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Background: A difficulty score for laparoscopic adrenalectomy (LA) is lacking in the literature. A retrospective cohort study was designed to develop a preoperative "difficulty score" for LA. Methods: A multicenter study was conducted involving four Italian tertiary centers for adrenal disease. The population was randomly divided into two subsets: training group and validation one. A multicenter study was undertaken, including 964 patients. Patient, adrenal lesion, surgeon's characteristics, and the type of procedure were studied as potential predictors of target events. The operative time (pOT), conversion rate (cLA), or both were used as indicators of the difficulty in three multivariate models. All models were developed in a training cohort (70% of the sample) and validated using 30% of patients. For all models, the ability to predict complicated postoperative course was reported describing the area under the curve (AUCs). Logistic regression, reporting odds ratio (OR) with p-value, was used. Results: In model A, gender (OR 2.04, p = 0.001), BMI (OR 1.07, p = 0.002), previous surgery (OR 1.29, p = 0.048), site (OR 21.8, p < 0.001) and size of the lesion (OR 1.16, p = 0.002), cumulative sum of procedures (OR 0.99, p < 0.001), extended (OR 26.72, p < 0.001) or associated procedures (OR 4.32, p = 0.015) increased the pOT. In model B, ASA (OR 2.86, p = 0.001), lesion size (OR 1.20, p = 0.005), and extended resection (OR 8.85, p = 0.007) increased the cLA risk. Model C had similar results to model A. All scores obtained predicted the target events in validation cohort (OR 1.99, p < 0.001; OR 1.37, p = 0.007; OR 1.70, p < 0.001, score A, B, and C, respectively). The AUCs in predicting complications were 0.740, 0.686, and 0.763 for model A, B, and C, respectively. Conclusion: A difficulty score based on both pOT and cLA (Model C) was developed using 70% of the sample. The score was validated using a second cohort. Finally, the score was tested, and its results are able to predict a complicated postoperative course. [ABSTRACT FROM AUTHOR]

Aim After endoluminal loco-regional resection ( ELRR) by transanal endoscopic microsurgey ( TEM) the N parameter may remain undefined. Nucleotide-guided mesorectal excision ( NGME) improves the lymph node harvest. The aim of the present study is to evaluate the long-term oncological results after ELRR with NGME. Method A total of 57 patients were enrolled over the period January 2001 to June 2015. All patients underwent ELRR by TEM. Prior to surgery, 99 m-technetium-marked nanocolloid was injected into the peritumoural submucosa. After removal of the specimen, the residual defect was probed to detect any residual radioactivity and 'hot' mesorectal fat was excised. All patients were included in a 5-year follow-up programme. Results Significant radioactivity in the residual cavity was found in 28 out of 57 patients (49%). The mean number of lymph nodes harvest in irradiated and nonirradiated patients was 1.66 and 2.76, respectively. After 68.2 months' follow-up overall survival was 91.2%, disease-related mortality 3.5% and disease-free survival 89.5%. Two patients developed pulmonary metastases: one ypT3N0 patient underwent lung lobectomy after chemotherapy and one pT2N0 patient was managed with lung radiotherapy. Both patients are currently alive and disease-free at 48 months' follow-up. Two patients developed local recurrence 1 year after ELRR, both treated with neoadjuvant chemo-radiotherapy and total mesorectal excision. Comparing the present series with previous patients who did not undergo NGME, an increased number of harvested lymph nodes were observed, with a statistically significant difference ( P = 0.0085). Conclusion NGME during ELRR improves the lymph node harvest and staging accuracy. The long-term results showed satisfactory local (3.5%) and distant (7%) recurrence rates. [ABSTRACT FROM AUTHOR]

Summary: Hepatic resection is the treatment of choice for primary and secondary hepatic tumors but only 15–25% of patients with hepatic colorectal metastases are eligible for a curative hepatic resection. Cryosurgical ablation (CSA) is employed when curative resection of metastases cannot be obtained. Sixty-four patients (35 males, 29 females, mean age 58.8 years, range 30–79 years) with hepatic colorectal metastases underwent CSA, under laparoscopic control (15 cases) or with open surgery (49 cases), with subsequent close follow-up. Intraoperative bleeding occurred in 32 out of 49 patients in the open group and only in 2 patients in the laparoscopic group. Minor morbidity that resolved with conservative treatment was 54.8% in the open group and 53.3% in the laparoscopic group. Major morbidity occurred in 11 cases (26.2%) in the open group and in 1 case (6.7%) in the laparoscopic group. Mortality occurred in two patients, both in the open group, from renal insufficiency in one case and from liver failure in the other case. Mean hospital stay was 16.7 days in the open group (range 8–72 days) and 10.6 days in the laparoscopic group (range 3–18 days). No patient was lost to follow-up. At a mean follow-up of 87.1 months (range 52.2–125.2 months), selected patients undergoing laparoscopic CSA had an overall survival rate of 66.7% (10 patients), with 30% of patients (3) who are disease-free. Median survival was 94.2 months. Recurrence was observed in seven patients. None of the intrahepatic recurrences was at the cryoablation site. In the open group, median survival was 22.9 months with a survival rate of 30.9% (13 patients) at a mean follow-up of 39.3 months (range 1.9–124.5 months); 9 patients (19.1%) are disease-free. In selected patients, laparoscopic CSA is associated with survival rates which are similar to those after hepatic resection. In patients with a larger tumor burden, CSA offers a curative treatment to patients with otherwise a dismal prognosis and it improves survival as compared to patients receiving chemotherapy alone. However, the procedure is associated with substantial morbidity, particularly bleeding, and therefore careful patient selection is recommended. [Copyright &y& Elsevier]

Background: The aim of the present study was to evaluate the effectiveness and long-term results of laparoscopic transcystic common bile duct exploration (TC-CBDE).Methods: Ductal stones were present in 344 of 3212 patients (10.7%) who underwent laparoscopic cholecystectomy (LC). The procedure was completed laparoscopically in 329 patients (95.6%), with TC-CBDE performed in 191 patients (58.1%) who are the object of this study, or with a transverse choledochotomy in 138 cases (41.9%).Results: Biliary drainage was employed in 71 of 191 cases (37.2%). Major complications occurred in 10 patients (5.1%), including retained stones in 6 (3.1%). Mortality was nil. No patients were lost to follow-up (median: 118.0 months; range: 17.6-168 months). No signs of bile stasis, no recurrent ductal stones and no biliary stricture were observed. At present 182 patients are alive with no biliary symptoms; 9 have died from unrelated causes.Conclusions: Long-term follow-up after laparoscopic TC-CBDE proved its effectiveness and safety for single-stage management of gallstones and common bile duct stones. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the long-term results of laparoscopic transverse choledochotomy (TC) during laparoscopic cholecystectomy (LC).Methods: Ductal stones were present in 344 of 3,212 patients (10.7%) who underwent LC. The procedure was completed laparoscopically in 329 cases (95.6%), with a TC in 138 cases (41.9%) (the subjects of this study), and with a transcystic duct approach in 191 cases (58.1%).Results: Biliary drainage was used in 131 of 138 cases (94.9%). There were major complications in eight patients (5.7%), and one patient died (0.7%). Retained stones were seen in 11 cases (8%). None of the patients was lost to follow-up (mean, 72.3 months; range, 11-145). Ductal stones recurred in five patients (3.6%). No signs of bile stasis and no biliary strictures were observed. In all, 121 patients are alive with no biliary symptoms; 16 have died from unrelated causes.Conclusion: Long-term follow-up after laparoscopic TC during LC proved its safety and efficacy. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic common bile duct (CBD) exploration is gaining favor in the treatment of patients with gallstones and CBD stones. Our aim is to report our results with this procedure, focusing on the technical aspects. Patients and Methods: All patients with proven CBD stones undergo laparoscopic transcystic CBD exploration, preferably, or a choledochotomy if the former is not feasible. According to CBD stone load and diameter, a biliary drainage tube is positioned for postoperative biliary decompression. Results: Among 284 patients who underwent laparoscopic CBD exploration, 4 (1.4%) were converted to open surgery. Transcystic CBD exploration was feasible in 163 cases (58.2%), but a choledochotomy was required in 117 (41.8%). Biliary drains were positioned in 204 patients (72.8%). Minor complications included hyperamylasemia (11; 3.9%) and minor subhepatic bile collection (7; 2.5%). Major complications were bile leakage (5; 1.8%), hemoperitoneum from cystic artery bleeding (2; 0.7%), subhepatic abscess (2; 0.7%), acute pancreatitis (1; 0.3%), and jejunal perforation (1; 0.3%). Retained CBD stones in 15 patients (5.3%) were removed through the biliary drainage sinus tract (8) or after endoscopy and sphincterotomy (6). In one patient, a small stone passed spontaneously (overall success rate 94.6%). Death from a cardiovascular complication was observed in one elderly high-risk patient (0.3%). Recurrent ductal stones in 5 patients (1.8%) were treated with ERCP and endoscopic sphincterotomy. One patient with re-recurrent ductal stones underwent hepaticojejunostomy. Conclusions: Laparoscopic CBD exploration during LC in unselected patients solves two problems during the same anesthesia with high success rates (94.6%), low minor (6.4%) and major (3.8%) morbidity rates, and a low mortality rate (0.3%). Standardization of the technique is mandatory to achieve high success rates. [ABSTRACT FROM AUTHOR]

Background: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open).Methods: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences.Results: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open.Conclusions: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced. [ABSTRACT FROM AUTHOR]

Background: Aim was to study the incidence of recurrent ductal stones and of biliary strictures at follow-up after laparoscopic treatment of gallstones and common bile duct stones and to update the short-term results.Methods: Ductal stones were proven in 161 patients of 1,975 (8.1%) undergoing laparoscopic cholecystectomy. Laparoscopic transcystic CBD exploration was the method of choice. If this was unsuccessful, laparoscopic choledochotomy was performed. After treatment, all patients were enrolled in a continued, ongoing follow-up study.Results: Laparoscopic CBD exploration was completed in 157 cases (transcystic 107, choledochotomy 50). Retained stones occurred in eight patients (5%) and major complications (cystic duct leakage, hemoperitoneum) in six (3.8%); mortality occurred in one high-risk patient (0.6%). Follow-up available in 154 patients (two unrelated deaths) for a period of up to 62 months showed the occurrence of recurrent ductal stones in five cases (3.2%) and no signs of bile stasis, suggestive of ductal stricture, on the basis of clinical and laboratory findings.Conclusions: This prospective, ongoing follow-up study demonstrates that laparoscopic treatment of gallstones and common bile duct stones in unselected patients is feasible and safe. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about long-term results of laparoscopic and open resections for rectal cancer in 124 unselected patients.

Comments on M. Schafer and colleagues' article on the incidence and management of Mirizzi syndrome, a rare benign obstruction of the common hepatic duct that poses a diagnostic and therapeutic challenge for the general surgeon, particularly in the era of laparoscopic surgery. Components of Mirizzi syndrome; Clinical manifestations of the syndrome; Impact of the introduction of laparoscopic cholecystectomy on the clinical presentation of the disease.

Background: The identification of metastatic lymph nodes is one of the most important prognostic factors in gastrointestinal (GI) cancers. Near-infrared fluorescence (NIRF) imaging has been successfully used in GI tumors to detect the lymphatic pathway and the sentinel lymph node (SLN), facilitating fluorescence image-guided surgery (FIGS) with the purpose to achieve a correct nodal staging. The aim of this study was to analyze the current results of NIRF SLN navigation and lymphography through data collected in the EURO-FIGS registry. Methods: Prospectively collected data regarding patients and ICG-guided lymphadenectomies were analyzed. Additional analyses were performed to identify predictors of metastatic SLN and determinants of fluorescence positivity and nodal metastases outside the boundaries of standard lymphadenectomies. Results: Overall, 188 patients were included by 18 surgeons from 10 different centers. Colorectal cancer was the most reported pathology (77.7%), followed by gastric (19.1%) and esophageal tumors (3.2%). ICG was injected with higher doses (p < 0.001) via extraparietal side (63.3%), and with higher volumes (p < 0.001) via endoluminal side (36.7%). Overall, NIRF SLN navigation was positive in 75.5% of all cases and 95.5% of positive SLNs were retrieved, with a metastatic rate of 14.7%. NIRF identification of lymph nodes outside standard lymphatic stations occurred in 52.1% of all cases, 43.8% of which were positive for metastatic involvement. Positive NIRF SLN identification was an independent predictor of metastasis outside standard lymphatic stations (OR = 4.392, p = 0.029), while BMI independently predicted metastasis in retrieved SLNs (OR = 1.187, p = 0.013). Lower doses of ICG were protective against NIRF identification outside standard of care lymphadenectomy (OR = 0.596, p = 0.006), while higher volumes of ICG were predictive of metastatic involvement outside standard of care lymphadenectomy (OR = 1.597, p = 0.001). Conclusions: SLN mapping helps identifying potentially metastatic lymph nodes outside the boundaries of standard lymphadenectomies. The EURO-FIGS registry is a valuable tool to share and analyze European surgeons' practices. [ABSTRACT FROM AUTHOR]

Several images related to non-advanced low rectal cancer (NALRC) are presented.

Background: Some authors consider adrenal lesions size of less than 4 cm as a positive cut-off limit to set the indications for minimally invasive surgery due to a lower risk of malignancy. Aim of this study is to report the risk of cancer for adrenal lesions measuring 4 cm or more in diameter, assessed as benign at preoperative workup (primary outcome), and to evaluate the feasibility and safety of laparoscopic adrenalectomy (LA) in these cases (secondary outcome). Methods: From January 1994 to February 2019, 579 patients underwent adrenalectomy. Fifty patients with a preoperative diagnosis of primary adrenal cancer or metastases were excluded. The remaining 529 patients were included and divided in five subgroups based on adrenal lesion size at definitive histology: group A, 4–5.9 cm (137 patients); group B, 6–7.9 cm (64 patients); group C, 8–9.9 cm (13 patients); group D, ≥ 10 cm (11 patients); group E, < 4 cm (304 patients). Each group was further divided based on diagnosis of benign or malignant lesions at definitive histology. Results: Four (2.9%) malignant lesions were observed in group A, 5 (7.8%) in group B, 2 (15.4%) in Groups C and D (18.2%) and 13 (4.3%) in Group E. Comparing the cancer risk among the groups, no statistically significant differences were observed. Operative time increased with increasing lesion size. However, no statistically significant differences were observed between benign and malignant lesions in each group comparing operative time, conversion and complication rates, postoperative hospital stay and mortality rate. Conclusions: Adrenal lesions measuring 4 cm or more in diameter are not a contraindication for LA neither in terms of cancer risk nor of conversion and morbidity rates, even if the operative time increases with increasing adrenal lesion diameter. Further prospective studies with a larger number of patients are required to draw definitive conclusions. [ABSTRACT FROM AUTHOR]

The article examines the results of local excision in patients with small T2 and T3 distal rectal tumors after neoadjuvant therapy. All patients underwent preoperative radiotherapy followed by local excision through transanal endoscopic microsurgery. The study concludes that treatment of small uT2 and uT3 uN0 rectal cancers with preoperative high-dose radiotherapy followed by transanal endoscopic microsurgery is an alternative to traditional radical resection.

Background: This study aimed to compare the results and the oncologic outcomes of transanal endoscopic microsurgery (TEM) with neoadjuvant radiochemotherapy and laparoscopic resection (LR), also with neoadjuvant radiochemotherapy, in the treatment of T(2)-N(0) low rectal cancer.Methods: The study enrolled 40 patients with T2-N(0) rectal cancer, randomizing 20 to TEM (arm A) and 20 to LR (arm B).Results: After neoadjuvant radiochemotherapy, tumor downstaging was observed for 13 patients (65%) in arm A (7 pT0 and 6 pT1) and in 11 patients (55%) in arm B (7 pT0 and 4 pT1). More than a 50% reduction of the tumor diameter was observed in four arm A cases and in six arm B cases. At a median follow-up period of 56 months (range, 44-67 months) in both arms, one local failure (5%) occurred after 6 months in arm A and one (5%) after 48 months in arm B. Distant metastases occurred in one arm A patient (5%) after 26 months of follow-up evaluation and in one arm B patient (5%) at 31 months. The probability of local or distant failure was 10% for TEM and 12% for laparoscopic resection, whereas the probability of survival was 95% for TEM and 83% for laparoscopic resection.Conclusions: The findings show comparative results between the two study arms in terms of probability of failure and survival. [ABSTRACT FROM AUTHOR]

Purpose: Aim of this systematic review is to assess the changes in esophageal motility and acid exposure of the esophagus through esophageal manometry and 24-hours pH-monitoring before and after laparoscopic sleeve gastrectomy (LSG). Methods: Articles in which all patients included underwent manometry and/or 24-hours pH-metry or both, before and after LSG, were included. The search was carried out in the PubMed, Embase, Cochrane, and Web of Science databases, revealing overall 13,769 articles. Of these, 9702 were eliminated because they have been found more than once between the searches. Of the remaining 4067 articles, further 4030 were excluded after screening the title and abstract because they did not meet the inclusion criteria. Thirty-seven articles were fully analyzed, and of these, 21 further articles were excluded, finally including 16 articles. Results: Fourteen and twelve studies reported manometric and pH-metric data from 402 and 547 patients, respectively. At manometry, a decrease of the lower esophageal sphincter resting pressure after surgery was observed in six articles. At 24-hours pH-metry, a worsening of the DeMeester score and/or of the acid exposure time was observed in nine articles and the de novo gastroesophageal reflux disease (GERD) rate that ranged between 17.8 and 69%. A meta-analysis was not performed due to the heterogeneity of data. Conclusions: After LSG a worsening of GERD evaluated by instrumental exams was observed such as high prevalence of de novo GERD. However, to understand the clinical impact of LSG and the burden of GERD over time further long-term studies are necessary. [ABSTRACT FROM AUTHOR]

Background: Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer.Methods: A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patient's choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l-9 years).Results: We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group ( p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group ( p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group ( p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery ( n = 10) and patients who had undergone surgery in the past year ( n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection ( p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group ( p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection ( p = 0.162), whereas for Dukes' stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 ( p = 0.392), 0.722 vs 0.584 ( p = 0.199), and 0.500 vs 0.417 ( p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free ( p = 0.623).Conclusions: Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international randomized controlled trials. [ABSTRACT FROM AUTHOR]

Background and Purpose: In the last decade, laparoscopy has dramatically changed colonic surgery. Laparoscopic procedures are applied to the treatment of almost all colonic diseases, including both benign and malignant lesions. Focusing our attention on the laparoscopic oncologic operative technique, we compared the perioperative results and the long-term outcome of laparoscopic surgery (LS) with those of conventional open surgery (OS) in a series of 360 unselected consecutive patients. Patients and Methods: Between 1992 and 2001, excluding 102 patients with rectal tumors, 207 patients underwent laparoscopic colonic resection (72.5% for malignant lesions), whereas 153 (71.9% with malignant lesions) were treated by OS. The treatment modality was selected by the patients after reading the informed consent form. The statistical significance of differences in the morbidity and mortality rates, local recurrence rate, and incidence of distant metastases in the two groups was assessed by χ[sup 2] test. The survival probability analysis was performed by the Kaplan-Meier method. Significant differences in survival probability between groups were assessed by the log-rank test. A level of 5% was used as the criterion of statistical significance. Results: Laparoscopic surgery was technically feasible in 95.7% of the patients. No statistically significant difference was observed in the major complication rate (3.5% after LS and 3.3% after OS; P = 0.870) or in perioperative mortality (1.5% v 1.3%; P = 0.769). The mean follow-up in the patients with malignant disease was 42.2 months, during which time, we observed 2 cases of abdominal wall metastases (1.9%) in patients with advanced disease. The local recurrence rate was lower after LS than OS: 2.8% v 8.1%; P = 0.223). Distant metastases occurred in 8.6% of patients after LS and 9.3% after OS (P = 0.926). At 48 months of follow-up, the cumulative survival probability in the LS-completed malignant group was 0.934 compared with 0.860 after OS (P = 0.781). Conclusion: Laparoscopic colonic resection for both benign and malignant lesions is technically feasible, without additional risks for the patients. However, oncologic outcomes have not been determined because no data from the ongoing randomized controlled trials are yet available. [ABSTRACT FROM AUTHOR]

Background: The feasibility, safety, and results of 108 laparoscopic anterior transperitoneal adrenalectomies (six bilateral) were evaluated in a series of 105 patients. Three patients with a preoperative diagnosis of primary adrenal carcinoma were excluded from the study.Methods: A total of 102 patients were included in the study based on exhaustive endocrinological and imaging assessment. Twenty-nine patients with nonsecreting adenoma, 34 with aldosterone-producing adenoma, 27 with cortisol-producing adenoma (five bilateral), 13 with pheochromocytoma (one bilateral), two with androgen-secreting adenoma, and three with metastases were considered eligible for adrenalectomy. Lesion size ranged from 3.5 to 12 cm. Concurrent surgical procedures were performed in 10 patients (9.8%).Results: One (0.9%) intraoperative complication, a colon tear in a bilateral adrenalectomy, required conversion. There were two (1.9%) postoperative complications: one patient with thrombocytopenia developed hemoperitoneum and required a second laparoscopic procedure, and an intraabdominal abscess was treated medically. Mean postoperative hospital stay was 2.5 days (range, 1-7 days). Postoperative mortality was 0.9%; the patient with the colon tear died of sepsis 60 days after the operation. At a mean follow-up of 30 months (range, 1-62), normalization or improvement in hormone levels was observed in all patients with secreting adenomas, and significant improvement or cure was achieved in all patients with hypertension.Conclusion: Patients with secreting and nonsecreting adrenal lesions can be treated safety and effectively by laparoscopy with the anterior transperitoneal approach. [ABSTRACT FROM AUTHOR]

Feasibility, success rate, safety, and short-term results of single-stage, laparoscopic, transcystic--whenever possible--or choledochotomic treatment of gallstones and common bile duct (CBD) stones were evaluated in 120 unselected patients. Of 1095 patients who underwent laparoscopic cholecystectomy, 120 had ductal stones; among those patients, stones were suspected or proven in 72, 27 of whom were referred after failed endoscopic sphincterotomy (ES) performed elsewhere; unsuspected CBD stones were discovered in 48. The procedure was successful in 116 patients. Four patients required conversion to open surgery. The transcystic access was feasible in 77 patients; a choledochotomy was required in 39. Incidence of retained CBD stones was 4.3%. Minor complications, major complications, and mortality were observed in 6.8%, 1.7%, and 0.8% of patients, respectively. Single-stage laparoscopic treatment of gallstones and CBD stones in unselected patients is safe and feasible in the majority of cases, with success rates and short-term results that are not inferior to reported results of ERCP/ES and cholecystectomy. [ABSTRACT FROM AUTHOR]

Introduction: Near-infrared fluorescence cholangiography (NIRF-C) is a popular application of fluorescence image-guided surgery (FIGS). NIRF-C requires near-infrared optimized laparoscopes and the injection of a fluorophore, most frequently Indocyanine Green (ICG), to highlight the biliary anatomy. It is investigated as a tool to increase safety during cholecystectomy. The European registry on FIGS (EURO-FIGS: www.euro-figs.eu ) aims to obtain a snapshot of the current practices of FIGS across Europe. Data on NIRF-C are presented.Methods: EURO-FIGS is a secured online database which collects anonymized data on surgical procedures performed using FIGS. Data collected for NIRF-C include gender, age, Body Mass Index (BMI), pathology, NIR device, ICG dose, ICG timing of administration before intraoperative visualization, visualization (Y/N) of biliary structures such as the cystic duct (CD), the common bile duct (CBD), the CD-CBD junction, the common hepatic duct (CHD), Visualization scores, adverse reactions to ICG, operative time, and surgical complications.Results: Fifteen surgeons (12 European surgical centers) uploaded 314 cases of NIRF-C during cholecystectomy (cholelithiasis n = 249, cholecystitis n = 58, polyps n = 7), using 4 different NIR devices. ICG doses (mg/kg) varied largely (mean 0.28 ± 0.17, median 0.3, range: 0.02-0.62). Similarly, injection-to-visualization timing (minutes) varied largely (mean 217 ± 357; median 57), ranging from 1 min (direct intragallbladder injection in 2 cases) to 3120 min (n = 2 cases). Visualization scores before dissection were significantly correlated, at univariate analysis, with ICG timing (all structures), ICG dose (CD-CBD), device (CD and CD-CBD), surgeon (CD and CD-CBD), and pathology (CD and CD-CBD). BMI was not correlated. At multivariate analysis, pathology and timing remained significant factors affecting the visualization scores of all three structures, whereas ICG dose remained correlated with HD visualization only.Conclusions: The EURO-FIGS registry has confirmed a wide disparity in ICG dose and timing in NIRF-C. EURO-FIGS can represent a valuable tool to promote and monitor FIGS-related educational and consensus activities in Europe. [ABSTRACT FROM AUTHOR]

Background: The aim is to evaluate safety and efficacy of near infra-red (NIR) indocyanine green (ICG) fluorescence structural imaging during laparoscopic cholecystectomy (LC) (Group A) and to compare perioperative data, including operative time, with a series of patients who underwent LC with routine traditional intraoperative cholangiography (IOC) (Group B).Methods: Forty-four patients with acute or chronic cholecystitis underwent NIR-ICG fluorescent cholangiography during LC. ICG was administered intravenously at different time intervals or by direct gallbladder injection during surgery. Fluorescence intensity and anatomy identification were scored according to a visual analogue scale between 1 (least accurate) and 5 (most accurate). Group B patients (n = 44) were chosen from a prospectively maintained database of patients who underwent LC with routine IOC, matched for age, sex, body mass index, and diagnosis with group A patients.Results: No adverse reactions were recorded. In group A, mean time between intravenous administration of ICG and surgery was 10.7 ± 8.2 (range 2-52) h. Administered doses ranged from 3.5 to 13.5 mg. Fluorescence was present in all cases, scoring ≥ 3 in 41 patients. Mean operative time was 86.9 ± 36.9 (30-180) min in group A and 117.9 ± 43.4 (40-220) min in group B (p = 0.0006). No conversion to open surgery nor bile duct injuries were observed in either group.Conclusions: LC with NIR-ICG fluorescent cholangiography is safe and effective for early recognition of anatomical landmarks, reducing operative time as compared to LC with IOC, even when residents were the main operator. NIR-ICG fluorescent cholangiography was effective in patients with acute cholecystitis and in the obese. Data collection into large registries on the results of NIR-ICG fluorescent cholangiography during LC should be encouraged to establish whether this technique might set a new safety standard for LC. [ABSTRACT FROM AUTHOR]

Background: The aim of this case–control study is to compare the surgical outcomes of laparoscopic adrenalectomy (LA) for lesions measuring ≥6 cm versus ≤5.9 cm in diameter. Methods: Eighty-one patients with adrenal gland lesions ≥6 cm in diameter (intervention group) were identified. Patients were matched to 81 patients with adrenal gland ≤5.9 cm in diameter (control group) based on disease (Conn–Cushing syndrome, pheochromocytoma, primary or secondary adrenal cancer or other disease), lesion side (right, left), surgical technique (anterior transperitoneal approach for right and left LA or anterior transperitoneal submesocolic for left LA) and body mass index class (18–24.9, 25–29.9, 30–34.9, 35–39.9, ≥40 kg/m2). Surgical outcomes were compared between the intervention and control groups. Results: Mean operative time was statistically significantly longer in the interventional arm (101.4 ± 52.4 vs. and 85 ± 31.6 min, p = 0.0174). Eight conversions were observed in the intervention group (9.8%) compared to four in the control group (4.9%) (p = 0.3690). Five (6.1%) and three (3.7%) postoperative complications were observed in the intervention and control groups, respectively (p = 0.7196). Mean postoperative hospital stay was 4.6 ± 2.4 and 4.1 ± 2.3 days in the intervention and control groups, respectively (p = 0.1957). Conclusions: Operative time was statistically significantly longer in adrenal gland lesions ≥6 cm in diameter (vs. ≤5.9 cm). Conversion and complication rates were also higher, but the difference was not statistically significant. Based on the present data, adrenal gland lesions ≥6 cm in diameter are not an absolute contraindication to the laparoscopic approach. [ABSTRACT FROM AUTHOR]

Purpose: Effects of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms are controversial. Our aim is to evaluate the effects of LSG on GERD symptoms in obese patients using a validated quality-of-life questionnaire. Methods: Records of 100 patients (median body mass index [BMI] 44.4 kg/m2, range 35-63.6) without hiatal hernia or severe GERD were analyzed. GERD symptoms were evaluated by GERD Health-Related Quality-of-Life (HRQL) questionnaire before and after surgery. Weight loss and comorbidity resolution were recorded. Results: Median GERD-HRQL scores decreased from 7 (range 0-44) to 3 (0-34) (P = .025) (median follow-up 56 months [range 7-136]). GERD-HRQL scores improved in 55 patients and worsened in 21; de novo GERD was observed in 10; no change occurred in 14 patients (differences being statistically significant: P = <.0001). On multilinear regression analysis, total preoperative GERD-HRQL score and postoperative BMI were independent variables for overall postoperative GERD-HRQL score: higher total preoperative GERD-HRQL score was associated with improved postoperative GERD-HRQL scores, whereas higher postoperative BMI was associated with worse total postoperative GERD-HRQL score. Resolution of diabetes, hypertension, and sleep apnea syndrome occurred in 84.4%, 68%, and 89.7% of patients, respectively. Conclusions: In obese patients, although LSG was associated with statistically significantly improved postoperative GERD-HRQL scores at mid-term follow-up in 55% of patients, only preoperative GERD-HRQL score and postoperative BMI were independent predictors of GERD after LSG. Higher overall preoperative GERD-HRQL score was associated with improved postoperative GERD-HRQL score. However, further research is needed to assess how to predict GERD outcome. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to evaluate the feasibility, safety, advantages and surgical outcomes of laparoscopic bilateral adrenalectomy (LBA) by an anterior transperitoneal approach.Methods: From 1994 to 2018, 552 patients underwent laparoscopic adrenalectomy, unilateral in 531 and bilateral in 21 patients (9 females and 12 males). All patients who underwent LBA were approached via a transperitoneal anterior route and form our study population. Indications included: Cushing's disease (n = 11), pheochromocytoma (n = 6), Conn's disease (n = 3) and adrenal cysts (n = 1).Results: Mean operative time was 195 ± 86.2 min (range 55-360 min). Conversion was necessary in one case for bleeding. Three patients underwent concurrent laparoscopic cholecystectomy with laparoscopic common bile duct exploration and ductal stone extraction in one. Three postoperative complications occurred in one patient each: subhepatic fluid collection, intestinal ileus and pleural effusion. Mean hospital stay was 6.1 ± 4.7 days (range 2-18 days).Conclusions: In our experience, transperitoneal anterior LBA was feasible and safe. Based on our results, we believe that this approach leads to prompt recognition of anatomical landmarks with early division of the main adrenal vein prior to any gland manipulation, with a low risk of bleeding and without the need to change patient position. Unlike the lateral approach, there is no need to mobilize the spleno-pancreatic complex on the left or the liver on the right. The ability to perform associated intraperitoneal procedures, if required, is an added benefit. [ABSTRACT FROM AUTHOR]

The aim of this study is to demonstrate the possibility of performing curative treatment, achieving R0 resection specimens for both the colonic tumour and liver resection using a totally laparoscopic approach. Laparoscopic extended right hemicolectomy for transverse colon cancer with segment 4 liver resection for synchronous metastasis guided by near infrared indocyanine green fluorescence - A video vignette We present a case of laparoscopic extended right hemicolectomy for a transverse colon cancer with segment four (S4) liver resection for synchronous metastasis guided by near infrared (NIR) indocyanine green (ICG) fluorescence. [Extracted from the article]

Background: The aim of the present study is to report and to compare the results of three different laparoscopic transperitoneal surgical approaches [lateral transperitoneal (LT), anterior transperitoneal (AT) and anterior transperitoneal submesocolic (ATS)] for the treatment of Conn's and Cushing's syndrome from left adrenal disease.Methods: This study is a retrospective analysis of prospectively collected data. From 1994 to 2017, 535 laparoscopic adrenalectomies (LA) were performed. One hundred and sixty-four patients with Conn's or Cushing's syndrome underwent left LA. Patients were divided in three groups based on the approach: LT (Group A), AT (Group B) and ATS (Group C).Results: The diagnosis was Conn's and Cushing's syndrome in 99 and 65 patients, respectively. LT was used in 13 cases, AT in 55 and ATS in 96. No significant differences in patient's gender, age and BMI were observed. Mean operative time was 117.6 ± 33.7, 107.6 ± 40.3 and 96.2 ± 47.5 min for Groups A, B and C, respectively. Conversion to open surgery was observed in 4 Group C patients (4.1%). Morbidity occurred in 2 Group B (2%) and in 5 Group C patients (5.2%).Conclusions: In case of Conn's or Cushing's syndrome, left LA with ATS approach is equally safe and effective as compared to the LT and AT approaches. Early control of the adrenal vein with minimal gland manipulation and limited surgical dissection are the major advantages of the submesocolic approach. Even if statistically significant differences are not observed, postoperative results are the same as those reported in the literature with other approaches. [ABSTRACT FROM AUTHOR]

Purpose: Bile duct injuries (BDIs) are more frequent during laparoscopic cholecystectomy (LC). Several BDI classifications are reported, but none encompasses anatomy of damage and vascular injury (A), timing of detection (To), and mechanism of damage (M). Aim was to apply the ATOM classification to a series of patients referred for BDI management after LC.Methods: From 2008 to 2016, 26 patients (16 males and 10 females, median age 63 years, range 34-82 years) with BDIs were observed. Fifteen patients were managed by percutaneous transhepatic cholangiography (PTC)+endoscopic retrograde cholangiopancreatography (ERCP); five and six underwent PTC and ERCP alone, respectively. Median overall follow-up duration was 34 months. Three patients died from sepsis.Results: Out of 26 patients, 20 presented with main bile duct and six with nonmain bile duct injuries. Using the ATOM classification, every aspect of the BDI in every case was included, unlike with other classifications (Neuhaus, Lau, Strasberg, Bergman, and Hanover).Conclusions: The all-inclusive European Association for Endoscopic Surgery (EAES) classification contains objective data and emphasizes the underlying mechanisms of damage, which is relevant for prevention. It also integrates vascular injury, necessary for ultimate management, and timing of discovery, which has diagnostic implications. The management complexity of these patients requires specialized referral centers. [ABSTRACT FROM AUTHOR]

Introduction. In obese patients with hiatal hernia (HH), laparoscopic sleeve gastrectomy (LSG) with cruroplasty is an option but use of prosthetic mesh crura reinforcement is debated. The aim was to compare the results of hiatal closure with or without mesh buttressing during LSG. Methods. Gastroesophageal reflux disease (GERD) was assessed by the Health-Related Quality of Life (GERD-HRQL) questionnaire before and after surgery in two consecutive series of patients with esophageal hiatus ≤ 4 cm2. After LSG, patients in group A (12) underwent simple cruroplasty, whereas in group B patients (17), absorbable mesh crura buttressing was added. Results. At mean follow-up of 33.2 and 18.1 months for groups A and B, respectively (p=0.006), the mean preoperative GERD-HRQL scores of 16.5 and 17.7 (p=0.837) postoperatively became 9.5 and 2.4 (p=0.071). In group A, there was no difference between pre- and postoperative scores (p=0.279), whereas in group B, a highly significant difference was observed (p=0.002). The difference (Δ) comparing pre- and postoperative mean scores between the two groups was significantly in favor of mesh placement (p=0.0058). Conclusions. In obese patients with HH and mild-moderate GERD, reflux symptoms are significantly improved at medium term follow-up after cruroplasty with versus without crura buttressing during LSG. [ABSTRACT FROM AUTHOR]

Purpose: Aim is to report the learning curve and standardization process of Laparoscopic Sleeve Gastrectomy (LSG), describing the evolution in surgical technique and patient management in the authors' experiences.Methods: One hundred twenty-seven patients were divided in three Groups (A, B, and C), based on bougie size and technical details, and included 36, 46, and 45 patients, respectively.Results: Mean operative time in Groups A, B, and C was 201.5, 150.8, and 172 minutes, respectively. Conversion to open surgery occurred in 1 Group A case. Eleven postoperative complications (8.6%) were observed (1 Group A, 8 Group B, 2 and Group C). Mean hospital stay in Groups A, B, and C, was 7.1, 6.9, and 3.1 days, respectively. At a mean follow-up of 69.7 months (Group A), 33.3 months (Group B), and 14.8 months (Group C), mean postoperative body mass index is 32.6, 28.1, and 31.5 kg/m2, respectively. Percentage estimated body mass index loss (%EBMIL) was 74.8% for Group A, 85.7% for Group B, and 68.1% for Group C.Conclusions: LSG is a safe and effective procedure. In the postoperative course, meticulous alertness to early warning signs of sepsis and aggressive patient management are mandatory to prevent mortality. The use of a larger bougie size was associated with weight regain. [ABSTRACT FROM AUTHOR]

Aim In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function. Method Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B). Results In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months ( P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment. Conclusion TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence. [ABSTRACT FROM AUTHOR]

Background Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endo-laparoscopic treatment, but with shorter hospital stay, lower cost and recurrent stone rate. Aim of this paper was to report the authors’ experience with LCBDE during LC. Methods A retrospective analysis of patients who underwent LCBDE for ductal stones was performed. Recurrent stones were defined as CBD stones detected beyond 6 months from the procedure. Postoperative biliary stricture was defined as a symptomatic reduction of CBD diameter. Results Out of 3444 patients who underwent LC, 384 (11%) had CBD stones treated by trans-cystic duct exploration [214 (6%) patients, TCD-CBDE] or choledochotomy [170 (5%) patients, C-CBDE]. For TCD-CBDE and C-CBDE, mean operative time was 127 ± 69 and 191 ± 74 min, respectively. Major morbidity rate was 3% (n = 6) in TCD-CBDE and 6% (n = 11) in C-CBDE. The incidence of residual stones was 5% (n = 20) and complete ductal clearance rate was 95% (n = 364). After long-term follow-up (mean 189 ± 105 months) the recurrent stone rate was 2%. Discussion In expert centers, LCBDE during LC is safe and effective with low short and long term morbidity rates. [ABSTRACT FROM AUTHOR]

PurposeThe aim of this study is to evaluate the safety and efficacy of endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) after R1 endoscopic resection or local recurrence of early rectal cancer after operative endoscopy.Material and methodsTwenty patients with early rectal cancer were enrolled, including patients with incomplete endoscopic resection, or complete endoscopic resection of a tumor with unfavorable prognostic factors (group A, ten patients), and local recurrence after endoscopic removal (group B, ten patients). At admission, histology after endoscopic polypectomy was: TisR1(4), T1R0G3(1), T1R1(5) in group A, and TisR0(8), T1R0(2) in group B. All patients underwent ELRR by TEM with nucleotide-guided mesorectal excision (NGME).ResultsMean operative time was 150 minutes. Complications occurred in two patients (10%). Definitive histology was: moderate dysplasia(4), pT0N0(3), pTisN0(5), pT1N0(6), pT2N0(2). Mean number of lymph-nodes was 3.1. Mean follow-up was 79.5 months. All patients are alive and disease-free.ConclusionsELRR by TEM after R1 endoscopic resection of early rectal cancer or for local recurrence after operative endoscopy is safe and effective. It may be considered as a diagnostic procedure, as well as a curative treatment option, instead of a more invasive TME. [ABSTRACT FROM AUTHOR]

Background: In selected patients with N0 rectal cancer, endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to laparoscopic total mesorectal excision (LTME). Aim of this study is to evaluate the short- and medium-term quality of life (QoL) from a retrospective analysis of prospectively collected data in patients with iT2-iT3 N0-N+ rectal cancer, who underwent ELRR by TEM or LTME after neoadjuvant radio-chemotherapy (n-RCT).Methods: Thirty patients with iT2-iT3 rectal cancer who underwent ELRR by TEM (n = 15) or LTME (n = 15) were enrolled in this study. The choice for one operation or the other was made on the basis of predefined criteria. QoL was evaluated by EORTC QLQ-C30 and QLQ-CR38 questionnaires at admission, after n-RCT and 1, 6, and 12 months after surgery.Results: No statistically significant differences in QoL evaluation were observed between the two groups, both at admission and after n-RCT. At 1 month after surgery, significantly better results in the ELRR group were observed by QLQ-C30 in: Nausea/Vomiting (p = 0.05), Appetite Loss (p = 0.003), Constipation (p = 0.05), and by QLQ-CR38 in: Body Image (p = 0.05), Sexual Functioning (p = 0.03), Future Perspective (p = 0.05) and Weight Loss (p = 0.036). At 6 months after surgery, a statistically significant worse impact after LTME was observed by QLQ-C30 in: Global Health Status (p = 0.05), Emotional Functioning (p = 0.021), Dyspnea (p = 0.008), Insomnia (p = 0.012), Appetite Loss (p = 0.014) and by QLQ-CR38 in Body Image (p = 0.05) and Defecation Problems (p = 0.001). At 1 year, the two groups were homogenous as assessed by QLQ-C30, whereas the QLQ-CR38 still showed better results of ELRR versus LTME in Body Image (p = 0.006), Defecation Problems (p = 0.01), and Weight Loss (p = 0.005).Conclusions: Based on the present series, in selected patients, earlier restoration of patients' functions is observed after ELRR by TEM than after LTME. [ABSTRACT FROM AUTHOR]

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique. [ABSTRACT FROM AUTHOR]

Author's Reply: Are Adrenal Lesions of 6 cm or more in Diameter a Contraindication to Laparoscopic Adrenalectomy? In this sense, hand-assisted laparoscopy allows to perform an atraumatic exposure of the structures using finger dissection and to restore the surgeon's tactile sense, which can be very useful during surgery, especially in case of suspected or confirmed primary adrenal cancer or metastasis [[4]]. Author contributions Dr. AB, Dr. LP, Dr. FM, Dr. DC, Dr. MO, Dr. PU, Prof. MG, Dr. SQ and Prof. [Extracted from the article]

Background: In selected patients with early low rectal cancer, locoregional excision combined with neoadjuvant therapy may be an alternative treatment option to total mesorectal excision (TME). Methods: This prospective randomized trial compared endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery versus laparoscopic TME in the treatment of patients with small non-advanced low rectal cancer. Patients with rectal cancer staged clinically as cT2 N0 M0, histological grade G1-2, with a tumour less than 3 cm in diameter, within 6 cm of the anal verge, were randomized to ELRR or TME. All patients underwent long-course neoadjuvant chemoradiotherapy. Results: Fifty patients in each group were analysed. Overall tumour downstaging and downsizing rates after neoadjuvant chemoradiotherapy were 51 and 26 per cent respectively, and were similar in both groups. All patients had R0 resection with tumour-free resection margins. At long-term follow-up, local recurrence had developed in four patients (8 per cent) after ELRR and three (6 per cent) after TME. Distant metastases were observed in two patients (4 per cent) in each group. There was no statistically significant difference in disease-free survival ( P = 0·686). Conclusion: In selected patients, ELRR had similar oncological results to TME. Unique Protocol ID: URBINO-LEZ-1995; registration number: NCT01609504 (). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic resection for cure of colorectal cancer is controversial. More investigations on long-term results are required. This study aimed to compare the long-term outcome with a minimum follow-up of 5 years between laparoscopic or open approach for the treatment of colo-rectal cancer.Methods: The treatment modality (laparoscopic or open) was related to the patients (pts) choice. The following parameters between the two groups (laparoscopic and open) were assessed: wound recurrences rate, local recurrences rate, incidence of distant metastases and survival probability analysis.Results: We report the long term outcome of 149 pts with colon cancer of which 85 treated by Laparoscopic Surgery (LS) and 64 by Open Surgery (OS) and of 86 patients with rectal cancer of which 52 treated by LS and 34 by OS. In the pts with colonic cancer, mean follow-up was 82.8 months. No Statistically Significant Difference (SSD) was observed in the local recurrences rate (3.5% after LS and 6.2% after OS) and in the incidence of distant metastases (10.5% after LS and 10.9% after OS). Cumulative survival probability in LS was 0.882 as compared to 0.859 after OS. In the pts with rectal cancer, mean follow-up was 78.5 months. No SSD was observed in the local recurrences rate (19.2% after LS and 17.6% after OS) and in the incidence of distant metastases (15.3% after LS and 20.5% after OS). Cumulative survival probability in LS was 0.711 as compared to 0.617 after OS. We report an interesting data about the time of recurrences between LS and OS: the recurrences were delayed after LS, both after colonic (22.6 months vs 6.5) and rectal (25.7 months vs 13.0) resections, respectively.Conclusion: We suppose that laparoscopic surgery in the treatment of colo-rectal cancer is quite safe. However, further investigation is needed. [ABSTRACT FROM AUTHOR]

Background: This article reports an alternative laparoscopic access to left adrenal gland.Methods: From January 1994 to August 2004, 209 laparoscopic adrenalectomies were performed in our Department. Indications were Conn adenoma (55 cases), incidentaloma (64), Cushing adenoma (45), pheochromocytoma (32), adreno-genital syndrome (two), mielolipoma (two), and metastatic mass(nine). Of 209, in 12 cases the left adrenalectomy was performed through a submesocolic access (seven pheochromocytoma, two incidentaloma, two Cushing adenoma, one Conn adenoma,). The identification and closure of the adrenal vein with minimal gland manipulation resulted the main benefit of this approach. Moreover, the adrenalectomy was performed with minimal anatomical dissection.Results: No mortality or major complications occurred. During the operation, the blood pressure and cardiac rhythm were significantly more stable, in the group of patients who underwent a left adrenalectomy by the submesocolic approach compared to the anterior or flank lateral transperitoneal group.Conclusions: Left adrenal lesions, as selected cases of pheochromocytoma, can be safely treated by laparoscopic submesocolic access. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic common bile duct (CBD) exploration is a well-established treatment option in dedicated centers. However, few data are available on the results in elderly patients.Methods: The outcome after laparoscopic CBD exploration in elderly patients (age <70 years) was compared with that in a concurrent control group of younger patients (age, <70 years).Results: There were 77 elderly patients in group A and 207 younger patients in group B. American Society of Anesthesiology (ASA) III and IV patients and prior abdominal operations were more frequent in group A (p <0.001). Two patients from each group underwent conversion to open surgery. There was no significant difference frequency of use between the transcystic and choledochotomy approaches, although the latter tended to be more frequent in the group A because of larger stones, (group A 53.4%; group B, 37.6%). Minor and major morbidity (group A, 12%; group B, 13.6%), rate of recurrent stones (group A, 1.3%; group B, 1.9%), and mortality (group A, 1.3%; group B, 0%) were not significantly different between the two groups. The single death in group A involved a patient with acute toxic cholangitis who underwent emergency surgery after multiple failed attempts at endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy performed elsewhere. No CBD stenosis was observed at follow-up assessment.Conclusions: Elective laparoscopic CBD exploration is safe and effective. It may become the standard of care in both elderly and younger patients. [ABSTRACT FROM AUTHOR]

In the majority of patients undergoing laparoscopic choledochotomy, it is advisable to insert a T-tube into the duct after ductal exploration, as bile sludge or fibrin deposits may obstruct the papilla and cause postoperative cholangitis. Based on our experience in open surgery, a limited transverse choledochotomy is preferred, which reduces the possibility of damaging the common bile duct blood supply. Such a technique can complicate laparoscopic T-tube positioning, however. After experimenting with the method described by Kitano et al. [Surg Endosc 7:104-105 (1993)], which was abandoned because it was difficult to carry out with the type of soft silicone rubber tubes that we normally use, two subsequent techniques were developed and are described. They were employed in 3 and 10 patients, respectively, out of 21 who underwent laparoscopic transverse choledochotomy. The most satisfying results were obtained using a system employing two sets of telescopic cannulae of different diameters. Laparoscopic T-tube introduction through a transverse choledochotomy using two telescopic cannulae was rapid and safe and allowed to precisely guide T-tube positioning inside the common duct. [ABSTRACT FROM AUTHOR]

Background: The rectosigmoid colon is affected by deep pelvic endometriosis in 3-37% of cases. In the past, treatment of the affected gastrointestinal tract generally required conversion to conventional surgery. We describe our experience with complete laparoscopic management of deep pelvic endometriosis with bowel involvement.Methods: From March 1995 to March 2003, 29 consecutive patients with endometriosis requiring laparoscopic intervention were evaluated. In seven patients (24%) colorectal involvement was identified prior to the operation. A low anterior resection was performed in four patients (57%) and a sigmoid resection in three (43%). In all cases, colonoscopy showed a normal mucosa. In all cases, treatment consisted of resection of the bowel involved together with the excision of all other implants. Data analysis included age, previous abdominal operations, previous history of endometriosis, operative time, conversion rate, complications, length of stay, and pain relief.Results: There were seven patients with colorectal involvement whose median age was 32.8 years (range, 28-40), with a history of previous abdominal operation in two (28%). Preoperative symptoms were as follow: dysmenorrea in four patients (57%), dyspareunia in four (57%), pelvic pain in seven (100%), rectal bleeding in one (14%), and tenesmus in five (71%). Mean operative time was 190 min (range, 165-230). Length of stay was 8.3 days (range, 7-11). There were no anastomotic leak and no major postoperative complication. One patient had temporary urinary retention. At a median follow-up of 38.7 months (range, 1-84), complete relief of pelvic symptoms was achieved in five patients (71%), and there was improvement in one patient. In one patient complaining of persistent pain, a new colonic implant was diagnosed two years after the surgery requiring reoperation.Conclusions: The results show that provided that the surgeon is highly skilled in laparoscopy, laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement is feasible and effective in nearly all patients. [ABSTRACT FROM AUTHOR]