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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]

Abstract Introduction Cutaneous metastases from carcinomas of the bladder are very rare. They are related to advanced stages of the disease and have poor prognosis with low survival rates. The common treatment modality of cutaneous metastases from a primary bladder cancer is wide local excision followed by chemotherapy. Case presentation We report a case of solitary skin metastasis from a rare type of urinary bladder carcinoma in a 68 year-old Caucasian man. Urinary bladder carcinoma metastasizing to the skin is an uncommon finding despite the high incidence of this tumor. Skin metastasis generally presents in the late stages of this disease and indicates a poor outcome. Conclusions Because of the extremely aggressive malignant potential of sarcomatoid carcinomas, the indications for a transurethral resection of the bladder should be carefully assessed and suitable therapeutic strategies should be examined further.

Abstract Seventeen cases of peritonitis due to rupture of a pyonephrosis have been reported. The majority of these cases occur secondary to renal stones. Only two cases of ruptured pyonephrosis with concurrent kidney neoplasm have been described and only one of these presented as an acute peritonitis. In this presentation we discuss an unusual case of a 68 year old man with a chronic history of bilateral nephrolithiasis and recent pyonephrosis. He presented acutely with peritonitis and was later found to have a carcinosarcoma of the kidney. The case highlights the importance of recognizing the possibility of underling renal carcinoma in patients presenting with a ruptured pyonephrosis and discuss steps to avoid this serious complication.

The necessity of liver donors has contributed to overcoming the traditional criteria and to propose new ones for the acceptance of livers for transplantation. For this reason expanded or extended criteria donation (ECD) or even overextended criteria for marginal or high-risk organ donors have been developed. Ethical, Legal and Psychological Aspects of Organ Transplantation (ELPAT) and European Liver and Intestine Transplant Association (ELITA) – European Liver Transplantation Registry (ELTR) coordinated the distribution of a previously reported questionnaire that was sent to 53 European liver transplant centers. Criteria were divided based on the response rate. Donor criteria such as steatosis and serum sodium >165 mmol/L, as well as recipient criteria such as previous history of cancer, were not considered contraindications to transplantation in more than 60% of cases. Criteria such as ICU (intensive care unit) stay, body mass index >30, serum bilirubin >3 mg/dL, and HIV infection or critical illness were not considered adequate for transplantation in 30% to 59% of cases. On the other hand, there was no agreement on other extended liver donor and recipient criteria, such as age up to 80 years, serum glutamic oxaloacetic transaminase >90 U/L, serum glutamic pyruvic transaminase >105 U/L, high-risk sex practices, drug users, patients older than 65 years, and patients younger than 65 years, respectively. Criteria such as serum sodium could not be considered ECD criteria. In conclusion, development of more studies and inclusion of more liver transplantation centers are required to confirm these data. [ABSTRACT FROM AUTHOR]

Aim: Solitary rectal ulcer syndrome (SRUS) is a benign and poorly understood disorder with complex management. Typical symptoms include straining during defaecation, rectal bleeding, tenesmus, mucoid secretion, anal pain and a sense of incomplete evacuation. Diagnosis is based on characteristic clinical symptoms and endoscopic/histological findings. Several treatments have been reported in the literature with variable ulcer healing rates. This study aimed to evaluate the efficacy of different treatments for SRUS., Materials and Methods: A systematic review and network meta-analysis were performed according to the PRISMA guidelines. Studies in English, French and Spanish languages were included. Papers written in other languages were excluded. Other exclusion criteria were reviews, case reports or clinical series enrolling less than five patients, study duplications, no clinical data of interest and no article available. A systematic literature search was conducted from January 2000 to March 2024 using the following databases: PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus. The biases of the studies were assessed using the Newcastle-Ottawa scale or the Jadad scale when appropriate. Types of treatment and their efficacy for the cure of SRUS were collected and critically assessed. The study's primary outcome was to estimate the rate of patients with ulcer healing., Results: A total of 22 studies with 911 patients (men 361, women 550) diagnosed with SRUS were analysed in the final meta-analysis. The pooled effect estimates of treatment efficacy revealed that surgery showed the highest ulcer healing rate (70.5%; 95% CI 0.57-0.83). Surgery was superior in the cure of ulcers with respect to medical therapies and biofeedback (OR 0.09 and OR 0.14)., Conclusion: Solitary rectal ulcer syndrome is a challenging clinical entity to manage. Proficient results have been reported with the surgical approach, suggesting its positive role in cases refractory to medical and biofeedback therapy. Further studies in homogeneous populations are required to evaluate the efficacy of surgery in this setting. (PROSPERO registration number CRD42022331422)., (© 2024 Association of Coloproctology of Great Britain and Ireland.)

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., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Poor data exist on the influence of holidays and weekdays on the number and the results of liver transplantation (LT) in Italy. The study's main objective is to investigate the impact of holidays and the different days of the week on the LT number and early graft survival rates in a multi-centric Italian series. We performed a retrospective analysis on 1,026 adult patients undergoing first deceased-donor transplantation between January 2004 and December 2018 in the three university centers in Rome. During the 4,504 workdays, 881 LTs were performed (85.9%; one every 5.1 days on average). On the opposite, 145 LTs were done during the 975 holidays (14.1%; one every 7.1 days on average). Fewer LTs were performed on holidays (P = 0.004). There were no substantial differences in donor-, recipient- and transplant-related characteristics in LTs performed on weekdays or holidays. On Monday, fewer transplants were performed (vs. other weekdays: P < 0.0001; vs. Sunday: P = 0.03). At multivariable Cox regression analysis, LTs performed during the holiday or during the different days of the week were not found to be independent risk factors for the risk of 3- and 12-month graft loss. At three-month survival curves, no differences were observed among the transplants performed during the holidays versus the workdays (86.2 vs. 85.0%; P-0.70). The range of graft survival rates based on the day of the week was 81.6-86.9%, without showing any significant differences (P = 0.57). Fewer transplants are performed on holidays and Mondays. Survivals are not affected by holidays or the day the transplant is performed., (© 2022. The Author(s).)

Background and Objectives : Liver transplantation (LT) is the best strategy for curing several primary and secondary hepatic malignancies. In recent years, growing interest has been observed in the enlargement of the transplant oncology indications. This paper aims to review the most recent developments in the setting of LT oncology, with particular attention to LT for unresectable colorectal liver metastases (CRLM) and cholangiocellular carcinoma (CCA). Materials and Methods : A review of the recently published literature was conducted. Results : Growing evidence exists on the efficacy of LT in curing CRLM and peri-hilar and intrahepatic CCA in well-selected patients when integrating this strategy with (neo)-adjuvant chemotherapy, radiotherapy, or locoregional treatments. Conclusion : For unresectable CCA and CRLM management, several prospective protocols are forthcoming to elucidate LT's impact relative to alternative therapies. Advances in diagnosis, treatment protocols, and donor-to-recipient matching are needed to better define the oncological indications for transplantation. Prospective, multicenter trials studying these advances and their impact on outcomes are still required.

Background: Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis., Methods: A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis., Results: A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%., Conclusion: Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Aims: Indocyanine green (ICG) fluorescence angiography (FA) is used for several purposes in general surgery, but its use in bariatric surgery is still debated. The objective of the present pilot study is to evaluate the intraoperative utility of ICG-FA during bariatric surgery in order to focus future research on a reliable tool to reduce the postoperative leak rate., Methods: Thirteen patients (4 men, 30.8%, 9 women, 69.2%) with median age of 52 years (confidence interval, CI, 95% 46.2-58.7 years) and preoperative median body mass index of 42.6 kg/m 2 (CI, 95% 36 to 49.3 kg/m 2 ) underwent bariatric surgery with ICG-FA in our center. Three mL of ICG diluted with 10 cc sterile water were intravenously injected after gastric tube creation during laparoscopic sleeve gastrectomy (LSG) and after the gastric pouch and gastro-jejunal anastomosis creation during laparoscopic gastric by-pass (LGB). For the ICG-FA, Karl Storz Image 1S D-Light system (Karl Storz Endoscope GmbH & C. K., Tuttlingen, Germany) placed at a fixed distance of 5 cm from the structures of interest and zoomed vision modality were used to identify the vascular supply. The perfusion pattern was assessed by the surgical team according to a score. The score ranged from 1 (poor vascularization) to 5 (excellent vascularization) based on the intensity and timing of fluorescence of the vascularized structures., Results: Fom January 2021 to February 2022, six patients underwent LSG (46.2%), three patients underwent LGB (23.1%), and four patients underwent re-do LGB after LSG (30.8%). No adverse effects to ICG were observed. In 11 patients (84.6%) ICG-FA score was 5. During two laparoscopic re-do LGB, the vascular supply was not satisfactory (score 2/5) and the surgical strategy was changed based on ICG-FA (15.4%). At a median follow-up of five months postoperatively, leaks did not occur in any case., Conclusions: ICG-FA during bariatric surgery is a safe, feasible and promising procedure. It could help to reduce the ischemic leak rate, even if standardization of the procedure and objective fluorescence quantification are still missing. Further prospective studies with a larger sample of patients are required to draw definitive conclusions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Balla, Corallino, Quaresima, Palmieri, Meoli, Cordova Herencia and Paganini.)

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., (© 2021. The Author(s).)

Neurogenesis persists in selected regions of the adult mouse brain; among them, the ventricular-subventricular zone (V-SVZ) of the lateral ventricles represents a major experimental paradigm due to its conspicuous neurogenic output. Postnatal V-SVZ neurogenesis is maintained by a resident population of neural stem cells (NSCs). Although V-SVZ NSCs are largely quiescent, they can be activated to enter the cell cycle, self-renew and generate progeny that gives rise to olfactory bulb interneurons. These adult-born neurons integrate into existing circuits to modify cognitive functions in response to external stimuli, but cells shed by V-SVZ NSCs can also reach injured brain regions, suggesting a latent regenerative potential. The V-SVZ is endowed with a specialized microenvironment, which is essential to maintain the proliferative and neurogenic potential of NSCs, and to preserve the NSC pool from exhaustion by finely tuning their quiescent and active states. Intercellular communication is paramount to the stem cell niche properties of the V-SVZ, and several extracellular signals acting in the niche milieu have been identified. An important part of these signals comes from non-neural cell types, such as local vascular cells, ependymal and glial cells. Understanding the crosstalk between NSCs and other niche components may aid therapeutic approaches for neuropathological conditions, since neurodevelopmental disorders, age-related cognitive decline and neurodegenerative diseases have been associated with dysfunctional neurogenic niches. Here, we review recent advances in the study of the complex interactions between V-SVZ NSCs and their cellular niche. We focus on the extracellular cues produced by ependymal and vascular cells that regulate NSC behavior in the mouse postnatal V-SVZ, and discuss the potential implication of these molecular signals in pathological conditions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Quaresima, Istiaq, Jono, Cacci, Ohta and Lupo.)

Background: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry., Methods: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications., Results: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013-0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not., Conclusion: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

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.

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.

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/m 2 ). 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.

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/m 2 , 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.

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.

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.

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.

Introduction: Accidental thermal injuries are infrequent, nonetheless, dangerous complications in laparoscopic surgery. Burns are produced because of direct contact, lack of instrument insulation and capacitive coupling. Biological fluids on the surface of laparoscopic instruments behave as electric conductors on the sheath and may be responsible for accidental thermal injuries. Our hypothesis is that using an insulator device may prevent those injuries., Materials and Methods: After evaluating different materials for dielectric properties, costs, and temperature increase tolerance, we selected polytetrafluoroethylene (PTFE) to develop a sleeve that works as an electrical insulator when applied on the sheath of laparoscopic instruments. Efficacy of this PTFE cover in reducing conduction of electricity was tested on both reusable and disposable laparoscopic instruments., Results: Electric conduction of the laparoscopic instrument sheaths was tested using an ex vivo model that reproduces the abdominal environment in basal conditions and in presence of blood. Electric conduction of laparoscopic instruments was measured before and after the placement of the PTFE cover. We measured a significant difference in electric resistance on the sheath's surface without and with blood, revealing a weak electrical conduction: infinity versus a median value of 251.11 Mohm, respectively., Conclusions: This ex vivo study demonstrated that a PTFE sleeve may reduce electricity conduction of laparoscopic instruments. A pilot in vivo study is planned to test its safety and efficacy.

Aim: Minimally invasive adrenalectomy is the treatment of choice for benign adrenal lesions including pheocromocytoma (PHE) and in selected patients with malignant lesions. The aim of the present study is to evaluate the authors' results after laparoscopic left anterior transperitoneal submesocolic adrenalectomy (LLATSA) for unilateral PHE., Material of Study: This study is a retrospective analysis of prospectively collected data. From 1994 to 2018, 552 patients underwent laparoscopic adrenalectomy (LA). Of these, 34 patients (14 men, 20 women, mean age 52.8 years) underwent LLATSA for PHE., Results: Mean operative time was 93.1 ± 44.9 minutes. Conversion to open surgery occurred in two patients due to difficult identification of the anatomy. Intraoperative blood pressure and heart rate instability were observed in four cases, but with no need for conversion. Postoperative morbidity was nil. One American Society of Anesthesiologists (ASA) III patient died on postoperative day 4 from acute myocardial infarction. Mean postoperative hospital stay was 3.8 ± 1.8 days (range 2 - 8)., Discussion: The main advantage of this approach is the early ligation of the main adrenal vein prior to any gland manipulation. This reduces the risk of catecholamines' spread and consequently the risk of hemodynamic instability. Intraperitoneal dissection is limited and there is no need to mobilize the colon or pancreas, with a lower risk of complications from organ manipulation., Conclusions: LLATSA is feasible and safe for the treatment of PHE. A randomized trial design and a larger cohort of patients would be required to confirm these conclusions., Key Words: Adrenal tumors, Adrenal lesions, Laparoscopic adrenalectomy, Pheochromocytoma, Transperitoneal anterior approach, Laparoscopic left anterior transperitoneal submesocolic adrenalectomy (LLATSA).

The authors of the published version of this article missed to add the second affiliation of Mostafa Shalaby. The new affiliation is now added and presented correctly in this article. The remainder of the article remains unchanged.

Background: Aim of this study is to report and to analyze the incidence, clinical impact and treatment options of ectopic air localizations after transanal procedures., Methods: A systematic literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The research was carried out using the PubMed database, identifying 40 articles with the following keywords: "transanal" AND "emphysema"; "transanal" AND "subcutaneous emphysema"; "transanal" AND "pneumomediastinum"; "transanal" AND "pneumothoraces"; "transanal" AND "pneumopericardium"; "transanal" AND "retropneumoperitoneum"., Results: Nineteen articles, published between 1993 and 2017, were included in the study for a total of 29 patients. The most frequent air localization was in the retroperitoneum, followed by subcutaneous tissues, mediastinum and neck. This condition was treated conservatively in 20 patients, with colostomy in 4 patients, with bowel resection and negative diagnostic laparoscopy in one patient each. In three cases the treatment was not specified. Ectopic air location resolved in all cases., Conclusions: Pneumo-mediastinum and pneumo-retroperitoneum after transanal procedures are unusual complications with a dramatic radiological appearance but can be managed successfully with a completely benign course in most cases. Initially, a conservative approach is recommended. Surgical treatment should be reserved only in case of fluid collection or suture dehiscence., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: "Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis., Methods: We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed., Results: Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days., Conclusions: Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.

Aim of the present study is to report clinical characteristics and outcomes of patients treated in authors' hospital for GI metastasis from primary lung cancer, and to report and analyse the same data concerning patients retrieved from a systematic literature review. We performed a retrospective analysis of prospectively collected data, and a systematic review using the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Ninety-one patients were included, 5 patients from the authors' hospital and 86 through PubMed database using the keywords "intestinal metastasis" AND "lung cancer". The median time between primary lung cancer diagnosis and GI metastasis diagnosis was 2 months and the median overall survival was 4 months. This group of patients present a poor prognosis and the gold standard treatment is not defined. None of the reported treatments had a significant impact on survival., (Copyright © 2018 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Vaginoplasty by penile and scrotal skin inversion is a well-established technique for male-to-female gender confirmation surgery. In this setting, chronic inflammation and lacerations associated with history of human papillomavirus (HPV) infection may induce a high risk of malignant degeneration in the long term. A 78-year-old transgender woman was admitted with genital discomfort and neovaginal discharge. The patient's history revealed male-to-female gender confirmation surgery with construction of a neovagina by penile and scrotal skin inversion at 33 years of age. Physical examination of the genitalia revealed presence of fecal material, suggestive of recto-neovaginal fistula. A biopsy specimen was positive for well-differentiated HPV-related squamous cell carcinoma. Magnetic resonance imaging (MRI) showed a bulky mass in the posterior wall of the neovagina that infiltrated the urethra, prostatic gland and the anterior rectal wall. Following a multidisciplinary evaluation, we performed a definitive sigmoid colostomy and administered chemotherapy. Long-term follow-up seems advisable in patients after vaginoplasty due to the possibility of delayed development of cancer. Following biopsy, we consider MRI as the modality of choice to identify possible infiltration of the adjacent structures. As data regarding these lesions are scarce and management is complex, a multidisciplinary approach is recommended.

Background: The aim of this study is to evaluate the long-term results of Muzi's tension free primary closure technique for pilonidal sinus disease (PSD), in terms of patients' discomfort and recurrence rate., Methods: This study is a retrospective analysis of prospectively collected data. Five hundred fourteen patients were treated. Postoperative pain (assessed by a visual analog scale, VAS), complications, time needed to return to full-day activities, and recurrence rate were recorded. At 12, 22, and 54 months postoperative, patients' satisfaction was evaluated by a questionnaire scoring from 0 (not satisfied) to 12 (greatly satisfied)., Results: The median operative time was 30 min. The overall postoperative complication rate was 2.52%. Median VAS score was 1. The mean of resumption to normal activity was 8.1 days. At median follow-up of 49 months, recurrence rate was 0.4% (two patients). At 12 months' follow-up, the mean satisfaction score was 10.3 ± 1.7. At 22 and 54 months' follow-up, the score was confirmed., Conclusions: Muzi's tension free primary closure technique has proved to be an effective treatment, showing in the long-term follow-up low recurrence rate and high degree of patient satisfaction. Therefore, we strongly recommend this technique for the treatment of PSD.

[This corrects the article on p. 139 in vol. 32, PMID: 27626024.].

[This corrects the article on p. 46 in vol. 33, PMID: 28503515.].

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/m 2 , 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.