Search

Introduction. We report a rare case of a heterotopic abdominal pregnancy with three intrauterine pregnancy, one with a viable fetus, treated successfully by laparoscopy. Methods. A 40-year-old patient with primary sterility, who un- derwent pharmacological ovulation induction, presented abdominal pain in the right iliac region. A trans-vaginal ultrasound showed an image suggestive of ectopic gestation near the right ovary, associated with three intrauterine gestational sacs with only one viable fetus. Basing on this observation, we performed an operative laparoscopy that confirmed the presence of a right ectopic abdominal pregnancy. Since the right ampullar tubal was ruptured and bleeding, we car- ried out a salpingectomy with complete removal of ectopic abdominal pregnancy. Discussion. After laparoscopic surgery, on postoperative day 1, ultrasonographic examination showed an ongoing intrauterine pre- gnancy with the two empty gestational sacs. Postoperative course was without any complications and the patient was discharged on posto- perative day 3. Gestation went on uneventfully until at term vaginal delivery.Conclusions: Laparoscopic treatment of abdominal pregnancy with an intrauterine viable pregnancy resulted safe for both mother and fetus. An adnexal mass in a pregnant patient with a history of ovulation induction might be the indicator of an heterotopic pre- gnancy.

Peritoneal dissemination from colorectal cancer (CRC) has long been associated with unfavorable prognosis. However, in the last decades, the combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) was able to obtain up to 30% 5-year survival rate in selected centers. Despite the wide diffusion of CRS and HIPEC, until now, there are no clear recommendations on the drug of choice for HIPEC nor its technique, and safety and efficacy data of HIPEC regimens and techniques are lacking. We performed a retrospective analysis of a prospectively maintained database of 26 CRS and mitomycin C HIPEC with CO2 recirculation (HIPEC-CO2) for CRC peritoneal metastasis (PM) performed at our center. The main endpoints were morbidity, mortality, the temperature of perfusate during HIPEC and metabolic changes throughout the procedure. Morbidity was assessed by analysis of postoperative adverse events according to the Common Terminology Criteria for Adverse Events (CTCAE version 4.0). Continuous variables of Arterial Blood Gas (ABG) analysis at three time-points were compared by the Student t test. There were no postoperative deaths. The overall grade 3–4 CTCAE complications rate at 30days was 38.4%, with ten severe adverse events occurring to six (23.0%) patients. The temperature within HIPEC perfusion maintained between 41 and 42°C in all cases and we experienced no HIPEC-related intraoperative complications. We observed a significant difference between all baseline and pre-HIPEC ABG parameters evaluated but no statistically significant differences between pre- and post-HIPEC ABG outcomes. This study shows that mitomycin C HIPEC-CO2 is feasible and has a safety profile comparable to that of other HIPEC techniques reported in the literature. Further research is needed to validate prospectively the safety and efficacy of this technique.

Highlights • Integration of PIPAC to systemic chemotherapy can have good tolerance profile. • Repeated biopsies performed during PIPAC allowed therapy-response monitoring. • Analysis of biopsies performed during PIPAC allowed tailoring of chemotherapy. • Integration of PIPAC to systemic chemotherapy can permit good quality of life., Introduction Pancreatic ductal adenocarcinoma (PDAC) with peritoneal metastases (PM) has a dismal prognosis and palliative systemic chemotherapy, which represents the standard treatment option, has significant pharmacokinetics limitations and low efficacy. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new method of drug delivery that is expected to maximize exposure of peritoneal nodules to antiblastic agents. A combination of systemic chemotherapy and PIPAC may be valuable. Presentation of case A 55 years old male affected by PDAC with synchronous PM underwent a multimodal treatment comprising systemic chemotherapy and PIPAC without any procedural-related adverse events. Tumor genomic profiling evaluation from peritoneal biopsies addressed further tailored systemic chemotherapy. Discussion The presented case illustrates the possibility of adding PIPAC to systemic chemotherapy with a fair tolerance profile and good quality of life while allowing monitoring of therapy-response and tailoring of the antiblastic treatment.

Introduction: Patients with peritoneal metastasis frequently develop malignant bowel obstruction (MBO). Medical palliative management is preferred but often fails. Conversely, the role of palliative surgery remains unclear and debated. This study aims to identify patients who could benefit from invasive surgical interventions and factors associated with successful surgical palliation.Materials and Methods: In this retrospective study, 98 consecutive patients who underwent palliative surgery for MBO over 5 years were reviewed. We evaluate as the primary outcome surgical failure to select patients who could benefit from palliative surgery, avoiding unnecessary surgery. A prognostic score was developed based on a logistic regression model to identify patients at risk of surgical failure. The score was evaluated for overall accuracy by receiver operating characteristic curve analysis.Results: Palliative surgery was achieved in 76 (77.5%) patients. The variables that were found to be significant factors for surgical failure are recurrent disease (P = 0.015), absence of bowel obstruction (P < 0.001), absence of bowel distension (P < 0.001), and mesenteric involvement (P = 0.001) and retraction (P < 0.001). The absence of bowel distension (P = 0.046) and bowel obstruction (P = 0.012) emerged as independent predictors of surgical failure. Carcinomatosis level assessment for peritoneum score, based on these factors, was built to evaluate the risk of surgical failure.Conclusion: Our proposed scoring system might help select patients most likely to benefit from palliative surgery.

Highlights • Pelvic organ prolapse (POP) represents a common and bothersome condition in parous women. • The demand to “save” the uterus has fuelled a renewal of the surgical technique. • Robotic surgery was conceived with the intent to overcome the limitations of laparoscopic surgery. • The characteristics of the robotic system help surgeons to perform conservative management of POP., Introduction To report a case of uterine preservation in pelvic organ prolapse robot-assisted laparoscopic surgery. Presentation of case The patient is a 42-year old Caucasian woman with pelvic organ prolapse. She previously had undergone a pelvic floor reconstruction with vaginal surgical approach, she had suffered from anorexia nervosa and she had two childbirths with vaginal deliveries. The woman was treated with robotic-assisted laparoscopic sacrohysteropexy and retropubic colposuspension. Discussion Data suggest that abdominal surgery, typically with an abdominal sacralcolpopexy, provides better objective anatomic outcomes, than vaginal procedures, despite the longer operating times and grater delay in the resumption of activities which can be mitigated by the use of laparoscopic or robotic surgery. Several studies about vaginal approaches suggest that uterus-preserving surgery with vaginal procedures have similar success rates, less blood loss and shorter surgical time compared with hysterectomy. A multicenter study compared laparoscopic sacrohysteropexy with vaginal mesh hysteropexy reported similar one-year cure rates, improvement in pelvic floor symptoms, improvement in sexual function, and satisfaction rates. Conclusion We found robotic-assisted laparoscopic sacrohysteropexy to be a feasible and successful procedure. Combining robotic retropubic colposuspension to sacrohysteropexy is a safe and efficient approach for the treatment of stress urinary incontinence. Further studies are needed to define the standard surgical steps and confirm the efficacy and the advantages of this procedure.

Background: Systemic chemotherapy for pancreatic adenocarcinoma (PDAC) and cholangiocarcinoma (CC) with peritoneal metastases (PM) is affected by several pharmacological shortcomings and low clinical efficacy. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is expected to maximize exposure of peritoneal nodules to antiblastic agents. This study aims to evaluate safety and efficacy of PIPAC for PM of PDAC and CC origin. Methods: This is a retrospective analysis of consecutive PDAC and CC cases with PM treated with PIPAC at two European referral centers for peritoneal disease. We prospectively recorded from August 2016 to May 2019 demographic, clinical, surgical, and oncological data. We performed a feasibility and safety assessment and an efficacy analysis based on clinical and pathological regression. Results: Twenty patients with PM from PDAC (14) and CC (six) underwent 45 PIPAC administrations. Cisplatin–doxorubicin or oxaliplatin were administered to eight and 12 patients, respectively. We experienced one intraoperative complication (small bowel perforation) and 18 grade 1–2 postoperative adverse events according to Common Terminology Criteria for Adverse Events version 4.0. A pathological regression was recorded in 50% of patients (62% in the cisplatin–doxorubicin cohort and 42% in the oxaliplatin one). Median survival from the first PIPAC was 9.7 and 10.9 months for PDAC and CC, respectively. Conclusion: PIPAC resulted feasible and safe without relevant toxicity issues, with both cisplatin–doxorubicin and oxaliplatin. The pathological response observed supports the evidence of antitumoral activity. Despite the study limitations, these outcomes are encouraging, recommending PIPAC in prospective, controlled trials in the palliative setting or the first line chemotherapy for PM from PDAC and CC.

Background Few patients affected by gastric cancer peritoneal metastasis (GCPM) are offered locoregional treatment, despite several proof-of-efficacy trials. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has emerged in recent years as a promising tool to control peritoneal carcinomatosis. The combination of PIPAC with systemic chemotherapy may offer a greater clinical benefit than standard treatment alone. Methods A single-center cohort of 28 consecutive patients affected by GCPM was scheduled for bidirectional treatment, comprising PIPAC and systemic chemotherapy, from September 2017 to September 2019. Data recorded included safety, efficacy and survival outcomes. Ascite volumes, the Peritoneal Cancer Index (PCI) and pathological response through the Peritoneal Regression Grading Score (PRGS) were compared in those patients who underwent more than one PIPAC procedure. Results Forty-six PIPAC procedures were administered, with a mean of 1.7 PIPAC procedures per patient. The median time to resume systemic chemotherapy after PIPAC was 6 days (range 4–7). Concerning safety, two grade 3–4 CTCAE (Common Terminology Criteria for Adverse Events v4.0) toxicity events and one intraoperative complication were recorded. Thirteen patients repeated PIPAC. A pathological response was recorded in 61.5% of patients (one with complete and seven with partial regression). The median overall survival was 12.3 months in the overall population and 15.0 months in patients undergoing more than one PIPAC procedure. Conclusions A bidirectional approach for GCPM was feasible and safe, as the PIPAC procedure integrates well with several systemic chemotherapy regimens. The pathological response demonstrated the antitumoral efficacy of PIPAC. The proposed bidirectional approach may be further investigated in the first-line treatment of metastatic gastric cancer.

Introduction Systemic chemotherapy offers poor control over peritoneal disease, maybe as a consequence of restricted drug availability within the abdominal cavity. Locoregional chemotherapy may overcome these shortcomings but its administration is limited to a few patients with confined peritoneal spread. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) emerged in the last years as a novel method of intraperitoneal drug administration. Evidence acquisition We report a meta-analysis of published studies on PIPAC safety and pathological anti-tumoral efficacy on PC from various tumor entities, with the aim of providing more evidence to support further research. This systematic review and meta-analysis were designed, conducted and reported according to the PRISMA statement. Evidence synthesis An overall pathological response rate of 43.7% was calculated on a total of 668 patients who underwent 1480 PIPAC cycles across the 20 studies. Pooled severe adverse events rate (CTCAE grade 3-4) was 10% and seven deaths across all studies were reported, of which only four were related to PIPAC. Conclusions PIPAC is a safe procedure which has a relevant anti-tumoral activity on peritoneal carcinomatosis. Further studies, even in the early stage of disease, are awaited to assess the clinical benefit of PIPAC. This review may serve as a reliable basis for future research.

To comment on the prevalence, diagnosis, and treatment of the septate uterus, with special reference to hysteroscopic metroplasty and its effect on reproductive outcome, we searched publications in PubMed and Embase. Original articles, meta-analysis, reviews, and opinion articles were selected. The studies suggest that the prevalence of the septate uterus is increased in women with repeated pregnancy loss and infertility. Reliable diagnosis depends on accurate assessment of the uterine fundal contour and uterine cavity by means of magnetic resonance and three-dimensional ultrasound. Pertinent published data comparing pregnancy outcome before and after hysteroscopic metroplasty indicated a marked improvement after surgery. Magnetic resonance and three-dimensional ultrasound represent the gold standard for diagnosis of septate uterus. Hysteroscopic metroplasty with its simplicity, minimal postoperative sequelae, and improved reproductive outcome is the gold standard for treatment, not only in patients with recurrent pregnancy loss and premature labor but also in patients with infertility, especially if in vitro fertilization is being contemplated.

Ectopic adrenal tissue is an occasional finding during surgery procedures. These remnants are usually found near the primary gland or along the course of gonadal vessels consistently with embryologic development. The appearance is of a small but distinct, soft, round, yellow nodule and only cortical adrenal tissue is normally observed. We report a case of an emergency laparoscopic salpingostomy for isolated tubal torsion with excision of EAT, incidentally found in left ovarian pedicle, followed by postoperative resumption of regular menses and regression of hirsutism. Although intraoperative research of ectopic adrenal tissue is not necessary its removal is indicated in case of incidental finding. If hyperandrogenic features are present, ectopic adrenal tissue should be actively researched when surgery is performed.

Objective The evolution of minimally invasive surgery has moved beyond reduction of surgical trauma while maintaining adequate efficacy and safety standards. Percuvance™ Percutaneous Surgical System (PSS) instruments represents the last novelty in this panorama. Consisting of less than 3 mm laparoscopic shaft introduced percutaneously with an interchangeable 5 mm tool installed in place of the needle tip, they combine micro-invasiveness and operative performance. Study design We prospectively collected and retrospectively analyzed data of 10 cases of laparoscopic total hysterectomy with Percuvance™ PSS for benign or early malignant gynecological diseases in order to assess the capability and safety of this new device. Data were recorded in a prospectively designed clinical database including patient demographics characteristics, operative data, intra- and postoperative complications, conversion rate, length of hospital stay and cosmetic outcome. Results The reported series consisted of 10 patients undergoing total laparoscopic hysterectomy with a median age of 51.5 years (range 44–72 years) and a median BMI (body mass index) of 25.3 (range 19.7–30.4). All patients had bilateral salpingo-oophorectomy or bilateral salpingectomy and two of them underwent pelvic lymphadenectomy. A median operative time of 67 min (range 45–180 min) and a median estimated blood loss (EBL) of 50 ml (range 10–100 ml) were registered. Median PSS introduction time was 5 min (range 3–10 min). No conversions to standard laparoscopy or laparotomy were required and no intraoperative complications occurred. Discharge was on day 1 in 4 cases, on day 2 in the other 6 cases. All patients conveyed complete satisfaction with the cosmetic result and postoperative pain control. No complications were registered within 30 days after surgery. Conclusions PSS total laparoscopic hysterectomy is safe and feasible with good results in terms of operative time, cosmesis, postoperative pain, recovery and short hospitalization. Further studies are needed to compare PSS total hysterectomy to conventional multi-access laparoscopic and other mini-invasive approaches.

An electronic search concerning the surgical approach in cases of interstitial pregnancy from January 2000 to May 2013 has been carried out. Fifty three studies have been retrieved and included for statistical analysis. Conservative and radical surgical treatments in 354 cases of interstitial pregnancy are extensively described. Hemostatic techniques have been reported as well as clinical criteria for the medical approach. Surgical outcome in conservative versus radical treatment were similar. When hemostatic techniques were used, lower blood losses and lower operative times were recorded. Conversion to laparotomy involved difficulties in hemostasis and the presence of persistent or multiple adhesions. Laparoscopic injection of vasopressin into the myometrium below the cornual mass was the preferred approach.

We investigate the concept of norm compliance in business process modeling. In particular we propose an extension of Formal Contract Logic (FCL), a combination of defeasible logic and a logic of violation, with a richer deontic language capable of capture many different facets of normative requirements. The resulting logic, called Process Compliance Logic (PCL), is able to capture both semantic compliance and structural compliance. This paper focuses on structural compliance, that is we show how PCL can capture obligations concerning the structure of a business process.

Wireless Mobile Ad Hoc Networks (MANETs) have been defined as infrastructure-less networks, including mobile and fixed nodes relying on peer-to-peer protocols and management. To support more reliable communications, efficient network management and high resources' utilization, distributed clustering protocols have been considered as a solution to introduce some kind of hierarchy in MANETs by means of dynamic and adaptive virtual infrastructures. In clustering schemes, the different node-roles, and respective management tasks, could take advantage by Medium Access Control (MAC) protocols able to differentiate distributed nodes' accesses. To cope with the system dynamics, the MAC itself is required to exploit existing clustering schemes, and to be adaptive to load and clustering variations, with no static access schemes. In this paper we propose and analyze a possible solution for the mutual support of distributed MAC and clustering schemes, named Differentiated Distributed Coordination Function (DDCF). The DDCF scheme is based on the IEEE 802.11 DCF access scheme, and inspired to the IEEE 802.11e design. Unlike IEEE802.11e, whose focus is to support Quality of Service (QoS) on the prioritized frame-flows basis, the focus of the DDCF is to implement nodes differentiation based on the node roles, which have been assigned by the upper-layer clustering scheme. Extensive, still preliminary, performance evaluation shown that the proposed DDCF access scheme can adaptively exploit the roles of cluster nodes, to support heterogeneous and differentiated MAC access needs.