Search

Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.

Purposes : Accurately localizing colorectal cancer during surgery may be challenging due to intraoperative limitations. In the present study, localization of left-sided colon cancer (LCC) by CT scan is compared to colonoscopy. Material and methods : Consecutive patients with LCC located by colonoscopy and CT scan and undergoing left-hemicolectomy were included. Tumor distance from the anal verge (TDAV) was calculated by both CT-scan and colonoscopy, and then compared, using as reference TDAV measured intraoperatively. Statistical analysis was performed including (1) comparison of means between all three TDAVs, (2) comparison of mean differences between all three TDAVs, (3) comparison of number of patients with a difference between endoscopic TDAV and intraoperative TDAV ≤5 cm and the number of patients with a difference between CT scan TDAV and intraoperative TDAV ≤5 cm (4) statistical relationship between either CT scan and endoscopic and intraoperative TDAVs. Results : Both CT scan and endoscopy overestimate TDAV (25.8 ± 12.5 cm and 24.6 ± 10.6 cm vs. 21.5 ± 7.4 cm, p  = 0.005), but CT scan TDAV resulted as being different from intraoperative TDAV ( p  < 0.01). Regression analysis reported an increasing divergence of measurements with increasing values of intraoperative TDAV, which resulted greater for CT. Tumors within 5 cm of intraoperative TDAV were 22/28 (78.6%) for endoscopy, and 17/28 (60.7%) for CT ( p  = 0.2448). Conclusions : Accuracy of both examinations seems poor, with a mean overestimation >3 cm and a significant number of tumors found at >5 cm from preoperative evaluation. Preoperative examinations' bias increase proportionally with TDAV length, decreasing their interest especially for tumors located at a greater distance from anal verge.

Introduction: De Garengeot Hernia is described as the presence of an appendix within a femoral hernia., Case Report: We report the case of an elderly woman, who presented with incarcerated femoral hernia without signs of bowel obstruction. CT showed a femoral hernia with appendix in the femoral canal with signs of strangulation. the patient underwent emergency surgery. Diagnostic laparoscopy revelead a non-reducible appendix in the femoral canal, in the absence of signs of peritonitis. An infrainguinal incision was performed. An gangrenous appendix within the sac was revealed, detached from the sac and reintroduced into the abdomen through the femoral canal. The laparoscopic appendectomy was then performed. The hernia repair was performed by suturing the iliopubic tract to Cooper's ligament. Patient had a regular course., Discussion: De Garengeot's hernia is a rare occurrence. After the year 2000 a total of 32articles, wich presented 34 cases of de Garengeot's hernia have been published. Due to the rarity of this disease there is not standard procedure; laparoscopy may be a valid technique for determining the condition of the hernia, but due to the difficulty of preoperative diagnosis it is unlikely to be the first choice for the surgical approach. The use of CT can therefore be decisive to help the surgeon in the choice of the approach., Conclusion: De Garengeot's hernia can be approached in urgent laparoscopy even in the complicated forms of appendicular inflammation. (www.actabiomedica.it).

Background/purpose: In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset., Methods: A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy., Results: Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients., Conclusions: Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions., Type of Study: Systematic review., Level of Evidence: IV., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Recently, Indocyanine Green (ICG)-enhanced fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical informations. The aim of our study is the application of ICG imaging during laparoscopic colorectal resections: to assess anastomotic perfusion to reduce the risk of anastomotic leak, to facilitate vascular dissection when vascular anatomy of tumor site is unclear, and to identify ureter to prevent iatrogenic injury. After the transection, 5 ml of ICG solution is intravenously injected. A Full HD IMAGE1S camera, switching to NIR mode, in few seconds provides a real-time angiography of colonic perfusion. After anastomosis, another bolus is injected to confirm the anastomotic perfusion. When the tumor is localized in difficult site, the fluorescence provides a real-time angiography of tumor area vascularization to perform the vascular dissection. When the tumor is tightly attached to the ureter, the ICG solution injection through the catheter allows ureter identification. From November 2016, 38 patients were enrolled: ten left colectomies, 22 right colectomies, three transverse resections, and three splenic flexure resections. In five cases, intraoperative angiography led to the identification of vascular anatomy. In one case the surgical strategy was changed. In one procedure, ureter identification allowed to prevent injury. Three postoperative complications that required surgical reoperation occured, of which one anastomotic leak, due to a mechanical problem. ICG-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. It can be employed also in small hospitals without learning curve. It is recommended to obtain additional information on anatomy and perfusion in colorectal surgery.

Background and Aim of the Work: Pancreatic pseudocyst endoscopic drainage by pancreatogastrostomy "pigtail" drain placement is spreading worldwide, with high success-rate and low morbidity, and is increasingly performed as outpatient procedure. The paper reports an unusual very early complication of this procedure and discusses the peculiar aspects of this event in an outpatient setting., Methods: The first case of a 56-year-old outpatient developing a postoperative diffused acute peritonitis by gastric juice spilling caused by the  misplacement of the distal end of two transgastric drains not reaching the pseudocyst is reported. As the case was programmed as outpatient and acute peritonitis symptoms occurred eight hours postoperatively, the patient was discharged and rehospitalized. A review of the literature of rare perforative complications of pancreatogastrostomy is performed., Results: CT scan allowed the prompt diagnosis, as it showed massive pneumoperitoneum, free fluid collection, and pigtail drain misplacement. Emergency laparoscopy allowed the removal of the two misplaced drains and gastric reparation. The procedure lasted 65 minutes, mostly needed for lavage. The patient was discharged 5 days later and outcomes are unremarkable 7 months after the procedure., Conclusion: The indication to endoscopic pancreatogastrostomy and its outpatient management should be carefully pondered. Pancreogastrostomy drain misplacement may cause a life-threatening acute peritonitis associated with early aspecific symptoms, resulting in a challenging situation, especially in an outpatient setting. CT-scan may allow prompt diagnosis and effective management by minimally invasive surgery.

Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) has gained popularity as bridge management to resolve jaundice, but its role is being challenged as it is thought to increase morbidity. To clarify the current recommendations for PBD prior to PD, we reviewed the literature, including all relevant articles published in English up until December, 2015. There is increasing evidence that PBD causes bile infection, which is related to the morbidity of infectious complications. Results of transhepatic drainage are poorer than those of endoscopic stenting, especially in an oncologic setting, although it is still unclear whether metallic stents are superior to nasobiliary drainage. PBD should be avoided whenever possible and performed only in selected cases, such as the emergency setting, an inevitable long delay (>4 weeks) before PD, and jaundice-related anorexia. Seemingly, transhepatic drainage should be reserved for refractory cases if endoscopic drainage is not possible. Further studies comparing endoscopic drainage techniques, such as metallic stents and nasobiliary drainage, are required to assess the most effective technique of PBD. Bile infection should be prevented by adequate antibiotic prophylaxis and treated even in the absence of symptoms, and bile status should be assessed systematically.

Background and Objectives: Anastomotic recurrence (AR), whose etiopathogenesis is attributed to intraluminal implantation of cancerous cells or metachronous carcinogenesis, is a major issue for patients undergoing colon cancer (CC) resection. The objective of the study is to throw some light on AR etiopathogenesis and to identify risk factors of AR in selecting patients to undergo early endoscopy., Methods: An analysis of clinical and histopathological parameters, including MSI and LOH of seven sites (Myc-L, BAT26, BAT40, D5S346, D18S452, D18S64, D16S402) was performed in primary CC and AR of 18 patients. They were then compared to 36 controls not developing AR., Results: A genetic instability was present in 16/18 patients, with distinct genetic patterns between primaries and ARs. LOH at 5q21 and/or 18p11.23 were found in both primary and AR in >50% of cases, but this rate was no different from control population. CEA resulted as associated with AR (P = 0.03), whereas N status presented a borderline result (P = 0.08)., Conclusions: Our findings challenge present theories about AR development. No "genetic marker" has been found. CEA and, to a lesser extent, N status, appear associated with AR. Rectal washout is seemingly meaningless. Iterative resection should be recommended since a long survival may be expected. J. Surg. Oncol. 2016;114:228-236. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: Endoscopic stenting has spread as bridge management before pancreatoduedenectomy (PD) to resolve jaundice, but its role is nowadays challenged as it is reported to increase morbidity. Although bile sampling is increasingly performed, its clinical role is unclear. The objective of the study is to assess bile colonization's impact on outcome., Methods: Results of pancreatoduodenectomy after endoscopic stenting are analyzed in 61 high-risk patients presenting bacterial bile colonization. The impact of 11 demographic, clinical, infectious, and laboratory parameters and outcome, including pancreatic leakage, morbidity, and mortality, is analyzed., Results: All stented patients present bacterial bile colonization and PD mortality approaches 10 %. The presence of E. coli in the bile is significantly related to poor outcome, including 23.5 % mortality (p = 0.034), whereas age (≥70 years) and diabetes present borderline results (p < 0.070 and p < 0.066, respectively). E. coli (p = 0.002) and age (p = 0.017) are also related to grade C pancreatic fistula., Conclusions: In high-risk patients undergoing PD, bile colonization inevitably occurs after endoscopic stenting and is a major risk factor of poor outcome, reaching its maximum in the case of E. coli colonization and elderly patients, where the indication to stent and/or to perform PD should be accurately evaluated. E. coli-targeted antibiotic prophylaxis should be administered.

Background: Splenic hydatidosis is a rare condition and is usually managed by total splenectomy, which is associated to various complications, including overwhelming post-splenectomy sepsis and thrombosis. Probably due to supposed technical difficulties, the partial splenectomy is rarely performed being often unknown to physicians, infectious disease specialists and surgeons., Methods: Demographic, clinical and surgical data were collected of four consecutive patients undergoing partial (or hemi-) splenectomy using an original, recently improved technique as a treatment for polar splenic hydatid cyst. The procedure implies a selective vascular ligation, a mechanical stapler-assisted section and haemostatic agents (Surgicel(®)) application on the cutting surface. Three patients were treated by laparotomy (including one affected by both liver and spleen localizations) whereas the last one was approached laparoscopically., Results: Partial splenectomy operative time reached 74 min (range: 60-94 min) and blood loss was 8 ml (range: 5-10 ml). Hospital stay was 5.6 days (range: 5-7 days). At a mean follow-up of 20 months (range: 12-36 months), outcomes were uneventful., Conclusions: Partial splenectomy for hydatidosis is effective and safe. Physicians and surgeons should be aware of such an easy-to-catch option when dealing with benign splenic conditions, such as parasitic cysts. Cost-effectiveness, low morbidity and the possible prevention of splenectomy-related infectious complications should plead in favor of this technique in developing countries, where hydatidosis is endemic and post-splenectomy drugs and vaccines may be lacking., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Background: Prognosis assessment of node-positive colorectal cancer patients by Astler-Coller (AC) and TNM classifications is suboptimal. Recently, several versions of lymph node ratio (LNR; ratio metastatic/examined nodes) have been proposed but are still mostly unused., Methods: The prognostic value of several criteria, including LNR (two classes-LNR1 and LNR2-identified by a 15% cut-off) was studied in 761 consecutive patients, from 2000 through 2010. The relationships between total examined nodes, N, T and LNR were also analysed. LNR1 and LNR2 patients' survival was analysed within AC and TNM subgroups, and then coupled with them., Results: Age, tumour location and LNR are independent factors predicting survival. The relationships between LNR, N stage and T stage with examined nodes suggest confusing factors. LNR allows for identification of subgroups with different survival within AC and TNM classifications (p < 0.0001). Patients with LNR class discordant from AC stage (LNR1-C2 and LNR2-C1) have a similar 5-year survival (54 and 57%, respectively). LNR2 and TNM stage IIIC define a poor 5-year prognosis (33%)., Conclusions: LNR is a powerful prognosis predictor, easily integrated with TNM and AC classifications to improve prognosis assessment and facilitate clinical use. Possible confusing factors should be considered in future studies.

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Because pancreaticocystostomy is a method of exocrine secretion management in pancreas transplantation, a legitimate question is whether a pure pancreatic fistula could be shunted into the bladder. After duodenopancreatectomy for cancer, a pancreaticojejunostomy leakage was treated by pancreas-saving anastomosis disconnection. The resulting pure pancreaticocutaneous fistula was later diverted into the bladder using a Denver valved-pump device. Technical problems necessitated redoing the shunt using a modified technique and device. Although the system did work, catheter displacement outside the bladder finally caused device takedown and external fistula restoration. Our attempt did not succeed mostly because of our inexperience in dealing with an altogether novel issue without appropriate technology. Supposing its feasibility, a pancreatic-bladder shunt might have a role in treating pure pancreatic fistulas or creating an external fistula whenever the pancreatic remnant is unreliable for an anastomosis, or when a leaked anastomosis' disconnection is preferable to completion pancreatectomy.

The association between hospital high volumes and good outcomes after complex surgery has given rise to a worldwide controversial debate. Important and unsolved questions have followed, both theoretical and practical, which could have repercussions on health care and health economic policies, such as the centralization/regionalization of major surgical procedures.We read a recent study on the impact of surgery volumes on short-term outcomes after colon cancer resection in Emilia Romagna, Italy, the same geographic area where we operate. Ten issues were submitted to critical analysis and many sources of planning and methodology bias were identified, which, in our opinion, paradigmatically led to unreliable results, inadequate statistical analysis and deceptive conclusions. Despite the authors' admitted awareness of their study's limits, their conclusive message was, surprisingly, that centralization of colon cancer surgery should be substantially encouraged.Unrecognized, systemic biases may easily turn into cognitive biases, into logical short cuts which could confuse healthcare policy-makers. The volume-outcome relationship, in which a direct causal link has never been demonstrated, should not be used as a reliable measure of quality, rather  than less implementable process indicators, to address centralization policies.A disregarded negative consequence of centralization could be that non-high-volume centres, after a further progressive workload decrease and depletion in resources and surgical skills, will have to cope with patients in bad general condition and at high risk, who must be treated in emergency or cannot anyway afford the move for age, indigence or severe co-morbidities. Thus, centralization policies might disadvantage the weak segments of the population, thereby moving towards an iniquitous health service.

Background: Hyperpyrexia associated with right iliac fossa pain and tenderness in a young patient is a common finding in an Emergency Department, and is frequently caused by acute appendicitis or genitourinary affliction. Especially in the case of young males, it is debated whether the patient should undergo immediate surgery or be referred for imagery, and, when surgery is finally planned, whether an open incision of the iliac fossa or a laparoscopic approach is preferred., Objective: We describe a case of a patient with a twisted, ischemic ileal hemangioma mimicking an acute appendicitis, which was diagnosed and managed laparoscopically., Case Report: A 16-year-old boy was admitted to the Emergency Department with a 2-day history of hyperpyrexia, nausea, right iliac fossa pain, and tenderness. Perioperative computed tomography scan showed a 3-cm image that was interpreted as a periappendicular abscess. At laparoscopy, a twisted ischemic mass adherent to the surrounding ileum was located and removed. The patient's outcome was uneventful. Pathology showed a benign hemangioma of the ileal mesentery. To our knowledge, this is the first case treated by laparoscopic resection., Conclusions: Rare conditions, such as peduncolated tumors, can mimic common conditions like acute appencitis. Also, due to the aspecificity of symptoms and difficult interpretation of imagery, diagnosis can be difficult to achieve preoperatively and surgery can be challenging. Laparoscopy can allow a diagnosis to be made and the appropriate treatment to be performed without the need for laparotomy. Rare causes of appendicitis-like syndrome represent an argument in favor of a laparoscopic approach, even in the case of young male patients., (Copyright © 2013 Elsevier Inc. All rights reserved.)

A case of hemoperitoneum caused by a ruptured gastrointestinal stromal tumor (GIST) of the posterior gastric wall is presented. An otherwise healthy 81-year-old man presented with abdominal pain/tenderness and anemia (hemoglobin: 7.4 g/dL). Computed tomography scan showed hemoperitoneum and a gastric mass of uncertain nature. As the patient was hemodynamically stable, a mini-invasive approach was decided. Esophagogastroscopy revealed an umbilicated mass of the posterior gastric wall, therefore allowing for a correct preoperative diagnosis of GIST and its appropriate treatment by laparoscopic atypical gastrectomy. Laparoscopically, a longitudinal resection of gastric fundus including the tumor was performed in a sleeve gastrectomy fashion, 25 minutes after the induction of pneumoperitoneum. The outcome was uneventful. Pathologic examination confirmed a benign 4 × 3-cm gastric GIST with <1 mitosis per 50 high power field, staining positive for CD117 (C-KIT) and negative for S-100 protein and smooth muscle actin. To our knowledge, it is the first case of a successful laparoscopic resection of an endoscopically diagnosed gastric GIST in an emergency setting. Hemoperitoneum is a rare, potentially severe complication of GIST. As bleeding is rarely severe, most patients may benefit from a mini-invasive approach, even if the tumor is located in the posterior gastric wall.

Aim: To investigate genetics of two cases of colorectal tumor local recurrence and throw some light on the etiopathogenesis of anastomotic recurrence., Methods: Two cases are presented: a 65-year-old female receiving two colonic resections for primary anastomotic recurrences within 21 mo, and a 57-year-old female undergoing two local excisions of recurrent anastomotic adenomas within 26 mo. A loss of heterozygosity (LOH) study of 25 microsatellite markers and a mutational analysis of genes BRAF, K-RAS and APC were performed in samples of neoplastic and normal colonic mucosa collected over the years., Results: A diffuse genetic instability was present in all samples, including neoplastic and normal colonic mucosa. Two different patterns of genetic alterations (LOH at 5q21 and 18p11.23 in the first case, and LOH at 1p34 and 3p14 in the second) were found to be associated with carcinogenesis over the years. A role for the genes MYC-L (mapping at 1p34) and FIHT (mapping at 3p14.2) is suggested, whereas a role for APC (mapping at 5q21) is not shown., Conclusion: The study challenges the most credited intraluminal implantation and metachronous carcinogenesis theories, and suggests a persistent, patient-specific alteration as the trigger of colorectal cancer anastomotic recurrence.

Purpose: Despite the encouraging results of chemotherapy in patients affected by incurable colorectal cancer (CRC), surgical resection of a primitive tumor is still a common approach worldwide. The identification of prognostic factors related to short survival (<6 months) may allow excluding from resective surgery those who may not benefit from it., Methods: A retrospective analysis was performed of 15 variables in a population of 71 patients undergoing nonemergency palliative primary resections of incurable CRC, including patients' demographics and clinical/histopathological characteristics of the tumor., Results: No variables were related to perioperative mortality (8.5% overall). A multivariate analysis revealed that older age (≥80 years) and metastasis to more than 25% of the lymph nodes were associated with survival (4 and 6 months, respectively). Mucoid adenocarcinoma therefore tends to be associated with the prognosis (P = 0.070)., Conclusions: An elderly age tends to be a contraindication to an elective primary tumor resection in patients affected by incurable CRC. Massive lymph node involvement and mucoid adenocarcinoma should also be considered before planning major colonic surgery.

Background: The current literature does not provide unequivocal data on prognostic factors in conservative management of fecal incontinence. Moreover, the physiopathologic effects of pelvic floor rehabilitation on anorectal function are not well understood. Our aim is to identify some prognostic parameters and assess their effects on anorectal physiology of biofeedback therapy plus anal electrostimulation for fecal incontinence., Methods: We studied prospectively 45 consecutive adult patients with fecal incontinence treated at our institution with biofeedback plus electrostimulation. The outcome parameter was modification of the Wexner Incontinence Score (WIS) at the end of treatment. In addition, we studied the modifications of anorectal manometry and the rectal sensitivity threshold after treatment., Results: At univariate analysis, age, the pretreatment WIS, and the pretreatment resting and maximum squeeze pressures were correlated with the clinical outcome. Patients showed a significant reduction in the rectal sensitivity threshold but no significant change in manometric parameters after treatment., Conclusions: We identify good sphincter function and mild to moderate symptomatology as favorable prognostic factors in biofeedback and anal electrostimulation therapy. Improvement in rectal sensitivity can be implicated in symptomatic improvement. The impossibility of correlating the clinical results with the effects on anorectal physiology suggests a nonspecific effect of conservative treatment.

Background: Recent trials proposed chemotherapy (CHT) as the treatment of choice for patients affected by incurable colorectal cancer (ICRC). Nevertheless, surgery is still commonly offered to these patients. On the other hand, CHT is offered to ICRC patients regardless of the pattern of spread of the disease, local or distant, despite some evidence suggesting that metastatic pattern may influence the response to treatment., Methods: A retrospective analysis was performed of 133 patients undergoing palliative treatment for ICRC from 1994 through 2007. Palliation consisted of surgery alone until 2002 and surgery with CHT (FOLFOX-FOLFIRI) thereafter. The impact of CHT and surgery was evaluated in the whole series as well as with respect to metastatic pattern (locally aggressive primary tumor and distant metastasis only), tumor site, and grading., Results: Chemotherapy prolonged survival by 9 months (p = 0.001). In patients undergoing CHT, resective surgery did not prolong survival (p = 0.931), whereas in patients not undergoing CHT, it improved prognosis by 5 months (p = 0.023). Considering patients with distant metastasis only, CHT significantly prolonged survival (p < 0.001), whereas it did not improve the prognosis of patients with a locally aggressive primary tumor (p = 0.943). No difference in CHT effectiveness with respect to tumor site and grading was recorded., Conclusions: CHT should be the preferred option in patients undergoing elective treatment for ICRC, whereas surgery should be considered whenever CHT is not administered. CHT significantly increases survival of patients with unresectable distant metastasis only, whereas it seems to be useless in patients with locally aggressive primary tumors.

The introduction of laparoscopy in incisional hernia repair is giving rise to a new class of complications, specific of new techniques and materials. A case of early failure of incisional hernia laparoscopic repair complicated by the strangulation of a jejunal loop four months after surgery is reported. The use of inappropriate material (tacks) to fix the prosthesis to the abdominal wall, a sudden increase of intra-abdominal pressure caused by an episode of haematemesis four hours postoperatively (associated to its consequent endoscopic treatment), and the formation of rectus abdominis muscle hematoma are reported as the main factors determining the slippage of the mesh from the correct position and, ultimately, the early failure of the ventral hernia repair. Furthermore, the aetiology of early failure of laparoscopic incisional hernia repair, reported in literature, is reviewed.

Background: Cholecystocolonic fistula (CCF) is the second most common cholecystoenteric fistula and is often discovered intraoperatively, resulting in a challenging situation for the surgeon, who is forced to switch to a complex procedure, often in old, unfit patients. Management of this uncommon but possible finding is still ill defined., Methods: An extensive review of 160 articles published from 1950 to 2006 concerning 231 cases of CCF was performed., Results: CCF is mostly an affliction of women in their sixth to seventh decades and is rarely diagnosed preoperatively. Chronic diarrhea is the key symptom in nonemergency patients, but, in one-fourth of cases, CCF presents with an acute onset, mostly biliary ileus. In one-fourth of patients, a second hepatobiliary abnormality is present, including gallbladder cancer in 2% of cases. In uncomplicated cases, diverting colostomy is not performed anymore, and laparoscopy treatment has been described in specialized centers. Symptomatic treatment of concomitant biliary ileus (without treating CCF) is a feasible option. Resolution of colonic biliary ileus by interventional endoscopy is reported., Conclusion: CCF should be considered in differential diagnosis of diarrhea, especially in old, female patients. A possible second hepatobiliary abnormality should be always investigated. Extemporaneous frozen section should be performed if gallbladder cancer is suspected. Depending on clinical presentation, different treatments for CCF are indicated, ranging from minimally invasive procedures to extensive resection.

Clinical presentation of primary torsion of the greater omentum is nonspecific, thus rarely allowing for a preoperative diagnosis. Three patients presented with acute but nonspecific abdominal symptoms. Because ultrasonographic and radiologic findings were unclear, all patients underwent diagnostic laparoscopy. In all cases, laparoscopy enabled us to achieve the diagnosis and to perform a resection of necrotic omentum. The mean duration of the procedure was 56 minutes (range: 42 to 76). The postoperative course was uneventful and the patients were discharged on postoperative day 1 (2) and 3. The value of diagnostic laparoscopy increases when the disease can be treated laparoscopically. The laparoscopic vision allowed us to explore the whole peritoneal cavity, so achieving the diagnosis, and to place the operative trocars at the most convenient sites. The laparoscopic resection of the greater omentum is an easy task even for inexperienced laparoscopic surgeons, allowing patients to benefit from the advantages of a mini-invasive approach.

Background: In a few patients undergoing extensive colorectal resections, a short intermediate colon segment could be saved and interposed between the ileum and the anorectum, although technical problems usually lead to its loss., Cases Presentation: Two cases of anti-peristaltic ileocolonproctoplasty after demolitive surgery of both proximal and distal colon (necrosis of the colonic stump after debulking of ovarian cancer and Crohn's disease) are reported. Because the length of the colonic stump was insufficient to allow for a regular clockwise rotation of the colon and an orthotopic, iso-peristaltic colorectal anastomosis, the remnant colon was rotated in an anti-clockwise fashion and an anti-peristaltic anastomosis was performed, similar to a technique we have recently proposed (anti-peristaltic cecorectal anastomosis) for slow-transit constipation. Owing to the different pathological and surgical findings, two technical variants were adopted, involving the preservation of the middle colic artery and the left colic artery, respectively., Results: Post-operative course was uneventful, and the patients shortly recovered normal bowel habits (a mean of 4 and 3 motions over 24 h, respectively)., Conclusions: In selected patients, the anti-peristaltic interposition of a saved intermediate colon segment between the ileum and the rectal remnant is an advisable technical solution to preserve some re-absorption and reservoir function and to reduce the risk of diarrhoea, incontinence and urgency.

Background: It is still a matter of debate as to whether resective surgery of the primary tumor may prolong the survival of patients affected by incurable colorectal cancer (CRC). The main goal of this retrospective study, carried out on patients not undergoing any therapy other than surgery, was to quantify the benefit of primary tumor removal in patients with differently presenting incurable CRC., Methods: One hundred and thirty consecutive patients were operated on for incurable CRC (83 undergoing resective and 47 non-resective procedures). With the purpose of comparing homogenous populations and of identifying patients who may benefit from primary tumor resection, the patients were classified according to classes of disease, based on the "metastatic pattern" and the "resectability of primary tumor.", Results: In patients with "resectable" primary tumors, resective procedures are associated with longer median survival than after non-resective ones (9 months vs 3). Only patients with distant spread without neoplastic ascites/carcinosis benefit from primary tumor removal (median survival: 9 months vs 3). Morbidity and mortality of resective procedures is not significantly different from that of non-resective surgery, either in the population studied or in any of the groups considered., Conclusions: Palliative resection of primary CRC should be pursued in patients with unresectable distant metastasis (without carcinomatosis), and, intraoperatively, whenever the primary tumor is technically resectable.

Background: Evidence-based strategies are lacking regarding the appropriate management of periampullary retroperitoneal perforations complicating endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES). We propose a transduodenal operative repair of periampullary retroperitoneal perforation., Methods: Six patients with duodenal periampullary perforation induced by endoscopic sphincterotomy underwent operation after failure of an attempt of conservative management. After mobilization of the second and the third part of the duodenum, a minimal transversal duodenotomy was carried out, the papilla was exposed, periampullary perforation was readily identified, and was sutured easily as a sphincteroplasty or by 2 or 3 Vicryl 3/0 sutures. Patient outcomes were measured., Results: Periampullary perforation was repaired as sphincteroplasty in 2 cases, and with Vicryl 3/0 sutures in 4 cases. The mean duration of operation was 176 minutes. There were no intraoperative complications. None of the patients required reoperation after transduodenal repair of the perforation. The patients had a normal postoperative course. The median hospital stay was 10.5 days (range, 9 to 20 days) and the mortality rate was nil. There were no delayed complications during a median follow-up of 60 months., Conclusions: The transduodenal operative approach to periampullary perforation after ERCP/ES at an early stage in the clinical evolution of the perforation is a safe and effective procedure. We consider this approach a useful option for the treatment of periampullary perforation after ERCP/ES when initial endoscopic and conservative management do not yield good results within 24 hours.

We recently described a laparoscopically assisted subtotal colectomy with extracorporeal antiperistaltic cecorectal anastomosis (CRA). We modified this technique by performing an intracorporeal CRA: the anvil head assembly removed from the circular stapler with an ancillary trocar placed into the anvil shaft is pushed through the bottom of the cecum, the cecum with the anvil head assembly is brought into the pelvis, the circular stapler is inserted into the rectum and the cecoproctostomy is performed. Two patients underwent this new laparoscopic subtotal colectomy with CRA. The operating times were 230 and 260 minutes, respectively. There was no postoperative morbidity. Our results allow us to state that intracorporeally performed antiperistaltic cecoproctostomy after laparoscopic subtotal colectomy is feasible.

Background: The aim of this study was to evaluate the subjective anorectal function in patients with left hemicolectomy and to clarify the clinical factors influencing postoperative anorectal function problems., Materials and Methods: One hundred and twenty one patients who underwent left hemicolectomy from April 2002 to December 2003 were enrolled in this study and sent questionnaires concerning anorectal function. Left hemicolectomy in patients with cancer was performed by high ligation of the inferior mesenteric artery; in patients with diverticulitis or polyposis, the inferior mesenteric artery was cut just below the branch of the left colonic artery. One hundred patients replied to the questionnaire: 52 men and 48 women, aged 37 to 85, with a mean age of 66.6 years. Differences were analyzed for statistical significance by the Chi square test and by logistic regression., Results: Anorectal function problems was present in 33% of patients: female gender (P = 0.02), laparoscopic surgery (P = 0.04), and postoperative diarrhea (P = 0.04) had significant independent effects on anorectal function problems. Transient early fecal incontinence was observed in 16% of patients and laparoscopic surgery had significant independent effects on this problem (P = 0.04). Inability to discriminate between gas and stool, tenesmus, or urgency were present in 21%, 18%, and 17% of cases, respectively, and were independently associated respectively with laparoscopic surgery (P = 0.005) and postoperative diarrhea (P = 0.019) (P = 0.015)., Conclusion: In our study the following two issues were clarified: anorectal function problems are frequent after left hemicolectomy, and the laparoscopic technique is linked to poor postoperative anorectal function. The technical methods of high ligation of the inferior mesenteric artery could explain this result.

Because of their extremely variable and often indolent natural course, therapeutic management of neuroendocrine tumors is still controversial. Hepatic metastases, especially for gastro-entero-pancreatic-endocrine neoplasms, are common and often responsible for symptomatology onset. Although it has not been clearly shown, liver resection probably represents the best treatment of hepatic metastases, in terms of symptom palliation and survival prolongation. We present a case, to our knowledge the first in the recent literature, of a 60-year-old patient submitted to a pancreatico-duodenectomy for a pancreatic endocrine carcinoma 20 months after a right hepatectomy for an isolated symptomatic metastasis.

Background: Short-term outcome and anorectal function results after laparoscopic hemicolectomy for colon cancer were compared with results after laparoscopic hemicolectomy for benign diseases., Methods: A total of 108 patients who underwent laparoscopic left colectomy (60 for colon cancer, 48 for diverticulitis or polyposis) were enrolled in the study. Left hemicolectomy in patients affected by cancer was performed by high ligation of the inferior mesenteric artery. A questionnaire concerning anorectal function was mailed to patients 6 months after surgery., Results: Complications were more frequent in the cancer group than in the benign disease group: overall morbidity rate (29.6% versus 8.7%; P = 0.009), diarrhea during the first 6 postoperative months (58.7% versus 34.1%; P = 0.022), and anorectal function problems (fecal incontinence and/or the inability to discriminate between gas and stool, and/or urgency, and/or tenesmus) (65.2% versus 31.7%; P = 0.002)., Discussion: The level of ligation of the lower mesenteric artery and damage at the lower mesenteric ganglion could explain the poorer anorectal function outcome in the colon cancer group.

Context: Brunner's gland hyperplasia is rarely associated with clinical symptoms. Most of the lesions are less than 1 cm in diameter and accounts for about 6.8% of all endoscopically removed duodenal polyps. When symptoms occur, this hyperplasia can be effectively treated with endoscopy. However, when the lesion is too large to pass through the endoscopic snare, endoscopic treatment is not possible and surgical treatment is necessary. This treatment may vary from local excision to more complex operations. When Brunner's gland hyperplasia does not have common dimensions, it may also mimic a malignancy of the duodenal-pancreatic area. In this case, a biopsy is indicated even though its result may be not informative., Case Report: We report the case of a 60-year-old man with a large Brunner's gland hyperplasia mimicking a malignancy and in which the impossibility of a correct diagnosis by pre-operative and intra-operative biopsy led to 'over-treatment' involving a duodenocephalopancreatectomy., Conclusion: This 'over-treatment' may be justified since nowadays the consequences of leaving an undiagnosed pancreatic cancer are much worse than the risk of undergoing a major pancreatic operation.

Different approaches are described in the literature for the detection and treatment of common bile duct stones in patients undergoing laparoscopic cholecystectomy (pre-, intra- or postoperative treatment; combined endoscopic and laparoscopic or total laparoscopic management). No particular "gold standard" treatment can be identified, since too many variables and too many techniques need to be compared. Since it is impossible to establish any single protocol, the reviewing of different large experiences is useful to identify the pros and cons of each procedure. We present the evolution of our own experience over the period 1991-2000 in 1741 patients treated by laparoscopic cholecystectomy for gallbladder stones. We have chosen to assess and treat patients with symptomatic common bile duct stones preoperatively, whereas in the asymptomatic cases we have adopted a protocol that has been modified over the years, consisting first in routine intravenous cholangiography and then in the use of a scoring system which, with the aid of ultrasound data, has allowed us to assess the risk of choledocholithiasis and to administer selective preoperative treatment for common bile duct stones.

The recent progress of surgical endoscopy has allowed to perform minimally invasive esophagectomy both by a combined laparoscopic/thoracoscopic and a totally laparoscopic transhiatal approach. Up to now, all these techniques imply a thoracic (or thoracoscopic) and/or cervical access to perform the esophagogastric anastomosis. In the presented case, a 44-year-old white male patient affected by adenocarcinoma of the cardia (Siewert type 2) underwent a distal esophagectomy entirely accomplished by laparoscopy (including the realization of a mechanical intrathoracic esophagogastrostomy), without the need of any thoracic (nor thoracoscopic) nor cervical access. Duration of surgery was 407 minutes. Postoperative course was uneventful and the patient was discharged on day 7. In selected cases, a totally laparoscopic esophago-gastrectomy without thoracic nor cervical access, may improve the patient's outcome

A number of patients undergoing curative colorectal resection present with local recurrences that are not resectable at the time of diagnosis. Whereas these are predominantly perianastomotic, only a few are primarily anastomotic occurring at the suture line. A 65-year-old female with Dukes B2 adenocarcinoma of the sigmoid colon after a radical left hemicolectomy had further resections with stapled anastomosis at 12 and 22 months, for primary anastomotic recurrences. She remains well 54 months after initial surgery. The recurrent cancers were histologically similar and showed no features of microsatellite instability. The microenvironment at the anastomosis and the suture material must have contributed to this unusual course.

Presented as a possible "second" revolution in general surgery after the introduction of laparoscopy during the last few years, the robotic approach to mini-invasive surgery has not yet witnessed wide, large-scale diffusion among general surgeons and is still considered an "experimental approach". In general surgery, the laparoscopic treatment of gastrooesophageal reflux is the second most frequently performed robot-assisted procedure after cholecystectomy. A review of the literature and an analysis of the costs may allow a preliminary evaluation of the pros and cons of robotic fundoplication, which may then be applicable to other general surgery procedures. Eleven articles report 91 cases of robotic fundoplication (75 Nissen, 9 Thal, 7 Toupet). To date, there is no evidence of benefit in terms of duration of surgery, rate of complications and hospital stay. Moreover, robotic fundoplication is more expensive than the traditional laparoscopic approach (the additional cost per procedure due to robotics is 1,882.97 euros). Only further technological upgrades and advances will make the use of robotics competitive in general surgery. The development of multi-functional instruments and of tactile feedback at the console, enlargement of the three-dimensional laparoscopic view and specific "team" training will enable the use of robotic surgery to be extended to increasingly difficult procedures and to non-specialised environments.

Background and Aims: Surgical and functional results after abdominoperineal resection and total anorectal reconstruction by electrostimulated gracilis muscle transposition are still poorly documented. This study prospectively evaluated surgical and functional outcome over time in our patients., Patients and Methods: Twenty-three patients underwent abdominoperineal resection, coloperineal pullthrough, double graciloplasty, and loop abdominal stoma. Temporary external-source intermittent electrostimulation, biofeedback training, and selective delayed stimulator implantation to improve unsatisfactory results were carried out in the first 13 patients (1st series); thereafter (2nd series) the stimulator was implanted during graciloplasty. Surgical and oncological results were followed up in all patients. Functional results were evaluated in 16 patients who underwent abdominal stoma takedown, eight in each of the two series, by anomanometry (up to 1 year) and our own 0-20 scoring system (up to 8 years from initial surgery)., Results: The rate of major and minor postoperative complications was 21.7% and 65%, respectively. Continuous electrostimulation proved effective on resting anal pressure. Early clinical assessments showed satisfactory functional results (considered as having a score < or =8) in all first-group patients, including five who had stimulator support, and in one-half of second-group patients. After impairment (at least 2 points) at 1 year in five patients, four of whom were from the first group, all functional results improved and became satisfactory from 5 years on (1st series) and from 4 years on (2nd series)., Conclusion: Despite marked morbidity the high rate of good results, which improved over time, suggests that total anorectal reconstruction is worth being performed as part of abdominoperineal resection in well-selected patients with a strong motivation to avoid a permanent colostomy.

Afferent loop syndrome after Billroth II gastrectomy is usually caused by those events that impair the evacuation of the afferent duodenal loop. The formation of an enterolith in an afferent loop is a rare but dangerous event. We present a unique report of a patient in whom a huge enterolith developed in the afferent loop of a Billroth II anastomosis, which led to intestinal occlusion. This migration occurred after a laparoscopic procedure, so we hypothesized that this procedure could be the cause of enterolith migration.

The most usual reconstruction after subtotal colectomy is ileo-rectal anastomosis, which requires the removal of the caecum. We propose the treatment of chronic slow-transit constipation with subtotal colectomy and antiperistaltic caecoproctostomy. The sparing of the caecum, the ileo-caecal valve and the distal ileal loop, leaving a physiologic reservoir, allowing the presence of colic bacterial flora which metabolizes the undigested starch and produces short chain fatty acids, should guarantee a normal stool consistency, normal absorption of water, sodium and vitamin B12 and the prevention of renal and gallbladder lithiasis. In 1992, we started a study on the outcome of 19 patients who had undergone subtotal colectomy and antiperistaltic caeco-rectal anastomosis for slow-transit constipation. The surgical procedure was carried out without any serious complications and without mortality. The mean clinical follow-up was 64 months (range 5-132). Six months after surgery, 13 patients reported normal bowel movements with solid stool consistency, 5 reported diarrhoea and the need for antidiarrhoeal agents, and one reported constipation easily controlled with laxatives. Fifteen patients considered their quality of life as having improved compared with that before surgery. Selection of patients justify such very satisfying results. It is well known that colic resection is effective only in the case of slow transit constipation, and thus a careful physiologic assessment is needed to rule out other causes of constipation, such as outlet obstruction syndrome.

Background and Aims: Besides incontinence, constipation is important after TAR. We aimed at evaluating their correlation and role in functional outcome., Materials and Methods: 81 diaries in 16 patients (up to 8 years) were assessed, by a specific scoring system, regarding incontinence and evacuation. In the overall series and in three postoperative time groups, the correlation between the two items, their mean scores and relative score rates (% of the maximum possible scoring) were calculated., Results: The Spearman correlation coefficient in all assessments was -0.128. According to timing, it was: 0.468 (short term), -0.036 (mean term) and -0.69 (long term). Incontinence was more disabling than evacuation; constipation occurred more frequently. Incontinence improved over time; constipation did not substantially change., Conclusions: Current criteria for functional assessment do not describe the true conditions after TAR and their variations over time. Profound consideration is necessary before announcing ultimate judgements on TAR.

Objective: To evaluate whether preoperative ultrasonographic assessment of the number and size of gallbladder stones can identify patients at increased risk of having asymptomatic common bile duct stones., Methods: Ultrasonographic data for 300 consecutive patients undergoing laparoscopic cholecystectomy were analyzed. Patients were divided into a group in which multiple small (< or = 5 mm) or multiple variably sized (both < or = 5 and > 5 mm) gallbladder stones were present ("positive" stones) and a group with multiple large (> 5 mm) or single gallbladder stones, considered "negative." The ultrasonographic description was compared with surgical findings; finally, the prevalence of asymptomatic common bile duct stones in the 2 groups was compared., Results: Ultrasonographic classification of gallbladder stones was confirmed at surgery in 285 cases (95%). Asymptomatic common bile duct stones were diagnosed in 9.5% of patients with an ultrasonographic diagnosis of positive gallbladder stones and in only 2.3% of patients with a diagnosis of negative gallbladder stones (P < .05)., Conclusions: Ultrasonography is able to accurately show gallbladder stones; the appearance of multiple small and variably sized gallbladder stones represent a risk factor for synchronous asymptomatic common bile duct stones.

Background and Aims: To test current systems evaluating for fecal continence after total anorectal reconstruction (TAR) we adapted the incontinence plus evacuation scoring system proposed by the Working Party on Anal Sphincter Replacement (WPASR)., Patients and Methods: We examined 51 monthly diaries recorded by 14 patients after TAR or at yearly checks (up to 5 years). A form detailing all items and frequencies of the WPASR system was given to 12 patients who assigned a rating to each item in a frequency cell. The mean values of cells were rounded off, and a 0-20 scoring scale was obtained. We corrected the scores using previously defined criteria aimed at complying with an objective rating of severity while preserving the overall patient rating. Diaries were reevaluated by both patient-rated and surgeon-corrected scales, and the correlation was calculated to each other and to Jorge and Wexner's and the Williams et al. systems; correlations between incontinence and evacuation scores were also calculated., Results: The surgeon-corrected system tended to have a lower mean score than the patient-rated one and was strongly correlated with it ( r=0.984), a significantly higher mean score than the Jorge and Wexner scale ( r=0.893), and a significantly lower mean score than the Williams et al. classification (quadrupled scores; r=0.857). No correlations between incontinence and evacuation were found., Conclusions: Although not validated, the patient-rated, surgeon-corrected adjustment of the WPASR system proved in our patients a reliable instrument for functional assessment. Its consensus administration to any given patient samples requires further research.