Gut Microbiota Association with Diverticular Disease Pathogenesis and Progression: A Systematic Review.

INTRODUCTION: Growing evidence supports the role of the intestinal microbiome in the development of different intestinal and extraintestinal diseases. Diverticular disease (DD) is one of the most common disorders in western countries. In the last years, different articles have suggested a possible role of the intestinal microbiome in DD pathogenesis and in the development of acute diverticulitis (AD). This systematic review aimed to clarify the current knowledge on the role of the intestinal microbiome in colonic diverticulitis in different stages according to the 2009 PRISMA guidelines. MATERIALS AND METHODS: Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, Cochrane Oral Health Group Specialized Register, ProQuest Dissertations and Theses Database, and Google Scholar. Patients with any stage of disease were included. The Newcastle-Ottawa scale for case-control and cohort studies was used for the quality assessment of the selected articles. RESULTS: Overall, nine studies were included in the review. Only one article was focused on patients with AD, while all other articles only considered patients with DD without acute inflammation signs. Enterobacteriaceae seems to be the microbiota most associated with the disease, followed by Bifidobacteria. CONCLUSIONS: All the included studies showed great heterogeneity in population characteristics and sampling methods. Therefore, given the high prevalence of colonic diverticulitis in the general population, further studies are needed to clarify the role of the intestinal microbiome, paving the way to new target therapies with important social implications.

Combined robotic inguinal and iliac-obturator lymphadenectomy for stage III skin cancers: Surgical technique and preliminary results.

BACKGROUND: Ilio-inguinal lymphadenectomy for stage III melanoma and skin cancers still represents the best therapeutic option for a subset of patients, although the incidence of post-operative complications is dramatically high. Only a paucity of papers on robotic approach have been published, reporting experiences on isolated pelvic or inguinal lymphadenectomy, and no series on combined dissections have been described yet. We present the preliminary results achieved with combined robotic approach, with special emphasis on lymph nodal mapping, dissection technique and postoperative complications linked with the lymphatic system. METHODS: Between September 2019 and September 2021, 10 patients were submitted to robotic inguinal and iliac-obturator lymphadenectomy. RESULTS: Post-operative course was characterised by early mobilisation and minimal post-operative pain. Only one lymphoedema occurred and lymph nodal harvesting was more than satisfactory. CONCLUSIONS: Robotic surgery provides meticulous lymph nodal dissections, with promising functional and oncologic outcomes. Further series are advocated to confirm these preliminary results.

Learning curve for laparoscopic cholecystectomy has not been defined: A systematic review.

BACKGROUND: Laparoscopic cholecystectomy is one of the most performed surgeries worldwide but its learning curve is still unclear. METHODS: A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the learning curve of laparoscopic cholecystectomy were included. The Newcastle-Ottawa scale for cohort studies and the GRADE scale were used for the quality assessment of the selected articles. RESULTS: Nine cohort studies published between 1991 and 2020 were included. All studies showed a great heterogeneity among the considered variables. Seven articles (77.7%) assessed intraoperative variables only, without considering patient's characteristics, operator's experience, and grade of gallbladder inflammation. Only five articles (55%) provided a precise cut-off value to see proficiency in the learning curve, ranging from 13 to 200 laparoscopic cholecystectomies. CONCLUSIONS: The lack of clear guidelines when evaluating the learning curve in surgery, probably contributed to the divergent data and heterogeneous results among the studies. The development of guidelines for the investigation and reporting of a surgical learning curve would be helpful to obtain more objective and reliable data especially for common operation such as laparoscopic cholecystectomy.

MicroRNAs differential expression profile in metastatic colorectal cancer: A pilot study with literature review.

BACKGROUND AND OBJECTIVES: Colorectal cancer is still one of the leading causes of cancer-related deaths worldwide and specific tools to improve disease assessment and treatment response are advocated. The aim of this study was to analyze miRNAs expression in metastatic and non-metastatic colorectal cancer, in order to identify reliable biomarkers suitable for prognosis, treatment and patient's monitoring. MATERIAL AND METHODS: Among 25 patients (mean age 71 ± 12 years; Female/Male: 12/13) submitted to laparoscopic colorectal resection between August 2017 and February 2019, miRNAs were extracted from fresh frozen tissues of solid tumors. Gene expression's analysis arising from microarray technology was performed. RESULTS: Pathological evaluation identified 15 metastatic patients (8 presenting with stage III and 7 with stage IV cancers) and 10 non-metastatic patients (4 presenting with stage I and 6 stage II cancers). Bioinformatic analysis of solid biopsies revealed 16 miRNAs (11 upregulated and 5 downregulated) differently expressed between metastatic and non-metastatic groups, with three miRNAs (miR-7515, miR-7109-5p and miR-6831-5p) never linked to colorectal cancer before. CONCLUSIONS: Our study showed an association between miRNAs and metastatic colorectal cancer, suggesting their potential role as biomarkers for tumor management, if confirmed by further studies.

Pre-operative Renal Artery Embolization in Laparoscopic Radical and Partial Nephrectomy: A Multidisciplinary Approach to Renal Tumors.

BACKGROUND: Despite being widely adopted, the laparoscopic approach to radical and partial nephrectomy is still burdened by high rates of hemorrhagic complications, which require blood transfusions and conversion to open surgery with increased morbidity. While pre-operative renal artery embolization (PRAE) can prevent intraoperative blood loss and vascular injuries, its prophylactic use is still a matter of debate. This study evaluated the safety and efficacy of PRAE in overcoming the main pitfalls of laparoscopy, which are related to the absence of tactile feedback. METHODS: Data from 48 patients who underwent laparoscopic nephrectomy for cancer (34 laparoscopic radical nephrectomy (LRN) and 14 "off-clamp" laparoscopic partial nephrectomy (LPN) after selective and superselective PRAE, respectively) were retrospectively evaluated. RESULTS: The overall median blood loss was 50 ml and only 2 patients (4%) required one unit of blood products. While conversion to open surgery was not required in the LPN group, one case in the LRN group was converted to open surgery due to intraoperative incoercible bleeding from an unrecognized, and thus not embolized, aberrant inferior polar artery. Post-embolization syndrome occurred in 7 patients (15%), resulting in mild flank pain and nausea. No patients in the LPN group experienced new onset of acute renal failure. CONCLUSION: Our experience supports pre-operative renal embolization as a safe, minimally invasive procedure that is effective for reducing perioperative bleeding in the laparoscopic setting.

Is Needlescopic Cholecystectomy a Safe Way to Improve Mininvasiveness and Cosmesis in Young Female Patients?

INTRODUCTION: Needlescopic cholecystectomy (NC) was introduced in the late 1990s. It uses a reduced trocar caliber in an otherwise standard four-port laparoscopic cholecystectomy (LC) and seeks to achieve "scarless" surgery without compromising patient safety. MATERIALS AND METHODS: Between May 2016 and November 2017, 29 patients underwent elective NC at the Department of General Surgery of Sant'Andrea Hospital (La Spezia, Italy). Inclusion criteria were female sex, age between 18 and 45 years, good performance status (ASA 1-2) and BMI lower than 25. Twenty-one patients underwent a standard 4-port technique: 12mm port in the supraumbilical area, 5mm port in the subxiphoid position, 3mm port in the mid-epigastric area and another 3 mm port in the right mid-clavicular position. In 8 patients, 3mm ports were replaced by 2mm angiocath. A Critical View of Safety (CVS) was achieved in all procedures. Intra-operative cholangiography (IOC) via the cystic duct before any transection of the structures was routinely performed in selected cases, such as those with an unclear biliary anatomy or risk factors for main-duct stones. In our institution, laparoscopic transcystic common bile duct (CBD) exploration is routinely performed in CBD lithiasis. RESULTS: The mean operative time was 66.79 min (range 25-120 min). IOC was performed in 12 patients (41.4%) with suspected choledocolythiasis. There was no conversion to conventional laparoscopic cholecystectomy or open cholecystectomy. The mean hospital stay was 1.48 days (1-7 days). A Clavien-Dindo IIIB complication occurred in one patient on the third postoperative day. The mean VAS pain score was 3 (0-7). Closure of the skin with primary intention was achieved in all patients. Mean return to work was 6.76 days (3-15 days) and the mean return to previous physical activity was 12.17 days (4-30 days). All of the patients completed the Scar Satisfaction Questionnaire: 26 (89.7% ) and 3 patients (10.3%) were very satisfied and satisfied, respectively. CONCLUSION: Any effort to reduce invasiveness and improve cosmesis must not jeopardize safety. Our case series demonstrates that needlescopy can be safely associated with intraoperative cholangiography to recognize CBD stones. This technique offers the advantage of minor postoperative pain, better cosmesis results, early return to routine life activities and great satisfaction for the patient. Needlescopy is a valuable and safe alternative that is suitable for elective cholecystectomy in properly selected patients, such as young female patients.

Laparoscopic liver resection for large HCC: short- and long-term outcomes in relation to tumor size.

OBJECTIVE: In this study, we aim to assess the impact of tumor size on clinical and oncological outcomes in patients undergoing laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC). BACKGROUND: LLR has been shown to be feasible, safe, and oncologically efficient. However, it has been slow to develop in patients with HCC who often suffer from chronic liver disease which represents an additional challenge for the surgeon. The experience with large HCCs is even more limited. METHODS: Between 2003 and 2016, 172 patients from two high-volume liver surgery centers underwent LLR for HCC. Prospectively collected data were analyzed after stratification in 3 groups according to tumor major diameter (group 1: < 3 cm; group 2: between 3 and 5 cm; group 3: ≥ 5 cm). Perioperative and long-term outcomes were compared between the three groups and sub-analyses were carried out on the extent and location of the resections. RESULTS: Groups 1, 2, and 3 consisted of 82, 52, and 38 patients, respectively. Minor and major resections were performed in 98.8% and 1.2% in group 1, in 90.4% and 9.6% in group 2, and in 68.4% and 31.6% in group 3, respectively. Postero-superior "technically major" resections were performed in 15.8% patients in group 1, in 19.2% in group 2, and in 15.8% in group 3, respectively. Group 3 had higher conversion rates (p < 0.001), more frequent (p = 0.056) and more prolonged (p = 0,075) pedicle clamping and longer operative time (p < 0.001), higher blood losses (p = 0.025), and longer total hospital and intensive care unit stays. These differences ceased after removing the major resections from the study population, except for the postoperative length of stay. There were no differences in morbidity, mortality, completeness of resection rates, and long-term outcomes between the three groups. CONCLUSION: LLR for HCC appears to be safe and oncologically efficient when performed in high-volume HPB and laparoscopic centers. Tumor size does not appear to impact negatively on the outcomes except for postoperative hospital stay.

Precoagulation-assisted parenchyma-sparing laparoscopic liver surgery: rationale and surgical technique.

BACKGROUND: For the treatment of both primary and metastatic liver tumors, laparoscopic parenchyma-sparing surgery is advocated to reduce postoperative liver failure and facilitate reoperation in the case of recurrence. However, atypical and wedge resections are associated with a higher amount of intraoperative bleeding than are anatomical resections, and such bleeding is known to affect short- and long-term outcomes. Beyond the established role of radiofrequency and microwave ablation in the setting of inoperable liver tumors, the application of thermoablative energy along the plane of the liver surface to be transected results in a zone of coagulative necrosis, possibly minimizing bleeding of the cut liver surface during parenchymal transection. METHODS: From January 2013 to March 2016, a total of 20 selected patients underwent laparoscopic ultrasound-guided liver resection with thermoablative precoagulation of the transection line. RESULTS: During a period of 38 months, 50 laparoscopic thermoablative procedures were performed. Colorectal liver metastases were the most frequent diagnosis. Seventy-two percent of the nodules were removed using parenchymal transection with radiofrequency-precoagulation, while microwave-precoagulation was performed for 20 % of the resected nodules. The remaining 8 % of the nodules were treated by thermoablation alone. The hepatic pedicle was intermittently clamped in six patients. The mean blood loss was 290 mL, and four patients required perioperative transfusions. CONCLUSIONS: Precoagulation-assisted parenchyma-sparing laparoscopic liver surgery can get minimal blood loss during parenchymal transection and lower the need for perioperative transfusions, providing a nonquantifiable margin of oncological safety on the remaining liver. Additional results from larger series are advocated to confirm these preliminary data.

Laparoscopic Inferior Mesenteric Artery Peeling: An Alternative to High or Low Vascular Ligation for Sigmoid Colon Cancer Resection.

BACKGROUND: In sigmoid cancer, both inferior mesenteric artery high or low ligations are accepted for curative purposes. Since inferior mesenteric artery ligation could compromise blood flow to the anastomosis, potentially increasing anastomotic leakage onset, real oncological benefits and possible disadvantages related to vascular transection level are still on debate. We introduce totally laparoscopic inferior mesenteric artery peeling technique to release from the concept of lymph nodal harvesting linked to arterial transection level. METHODS: Over a period of 24 months, 31 patients presenting with sigmoid cancer were submitted to laparoscopic sigmoidectomy associated with inferior mesenteric artery peeling. Data on intraoperative and postoperative outcomes have been prospectively collected. RESULTS: Mean operative time was 180 min (range 110-330 min); mean intraoperative blood loss was 60 ml (range 30-150 ml), and mean postoperative hospitalization was 6.2 days (range 4-11 days). Mean number of lymph node harvested was 16.7 (range 12-28). CONCLUSIONS: Given a proper selection of patients, laparoscopic sigmoidectomy comprehensive of sub-adventitial IMA skeletonization from its aortic origin could provide good oncological outcomes and recanalization rate. Further data are advocated to confirm these preliminary results.

Surgical treatment of recidivist lymphedema.

Lymphedema is a chronic disease with a progressively ingravescent evolvement and an appearance of recurrent complications of acute lymphangitic type; in nature it is mostly erysipeloid and responsible for a further rapid increase in the volume and consistency of edema. The purpose of this work is to present our experience in the minimally invasive treatment for recurrence of lymphedema; adapting techniques performed in the past which included large fasciotomy with devastating results cosmetically; but these techniques have been proposed again by the use of endoscopic equipment borrowed from the advanced laparoscopy surgery, which allows a monoskin access of about one cm.

Celiac axis compression syndrome: laparoscopic approach in a strange case of chronic abdominal pain in 71 years old man.

Celiac Axis Compression Syndrome by the Median Arcuate Ligament is a very rare condition characterized by chronic postprandial abdominal pain (angina abdominis), nausea, vomiting, which occurs mostly in young patients. The main treatment is a surgical procedure that consists of the division of the arcuate ligament combined with the section of the close diaphragmatic crus and the excision of the celiac plexus. Actually laparoscopic management is feasible and safe.

Laparoscopic perspectives for distal biliary obstruction.

BACKGROUND: In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions. METHODS: We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected. RESULTS: In the six-years period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred. CONCLUSIONS: Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life.

Laparoscopic Parenchymal-Sparing Resections for Nonperipheral Liver Lesions, the Diamond Technique: Technical Aspects, Clinical Outcomes, and Oncologic Efficiency.

BACKGROUND: Surgical management of liver lesions has moved toward "parenchymal-sparing" strategies. Although open parenchymal-sparing liver resections are supported by encouraging results, the applicability of the laparoscopic approach for nonperipheral tumors is still questionable. Our aim was to assess the feasibility, safety, and oncologic adequacy of laparoscopic parenchymal-sparing liver resection for nonperipheral lesions with a description of the technique adopted in this setting. STUDY DESIGN: A prospectively collected single-center database of 517 laparoscopic liver resections was reviewed. Laparoscopic nonperipheral parenchymal-sparing liver resections (LapPSLRs), that is, entirely intraparenchymal limited resections performed on nonperipheral lesions, were selected. Intra- and perioperative outcomes were analyzed along with 3-year actuarial survival for patients with colorectal liver metastases. RESULTS: The group comprised 49 LapPSLRs. Colorectal liver metastases were the most frequent diagnosis (n = 24 patients). Lesions were located in segments 8, 7, 4a, and 3 in 51%, 8.2%, 36.7%, and 4.1% of cases, respectively. Conversion occurred in 4 patients (8%). Intra- and postoperative short-term outcomes were calculated for the 24 isolated LapPSLR (not associated with any concurrent liver resection). Median operative time and blood loss were 215 minutes and 225 mL, respectively. Pringle maneuver was used in 75% of cases. Postoperative 90-day mortality was nil and morbidity rate was 12.5%. Median postoperative stay was 3 days. Median tumor-free margin was 4 mm and 100% R0 rate was achieved for all LapPSLRs with curative intent. Three-year overall, recurrence-free, and disease-free survival rates were 100%, 65.2%, and 69.6%, respectively. CONCLUSIONS: Laparoscopic parenchymal-sparing liver resections for nonperipheral liver lesions are feasible and can be performed safely without compromising perioperative and oncological outcomes.

Synchronous totally laparoscopic management of colorectal cancer and resectable liver metastases: a single center experience.

PURPOSE: The simultaneous management of primary colorectal cancer and synchronous liver metastases has been reported extensively in open surgery. Data regarding feasibility, safety, and outcomes of the laparoscopic procedure is emerging from the experience of a few surgical centers. This paper aims at discussing the technique and results of a one-step laparoscopic approach for colorectal cancer and liver metastases resection on a series of 35 patients. METHODS: Between January 2008 and December 2013, 18 males and 17 females (median age 71 years) underwent colorectal and hepatic laparoscopic resection for colorectal metastatic cancer. RESULTS: Thirty-five colorectal resections and 66 liver resections were performed; no conversion to open surgery has been indicated. Median blood loss was 200 ml, median operative time 240 min, and median hospital stay was 8 days (range 4-30). According to Clavien-Dindo classification, two class II complications, two class IIIb complications, and one class IV complication were recorded. Two high-risk patients died within 30 days from surgery. CONCLUSIONS: This series confirms the feasibility of synchronous laparoscopic colorectal and hepatic resections. To ensure the best outcomes, a careful selection of patients is needed. However, most patients can benefit from this surgical approach.

Adult pulmonary blastoma: Report of an unusual malignant lung tumor.

Pulmonary blastoma is an uncommon lung malignancy, usually presenting itself as a large chest mass causing pain, hemoptysis, cough and dyspnea; however, it is asymptomatic in up to 40% of patients. We present the case and suggestive images of a 37-year-old non-smoking lady with a monophasic pulmonary blastoma located in the lower lobe of the left lung who underwent a left posterolateral thoracotomy with lower lobectomy, hilar and mediastinal node dissection, followed by chemo and radiation therapy. After 36 mo, there is no disease progression and the patient is in good health, clinically stable and without significant chest pain.

Ectopic breast cancer: case report and review of the literature.

UNLABELLED: Ectopic breast tissue comes in two forms: supernumerary and aberrant. Despite morphologic differences, ectopic breast tissue presents characteristics analogous to orthotopic breast tissue in terms of function and, most importantly, pathologic degeneration. Data in the literature concerning its precise incidence, the probability of malignant degeneration, and its standardized management are scarce and controversial. This study selected more than 100 years of literature, and this report discusses a case of ectopic breast cancer treatment, suggesting novel therapeutic advice that could bring considerable clinical advantages, improve cosmetic results, and reduce the psychological impact on patients. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orbital swelling as a first symptom in breast carcinoma diagnosis: a case report.

INTRODUCTION: The frequency of intra-orbital metastasis in systemic cancer is a controversial topic. Of all metastatic tumors to the orbit of the eye, breast carcinoma is considered to be the most prevalent. Orbital findings typically present themselves after the diagnosis of the primary tumor, with an average delay of three to six years. In spite of that, this study reports a case in which orbital manifestation was the initial symptom in breast carcinoma diagnosis. CASE PRESENTATION: A 66-year-old Italian Caucasian woman presented with a swelling located on the lower orbit of her right eye. CONCLUSIONS: Previous cases report orbital manifestations discovered secondary to breast cancer. This case demonstrates that orbital symptoms may be the primary presentation of the disease. Orbital metastasis originating from breast cancer predicts widespread metastatic disease in other organs. In the presence of an ambiguous infiltrative orbital process, diagnostic examination of the breast is recommended.