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Introduction: Previous studies reported that laparoscopic surgery (LPS) improved postoperative outcomes in patients undergoing colorectal surgery within an enhanced recovery program (ERP). However, the effect of minimally invasive surgery on each ERP item has not been clarified, yet. The aim of this study is to assess the impact of LPS on adherence to ERP items and recovery as measured by time to readiness for discharge (TRD). Methods: Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. Patients undergoing elective colorectal surgery were divided into three groups: successful laparoscopy, conversion to open surgery, primary open surgery. Adherence to 19 ERP elements and postoperative outcomes were compared among groups. Multivariate regression analysis was used to identify whether LPS had an independent role to improve ERP adherence and postoperative outcomes. Results: 714 patients (successful LPS 531, converted 42, open 141) underwent elective colorectal surgery within an ERP. Epidural analgesia was used in the 75.1% of open group patients versus 49.9% of LPS group patients (p = 0.012). After surgery, oral feeding recovery, i.v. fluids suspension, removal of both urinary and epidural catheters occurred earlier in the LPS group both in the overall series and in uneventful patients only. Mean TRD and length of hospital stay were significantly shorter in the LPS group (p < 0.001 for both). Overall morbidity rate was 18.7% in the LPS group versus 32.6% in the open group (p = 0.001). At multivariate analysis, LPS was significantly associated to an increased adherence to postoperative ERP items, a shorter TRD, and a reduced overall morbidity, whereas rectal surgery and new stoma formation impaired postoperative recovery. Conclusions: The present study showed that a successful laparoscopic procedure had an independent role to increase the adherence to postoperative ERP and to improve short-term postoperative outcome.

OBJECTIVE: To identify predictive risk factors for conversion to open splenectomy and postoperative complications in patients undergoing elective laparoscopic splenectomy. BACKGROUND: The laparoscopic approach represents the "gold standard" for splenectomy, but its use in the treatment of splenomegaly and malignant disease is controversial. Factors that influence immediate outcome are clinical, anatomic, and pathologic. METHODS: Univariate and multivariate analyses of data from the Italian Registry of Laparoscopic Surgery of the Spleen, a multicenter database supported by 25 referral centers. Analysis of data (1993-2007) was performed on a series of patients (n = 676) undergoing elective laparoscopic splenectomy. Demographic data, the operative indications, the surgical technique applied, and any intra- and/or postoperative complications with respect to the patients were assessed. Records were analyzed retrospectively using the Student t test, the chi test, and logistic regression. RESULTS: Conversion to open splenectomy was necessary in 39 cases (5.8%). Perioperative deaths occurred in 3 cases (0.4%). There were no complications in 560 patients (82.8%), with a mean hospital stay of 5 days (range, 2-54). Overall, morbidity occurred in 116 patients (17.2%). Multivariate analysis found that the body mass index (P = 0.01) and the presence of hematologic malignancy (P < 0.001) were independent predictors for intraoperative complications and surgical conversion. Spleen longitudinal diameter (P = 0.001) and surgical conversion (P = 0.001) were independent predictors for the occurrence of postoperative complications. CONCLUSIONS: This large multicenter study provides evidence for the significance of predictive risk factors for intra- and postoperative complications in laparoscopic splenic surgery. Besides splenic dimensions, other factors like the patient's habitus and the specific underlying hematologic pathology should be recognized by the surgeon to reduce complications and initiate adequate treatment.

The possibilities of laparoscopic surgery in the treatment of functional esophageal diseases (gastroesophageal reflux, achalasia and epiphrenic diverticula) are illustrated with special emphasis on the technical aspects, including intraoperative complications and postoperative care. Results are discussed on the ground of the following experience. Thirty-seven laparoscopic fundoplications were performed with 13% conversion rate, 2.7% postoperative morbidity (1 slipped Nissen requiring redo laparoscopic surgery). Median operative time was 140 min. One patient complained of dysphagia relieved by endoscopic dilation (2.7%). All patients are not asymptomatic after a median follow-up of 16 months although one has gastroesophageal reflux (GER) at 24-hrs pH monitoring. forty laparoscopic Heller-Dor procedures: 7% conversions, 5% postoperative morbidity. Median duration 120 min. One patient complained of persistent dysphagia requiring endoscopic dilation (2.5%) and asymptomatic GER was detected in 8% of patients. Finally, 2 patients underwent laparoscopic diverticulectomy, esophagomyotomy and Dor fundoplication without morbidity and excellent postoperative result. Laparoscopic treatment of functional diseases of the esophagus is safe and effective, provided it is performed by an experienced surgeon with respect for some important technical details. Further follow-up is needed to evaluate long-term results.

Laparoscopy is gaining an important role in the treatment of benign colorectal disorders. The aim of this study is the evaluation of clinical and functional results in 4 patients submitted to a laparoscopy rectopexy according to Wells.Four females (22-76, mean 53.7 years) affected from a total rectal prolapse with fecal incontinence underwent this procedure from 1993 through 1995. Six months after surgery, at the end of a rehabilitation program consisting of kinesitherapy, bio-feedback and electrostimulations, all patients have been re-evaluated by means of a clinical exam, anorectal manometry, defecography.Preliminary results seem satisfactory and may allow to prefer this approach instead of the traditional open one.

The occipital face area (OFA) has been shown to code the presence of symmetry in faces and in vertically symmetric dot patterns. However, it is not clear whether symmetry processing of face and non-face stimuli involve overlapping neural mechanisms in OFA. This was assessed using state-dependent TMS by employing a priming paradigm. Specifically, we examined whether prior presentation of low-level symmetry affects the impact of TMS on discrimination of symmetry in subsequently presented faces - indicating that the same neural mechanisms encode symmetry in both face and non-face stimuli. Participants performed a symmetry discrimination task on a series of faces, each of which was preceded by either a vertically symmetric, a horizontally symmetric or a non-symmetric dot configuration (prime) while receiving stimulation over either the right OFA, the right Lateral Occipital Cortex (rLO) or over a control site (Vertex). Vertically symmetric dot patterns primed symmetry discrimination in faces. The key finding was that the priming effect was not affected by TMS applied over OFA; stimulation of this site (but not of rLO) impaired the discrimination of facial symmetry regardless of prime type. Overall, these results suggest that distinct neural representations in OFA are involved in symmetry detection in face and non-face stimuli.

Highlights • TMS effects depend on various factors such as intensity, brain state and timing. • We examined how these factors interact to give rise to behavioral effects. • TMS was applied while participants performed a behavioral priming task. • State dependency of TMS effect was found to interact with intensity and timing., Behavioral effects of transcranial magnetic stimulation (TMS) have been shown to depend on various factors, such as neural activation state, stimulation intensity, and timing of stimulation. Here we examined whether these factors interact, by applying TMS at either sub- or suprathreshold intensity (relative to phosphene threshold, PT) and at different time points during a state-dependent TMS paradigm. The state manipulation involved a behavioral task in which a visual prime (color grating) was followed by a target stimulus which could be either congruent, incongruent or partially congruent with the color and orientation of the prime. In Experiment 1, single-pulse TMS was applied over the early visual cortex (V1/V2) or Vertex (baseline) at the onset of the target stimulus – timing often used in state-dependent TMS studies. With both subthreshold and suprathreshold stimulation, TMS facilitated the detection of incongruent stimuli while not significantly affecting other stimulus types. In Experiment 2, TMS was applied at 100 ms after target onset –a time window in which V1/V2 is responding to visual input. Only TMS applied at suprathreshold intensity facilitated the detection of incongruent stimuli, with no effect with subthreshold stimulation. The need for higher stimulation intensity is likely to reflect reduced susceptibility to TMS of neurons responding to visual stimulation. Furthermore, the finding that in Experiment 2 only suprathreshold TMS induced a behavioral facilitation on incongruent targets (whereas facilitations in the absence of priming have been reported with subthreshold TMS) indicates that priming, by reducing neural excitability to incongruent targets, shifts the facilitatory/inhibitory range of TMS effects.

Visual mirror symmetry plays an important role in visual perception in both human and animal vision; its importance is reflected in the fact that it can be extracted automatically during early stages of visual processing. However, how this extraction is implemented at the cortical level remains an open question. Given the importance of symmetry in visual perception, one possibility is that there is a network which extracts all types of symmetry irrespective of axis of orientation; alternatively, symmetry along different axes might be encoded by different brain regions, implying that there is no single neural mechanism for symmetry processing. Here we used fMRI-guided transcranial magnetic stimulation (TMS) to compare the neural basis of the two main types of symmetry found in the natural world, vertical and horizontal symmetry. TMS was applied over either right Lateral Occipital Cortex (LO), right Occipital Face Area (OFA) or Vertex while participants were asked to detect symmetry in low-level dot configurations. Whereas detection of vertical symmetry was impaired by TMS over both LO and OFA, detection of horizontal symmetry was delayed by stimulation of LO only. Thus, different types of visual symmetry rely on partially distinct cortical networks.

Background: Enhanced recovery after surgery (ERAS) pathways represent the optimal approach for patients undergoing colorectal surgery. Elderly or low physical status patients have been often excluded from ERAS pathways because considered at high risk. The aim of this study is to assess the adherence to ERAS protocol and its impact on short-term postoperative outcome in patients with different surgical risk undergoing elective colorectal resection. Methods: Prospectively collected data entered in an electronic Italian registry specifically designed for ERAS were reviewed. Patients were divided into four groups according to age (70-year-old cutoff) and preoperative physical status as measured by the ASA grade (I–II vs. III–IV). Adherence to 18 ERAS elements and postoperative outcomes were compared between groups. Regression analysis was used to identify independent factors associated with improved outcomes. Results: Eleven Italian hospitals reported data on 706 patients undergoing elective colorectal surgery within an ERAS protocol. Patients with low physical status had reduced adherence to preoperative carbohydrate loading, epidural analgesia, PONV prophylaxis, and early urinary catheter removal. No difference was found between groups for adherence to other perioperative elements. Major complications occurred in 37 (5.2 %) patients without significant differences among groups (p = 0.384). Median (IQR) time to readiness for discharge (TRD) was 4 (3–6) days, length of hospital stay (LOS) was 6 (4–7) days, and both were significantly shorter by only 1 day in the groups of younger patients (p

In addition to its well-documented role in processing of faces, the occipital face area in the right hemisphere (rOFA) may also play a role in identifying specific individuals within a class of objects. Here we explored this issue by using fMRI-guided TMS. In a first experiment, participants had to judge whether two sequentially presented images of faces or objects represented exactly the same exemplar or two different exemplars of the same class, while receiving online TMS over either the rOFA, the right lateral occipital cortex (rLO) or the Vertex (control). We found that, relative to Vertex, stimulation of rOFA impaired individuation of faces only, with no effect on objects; in contrast, TMS over rLO reduced individuation of objects but not of faces. In a second control experiment participants judged whether a picture representing a fragment of a stimulus belonged or not to the subsequently presented image of a whole stimulus (part-whole matching task). Our results showed that rOFA stimulation selectively disrupted performance with faces, whereas performance with objects (but not with faces) was selectively affected by TMS over rLO. Overall, our findings suggest that rOFA does not contribute to discriminate between exemplars of non-face objects.

Background & aims: The Enhanced Recovery After Surgery (ERAS) pathway represents an optimal approach in patients undergoing colorectal surgery but complexity in implementing its items could limit its application. The aim of this study is to identify possible core items within an ERAS pathway following elective colorectal resection. Methods: This is a retrospective review of data prospectively collected between January 2014 and September 2015 by 14 Italian Hospitals in an electronic registry dedicated to an ERAS protocol. 722 patients undergoing elective colorectal surgery within an ERAS protocol have been included in the study. Adherence to ERAS items was assessed in all patients. A secondary analysis was restricted to pre- and intraoperative ERAS items. Time to readiness for discharge (TRD) was the primary endpoint of the study. Postoperative overall morbidity was the secondary endpoint. Results: Multivariate analyses showed that active intraoperative warming (p = 0.008), early stop of intravenous fluids (p = 0.0001), and early removal of urinary catheter (p = 0.0001) were associated to a shorter TRD, while early stop of intravenous fluids (p < 0.001) also reduced morbidity. When the analysis was restricted to pre- and intraoperative items, removal of NGT at the end of surgery had an independent role to shorten TRD (p < 0.001) and to reduce overall morbidity (p = 0.019), while the absence of oral bowel preparation reduced postoperative overall morbidity (p = 0.021). Conclusions: In implementing an ERAS pathway, hospitals could initially focus on active intraoperative warming, early stop of intravenous fluids, early removal of urinary catheter, removal of NGT at the end of surgery, and absence of oral bowel preparation, keeping on continuous effort to apply the complete ERAS protocol.

Despite the fact that bilateral mirror symmetry is an important characteristic of the visual world, few studies have investigated its neural basis. Here we addressed this issue by investigating whether the object-selective lateral occipital (LO) cortex, a key brain region in object and shape processing, is causally involved in bilateral symmetry detection. Participants were asked to discriminate between symmetric and asymmetric dot patterns, while fMRI-guided repetitive TMS was delivered online over either the left LO, the right LO or two control sites in the occipital cortex. We found that the application of TMS over both right and left LO impaired symmetry judgments, with disruption being greater following right LO than left LO TMS, indicative of right hemisphere lateralization in symmetry processing. TMS over LO bilaterally also affected a visual contour detection task, with no evidence for hemispheric difference in this task. Overall, our results demonstrates that LO bilaterally plays a causal role in symmetry detection possibly due to symmetry acting as a strong cue in Gestalt processes mediating object recognition. © 2013 Elsevier Ltd.

Background: The right occipital face area (rOFA) is known to be involved in face discrimination based on local featural information. Whether this region is also involved in global, holistic stimulus processing is not known. Objective: We used fMRI-guided transcranial magnetic stimulation (TMS) to investigate whether rOFA is causally implicated in stimulus detection based on holistic processing, by the use of Mooney stimuli. Methods: Two studies were carried out: In Experiment 1, participants performed a detection task involving Mooney faces and Mooney objects; Mooney stimuli lack distinguishable local features and can be detected solely via holistic processing (i.e. at a global level) with top-down guidance from previously stored representations. Experiment 2 required participants to detect shapes which are recognized via bottom-up integration of local (collinear) Gabor elements and was performed to control for specificity of rOFA's implication in holistic detection. Results: In Experiment 1, TMS over rOFA and rLO impaired detection of all stimulus categories, with no category-specific effect. In Experiment 2, shape detection was impaired when TMS was applied over rLO but not over rOFA. Conclusions: Our results demonstrate that rOFA is causally implicated in the type of top-down holistic detection required by Mooney stimuli and that such role is not face-selective. In contrast, rOFA does not appear to play a causal role in detection of shapes based on bottom-up integration of local components, demonstrating that its involvement in processing non-face stimuli is specific for holistic processing. (C) 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

The extent to which the generation of mental images draws on the neuronal representations involved in visual perception has been the subject of much debate. To investigate this overlap, we assessed whether adaptation to visual stimuli affects the ability to generate visual mental images; such cross-adaptation would indicate shared neural representations between visual perception and imagery. Mental imagery was tested using a modified version of the clock task, in which subjects are presented with a digital time (e.g. "2.15") and are asked to generate a mental image of the clock hands displaying this time on an empty clock face. Participants were adapted to oriented lines either on the upper or lower side of the clock face prior to the mental image generation. The results showed that mental imagery was impaired when the mental image had to be generated in the adapted region of visual space (Experiment 1). In Experiment 2, we used TMS to determine whether this adaptation effect occurs in the early visual cortex (EVC; V1/V2). Relative to control conditions (No TMS and Vertex TMS), EVC TMS facilitated mental imagery generation when the mental image spatially overlapped with the adapter. Our results thus show that neuronal representations in the EVC which encode (and are suppressed by) visual input play a causal role in visual mental imagery.

Symmetry is an important cue in face and object perception. Here we used fMRI-guided transcranial magnetic stimulation (TMS) to shed light on the role of the occipital face area (OFA), a key region in face processing, and the lateral occipital (LO) cortex, a key area in object processing, in symmetry detection. In the first experiment, we applied TMS over the rightOFA, its left homolog (leftOFA), rightLO, and vertex (baseline) while participants were discriminating between symmetric and asymmetric dot patterns. Stimulation of rightOFA and rightLO impaired performance, causally implicating these two regions in detection of symmetry in low-level dot configurations. TMS over rightLO but not rightOFA also significantly impaired detection of nonsymmetric shapes defined by collinear Gabor patches, demonstrating that rightOFA responds to symmetry but not to all cues mediating figure-ground segregation. The second experiment showed a causal role for rightOFA but not rightLO in facial symmetry detection. Overall, our results demonstrate that both the rightOFA and rightLO are sensitive to symmetry in dot patterns, whereas only rightOFA is causally involved in facial symmetry detection.

Patients with type 2 diabetes are at increased susceptibility to a prolonged QT interval. Furthermore, insulin secretagogues, drugs used to treat diabetes, may prolong QT interval and provoke arrhythmias. We evaluated whether secretagogues can affect QTc interval during cardiac stress test in 20 patients with type 2 diabetes treated with secretagogues. ECG stress test was performed in all patients. QTc interval was calculated both before cardiac stress test (BCST) and at acme of cardiac stress test (ACST). Diabetic patients treated with secretagogues showed longer QTc-ACST values than those treated with metformin only. QTc-ACST values resulted shorter than QTc-BCST values in control group. Diabetic patients treated with secretagogues showed QTc-ACST values significantly longer than QTc-BCST values. In our study, diabetic patients treated with secretagogues did not show the QTc physiologic decrease that is a protective against arrhythmias. These results suggest to evaluate, in these patients, QT length, even during routine cardiac stress test. © 2012 Springer-Verlag Italia.