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Vagus nerve stimulation (VNS) is an accepted therapy for the treatment of refractory forms of epilepsy and depression. The brain-gut axis is increasingly being studied as a possible etiological factor of chronic inflammatory diseases, including inflammatory bowel diseases (IBD). A significant percentage of IBD patients lose response to treatments or experience side effects. In this perspective, VNS has shown the first efficacy data. The aim of this narrative review is to underline the biological plausibility of the use of VNS in patients affected by IBD, collect all clinical data in the literature, and hypothesize a target IBD population on which to focus the next clinical study.

Background and Objectives: The purpose of the investigation was to compare clinical results and diagnostic accuracy for conventional multiport laparoscopic lymph node biopsy (MPLB) and single-port laparoscopic lymph node biopsy (SPLB) operations at a single institution., Methods: A set of 20 SPLB patients operated on from October 2016 to May 2019 were compared to an historical series of 35 MPLB patients. Primary endpoints were the time of surgery, estimated blood loss, surgical conversion, length of stay and morbidity. The secondary endpoint was the diagnostic accuracy of the technique., Results: SPLB was completed laparoscopically in all cases. Two MPLB patients (5.7%) experienced a surgical conversion due to intraoperative difficulties. Duration of surgery was similar in SPLB and MPLB groups respectively (84 ± 31.7 min vs. 81.1 ± 22.2; P = .455). A shorter duration of hospital stay was shown for patients operated on by SPLB compared to the MPLB group (1.7 ± 0.9 days vs. 2.1 ± 1.2 days; P  =   .133). The postoperative course was uneventful in both groups. In 95% of the SPLB and 97.1% of the MPLB cases respectively, LLB achieved the necessary information for the diagnosis., Conclusion: SPLB has shown good procedural and postoperative outcomes as well as a high diagnostic yield, comparable to traditional MPLB. Therefore, our results show that this approach is safe and effective and can be an equally valid option to MPLB to obtain a diagnosis or to follow the progression of a lymphoproliferative disease. Further studies are necessary to support these results before its widespread adoption., Competing Interests: Conflicts of Interest: The authors declare no conflicts of interest., (© 2020 by JSLS, Journal of the Society of Laparoscopic & Robotic Surgeons.)

Background/aim: Inflammatory bowel diseases (IBD) are a group of conditions characterized by chronic inflammation of all or part of the digestive tract and primarily includes Ulcerative Colitis (UC) and Crohn's Disease (CD). This review has as target to summarize the complicated correlation between IBD and infections, which can affect patients' quality of life and increase substantially morbidity and mortality rates., Results: Scientific evidence in recent years shows a growing recognition of the phenomenon although the association between these two aspects is not definitively clear. Despite the fact that our understanding of this linkage is still incomplete, it is easily deducible that infections can start whether it be the onset or the relapse of IBD. In addition to this, the course of the disease predisposes the patient to numerous infections caused by the drugs used to treat IBD and this also raises the risk of infection complications., Conclusions: Clinical trials have demonstrated that the combined use of immunomodulating agents may increase the risk of new infections. The infections might be intensified by an insufficient vaccination of adults with IBD. Physicians have to be aware of these risks and try to attenuate and treat them properly., Key Words: Infections, Inflammatory bowel disease, Risk factors.

Background: Despite advances in the medical management of Ulcerative Colitis (UC), surgery is required in about a third of patients., Aims and Methods: A review of the literature of the last 20 years was conducted in order to analyze the results of Ileo-Rectal Anastomosis (IRA) and of Ileal Pouch-Anal Anastomosis (IPAA) in the treatment of mild-to-moderate UC. Postoperative complications, functional results and the risk of cancer were analyzed in each of the two groups of patients., Results: In IRA group postoperative morbidity is low, varying from 8 to 28%. The risk of urinary and sexual dysfunction are rare and fertility rates are higher, compared to IPAA. The cumulative probability of success (working IRA) is 84% at 5 years and 51-69% at 10 years. The postoperative morbidity of IPAA is higher; dehiscence and pelvic sepsis were observed respectively in 9.5% and in 5.5%. A sexual dysfunction is present in 3.4%. In 18.8% occurs pouchitis. The risk of failure of the pouch is 6.8% and increased to 8.5% after 5 years. The risk of cancer is higher after IRA than after IPAA, with a cumulative risk at 20 years of 6-14% and 4.2% respectively., Discussion: The choice between IPAA or IRA is based upon patient's preference and clinical criteria (malignancy or sphincter injury). IPAA, intervention of choice, is burdened by a higher rate of complications, such as anastomotic leak with pelvic sepsis and subsequent functional pouch failure, pouchitis, infertility in young women, lesions of the pelvic nerves and portal vein thrombosis. There have been reports of cancer not only in the anal transitional zone, but also in the same pouch, either after mucosectomy that after stapled anastomosis. IRA is less invasive than IPAA and postoperative complications are lower. Does not require dissection of the pelvic and presents no risk of injury of the nerves of the urogenital sphere. The long-term results of the IRA are generally satisfactory and most of the patients stated that after the intervention improve both the health status and quality of life., Conclusion: Today IPAA is the gold standard. The IRA is indicated in selected patients where they meet the following requirements: normal sphincter tone, absence of severe perineal disease, rectum does not actively involved by the disease, absence of dysplasia or cancer. It is also indicated in patients who refuse an ileostomy and it can be proposed as a possible interim procedure in young women, because it does not need a pelvic dissection and because the risk of infertility is minimal or absent when compared to IPAA. Because the risk of cancer is higher, patients undergoing IRA must be adequately informed about the risk, as well as recurrent proctitis, also of cancer, and must fully understand the need for surveillance and accept at least annual endoscopy with rectal biopsies; if these conditions are not met, patients should not be candidates for IRA., Key Words: IPAA, IRA, Surgical treatment, Ulcerative Colitis.

Background: The treatment of acute diverticulitis is a matter of debate and has undergone significant changes. Currently the main focus of surgical treatment is a more conservative and less invasive management., Aims and Methods: To focus the role of surgery in the treatment of acute diverticulitis, the Authors have conducted a review of the literature of the last two decades and have revised critically their own experience., Results: The indications for elective surgery based on the number of episodes, the young age at diagnosis and the presence of risk factors such as immunosuppression, have to be overcome in favour of a more individual approach based on the severity of the disease. Similarly the presence of pneumoperitoneum is no longer a compelling indication for urgent surgery just as it was in the past. In the treatment of complicated diverticulitis with abscess (Hinchey I-II) is used more and more conservative treatments consisting of guided percutaneous drainage combined with antibiotics. Resection with primary anastomosis with or without diverting ileostomy is preferable to Hartmann's procedure in case of perforated diverticulitis with peritonitis (Hinchey III-IV), using the latter only in the case of comorbidities, severe sepsis, hemodynamic instability or longtime feculent peritonitis (Hinchey IV). Recently, laparoscopic peritoneal lavage was introduced in the treatment of diverticulitis., Conclusions: Thanks to the progress made in conservative and interventional treatment and laparoscopic surgery, an increasingly less invasive treatment is proposed in the management of acute diverticulitis., Key Words: Acute diverticulitis, Laparoscopic surgery, Surgical treatment.

Background: Fecal Incontinence (FI) can seriously affect quality of life. The treatment of fecal incontinence starts conservatively but in case of failure, different surgical approaches may be proposed to the patient. Recently several not invasive approaches have been developed. One of these is the radiofrequency (RF) energy application to the internal anal sphincter., Case Presentation: We report a rare case of an anal abscess related to a SECCA procedure in a 66-year-old woman affected by gas and FI for twenty years., Conclusions: The complications post-SECCA procedure reported in literature are generally not serious and often self-limited, such as bleeding or anal pain. This is a case of an anal abscess. We suggest that this finding could consolidate the importance of administering antibiotic therapy to patients and to run a full course of at least 6 days rather than a short-term (24 h) therapy, with the aim to minimize the incidence of this complication.

Introduction: In case of massive splenomegaly, laparoscopic splenectomy (LS) becomes challenging, uncomfortable and risky both for the surgeon and for the patient. As a consequence of ongoing research to obtain efficient and cheaper "scarless surgery", single-port technique and hand-assisted devices were developed and improved in this field., Presentation of Case: We present the clinical case of a patient affected by idiopathic myelofibrosis (MF) and splenomegaly who was admitted to our Department to perform a splenectomy for a suspected 5-cm splenic lesion., Discussion: The splenic longitudinal diameter measured 26 cm. The patient underwent splenectomy by laparoscopy, combining a single-port access and a gel-port device. The operation was completed laparoscopically. The operating time was 220 min and the estimate blood loss was 100 ml. The patient was discharged at 11 post-operative day in overall good conditions. Upon pathological analysis the splenic lesion was a localization of diffuse large B-cell Lymphoma in the context of MF., Conclusion: this novel "hybrid technique" of splenectomy, combining the advantages of reduced number of abdominal incisions of the single-port technique to those of the hand assistance, is feasible in massive splenomegaly with good results. Furthermore, the use of the sovrapubic retrieval incision as the introduction site for the hand assisted device is convincing, since it's useful for both tasks. Further studies with large casuistries are necessary to confirm the effectiveness of the technique., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Primary lymphomas of appendix are extremely rare tumors. The incidence is 0.015% of all gastrointestinal lymphomas., Presentation of Case: We present a case of a 75 year-old male patient who presented with acute abdominal pain in the lower right quadrant and fever., Discussion: The patient received laparotomic appendectomy. The definitive histopathological examination revealed the presence of diffuse large cell B-lymphoma of the appendix. The neoplasms of appendix usually manifest clinically with sign and symptoms of acute appendicitis from luminal obstruction (30-50%). Preoperative diagnosis is difficult and often occurs through histopathological examination., Conclusion: Primary appendiceal lymphoma is rare and there are no clear guidelines for therapy. Primary surgical resection followed by post-operative chemotherapy showed high efficacy. The histopathological examination of all appendectomy is essential., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Schwannomas are benign tumours that originate from the myelin sheath of peripheral nerves. They are characterised by a slow growth tendency. Benign schwannomas represent 35% of the head and neck district tumours. Hypoglossal schwannomas account for 5% of non-vestibular schwannomas, and malignant schwannomas occur very rarely. In the present case report, the case of a 49-year-old man who presented with paraesthesias in the left parotid and submandibular region, associated with sensation of foreign bodies and dysphagia for solids, is described. A clinical examination revealed the presence of an ovoid palpable mass in the lateral-cervical region of the neck. The patient subsequently underwent excisional surgery, and neuropathological evaluation of the specimen confirmed the diagnosis of benign schwannoma with Antoni areas A and B. Despite the rarity of schwannomas, this condition should be considered in differential diagnoses for masses localised in the neck, as in cases where they reach considerable sizes (>3 cm in diameter). Surgery therefore represents the first-choice treatment.

Von Hippel-Lindau (VHL) disease is an inherited syndrome with autosomal-dominant transmission, characterized by central nervous system and retinal hemangioblastomas, visceral cysts and tumors. Optimal surgical treatment, including its timing, remains a controversial topic. The present study reports the case of a 67-year-old female patient with adrenal and pancreatic manifestations of VHL. A laparoscopic cortex-sparing left adrenalectomy for a 4-cm pheochromocytoma and pancreatic enucleation for pancreatic polypeptidoma of the pancreas tail were performed during the same operative procedure. The total operative time was 240 min. There were no operative complications, and the surgery was completed laparoscopically with minimal blood loss. A prolonged hospital stay was necessary to treat a grade C postoperative pancreatic fistula. The histopathological result was an adrenal pheochromocytoma and a well-differentiated neuroendocrine tumor, secreting pancreatic polypeptides. In conclusion, organ-sparing laparoscopic surgery is an important option for treating simultaneous lesions in several abdominal solid viscera, such as VHL disease, and the present case study represents, to the best of the authors' knowledge, the first report of single-stage laparoscopic adrenalectomy and pancreatic tumor enucleation.

Introduction: Primary myelofibrosis (MF) is a myeloproliferative neoplasm that results in debilitating constitutional symptoms, splenomegaly, and cytopenias. In patients with symptomatic splenomegaly, splenectomy remains a viable treatment option for MF patients with medically refractory symptomatic splenomegaly that precludes the use of ruxolitinib., Case Presentation: We present the clinical case of a patient who was admitted to our Department to perform a splenectomy in MF as a therapeutic step prior to an allogeneic stem cell transplantation (ASCT). A laparotomic splenectomy and excision of whitish wide-spread peritoneal and omental nodulations was performed. There were no operative complications and the surgery was completed with minimal blood loss. The histopathological exam revealed an extramedullary hematopoiesis in both spleen and peritoneal nodules., Conclusion: In primary myelofibrosis it must always be kept in mind the possible presence of peritoneal implants of extramedullary hematopoiesis and ascites of reactive genesis. We report a rare case of peritoneal carcinomatosis-like implants of extramedullary hematopoiesis found at splenectomy for MF., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: The purpose of this study was to assess the capability of contrast-enhanced ultrasound (CEUS) to identify residual tumor mass during glioblastoma multiforme (GBM) surgery, to increase the extent of resection., Methods: The authors prospectively evaluated 10 patients who underwent surgery for GBM removal with navigated ultrasound guidance. Navigated B-mode and CEUS were performed prior to resection, during resection, and after complete tumor resection. Areas suspected for residual tumors on B-mode and CEUS studies were localized within the surgical field with navigated ultrasound and samples were sent separately for histopathological analysis to confirm tumor presence., Results: In all cases tumor remnants were visualized as hyperechoic areas on B-mode, highlighted as CEUS-positive areas, and confirmed as tumoral areas on histopathological analysis. In 1 case only, CEUS partially failed to demonstrate residual tumor because the residual hyperechoic area was devascularized prior to ultrasound contrast agent injection. In all cases CEUS enhanced B-mode findings., Conclusions: As has already been shown in other neoplastic lesions in other organs, CEUS is extremely specific in the identification of residual tumor. The ability of CEUS to distinguish between tumor and artifacts or normal brain on B-mode is based on its capacity to show the vascularization degree and not the echogenicity of the tissues. Therefore, CEUS can play a decisive role in the process of maximizing GBM resection.

Introduction: Isolated splenic abscess is a rare clinical condition and remains a diagnostic dilemma. Clinical presentation is non-specific and the diagnosis is often delayed. Ultrasonography and CT scan are the gold standard. The treatment is still controversial: antibiotic therapy, percutaneous drainage (PCD) or splenectomy., Case Presentation: We present the clinical case of a patient, admitted to our Department because of abdominal pain, without fever. The preoperative radiological assesment showed three intrasplenic liquid collections, whose differential diagnosis was made between hematic collection and abscess. The treatment was splenectomy. The samples of collected liquid were positive for Escherichia Coli., Conclusion: In case of splenic abscess, splenectomy is the best therapeutic choice. The other therapeutical options like antibiotic therapy and PCD, can be used only in particular cases, but without the same efficacy., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Extra-abdominal fibromatosis is a rare, benign disease that is characterized by a local but not metastatic invasivity. In particular, desmoid tumors of the chest wall represent only 10-20% of all deep fibromatoses. The disease occurs more often in females and has a higher incidence between puberty and the fourth decade of life. The present study reports the case of a 34-year-old female who came to our attention due to a voluminous mass in the right subcostal region. The magnetic resonance imaging of the upper abdomen confirmed the presence of a neoplasm localized between the anterior hepatic margin and the right costal plane. Through a right subcostal laparotomy, the voluminous 95×45×94-mm neoplasm was excised. Histological examination showed evidence consistent with extra-abdominal fibromatosis. The patient has not shown recurrence of the disease for 4 years since the surgery. Overall, radical surgery with disease-free resection margins is the prime treatment option for this disease. Other therapeutic options, such as radiotherapy, hormonal therapy or treatment with imatinib mesylate, can also be considered in certain cases.

Short bowel syndrome is a complex clinical picture, characterized by signs and symptoms of malabsorption and subsequent malnutrition, which often occurs after extensive bowel resections. Short bowel syndrome's treatment must begin together with the planning of the first surgery, especially for disease that may need multiple interventions. Patients with short bowel should be individually managed because they all are different in diagnosis, length of the remaining bowel and in psychosocial characteristics. For all these reasons, a multidisciplinary approach between the various specialists is therefore needed.

Unlabelled: In patients who had previously undergone ileocolic resection due to Crohn's disease (CD) complications, anastomotic recurrence is a frequent event, which may lead to further surgical interventions. Optical colonoscopy with retrograde ileoscopy is currently the reference standard technique to confirm the clinical suspicion of anastomotic recurrence; however, the ileal side of ileocolic anastomoses may not be assessed due to technical complexities in approximately 1/3 of cases. Moreover, endoscopy allows for an investigation limited to the mucosal surface without demonstrating trans-mural involvement and/or penetrating complications (i.e. fistulas and abscesses). Imaging plays an important role in the assessment of both ileocolic and entero-enteric anastomoses in patients with CD. Conventional radiological methods (i.e. small bowel enteroclysis and small bowel follow through) can effectively depict the presence of aphthous ulcers and other mild and subtle mucosal abnormalities, but they are not precise for the diagnosis of transmural and extramural disease. CT - and MR- enterography accurately demonstrate both the extent of bowel wall involvement and the presence of penetrating complications. The main cross-sectional imaging findings observed in CD (including anastomotic recurrence) are small bowel wall thickening with bilaminar or trilaminar stratification, hyperdensity and oedema of the mesenteric fat, engorged mesenteric vasa recta ("comb sign"), sub-mucosal fibro-fatty infiltration and mesenteric adenopathy. Ultrasonography performed after distension of small bowel loops with anechoic contrast agents (Small Intestine Contrast Ultrasonography - SICUS -) is a non-invasive imaging technique which can detect early inflammatory alterations of the anastomosis. On the other hand ultrasonography is an operator-dependent technique and it lacks of a large anatomic field of view., Key Words: Computed Tomography enterography, Crohn's disease, Ileocolic anastomosis, Magnetic Resonance Imaging.

Malignant brain tumours are one of the most relevant causes of morbidity and mortality across a wide range of individuals. Malignant glioma is the most common intra axial tumor in the adult. Many researches on this theme brought advances in the knowledge of gliomas biology and pathogenesis and to the development of new agents for targeted molecular therapy. Recent studies focused on either tumor metabolism analysis or epigenetic regulation in the pathogenesis or maintenance of brain tumors. This Review summarizes these developments analyzing molecular pathology and possible further developments for targeted therapies.

Background: Re-approximation of the rectal muscles along the midline is recommended by some groups as a rule for incisional and ventral hernia repairs. The introduction of laparoscopic repair has generated a debate because it is not aimed at restoring abdominal wall integrity but instead aims just to bridge the defect. Whether restoration of the abdominal integrity has a real impact on patient mobility is questionable, and the available literature provides no definitive answer. The present study aims to compare the functional results of laparoscopic bridging with those of re-approximation of the rectal muscle in the midline as a mesh repair for ventral and incisional abdominal defect through an "open" access. We hypothesized that, for the type of defect suitable for a laparoscopic bridging, the effect of an anatomical reconstruction is near negligible, thus not a fixed rule., Methods and Design: The LABOR trial is a multicenter, prospective, two-arm, single-blinded, randomized trial. Patients of more than 60 years of age with a defect of less than 10 cm at its greatest diameter will be randomly submitted to open Rives or laparoscopic defect repair. All the participating patients will have a preoperative evaluation of their abdominal wall strength and mobility along with volumetry, respiratory function test, intraabdominal pressure and quality of life assessment.The primary outcome will be the difference in abdominal wall strength as measured by a double leg-lowering test performed at 12 months postoperatively. The secondary outcomes will be the rate of recurrence and changes in baseline abdominal mobility, respiratory function tests, intraabdominal pressure, CT volumetry and quality of life at 6 and 12 months postoperatively., Discussion: The study will help to define the most suitable treatment for small-medium incisional and primary hernias in patients older than 60 years. Given a similar mid-term recurrence rate in both groups, if the trial shows no differences among treatments (acceptance of the null-hypothesis), then the choice of whether to submit a patient to one intervention will be made on the basis of cost and the surgeon's experience., Trial Registration: Current Controlled Trials ISRCTN93729016.

Background: Cavernomas of the brain are congenital lesions clinically divided into hereditary and a sporadic forms. Multiple lesions are usually observed in the familial form, whereas the sporadic variant generally shows a single cavernoma. In this case we describe the simultaneous bleeding of two lesions in a patient with a non-familial cavernomatosis., Case Description: A 46-year-old woman presented with slight hyposthenia involving the left arm and cervical stiffness. Examinations revealed two cavernomas with recent signs of bleeding. The lesions were surgically removed achieving a total excision. The patient was discharged after 10 days with slight left hyposthenia., Discussion: Simultaneous hemorrhage of multiple cavernomas is rare. To the best of our knowledge, this is the first case showing a sporadic form presenting with two hemorrhagic lesions. We suggest an aggressive approach in order to avoid the risk of rebleeding, which is particularly high in case of hemorrhagic cavernomatosis.

Background: The objective of this study was to evaluate outcomes of mesh versus primary suture procedures for repair of anterior abdominal wall midline hernias., Results: Between 1995 and 2005, 98 patients (46 males) underwent repair of umbilical (69 cases) or epigastric (29 cases) hernias. Primary suture of the defect was performed in 34 cases (group 1). A polypropylene mesh was positioned in 64 cases (group 2). Overall, mean aponeurotic defect diameter was 2.5 cm (range 0.5 +/- 10 cm). Procedures were carried out under local anesthesia in 76 instances (71% group 1 vs. 81% group 2). Complications occurring in group 2 comprised three seromas, one hematoma and one prosthetic infection. Follow up was scheduled yearly up to the fifth postoperative year. Recurrence rate in group 1 was 14.7% compared to 3.1% in group 2 (logrank test p 0.0475)., Conclusions: Anterior preperitoneal mesh repair of abdominal wall midline hernias under local anesthesia seems to be a safe and effective technique that can be performed as a day surgery procedure. A slightly increased risk of postoperative local complications following mesh repair is offset by a reduced rate of recurrence in comparison to suture repair.

Introduction: The patients with Crohn's disease (CD) have a greater risk of gastrointestinal and hemopoietic cancers compared with background population. Identify groups of people affected by CD with exposition to factors that play a role in the development of cancer could be useful to plan correct diagnostic and therapeutic methods., Methods: A reaserch on "pubmed" with "Risk factors for cancer in patients with Crohn's disease", "Cancer and Crohn's disease" Crohn's disease and cancer risk" as key-words was conducted. We identified 35 studies and analized also references reported inside each single work., Results: Patients with CD have a higher risk of colorectal cancer (CRC). The risk of colon cancer alone was found to be increased, with no significant increase in the risk of rectal cancer. Factors that play a role in the development of CRC are: diagnosis of CD before 25-years-old, duration of disease, severity of inflammation, habit to cigarette's smoke, a familial history of CRC and immunosuppressive therapies. The risk of small bowel cancer was found to be increased, even if overall risk remains low. Although the role of immunosuppressive therapies remain to clarify yet, patients with CD have a higher risk of development lymphoma compared with background population., Conclusion: Patients with CD are at high risk of large bowel, small bowel, extraintestinal and hemopoietic cancers. Selected patients with extensive colonic disease, which has been present from a young age, are at high risk of cancer and should be candidates for colonscopic surveillance.