Single stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography for cholecysto-choledocholithiasis. Lesson learnt from the COVID-19 pandemic.

Introduction: Choledocholithiasis, a common complication of gallstone disease, poses significant risks including cholangitis and pancreatitis. Various treatment approaches exist, including single-stage and two-stage techniques, with recent literature suggesting advantages of the single-stage approach in terms of outcomes and cost-effectiveness. This study evaluates the feasibility, efficacy, and safety of single-stage laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC + iERCP) compared to the previously adopted two-stage approach. Methods: A retrospective analysis was conducted on patients undergoing single-stage LC + iERCP for cholecysto-choledocholithiasis during the COVID-19 pandemic (2020-2022). Data on demographics, preoperative assessments, intraoperative parameters, and postoperative outcomes were collected and compared with an historical control group undergoing the two-stage approach (LC + preopERCP). Hospitalization costs were also compared between the two groups. Results: A total of 190 patients were included, with 105 undergoing single-stage LC + iERCP. The single-stage approach demonstrated successful completion without cystic duct cannulation, with no conversions to open surgery. Operative time was comparable to the two-stage approach, while hospital stay, and costs were significantly lower in the single-stage group. Complication rates were similar between the groups. Conclusions: Single-stage LC + iERCP appears to be a feasible, effective, and safe approach for treating cholecysto-choledocholithiasis, offering potential benefits in terms of reduced hospital stay, OR occupation time, and costs compared to the two-stage approach. Integration of this approach into clinical practice warrants consideration, unless there are logistical challenges that cannot be overcome or lack of endoscopic expertise also for treating challenging urgent cases.

Colorectal medullary carcinoma: heterogeneous presentations of a rare clinico-pathological entity. Report of two cases.

Colorectal medullary carcinoma (CMC) is a rare subset of minimally differentiated carcinomas. CMC tend to be right-sided and present at an advanced stage. Despite this, distant metastases are rare at presentation. The liver and the regional lymph nodes represent the most common sites of metastases. Most of the time, CMCs exhibit mismatch repair deficiency and a strong association with high-level microsatellite instability. There is no conspicuous data regarding treatment strategies and short-term outcomes. CMC is supposed to be related to better prognosis compared to poorly-differentiated and undifferentiated colonic adenocarcinomas, but reports are controversial.This lesion, with heterogeneous presentations and unclear prognostic significance, may be unfamiliar to histopathologists and can lead to diagnostic uncertainty and overtreatments.Our aim is to renew the attention to this rare histological subtype through the report of two cases.

Pain Distraction During Awake Major Colorectal Surgery: Supporting Patients Beyond the COVID-19 Era. Preliminary Findings.

Introduction: During the coronavirus disease 2019 (COVID-19) pandemic, hospitals rapidly ran out of intensive care beds. Because minimally invasive surgery and general anaesthesia are both aerosol-generating procedures, their use has become controversial. We report a case series of awake undelayable colorectal surgeries which, innovatively, took advantage of intraoperative pain distraction. Moreover, we describe our frugal solution to social distancing in psychological support of inpatients. Methods: Between October 2020 and February 2021, five patients underwent acute-care colorectal surgery under locoregional anaesthesia in our department. A 3D mobile theatre (3DMT) was used during the operation to distract the patients from pain. Vital signs, pain intensity, ergonomic comfort/discomfort, sense of presence and distress were intraoperatively monitored. A postoperative "cuddle delivery" service was instituted: video messages from relatives and close friends were delivered daily to the patient through the 3DMT. Emotional effects were investigated through clinical interviews conducted by a psychologist at our hospital. Results: Both intraoperative and postoperative pain were always well controlled. Conversion to general anaesthesia and postoperative intensive support/monitoring were never necessary. The "cuddle delivery" initiative helped patients fill the emotional gap created by the strict containment measures implemented inside the hospital, distracting them from emotional anxiety and physical pain. Conclusions: During the next phase of the COVID-19 pandemic and even after the COVID-19 era, awake laparotomy under locoregional anaesthesia may be a crucial option for delivering acute-care surgery to selected patients when intensive care beds are unavailable and postponing surgery is unacceptable. We also introduce a new modality for the provision of emotional support during postoperative inpatient care as a countermeasure to the restrictions imposed by social distancing measures.