Hostile pelvis: how to avoid permanent stoma.

The aim was to report our experience with delayed colo-anal anastomosis (DCA) to avoid permanent stoma for complex rectal cases evaluating short- and long-term outcomes. Nine patients who underwent DCA from 2011 to 2016 were collected and analysed case by case. We considered medical history and surgical outcomes. Long-term bowel function was evaluated using the Wexner and low anterior resection syndrome (LARS) score at 6, 12 and 24 months. The range from previous surgery and salvage procedure was 337 days. All cases were performed with a full laparoscopic approach. The median length of hospital stay was 15 days. The median follow-up was 970.5 days. There was no peri-operative mortality. Two patients developed a post-operative pelvic abscess that required redo surgery. Long-term post-operative complications were mucosal prolapsed, anastomosis retraction and anastomotic stricture. The average values of LARS and Wexner scores were, respectively, at 6 months 33.7 and 16.2, at 12 months 28.5 and 11.7, at 24 months 21.1 and 6.7. Colo-anal sleeve delayed anastomosis appears a real answer to avoid permanent stoma in selected patients. The laparoscopic procedure is safe and feasible for skilful mini-invasive surgeons. Our experience describes the complexity of clinical history of these patients underlying a slow, but progressive improvement in continence after restoration of bowel continuity.

Colorectal surgery in Italy. Criteria to identify the hospital units and the tertiary referral centers entitled to perform it.

Improving the quality and effectiveness of care is a key priority of any health policy. The outcomes of health care can be considered as indicators of effectiveness or quality. The scientific literature that evaluates the association between the volume of activity and the outcome of health interventions has greatly developed over the past decade, but, for practical reasons, ethical and social issues, a few randomized controlled studies were made to evaluate this association, although there are numerous observational studies of outcome and systematic reviews of the studies themselves. The colorectal surgery is the most studied area and it represents the ideal testing ground to determine the effectiveness of the quality indicators because of the high incidence of the disease and the wide spread in the territory of the structures that aim to tackle these issues. Numerous studies have documented an association between the large number of colo-rectal surgical procedures and the quality of results. In particular, the volume of activity is one of the characteristics of measurable process that can have a significant impact on the outcome of health care. In conclusion, the ability to use volume thresholds as a proxy for quality is very tempting but it is only part of reality. Infact, the volume-outcome relationship strictly depends on the type of cancer (colon vs rectum) and it appears somehow stronger for the individual surgeon than for the hospital; especially for the 5-year overall survival, operative mortality and number of permanent stoma.

Urinary and sexual disorders after laparoscopic TME for rectal cancer in males.

BACKGROUND: Urinary and sexual dysfunctions are frequent after surgery for rectal cancer. Total mesorectal excision (TME) improves local recurrence and survival rates, and does not hamper recognition and sparing of hypogastric and pelvic splanchnic nerves. It is not known how laparoscopic rectal resection could change functional complication rates. MATERIALS AND METHODS: From a global series of 1,216 laparoscopic interventions for colorectal diseases, 35 cases of males less than 70 years old, undergoing rectal resection and TME for a T1-3M0 medium and low rectal cancer were selected. Urinary and sexual functions after the operations were retrospectively recorded by means of specific tools (International Prostate Symptom Score (IPSS) and IIEF questionnaires, respectively). RESULTS: None of the patients necessitated permanent or intermittent catheterization. More than half the patients had no complaints about urinary functions; about one third had nocturia; 72% of the patients had an IPSS less that 10, and no case of IPSS worse that 31 was recorded. Sexual desire was reduced and spontaneous erectile function was impaired in almost half the cases, while induced erections were possible in about 90% of cases; about 70% of patients still had the possibility of penetration and a normal ejaculation and orgasm after the intervention. DISCUSSION AND CONCLUSIONS: The present series confirms previous data and contribute to the creation of a benchmark specifically related to the laparoscopic approach to which surgeons should face when informing the patients before the operation. While severe urinary dysfunction is rare, sexual impairment remains a serious concern after rectal resection with TME.

Transecting the pancreas neck with electrothermal bipolar vessel sealer (LigaSure) in laparoscopic left pancreatectomy: case report.

BACKGROUND: Pancreatic fistula after distal pancreatectomy remains an unsolved problem, ranging in frequency between 15% and 40%, regardless of whether the intervention is performed laparoscopically or by open surgery. METHODS: Herein, presenting the case of a 68-year-old woman with a functioning insulinoma submitted to laparoscopic spleen preserving distal pancreatectomy, we propose a new technique of pancreatic transection by the LigaSure system, which seals vessels and other tubular structures by reforming parietal collagen and elastin. RESULTS: The patient had a favorable outcome. The reported technique presents the advantages of an easy employ and of a contemporary hemostasis, thus being particularly suitable by the laparoscopic way, and may offer from a theoretical point of view some advantages over conventional pancreatic stump closure techniques in terms of fistula formation. CONCLUSIONS: Laparoscopic pancreatic transection by LigaSure may prove useful, safe, and effective. A prospective clinical study has now been designed to confirm such hypothesis. SHORT SUMMARY: A simple and safe technique for pancreas neck transection, particularly suitable for laparoscopic left pancreatectomy, is described.

Leiomyosarcoma of the inferior vena cava: a case report and review of the literature.

Leiomyosarcoma of the inferior vena cava is a particularly rare tumour, originating from the smooth muscle of the vessel wall. The authors describe the case of a female patient admitted with a picture of anorexia and weight loss, accompanied by epi- and mesogastric pain. Preoperative examinations revealed the presence of a mass of considerable size originating from the inferior vena cava. The patient was submitted to surgery consisting in removal of the mass and of part of the wall of the vena cava. A review of the literature confirms the rarity of this tumour and demonstrates that optimal anatomical knowledge is absolutely indispensable for the management of this pathology.

Autoimmune-like pancreatitis in thymoma with myasthenia gravis.

A patient with thymoma and myasthenia gravis admitted for surgery presented increased serum levels of pancreatic amylase and lipase. Suspecting a thymoma-related autoimmune disorder, autoantibody serum titers were determined: increased autoantibody titers to acetylcholine receptors, thyroglobulin, thyroperoxidase and pancreatic insulin were detected. After thymectomy the serum levels of pancreatic enzymes decreased rapidly. Myasthenia gravis symptoms also improved. To the best of our knowledge no similar cases have been reported in the literature.