to Recurrent Pilonidal Sinus: A Retrospective Analysis.

Background: The aim of this study is to report short- and long-term results using video-assisted ablation of pilonidal sinus (PS) technique to treat recurrent PS. Methods: We included all consecutive patients with a recurrent PS disease operated on with endoscopic approach since 1st January 2014 to 31st December 2018. Analyzed outcomes were recurrence rate at 1, 3, and 5 years, time off work, time to sitting on toilet and to walk without pain, time to wound healing, rate of incomplete wound healing and postoperative infection, postoperative pain at 6 hours, 1 day, and 1 week, and patients' satisfaction after 1 month. Demographic and sinuses' data were recorded. To adjust for all the variables, multivariate analyses were performed with outcomes as dependent variables, and with patients' and sinuses' characteristics as independent variables. Results: Sixty-three patients were included in the analysis. Recurrence rate at 1-year follow-up was 4.7% (3 patients on 63), at 3-year follow-up was 11.7% (4 on 34), and at 5-year follow-up was 23.07% (3 on 13). A 3- and 5-year follow-up was completed by 34 and 13 patients, respectively. The mean time off work was 3.5 ± 1.5 days, time to sitting on toilet without pain was 1.5 ± 1.1 days, and time to walk without pain was 1.3 ± 0.9 days. The mean time to wound healing was 27.9 ± 10.3 days, with a rate of incomplete wound healing of 4.7%. Postoperative infection rate was 7.9%. The mean postoperative pain was 1 ± 0.9 at 6 hours after the procedure, 0.6 ± 0.6 at 1 day and 0.1 ± 0.3 at 1 week. Patients' satisfaction was good in 98.5% of patients. After the multivariate analysis, no parameters showed an influence on the postoperative outcomes. Conclusions: Our results encouraged to adopt an endoscopic approach even in case of recurrent PS.

Serrated lesions of the colon and rectum: Emergent epidemiological data and molecular pathways.

In 2010, serrated polyps (SP) of the colon have been included in the WHO classification of digestive tumors. Since then a large corpus of evidence focusing on these lesions are available in the literature. This review aims to analyze the present data on the epidemiological and molecular aspects of SP. Hyperplastic polyps (HPs) are the most common subtype of SP (70-90%), with a minimal or null risk of malignant transformation, contrarily to sessile serrated lesions (SSLs) and traditional serrated adenomas (TSAs), which represent 10-20% and 1% of adenomas, respectively. The malignant transformation, when occurs, is supported by a specific genetic pathway, known as the serrated-neoplasia pathway. The time needed for malignant transformation is not known, but it may occur rapidly in some lesions. Current evidence suggests that a detection rate of SP ≥15% should be expected in a population undergoing screening colonoscopy. There are no differences between primary colonoscopies and those carried out after positive occult fecal blood tests, as this screening test fails to identify SP, which rarely bleed. Genetic similarities between SP and interval cancers suggest that these cancers could arise from missed SP. Hence, the detection rate of serrated-lesions should be evaluated as a quality indicator of colonoscopy. There is a lack of high-quality longitudinal studies analyzing the long-term risk of developing colorectal cancer (CRC), as well as the cancer risk factors and molecular tissue biomarkers. Further studies are needed to define an evidence-based surveillance program after the removal of SP, which is currently suggested based on experts' opinions.