The Added Value of Intraoperative Near-Infrared Fluorescence Imaging in Elective Laparoscopic Cholecystectomy.

Bile duct injury is a major complication of laparoscopic cholecystectomy (LC). Intraoperative cholangiogram is useful, but faster techniques are available to assist the surgeon, like near-infrared fluorescent cholangiography (NIFC) with indocyanine green (ICG). The aim of our study is to evaluate the usefulness of NIFC during LC. This is a retrospective study conducted on prospectively recorded data of the General Surgery department of Trieste Academic Hospital, Italy. All patients underwent elective LC from January 2016 to January 2020. Patients were randomly divided in 2 groups: in one group, only white light imaging was used (n = 98 patients), in the NIFC group (n = 63) ICG was used. NIFC has been chosen more frequently by residents than consultants (P = .002). Operative time and length of stay resulted shorter in ICG group (P = .002 and .006), and this group showed also fewer intraoperative complications (P = .007). NIFC does not require any learning curve and makes surgery faster and safer.

A rare case of reverse midgut rotation and jejunal transmesenteric internal hernia in an adult with Beckwith-Wiedemann syndrome.

Intestinal malrotation is a rare congenital condition with an incidence in adulthood between 0,0001% and 0,19%, affecting nearly 1:500 live births. It results from an abnormal rotation of the bowel within the peritoneal cavity during embryogenesis. Generally it involves both small and large bowel, leading to an increased risk of intestinal obstruction. Depending on which phase of midgut embryological development is stopped or disrupted, a variety of anatomic anomalies may occur. Reverse rotation is the most rare form of intestinal malrotation (2-4%) and is more common in women. It origins from premature return of the caudad midgut into the abdominal cavity while the duodenal loop rotates clockwise during fetal life, between 4th and 12th gestational week. The cecum begins its migration and shifts to the right behind the superior mesenteric artery (SMA). As a result the transverse colon lies behind the duodenum and the SMA. Malrotation's most common clinical manifestations in neonates are acute duodenal obstruction and midgut volvulus, lifethreatening conditions resulting in acute bowel obstruction and ischemia. In adult patients the risk of volvulus decreases and clinical presentation is more aspecific, leading to delayed diagnosis, that may cause dangerous consequences. We report a rare case of an adult male patient presenting with acute abdominal symptoms caused by a reverse midgut rotation in a Beckwith-Weidemann Syndrome (BWS), a rare genetic disorder characterized by the association between adrenal cytomegaly, hemihypertrophy, macroglossia, omphalocele and pancreatic islet hyperplasia. KEY WORDS: Beckwith-Wiedemann syndrome, Reverse midgut rotation, Jejunal transmesenteric hernia.

Serum carcinoembryonic antigen pre-operative level in colorectal cancer: revisiting risk stratification.

BACKGROUND: Biomarkers may play a role as predictive and prognostic factors in colorectal cancer patients. The aims of the study were to verify the prognostic role of pre-operative serum carcinoembryonic antigen (CEA) level in predicting overall survival and risk of recurrence in a cohort of colorectal cancer patients and to evaluate optimal cut-off values. METHODS: A retrospective cohort analysis was performed on colorectal cancer patients undergoing elective curative surgery between 2004 and 2019 at an Italian Academic Hospital. Main outcomes were overall survival, disease-free survival at 3-years and risk of local, loco-regional and distant recurrence during follow-up. A receiver operating characteristic (ROC) curve analysis was plotted using CEA pre-operative values and follow-up data in order to estimate the optimal cut-off values. RESULTS: A total of 559 patients were considered. The mean CEA value was 12.1 ± 54.1 ng/mL, and the median 29.3 (0-4995) ng/mL. The ROC curve analysis identified 12.5 ng/mL as the best CEA cut-off value to predict the risk of metastatic development after surgery in stage I-III colorectal cancer patients, and 10 ng/mL as the best CEA cut-off value to predict overall survival and disease-free survival in stage III-IV patients. These data suggest a stratification of colorectal cancer patients in three classes of risk: a low risk class (CEA <10 ng/mL), a moderate risk class (CEA 10-12.5 ng/mL) and a high risk class (CEA >12.5 ng/mL). CONCLUSION: In conclusion, pre-operative serum CEA measurements could integrate information to enhance patient risk stratification and tailored therapy.

Direct comparison of three different mathematical models in two independent datasets of EUSOMA certified centers to predict recurrence and survival in estrogen receptor-positive breast cancer: impact on clinical practice.

PURPOSE: Prediction algorithms estimating survival rates for breast cancer (BC) based upon risk factors and treatment could give a help to the clinicians during multidisciplinary meetings. The aim of this study was to evaluate accuracy and clinical utility of three different scores: the Clinical Treatment Score Post-5 Years (CTS5), the PREDICT Score, and the Nottingham Prognostic Index (NPI). METHODS: This is a retrospective cohort analysis conducted on prospectively recorded databases of two EUSOMA certified centers (Breast Unit of Trieste Academic Hospital and of Cremona Hospital, Italy). We included patients with Luminal BC undergone to breast surgery between 2010 and 2015, and subsequent endocrine therapy for 5 years for curative intent. RESULTS: A total of 473 patients were enrolled in this study. ROC analysis showed fair accuracy for NPI, good accuracy for PREDICT, and optimal accuracy for CTS5 (AUC 0.7, 0.76, and 0.83, respectively). The three scores seemed strongly correlated in Spearman's rank correlation coefficient analysis. PREDICT partially overestimated OS in patients undergone to mastectomy, and in pT3-4, G3 tumors. Considering DRFS as a surrogate of OS, CTS5 showed women in intermediate and high risk class had shorter OS too (respectively p = 0.001 and p < 0.001). Combining scores does not improve prognostication power. CONCLUSION: Mathematical models may help clinicians in decision making (adjuvant therapies, CDK4/6i, genomic test's gray zones). CTS5 has the higher prognostic accuracy in predicting recurrence, while score predicting OS did not show substantial advances, proving that pN, G, and pT are still the most important variables in predicting OS.

Indocyanine green-enhanced fluorangiography (ICGf) in laparoscopic extraperitoneal rectal cancer resection.

Anastomotic leak (AL) is one of the worst complications of rectal anterior resection (RAR) and its incidence varies according to the anatomical site, increasing in lower anastomoses. Many etiological factors have been evaluated and most of these are related to bowel perfusion. Indocyanine green-enhanced fluorangiography (ICGf) has been proposed to help surgeons assess colonic perfusion with higher reliability than subjective clinical judgment. The aim of the study was to evaluate the efficacy of this tool in patients subjected to elective laparoscopic RAR for extraperitoneal rectal cancer. All the patients subjected to elective laparoscopic RAR for extraperitoneal rectal cancer between May 2015 and January 2017 were considered. In all of them, ICGf was performed to evaluate bowel perfusion. The control group included an equal number of patients subjected to the same procedure from January 2014 to April 2015, before the start of routine use of this tool at our institution. The endpoint of the study was to compare the incidence of AL between the two groups. A total of 33 patients were included in both groups. Relying on fluorescence intensity in the indocyanine green (ICG) group, we changed the level of resection in 6/33 patients (18.2%). An AL developed in 2/33 patients (6%) in the ICG group versus in 7/33 patients (21.2%) in the control group. The routine use of this technique may help surgeons in selecting the best level of proximal bowel resection during RAR.

Role of preoperative gut microbiota on colorectal anastomotic leakage: preliminary results.

BACKGROUND: The dysbiosis is defined as a disturbed symbiotic relationship between microbiota and the host and can cause a pro-inflammatory imbalance impairing the healing process at anastomotic level. The aim of this study is to detect, in fecal samples collected in the preoperative time, a peculiar microbiota composition that could predict the onset of colorectal anastomotic leakage. MATERIALS AND METHODS: We compared gut microbiota of healthy patients (Group A) and patients with colorectal cancer eligible for surgery (Group B). Group B was divided into patients who developed anastomotic leak (Group BL) and patients who had uneventful recovery (Group BNL). Stool samples were collected before surgery and after neoadjuvant treatment. RESULTS: We analyzed stool samples from 48 patients, 27 belonging to Group A and 21 to Group B. In Group B, five patients developed anastomotic leakage (Group BL). Compared to healthy subjects, Group B showed a moderate increase of Bacteroidetes and Proteobacteria, a moderate reduction of Firmicutes and Actinobacteria, and a statistically significant reduction of Faecalibacterium prausnitzii. Group BL patients showed an array of bacterial species which promoted dysbiosis, such as Acinetobacter lwoffii and Hafnia alvei. Group BNL patients showed that bacterial species like Faecalibacterium prausnitzii and Barnesiella intestinihominis have a protective function. CONCLUSIONS: The bacterial flora in subjects with colorectal cancer is statistically different compared to healthy patients. The presence of preoperative aggressive bacteria and the lack of protective strains has strengthened the hypothesis that a peculiar microbiota composition could represent a risk factor for the occurrence of anastomotic leakage.

From occult parodontopathy to splenic abscess leading to septic shock.

We present a case of a suspect splenic hematoma in an anticoagulated patient with an ignored diabetes mellitus, come to our emergency department. Lab tests showed increased CRP and INR, with an incoming hepatorenal syndrome. During the CT-scan the patient became unstable and the hemoglobin decreased. We decided for an emergency explorative laparotomy finding instead purulent collections with no evidence of bleeding, so we drained the pus and performed a splenectomy. After we excluded all the common primary sites of infection, we found out a severe chronic parodontopathy caused by multiple colonies of Candida albicans. KEY WORDS: Candida albicans, Parontopathy, Splenectomy, Splenic hematoma.

Candida albicans Osteomyelitis Pubis: The Possible Pathogenic Role of Pelvic Irradiation.

Radiation to the pelvis, mainly directed against either prostatic or gynecologic cancers, is burdened by a lot of complications. The genitourinary tract is most frequently involved, presenting with bladder irritation, incontinence, and fertility disorders. However, side effects of radiation can also affect the bone, usually causing an osteolytic process which deteriorates the bone structure and leads to fractures, avascular necrosis, and other pathological insults. Here, we describe a case of Candida albicans osteomyelitis of the pubic symphysis as late complication of pelvic radiotherapy performed against prostate cancer.