Intracorporeal anastomosis versus extracorporeal anastomosis after laparoscopic right hemicolectomy for colon cancer: morbidity comparison at long-term follow-up.

BACKGROUND: Minimally invasive right hemicolectomy is nowadays considered the gold standard for treatment of malignant right colon disease. What is still debated is instead the choice between intracorporeal or extracorporeal anastomosis. The aim of this study was to compare morbidity and the long-term results between these two techniques. METHODS: This retrospective, double-center cohort study was performed between January 2013 and December 2014. A total of 197 patients were enrolled after laparoscopic right hemicolectomy for malignant disease. The extracorporeal anastomosis group (ECA) included 95 patients, while the intracorporeal anastomosis group (ICA) included 102 patients. All patients were followed up for 5 years after surgery. Data analysis was performed in February 2021. RESULTS: The ICA group showed a reduced rate of non-surgical complications Clavien-Dindo grade I-II (10% vs. 31%; P=0.001) as well as a lower rate of wound infections (2% vs. 12%; P=0.01). Most importantly, a decreased risk of incisional hernias in a five-year follow-up period (1% vs. 8%; P=0.01) has been underlined. CONCLUSIONS: Intracorporeal anastomosis technique after totally laparoscopic right hemicolectomy showed better outcomes as it significantly reduces the risk for short and long-term complications, namely, incisional hernias.

Right-sided acute diverticulitis: A single Western center experience.

INTRODUCTION: Right sided diverticular disease is a rare condition in Western countries whereas is common amongst Asian population. The aim of this study is to evaluate options and outcomes for the treatment of right colonic diverticulitis. METHOD: We included only patients undergoing surgery with right colon diverticulitis (RCD) proven at histological specimen examination from September 2011 to December 2016. RESULTS: We performed 18 operations for RCD. Age was lower compared to left sided disease (49 ± 16 vs 67 ± 14; P < 0.001). Three patients were Asian (16.7%). RCD was diagnosed preoperatively in 8 cases (44.4%), whereas appendicitis was suspected in 9 cases (50%) and neoplasm in one (5.6%). We performed resection with anastomosis in 13 patients (72.2%) and in 5 cases we performed a diverticulectomy. Laparoscopy was performed in 14 cases (77.8%). Postoperative morbidity occurred in 3 patients (16.7%; grade 2 or 3a according to Clavien-Dindo) with no mortality. No postoperative events occured after diverticulectomy with shorter hospital stay (4 ± 1.5 vs 11 ± 13; P = 0.022), as no recurrence or need for elective surgery after a mean follow-up of 20 months. CONCLUSION: RCD is a rare but not irrelevant condition. Minimally invasive surgery is often feasible and complication rate is low. In selected patients, diverticulectomy can be a valid alternative to treat this condition providing improved postoperative results.

Laparoscopic appendectomy: Which factors are predictors of conversion? A high-volume prospective cohort study.

Appendicitis represents one of the most frequent condition requiring surgery. In Italy almost 0.2% of the population will be affected by acute appendicitis every year. Laparoscopic appendectomy (LA) has gained acceptance over the past years and despite several meta-analyses, randomized studies and retrospective studies have been conducted, the indications and results are still conflicting especially in cases of complicated appendicitis. The aim of our study is to evaluate which factors are related to conversion to open appendectomy (OA) during laparoscopic appendectomy (LA). MATHERIALS AND METHODS: From September 2011 to May 2013, appendectomy for acute appendicitis was performed on 434 patients in our Surgical Unit at S. Orsola-Malpighi Hospital, Bologna, Italy. Of these, 369 patients (85%) underwent LA. The clinical, demographic, surgical and pathological data of these patients were included in a prospective database. To note, only laparoscopic appendectomies were considered to be included in the analysis. The following factors were analyzed in order to identify which were associated with the conversion: age, sex, body mass index (BMI), previous abdominal surgery, comorbidities, clinical and laboratory parameters including Alvarado score, PCR, intraoperative findings such as anatomy and degree of inflammation. During our study period, laparoscopic appendectomies were performed by different surgeons both residents and attending surgeons. The decision to convert the intervention in an open procedure was taken by the individual surgeon. Regarding the postoperative period, were considered the time of hospitalization and related costs, time of oral intake of liquid and solid, time of passage of stool, readmissions and reoperations. RESULTS: At univariate analysis, the factors significantly related to the conversion were the presence of comorbidities (p < 0.001) and, among these, the presence of arterial hypertension (p = 0.006) or other cardiovascular diseases (p = 0.031) and the history of previous abdominal surgery (p = 0.023). Patients with higher mean age (33.9 ± 15.4 vs. 46.0 ± 19.3, p = 0.001) and higher body mass index (BMI) (23.5 ± 4.3 vs 25.8 ± 4.9 kg/m(2), p = 0.006) had a higher risk of conversion. Multivariate analysis finally showed that factors significantly related to the conversion were the presence of comorbidities (p = 0.029), the presence of an appendiceal perforation (p = 0.003), a retrocecal appendix (p = 0.004), the presence of appendicular abscess (p = 0.023) and the presence of diffuse peritonitis (p = 0.008). CONCLUSION: The majority of patients with acute appendicitis can be successfully managed with laparoscopy. We found that the only preoperative independent factor related to conversion during laparoscopic appendectomy is the presence of comorbidities. Nevertheless surgeons should take into account that presence of peri-appendicular abscess and diffuse peritonitis are both independently related not only to higher rate of conversion but also to higher risk of postoperative complication.

WHO 2010 classification of pancreatic endocrine tumors. is the new always better than the old?

BACKGROUND: In 2010, the World Health Organization released a new classification system for endocrine pancreatic tumors. The new categories replaced those in the old classification. METHODS: To test the safety and accuracy of the new classification in stratifying patients, we retrospectively evaluated 64 consecutive patients, surgically R0 resected for pancreatic endocrine tumors. RESULTS: In our experience, only 19/31 (61.3%) patients classified as having well-differentiated tumors were included in the new neuroendocrine tumor G1 category while the remaining 12 (38.7%) shifted into the G2 category. Moreover, 10/33 (30.3%) patients classified as affected by a malignant endocrine neoplasm in the old system were considered as G1 tumors in the new one. These differences were statistically significant (P < 0.001) and changed the risk category in 22 (33.3%) patients with well-differentiated pancreatic endocrine tumors. Multiple multivariate models were produced and the poor stratification of the new system was found to be in the G2 category which presents too wide a range of the Ki 67 index (2 to 20%). We built a model in which the G2 category was divided into two subcategories: tumors with a Ki 67 index ≥2 and <5% and tumors with a Ki index ≥5 and <20%, partially modifying the new classification. In this model, the modified classification showed a superiority with respect to the European Neuroendocrine tumor Society-Tumor-Node-Metastasis staging system in stratifying patients for recurrence, with a relative risk of 19 (P < 0.001). CONCLUSION: The new G2 category seems too large because it includes both benign, low and high grade malignant tumors.

The role of lymph node ratio in recurrence after curative surgery for pancreatic endocrine tumours.

BACKGROUND: The prognostic role of lymph nodes metastasis in pancreatic neuroendocrine tumours is unclear. METHODS: Retrospective study of 53 patients who underwent a curative standard resection for pancreatic neuroendocrine tumours. The endpoint was to define the role of the lymph nodes ratio in recurrence after curative surgery. The following data were considered as possible factors for predicting the risk of recurrence: gender, age, presence of symptoms, hormonal status, site of tumours, type of resection, size of the tumours, radical resection, pathological T, N and M stage, the Ki67 index, the number of lymph nodes harvested, the number of metastatic lymph nodes and the lymph node ratio. Recurrence rate and time of recurrence were evaluated. RESULTS: Twelve (26.4%) patients developed a recurrence with a median time of 42.8 (1-305) months. At multivariate analysis, the only factors related to recurrence were: size of lesions (HR 1.1, C.I. 95% 1.0-1.1, P = 0.011), Ki67 ≥ 5% (HR 3.6, C.I. 95% 1.3-10, P = 0.014) and LNR > 0.07 (HR 5.2, C.I. 95% 1.1-25, P = 0.045). CONCLUSIONS: Our study confirmed that the lymph nodes ratio played an important role in the recurrence rate and suggested that a low number of metastatic lymph nodes reduced the disease free survival.

Asymptomatic cholecystocolonic fistula: a diagnostic and therapeutic dilemma.

Cholecystocolonic fistulas (CCF) are rare complications of gallstones with a variable clinical presentation. Despite modern diagnostic tools, cholecystocolonic fistulas are often asymptomatic and it is difficult to diagnose them preoperatively. Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is the cholecystoduodenal (70%), followed by the cholecystocolic (10-20%), and the least common is the cholecystogastric fistula. Herein, we report a case of female patient with multiple episodes of acute recurrent cholangitis due to common bile duct and gallbladder stones in which preoperative imaging studies were negative for cholecystocolonic fistula that was incidentally discovered and treated during surgery and was appropriately treated. A review of the literature is reported too.

The usefulness of a grading system for complications resulting from pancreatic resections: a single center experience.

The aim of this study was to test the usefulness of the Clavien-Dindo classification after pancreatic resection. In 183 patients who underwent pancreatic resections, complications were classified according to Clavien-Dindo classification and each grade was evaluated regarding the length of the postoperative stay and was compared to the most important complications. Sixty-four (35.0%) patients had no complications; out of the 119 (65.0%) patients with complications, grade I, was 9.3%; grade II, 35.5%; grade III, 9.3%; grade IV, 7.7% and grade V, 3.3%. The postoperative pancreatic fistula rate was 29.1%, postpancreatectomy hemorrhage, 35% and delayed gastric emptying, 11.5%. There was a progressive increase in the length of hospitalization from patients with no complications to those having grade IV (P < 0.001). Postoperative pancreatic fistula, postpancreatectomy hemorrhage and delayed gastric empty rates significantly increased from Clavien-Dindo grade I to grade IV; only postoperative pancreatic fistula and postpancreatectomy hemorrhage severity significantly increased from grade I to grade IV (both P < 0.001). The Clavien-Dindo classification is an objective, simple, and reliable way of reporting all complications following pancreatic resections and it allows to recognize appropriately all the most important complications after pancreatic resection, and the severity of postoperative pancreatic fistula and postpancreatectomy hemorrhage.

Laparoscopic versus open distal pancreatectomy in pancreatic tumours: a case-control study.

Laparoscopic distal pancreatectomy has become an increasingly used procedure in the surgical treatment of benign or borderline cystic and endocrine tumours. The feasibility and safety of this technique is well known but its results when compared with open distal pancreatectomy were rarely reported in literature. Data from 22 consecutive patients who underwent laparoscopic distal pancreatectomy were recorded in a prospective database from January 2006 to January 2010. These patients were matched with 22 patients who underwent open distal pancreatectomy from January 2000 to December 2005, regarding age, gender, American Society of Anesthesiologists score, pancreatic pathology. Intraoperative parameters and postoperative outcome were compared between the two groups. Blood loss, amount of analgesic drugs administered, postoperative mortality and morbidity and pancreatic fistula rate were similar in laparoscopic and open groups. Tumour size was significantly smaller in laparoscopic group (2.0 ± 3.3 vs. 5.0 ± 4.2 cm; P = 0.038). Operative time was significantly shorter in open group (145 ± 49 vs. 225 ± 83 min, P = 0.045). Time to adequate oral intake and length of postoperative hospital stay were significantly better in laparoscopic group than in open group (3.0 ± 0.8 vs. 4.0 ± 0.7 days; P = 0.030 and 8.0 ± 1.3 vs. 11.0 ± 3.0 days; P = 0.011, respectively). Laparoscopic distal pancreatectomy is a feasible and safe surgical approach as well as open distal pancreatectomy.

Total pancreatectomy: indications, operative technique, and results: a single centre experience and review of literature.

The aims of this study were to identify the indications to perform a total pancreatectomy and to evaluate the outcome and quality of life of the patient who underwent this operation. A retrospective analysis of a prospective database, regarding all the patients who underwent total pancreatectomy from January 2006 to June 2009, was carried out. Perioperative and outcome data were analyzed in two different groups: ductal adenocarcinoma (group 1) and non-ductal adenocarcinoma (group 2). Twenty (16.9%) total pancreatectomies out of 118 pancreatic resections were performed. Seven (35.0%) patients were affected by ductal adenocarcinoma (group 1) and the remaining 13 (65.0%) by pancreatic diseases different from ductal adenocarcinoma (group 2) [8 (61.5%) intraductal pancreatic mucinous neoplasms, 2 (15.4%) well-differentiated neuroendocrine carcinomas, 2 (15.4%) pancreatic metastases from renal cell cancer and, finally, 1 (7.7%) chronic pancreatitis]. Eleven patients (55%) underwent primary elective total pancreatectomy; nine (45%) had a completion pancreatectomy previous pancreaticoduodenectomy. Primary elective total pancreatectomy was significantly more frequent in group 2 than in group 1. Early and long-term postoperative results were good without significant difference between the two groups except for the disease-free survival that was significantly better in group 2. The follow-up examinations showed a good control of the apancreatic diabetes and of the exocrine insufficiency without differences between the two groups. In conclusion, currently, total pancreatectomy is a standardized and safe procedure that allows good early and late results. Its indications are increasing because of the more frequent diagnose of pancreatic disease that involved the whole gland as well as intraductal pancreatic mucinous neoplasm, neuroendocrine tumors and pancreatic metastases from renal cell cancer.

The problems of radiofrequency ablation as an approach for advanced unresectable ductal pancreatic carcinoma.

Advanced ductal pancreatic carcinoma (PC) remains a challenge for current surgical and medical approaches. It has recently been claimed that radiofrequency ablation (RFA) may be beneficial for patients with locally advanced or metastatic PC. Using the MEDLINE database, we found seven studies involving 106 patients in which PC was treated using RFA. The PC was mainly located in the pancreatic head (66.9%) with a median size of 4.6 cm. RFA was carried out in 85 patients (80.1%) with locally advanced PC and in 21 (19.9%) with metastatic disease. Palliative surgical procedures were carried out in 41.5% of the patients. The average temperature used was 90 °C (with a temperature range of 30-105 °C) and the ratio between the number of passes of the probe and the size of the tumor in centimeters was 0.5 (range of 0.36-1). The median postoperative morbidity and mortality were 28.3% and 7.5%, respectively; the median survival was 6.5 months (range of 1-33 months). In conclusion, RFA is a feasible technique: however, its safety and long-term results are disappointing; Thus, the RFA procedure should not be recommended in clinical practice for a PC patient.

Managing unsuspected tumour invasion of the superior mesenteric-portal vein during surgery for pancreatic head cancer. A case report.

CONTEXT: In some cases, synchronous superior mesenteric-portal vein resection can be performed during pancreatic resection for cancer. The reconstruction technique is usually primary anastomosis; in only a few cases is an autologous vein graft needed. CASE REPORT: We report a case of reconstruction of the superior mesenteric-portal vein with a splenic vein autograft in a patient affected by pancreatic head adenocarcinoma who underwent a total pancreatectomy. CONCLUSIONS: The reconstruction of the superior mesenteric-portal vein with a splenic vein autograft should be performed in selected cases. It allows a reduction of operating time, it is a less invasive approach than reconstruction using an internal jugular vein autograft and it can be an oncologically correct approach.

Treatment of advanced gastric cancer with cetuximab plus chemotherapy followed by surgery. Report of a case.

The prognosis of patients affected by advanced gastric cancer who did not undergo non-curative resection is extremely poor. We report a case of a 26-year-old woman affected by gastric cancer with peritoneal carcinosis in whom surgical treatment was not considered. The patient was enrolled in the Italian phase II trial of cetuximab (Erbitux, Merck KGaA, Darmstadt, Germany), a monoclonal antibody, in combination with docetaxel and cisplatin chemotherapy. Restaging of the tumor showed progressive regression, so the patient underwent a total gastrectomy. The patient is alive, well and disease-free ten months after surgery. The good result achieved in this patient provides interesting prospects for chemotherapy combined with cetuximab, followed by surgery.