Standard Versus Advanced Protective Measures in a COVID-Free Surgical Pathway.

Introduction The importance of coronavirus disease (COVID)-free surgical pathways during the coronavirus disease 2019 (COVID-19) pandemic has been demonstrated. However, the extent of protective measures to be applied against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), particularly before vaccines became available, remained unclear. Methods This retrospective study included all SARS-CoV-2-negative patients admitted to the COVID-free pathway of a regional abdominal surgery hub center in Northern Italy over 12 months, before the vaccination campaign. During the first seven months, basic protective measures against SARS-CoV-2 were adopted (surgical masks, swabs for symptomatic patients, and intra- or interhospital transfers), since patients were treated as effectively negative (standard management). During the last five months, advanced measures were implemented (enhanced personal protections and systematic control swabs), as patients were considered potentially positive (advanced management). The aim of this article was to compare SARS-CoV-2 incidence and surgical outcomes in these periods. Results A total of 283 and 194 patients were admitted under standard and advanced management, respectively; pre-admission data differed only in the rate of previous SARS-CoV-2 infection (2.5% versus 6.7%, p= 0.034). The SARS-CoV-2 incidence was 3.9% and 3.1% for standard and advanced periods, respectively (p = 0.835). Two internal outbreaks developed during the standard phase. The advanced protocol significantly increased the rate of patients re-tested for SARS-CoV-2 (83% versus 41.7%, p < 0.001) and allowed early detection of all infections, which remained sporadic. Surgical outcomes were similar. Conclusions Advanced management was instrumental in detecting positive patients early and preventing outbreaks, without affecting surgical results; accordingly, it stands as a reproducible model for future pandemic scenarios.

Laparoscopic extended liver resection: are postoperative outcomes different?

BACKGROUND: Although laparoscopic major hepatectomy (LMH) is becoming increasingly common in specialized centers, data regarding laparoscopic extended major hepatectomies (LEMH) and their outcomes are limited. The aim of this study was to compare the perioperative characteristics and postoperative outcomes of LEMH to standard LMH. METHODS: All patients who underwent purely laparoscopic anatomical right or left hepatectomy and right or left trisectionectomy between February 1998 and January 2016 are enrolled. Demographic, clinicopathological, and perioperative factors were collected prospectively and analyzed retrospectively. Perioperative characteristics and postoperative outcomes in LEMH were compared to those of standard LMH. RESULTS: Among 195 patients with LMH, 47 (24.1%) underwent LEMH, colorectal liver metastases representing 66.7% of all indications. Preoperative portal vein embolization was undertaken in 31 (15.9%) patients. Despite more frequent vascular clamping, blood loss was higher in LEMH group (400 vs. 214 ml; p = 0.006). However, there was no difference in intraoperative transfusion requirements. Thirty-one patients experienced liver failure with no differences between LMH and LEMH groups. Postoperative mortality was comparable in the two groups [3 (2.5%) LMH patients vs. 2 (5%) LEMH patients (p = 0.388)]. Overall morbidity was higher in the LEMH group [49 LMH patients (41.5%) vs. 24 LEMH patients (60%) (p = 0.052)]. Patients treated with left LEMH experienced more biliary leakage (p = 0.011) and more major pulmonary complications (p = 0.015) than left LMH. CONCLUSION: LEMH is feasible at the price of important morbidity, with manageable and acceptable outcomes. These exigent procedures require high-volume centers with experienced surgeons.

Laparoscopic vs open restorative proctocolectomy with IPAA for ulcerative colitis: Impact of surgical technique on creating a well functioning pouch.

BACKGROUND: Patients with ulcerative colitis are often young, and proctocolectomy with restorative ileo-pouch anal anastomosis is a crucial act that can improve or worsen the quality of the rest of their lives. The literature is scant on long-term functional outcomes after laparoscopy. The purpose of this study was to investigate results in terms of pouch function after standardized total laparoscopic technique compared with open intervention. MATERIALS AND METHODS: This was a retrospective comparative study. Cases were collected from the prospectively-maintained database of the Unit of General and Oncologic Surgery, XXX, Torino, Italy. Patients treated between May 2005 and May 2015 with three-stage laparoscopic or open proctocolectomy and ileo-pouch anal anastomosis were enrolled. The primary study endpoint was the percentage of well-functioning pouches. Secondary endpoints were postoperative early and late outcomes such as morbidity and pouch survival. RESULTS: Of the 78 patients identified, 48 underwent the open technique and 30 underwent laparoscopy. Median follow-up was 4 years. The overall complication rates were 19% and 13% (p = 0.5), and there were major complications (Clavien-Dindo III-IV) in 14.6% and 13.3% of patients in the open and laparoscopic groups, respectively (p = 0.8). Late complications occurred in 26 patients. Nine (18.8%) and 5 (16.7%) patients had pouchitis (p = 0.8), and 6 (12.5%) and 2 (6.7%) had cuffitis in the open and laparoscopic groups, respectively (p = 0.70). Pouch failure occurred in 2 patients (4.2%) in the open group and 2 (6.7%) in the laparoscopic group. The pouch was observed to be functioning very well in 18 patients (37.5%) in the open group and in 17 patients (56%) in the laparoscopic group (p = 0.09). The study was limited by its retrospective, nonrandomized design. CONCLUSION: Our data demonstrated similar early and late results after total laparoscopic and open proctocolectomy, in particular concerning pouch function.

Safety and Efficacy of a Novel Double-Stapling Technique for Distal Esophageal Resection and Esophago-Jejunal Anastomosis.

BACKGROUND: The purpose of this study was to evaluate safety and efficacy of a new esophagojejunal anastomosis (EJA) technique allowing the insertion of the anvil of a common circular stapler without hand-sewn securing. METHODS: From August 2014 to May 2015, 20 consecutive patients with esophagogastric junction adenocarcinoma underwent surgery. EJA was performed using a new technique; the free margins of the esophageal stump were suspended and the anvil of a circular stapler on a new dedicated and registered support bar (characterized by a push-rod making possible to hook-unhook the anvil of the circular stapler) was inserted into the lumen. Subsequently, the linear suturing stapler was closed over the bar and fired to suture the distal stump of the esophagus; the bar was retracted and the push-rod of the anvil was pulled out through the linear suture. Finally, the anastomosis was performed using a circular stapler. RESULTS: There were no intraoperative complications, and R0 resection was achieved in all cases. Postoperative course has been uneventful for 18 patients (90%). Only 1 patient (5%) developed fistula, conservatively treated. CONCLUSIONS: Our preliminary clinical experience suggested that this technique was safe and efficient (for all online suppl. material, see www.karger.com/doi/10.1159/000446856).

A comparison of laparoscopic resection of posterior segments with formal laparoscopic right hepatectomy for colorectal liver metastases: a single-institution study.

INTRODUCTION: The benefit of by laparoscopic resection for lesions located in postero-superior segments is unclear. The present series aimed at comparing intraoperative and post-operative results in patients undergoing either laparoscopic RPS or laparoscopic RH for colorectal liver metastases located in the right postero-superior segments. METHODS: From 2000 to 2015, patients who underwent laparoscopic resection of segment 6 and/or 7 (RPS group) were compared with those with right hepatectomy (RH group) in terms of tumour characteristics, surgical treatment, and short-term outcomes. RESULTS: Among the 177 selected patients, 78 (44.1 %) had laparoscopic RPS and 99 (55.9 %) a laparoscopic RH. Among RPS patients, 26 (33.3 %) underwent anatomical resection of either segment 7, 8 or both. Three (3 %) patients undergoing RH died in the post-operative course and none in the RPS group. Sixty-three (35.5 %) patients experienced post-operative complications, including major complications in 24 (13.5 %) patients. Liver failure (17.1 vs. 0 %, p = 000.1), biliary leakage (6.0 vs. 1.2 %, p = 00.1), intra-abdominal collection (19.1 vs. 2.5 %, p = 000.1), and pulmonary complication (16.1 vs. 1.2 %, p = 000.1) were significantly increased in the RH group. CONCLUSION: The present series suggests that patients who underwent laparoscopic resection of CRLM located in the postero-superior segments developed significantly less complications than patients undergoing formal RH.

Novel double-stapling technique for distal oesophageal resection and oesophago-jejunal anastomosis.

AIM: The restoration of the digestive tract by performing an esophago-jejunal anastomosis (EJA) is a crucial step of the total gastric and distal esophagus surgical resection for esophago-gastric junction (EGJ) cancer. We have already ideated and tested on a cadaver model an innovative technique which could be useful to minimize the risk of complications related to the phase of securing the anvil of the circular stapler prior to perform the EJA. This surgical technique was derived from the well-known "double-stapling Knight and Griffen" one that was described for the rectal resection. We used the following described technique in 20 patients with EGJ cancer and it is efficient, reliable, safe, easy to learn and easy to perform. MATERIALS AND METHODS: From August 2014 to May 2015, 20 patients (14 male and 6 female) underwent surgery for esophagogastric junction cancer: In all patients a distal esophageal resection and total gastrectomy was performed. Through the trans-hiatal access, the free margins of the esophageal stump were suspended and the anvil of a circular stapler on a new dedicated and registered support bar was inserted into the lumen. Subsequently, the linear suturing stapler is closed over the bar and then fired to suture the distal stump of the esophagus; after the confirmation of a negative margin, the bar is retracted and the push-rod of the anvil is pulled out through the linear suture. Finally, the anastomosis is performed with the classic technique by using a circular stapler. RESULTS: No postoperative mortality occurred; postoperative course has been uneventful for 18 patients. One patient developed anastomotic fistula that has been treated conservatively with endoscopic prothesis, removed after 20 days. One patient developed in 3 POD myocardial infarction Mean Hospital stay has been 14 days (range 7-20 days). CONCLUSIONS: The aim of our new procedure is the insertion the anvil of a common circular stapler without handsewn securing; this is to reduce the technical difficulties related to the hand-sewn securing into a deep and narrow anatomic location, typical of the trans-hiatal approach. KEY WORDS: Anastomosis, Oesophago-gastric junction cancer, Stapler, Trans-hiatal.

Tungiasis in Italy: An imported case of Tunga penetrans and review of the literature.

Tungiasis is an animal and human parasitic disease caused by fleas of the genus Tunga (Siphonaptera, Tungidae), endemic in equatorial and subtropical regions and rarely described in European countries, where clinicians and general pathologists could be not aware of this parasitic disease. To our knowledge, only 75 cases of human tungiasis (not all described in detail) were previously reported in Italy. We described a new case in a 34-year-old Italian flight attendant who developed a granuloma-like, ulcerated nodule in the subungual region of his left 5th toe, partially detaching the nail, about 20-30 days after his return from Brazil. We performed a detailed review of the literature of the Italian cases, suggesting the use of histochemical stains (especially Trichrome stain) in order to underline parasitic details. Tourism in endemic regions and globalization may result in new cases in developed countries and previously unaffected regions, therefore pathologists should consider this parasitic disease.

Transanal total mesorectal excision for rectal cancer: a single center experience and systematic review of the literature.

PURPOSE: The present study aimed to compare the operative and oncologic results of transanal total mesorectum excision (Ta-TME) ("down-to-up") vs. laparoscopic TME (L-TME, "up-to-down") for low rectal cancer. Additionally, a systematic review of the literature was performed to assess the quality of the current body of evidence on Ta-TME. METHODS: The study population included 32 consecutive patients who underwent Ta-TME between January 2011 and December 2014 that were compared with a matched group of patients undergoing L-TME between January 2008 and December 2010. The literature search was performed following the PRISMA guidelines for a systematic review. RESULTS: Ta-TME was associated with significantly shorter operative time (195 vs. 225 min; p = 0.017) and hospital stay (7.8 vs. 9.7 days; p = 0.018) compared to L-TME. No group differences were observed for intra-/postoperative complications and oncologic outcomes. One patient in the Ta-TME and two patients in the L-TME group developed local recurrence. The estimated survival rate at 2 years was 95.5 % for the Ta-TME and 96.6 % for the L-TME group (p = 0.646). The literature search identified 22 relevant retrospective studies on 423 patients operated on Ta-TME or robotic-assisted transanal TME for rectal cancer. The only two comparative studies found similar short-term oncologic outcomes between Ta-TME and L-TME. A complete mesorectum was observed in 85 % of Ta-TME cases. The conversion rate was estimated at 4.3 % and the postoperative complication rate at 30.4 %. CONCLUSIONS: Ta-TME appears to be safe and feasible. It may find special application in patients with anatomic constraints that could make L-TME highly challenging.

Voluminous oesophageal bronchogenic cyst treated with thoracoscopic approach.

AIM: Bronchogenic cysts are congenital lesions deriving from the primitive foregut, and are usually located in close relation to tracheobronchial tree or oesophagus. We report a case of an oesophageal bronchogenic cyst appearing at preoperative examinations as a benign fibromuscular tumour (leiomyoma). CASE REPORT: A 62 years old male patient in good general conditions, was admitted to our Institution because of moderate dysphagia and upper post-prandial abdominal pain. Conventional imaging, endoscopy and echo endoscopy detected a parietal oesophageal wall mass looking like a solid formation, determining extrinsic compression and narrowing of the lumen. RESULTS: The mass has been radically removed with thoracoscopic approach. Postoperative stay was uneventful and the patient was discharged three days after the operation. At histological examination the mass appeared as a cystic formation with fibromuscular wall and ciliated epithelium (so-called disembriogenetic bronchogenic cyst). CONCLUSION: The case we have reported describes a very unusual case of a voluminous symptomatic intramural oesophageal disembriogenetic cyst whose characteristics had not been defined at preoperative examinations. Surgical removal of the mass has been achieved with a minimally invasive approach.