Could fluorescence-guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary.

BACKGROUND: Indocyanine green fluorescence vision is an upcoming technology in surgery. It can be used in three ways: angiographic and biliary tree visualization and lymphatic spreading studies. The present paper shows the most outstanding results from an health technology assessment study design, conducted on fluorescence-guided compared with standard vision surgery. METHODS: A health technology assessment approach was implemented to investigate the economic, social, ethical, and organizational implications related to the adoption of the innovative fluorescence-guided view, with a focus on minimally invasive approach. With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaires and self-reported interviews, considering the dimensions resulting from the EUnetHTA Core Model. RESULTS: From a systematic search of literature, we retrieved the following studies: 6 on hepatic, 1 on pancreatic, 4 on biliary, 2 on bariatric, 4 on endocrine, 2 on thoracic, 11 on colorectal, 7 on urology, 11 on gynecology, 2 on gastric surgery. Fluorescence guide has shown advantages on the length of hospitalization particularly in colorectal surgery, with a reduction of the rate of leakages and re-do anastomoses, in spite of a slight increase in operating time, and is confirmed to be a safe, efficacious, and sustainable vision technology. Clinical applications are still presenting a low evidence in the literature. CONCLUSION: The present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an HTA approach, sustains the use of fluorescence-guided vision in minimally invasive surgery, in the fields of general, gynecologic, urologic, and thoracic surgery, as an efficient and economically sustainable technology.

Stereotactic radiation therapy in oligometastatic colorectal cancer: outcome of 102 patients and 150 lesions.

To evaluate the local control (LC), progression free survival (PFS), out-field PFS, overall survival (OS), toxicity and failure predictors of SRT in a series of various sites oligometastatic CRC patients. Patients with oligometastatic CRC disease were analyzed retrospectively. The SRT prescribed dose was dependent on the lesion volume and its location. 102 consecutive oligometastatic CRC patients (150 lesions) were included. They underwent SRT between 2012 and 2015. Median prescription dose was 45 Gy (median dose/fraction was 15 Gy/3 fractions biological equivalent dose (BED10) 112.5 Gy). Median follow-up was 11.4 months. No patients experienced G3 and G4 toxicity. No progression was found in 82% (radiological response at 3 months) and 85% (best radiological response) out of 150 evaluable lesions. At 1 and 2 years: LC was 70% and 55%; OS was 90% and 90%; PFS was 37% and 27%; out-field PFS was 37% and 23% respectively. Progressive disease was correlated with BED10 (better LC when BED10 was ≥ 75 Gy (p < 0.0001)). In multivariate analysis, LC was higher in lesions with a Plpnning target volume (PTV) volume < 42 cm3 and BED10 ≥ 75 Gy. Patients with Karnofsky performance status < 90 showed higher out-field progression. SRT is an effective treatment for patients with oligometastases from CRC. Its low treatment-associated morbidity and acceptable LC make of SRT an option not only in selected cases. Further studies should be focused to clarify which patient subgroup will benefit most from this treatment modality and to define the optimal dose to improve LC while maintaining low toxicity profile.

Suprapubic approach for robotic complete mesocolic excision in right colectomy: Oncologic safety and short-term outcomes of an original technique.

INTRODUCTION: Right-sided colon cancer has a worse prognosis than left-sided colon cancer. Complete mesocolic excision (CME) with central vessels ligation (CVL) reduces local recurrence, but is technically demanding, particularly with a laparoscopic approach. Aim of this study is to describe a new robotic approach to right colectomy with CME and CVL and to report oncologic safety and short term outcomes. METHODS: Twenty consecutive patients were included. All patients had a right colon adenocarcinoma and underwent right colectomy with a suprapubic approach. Surgery was realized with the Da Vinci Xi® system and all trocars were placed along a horizontal line 3-6 cm above the pubis. CME with CVL was realized in all the patients. Data analysed were: duration of surgery, conversions to open surgery, intraoperative and postoperative complication by Clavien Dindo classification, margins of resections, length of specimen and number of lymph nodes retrieved. RESULTS: Patients median age was 69 years, median body mass index was 27 kg/m2. Median operative time was 249 min, blood loss was negligible, no conversions to open or laparoscopic surgery occurred. Median hospital stay was six days; two postoperative grade IIIa Clavien-Dindo complications occurred, no 30-days postoperative death was registered. Resection margins were negative in all patients; median tumour diameter was 3.6 cm, median specimen length was 40 cm, median number of harvested lymph nodes was 40. CONCLUSIONS: Robotic right colectomy with CME using a suprapubic approach is a feasible and safe technique that allows for an extended lymphadenectomy and provides high quality surgical specimens.

Dual-energy CT immediately after endovascular stroke intervention: prognostic implications.

PURPOSE: Posttreatment intracerebral hemorrhage (ICH) after recanalization therapy of acute ischemic stroke increases morbidity and mortality. Dual-energy (DE) computed tomography (CT) allows differentiation of blood-brain barrier disruption (BBBD) and ICH. We evaluated the incidence of ICH and BBBD immediately after endovascular recanalization therapy, the correlation between BBBD and final infarction or ICH size, and the prognostic value of postinterventional BBBD. METHODS: Imaging data sets (pretreatment CT, posttreatment DE-CT, and follow-up imaging by CT and/or magnetic resonance imaging) of 60 consecutive patients after endovascular recanalization therapy of acute ischemic stroke were retrospectively analyzed. After material differentiation, areas of increase attenuation in posttreatment DE-CT were correlated to ICH and infarction in follow-up imaging. RESULTS: Areas of hyperattenuation were observed in 80.0 % (48 of 60) of all posttreatment CT. In 10.4 % (5 of 48) of these, hyperattenuating areas matched the hyperdensities on virtual nonenhanced CT and were rated as hemorrhage. The remaining 89.6 % (43 of 48) of scans with hyperattenuating areas demonstrated hyperdensities exclusively on iodine-only images and were rated as BBBD. All suspected ICH on DE-CT were proven in follow-up imaging. There were no false-positive or false-negative findings of ICH in DE-CT. In 98.3 % (59 of 60) of cases, at least small ischemic infarctions were identified in follow-up imaging. No correlation between the extent of BBBD and the final infarct size and/or early ICH size was found. CONCLUSION: BBBD is a frequent finding after endovascular revascularization therapy. DE-CT allows for a reliable differentiation between frequent BBBD and rare ICH immediately after endovascular recanalization therapy.

Laparoscopic lymphatic roadmapping with blue dye and radioisotope in colon cancer.

Lymphatic mapping (LM) and sentinel lymph node (SLN) identification by blue dye in colon cancer is a procedure feasible during minimally invasive surgery, with good specificity, but still a low sensitivity (78% in our series). These results are in accordance with the literature and have limited more widespread diffusion of the method, both as a tool for upstaging and more controversially, as a potential roadmap to a tailored lymphadenectomy. It is possible to improve the results of LM with careful selection of patients and by the use of an intraoperative gamma camera. The preliminary results of intra-operative lymphoscintigraphy are promising in a well-selected small group of patients, with high levels of sensitivity and specificity. If these results are confirmed in further prospective analyses, it may be possible to undertake selected, tailored lymphadenectomy.

[Robotic rectal resection in rectal cancer: short term results in a monocentric prospective study]. / Trattamento chirurgico del cancro del retto con tecnica robotica: risultati a breve termine di uno studio prospettico monocentrico.

AIM: The aim of this study was to evaluate technical feasibility, oncological safety and short-term clinical results of robotic rectal resection for cancer. METHODS: From January 2008 to July 2010, 46 patients (27 males and 19 females, median age 69 years, median BMI 24.6 kg/m2) with histologically-proven adenocarcinoma of medium and distal rectum were enrolled in a prospective database. Preoperative assessment was performed with colonoscopy with biopsies, thoraco-abdominal CT scan, pelvic MRI and endorectal-ultrasound (ERUS). In the case of locally advanced non metastatic disease (T3/4 or N1/2), patients received preoperative radiotherapy (45 Grays in 5 weeks) and chemotherapy (oral Capecitabine). The robotic system was a four-arms Da Vinci® (Intuitive Surgical, Sunnyvale, CA, USA); arms position is not modified during the entire surgical procedure. RESULTS: Twenty-five patients received a preoperative radio-chemotherapy. Surgical procedure was an abdomino-perineal amputation in nine patients and an anterior resection in the remaining 37, with temporary ileostomy in 16 cases and a laparoscopic mobilization of splenic flexure in 25. Median operative time was 251 minutes, median time of first bowel movements 1.7 days and median hospital stay 6.7 days. Major complications requiring reoperation verified in 2 patients, while overall complication rate is 15.2%. Median number of harvested lymph nodes per patient was 18; median distance of the tumour from distal resection margin was 2 cm; distance of the tumour from circumferential margin was superior to 1 mm in all of the patients. At a median follow up of 11 months, all patients are alive and disease-free. CONCLUSION: Robotic rectal resection is a feasible technique which can provide good oncological and short-term clinical results.

Randomized trial of basiliximab induction versus steroid therapy in pediatric liver allograft recipients under tacrolimus immunosuppression.

Avoidance of corticosteroids could be beneficial after pediatric liver transplantation (LTx). To test this hypothesis, we performed a randomized prospective study to compare immunosuppression with tacrolimus (TAC) and steroids versus TAC and basiliximab (BAS) after pediatric LTx. Seventy-two patients were recruited, 36 receiving TAC and steroids and 36 TAC and BAS. The primary endpoint was the occurrence of the first rejection episode. Secondary endpoints were the cumulative incidence and severity of rejection, patient and graft survival, and incidence of adverse events. Overall 1-year patient and graft survival rates were 91.4% and 85.5% in the steroid group, and 88.6% and 80% in the BAS group (p = NS). Patients free from rejection were 87.7% in the BAS group and 67.7% in the steroid group (p = 0.036). The use of BAS was associated with a 63.6% reduction in incidence of acute rejection episodes. Overall incidence of infection was 72.3% in the steroid group and 50% in the BAS group (p = 0.035). We conclude that the combination of TAC with BAS is an alternative to TAC and steroid immunosuppression in pediatric LTx, which allows for a significant reduction in the incidence of acute rejection and infectious complications.

Rejection and tacrolimus conversion therapy in paediatric liver transplantation.

Rejection and efficacy of rescue therapy with tacrolimus were evaluated in 50 children who underwent primary, ABO-compatible, liver transplantation. Six patients who died within the first week and one child who underwent retransplantation from an ABO-incompatible donor were excluded from the study. No patient or graft were lost due to rejection. We observed 48 episodes of rejection in 33 patients. Fourteen patients required conversion to tacrolimus for steroid-resistant rejection with resolution of rejection. One of these children developed PTLD. Other indications for conversion were neurotoxicity and hirsutism. One patient developed blindness of unknown origin after the conversion. Other side effects of tacrolimus were minor and resolved by lowering the dose. Five patients developed rejection after conversion; all achieved resolution with either steroid therapy or increase of tacrolimus dose. In conclusion, our study confirms that tacrolimus is an effective rescue therapy for paediatric liver transplantation.

Extensive use of split liver for pediatric liver transplantation: a single-center experience.

The results of the extensive use of in situ liver splitting in a pediatric liver transplant program are presented. All referred donors were considered for split liver, and when the donor-recipient body weight ratio (DRWR) was greater than 2, the grafts were split. A modified split-liver technique was adopted when the DRWR was 2 or less. Eighty liver procurements were attempted and 72 (90%) were performed, enabling 65 children to receive 42 split, 22 whole, and 8 reduced-size livers. The right portions of the grafts were transplanted by other centers into adults. Median patient waiting time was 22 days, with no mortality on the waiting list. After a median follow-up of 14 months, overall patient and graft survival rates were 85% and 81%, respectively. Fifty-eight children received a single allograft, whereas 7 children required retransplantation. Two-year actuarial survival rates were 85% for split-liver recipients, 84% for whole-liver recipients, and 67% for reduced-size liver recipients. Vascular complications developed in 18% of the patients, with no difference among the 3 groups with different technique. Biliary complications developed in 25% of the children, mainly in reduced-size and split-liver recipients. Patient and graft survival rates for right split-liver grafts were 84% and 79%, respectively. Adopting a liberal policy of liver splitting provides allografts of optimal quality for pediatric transplantation, allowing a dramatic decrease in the waiting list time. The in situ split-liver technique should be considered the method of choice for expanding the cadaveric liver donor pool.

Morphogenesis in some freshwater Tintinnids (Ciliophora, Oligotrichida).

The morphogenesis of four freshwater tintinnids was investigated using protargol silver impregnation and scanning electron microscopy. Division is rather similar in Tintinnopsis cylindrata, Tintinnidium pusillum and T. semiciliatum, e.g. the oral primordium develops apokinetally posterior of somatic kinety 10 and the somatic ciliature originates by two rounds of intrakinetal basal body proliferations before cytokinesis. The peculiar ventral organelles form without apparent contact with parental ciliary structures as do the adorai membranelles and the paroral membrane; thus, the ventral organelles might be part of the oral apparatus. The morphogenesis of Codonella cratera differs from that of the other species by the reorganization of some parental ciliary rows and by a second round of somatic basal body proliferation after cytokinesis. Based on morphologic and morphogenetic similarities, Tps. cylindrata is transferred from the Codonellidae to the Tintinnidiidae, and Tps. baltica and Tps. subacuta are newly combined with Codonella: C. baltica nov. comb., C. subacuta nov. comb. We could not discern a unique character defining oligotrichs as a monophyletic group because the enantiotropic cell division is possibly less pronounced in some tintinnids and occurs also in peritrichs and a few prostomatids. We suggest, however, that the enantiotropic cell division evolved convergently in these taxa, and thus adhere to our view that this special mode of cell division is the most reliable apomorphy for the oligotrichs. In addition, the character combination, polar oral apparatus and apokinetal origin of the oral primordium, occurs only in oligotrichs. Morphogenetic similarities suggest a sister group relationship between tintinnids and strobilidiids.