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Background: Indocyanine green (ICG) fluorescence imaging has been extensively used in a variety of applications in visceral surgery. In minimally invasive liver resections, the detection of small s...

Microinvasion (MI), defined as infiltration of the portal or hepatic vein or bile duct and intrahepatic metastasis are accurate indicators of a poor prognosis for mall hepatocellular carcinomas (HCC). A previous study showed that intraoperative ultrasound (IOUS) definition of MI-HCC had a high concordance with histological findings. Aim of this study is to evaluate overall survival and recurrence patterns of patients with MI-HCC submitted to hepatic resection (HR) or laparoscopic ablation therapies (LAT). A total of 171 consecutive patients (78 h; 93 LAT) with single, small HCC (

Background. Most of the available evidence on the use of indocyanine green (ICG) fluorescence in clinical practice consists of articles published by surgeons of the Asian-Pacific area. We performed a prospective cohort study to assess the patterns of ICG fluorescence in Western hepatocellular carcinoma (HCC) counterparts. Methods. From April 2019 to January 2022, a total of 31 consecutive patients who underwent laparoscopic liver resection (LLR) for superficial HCC were enrolled in this prospective study. All patients underwent laparoscopic staging with both laparoscopic ultrasound (LUS) and ICG fluorescence imaging. Results. A total of 38 hepatocellular carcinomas (HCCs) were enrolled: 23 superficial (surfacing at the liver’s Glissonian capsule), 5 exophytic, 5 shallow (10 mm from the hepatic surface). The detection rate with preoperative imaging (abdominal CT/MRI), LUS, ICG fluorescence and combined modalities (ICG and LUS) was 97.4%, 94.9%, 89.7% and 100%, respectively. The five deep seated lesions underwent ultrasound-guided laparoscopic thermal ablation. The other 33 HCCs were treated with minimally invasive liver resection. Intraoperative ultrasound patterns were registered for each single nodule resected. The ICG fluorescence pattern was classified in two types: total fluorescence (all the tumoral tissue showed strong and homogeneous fluorescence), n = 9/33 (27.3%), and non-total fluorescence (partial and rim fluorescence), n = 24/33 (72.7%). There was a statistical correlation between ICG patterns and grade of differentiation. Almost all lesions with uniform fluorescence pattern were well-differentiated HCCs (G1-G2), while partial and rim-type fluorescence pattern were more common among moderately and poorly differentiated HCCs (G3-G4) (88.9% vs 11.1%, 37.5% vs 62.5%, P = .025, respectively). Conclusions. ICG fluorescence imaging could be used to identify early the grade of HCC, ie intraoperatively, thus influencing the intraoperative treatment.

Rectal prolapse is a condition that can cause significant social impairment and negatively affects quality of life. Surgery is the mainstay of treatment, with the aim of restoring the anatomy and correcting the associated functional disorders. During recent decades, laparoscopic abdominal procedures have emerged as effective tools for the treatment of rectal prolapse, with the advantages of faster recovery, lower morbidity, and shorter length of stay. Robotic surgery represents the latest evolution in the field of minimally invasive surgery, with the benefits of enhanced dexterity in deep narrow fields such as the pelvis, and may potentially overcome the technical limitations of conventional laparoscopy. Robotic surgery for the treatment of rectal prolapse is feasible and safe. It could reduce complication rates and length of hospital stay, as well as shorten the learning curve, when compared to conventional laparoscopy. Further prospectively maintained or randomized data are still required on long-term functional outcomes and recurrence rates.

Background Complete mesocolic excision (CME) for right colectomy increase the technical complexity of a laparoscopic approach especially when an intracorporeal anastomosis (IA) is associated. The robotic platform, with its intrinsic technical advantages, could potentially overcome the limitations of conventional laparoscopy. This study aimed to describe the robotic bottom-up technique and to evaluate short-terms outcomes of robotic right colectomy (RRC) with CME and IA. Methods Data from patients who underwent RRC for cancer with bottom-up suprapubic approach from October 2016 to April 2020 were prospectively collected and retrospectively analyzed. Intraoperative outcomes and complications, conversion rate, 30-day postoperative outcomes, incisional hernia rate and pathological outcomes were the variables assessed. Results A total of 109 patients were submitted to bottom-up suprapubic approach for RRC with CME and IA during the study period. Mean operative time was 179 min, no intraoperative complications were observed, and the conversion rate was 3.6%. Mean postoperative stay was 4.6 days and the overall 30-day complication rate was 15.6%. Thirteen patients (12%) had minor complications, while major postoperative complications occurred in 4 patients (3.6%). Anastomotic leak was recorded in 1 patient (0.9%) and the 30-day re-admission rate was 0.9%. Mean number of harvested lymph nodes was 22.6. Incisional hernia rate at the specimen extraction site was 0.9%. Conclusions Bottom-up approach for RRC with CME and IA carries a low rate of conversions, intraoperative and short-term postoperative complications.

The COVID-19 pandemic has spread rapidly, forcing some drastic changes not only in our daily lives, but also in our clinical and surgical activities. Given our extensive Italian experience, we hereby describe how our surgical unit activity has changed and how, in some cases, it was necessary to modify surgical strategies. We hope our experience can be shared with our global colleagues who are suffering under similar condition.

When compatible with the liver functional reserve, laparoscopic hepatic resection remains the treatment of choice for hepatocellular carcinoma while laparoscopic ablation therapies appear as a promising less invasive alternative. The aim of the study is to compare two homogeneous groups of patients submitted to either hepatic resection or thermoablation for the treatment of single hepatocellular carcinoma (≤ 3 cm). We enrolled 264 cirrhotic patients out of 905 cases consecutively evaluated for hepatocellular carcinoma. We performed 59 hepatic resections and 205 thermoablations through a laparoscopic approach, and they were then followed for similar follow-up (41.7 ± 31.5 months for laparoscopic hepatic resection vs. 38.7±32.3 for laparoscopic ablation therapy). Outcomes included short- and long-term morbidities, tumoral recurrence, and overall survival. Short-term morbidity was significantly higher in the resection group (but the two groups had similar rates for severe complications) while, during follow-up, recurrence was more frequent in patients treated with thermoablation, with a clear disadvantage in terms of survival. At multivariate analysis, only the type of surgical treatment was an independent predictor of disease recurrence, while plasmatic alpha-fetoprotein and Hb values, model for end-stage liver disease score, time to recurrence, and the type of surgical treatment were independent predictors of overall survival. Our data ultimately support some therapeutic advantages for hepatic resection in patients with a single nodule and preserved liver function. However, thermoablation is an adequate alternative in patients with nodules that would require complex surgical resections or imply a poor prognosis that might therefore better tolerate a less invasive procedure.

Optic pathway glioma (OPG) represents the most common central nervous system tumor in children with Neurofibromatosis type-1 (NF1). Although overall survival is usually good, no clear prognostic factors have been identified so far. We assessed the natural history of OPG in a cohort of unselected patients affected by NF1. We retrospectively evaluated 414 consecutive patients affected by NF1 and referred to our NF1 clinic before age 6. Average follow-up was 11.9 years: 52 out of 414 patients had OPG with a total cumulative incidence of 15.4% at age 15 (Kaplan-Meier estimate) and a statistically significant difference according to sex. Brain and orbit MRI was performed in 44.7% of patients: 34.6% for screening purposes and 65.4% because of the presence of neurological, ocular or other symptoms. OPG was diagnosed in 12.5% of cases in the first group, whereas in 36.4% in the latter group (p = 0.001). Clinical management was conservative in most patients, while 8 of them underwent therapy mainly because of visual deterioration. OPG was diagnosed earlier in treated patients, but the difference was not statistically significant. Conversely, all patients who underwent screening MRI had normal visual outcome. In conclusion, OPG location does not correlate with need for treatment; female patients were more frequently affected by OPG but not more frequently treated. OPG diagnosis by screening MRI does not affect the natural history of the tumor.

Introduction The wide use of hemoclips during laparoscopic surgery has led to a variety of unusual complications, among these, there is the migration of Hem-o-Lok clip into the duodenum. We performed a literature review of all cases of Hem-o-Lok clip migration into the duodenum after laparoscopic digestive surgery reported in literature. Evidence acquisition All relevant articles were extracted up to June 2019 based on the results of searches in MEDLINE, PubMed, Scopus, Web of Science and Google Scholar. Evidence synthesis At the time of this review, a total of seven cases have been described. The mean age was 49 years and the majority of these patients were women (57%). Previous laparoscopic surgery was performed for cholecystectomy (four patients), cholecystectomy with common bile duct exploration (one patient), right hemicolectomy (one patient) and distal gastrectomy (one patient). Symptoms occurred from 3 months to 2 years after laparoscopic surgery. The majority of patients developed symptoms of bowel occlusion and abdominal pain. Three patients remained asymptomatic. In many cases the Hem-o-Lok wedged into the wall of the first or second portion of the duodenum. In all cases, esophageal gastroduodenoscopy was the primary modality to make the diagnosis. Initial treatment was conservative with watch-and-wait strategy or proton pump inhibitors followed by endoscopic removal, while surgical treatment was required in two cases. Conclusions The application of Hem-o-Lok clip during laparoscopic surgery is safe and effective. Postoperative Hem-o-Lok migration into the duodenum is rare. The treatment could be conservative in the majority of cases.

Introduction Wandering spleen (WS) is a rare and generally acquired condition, resulting from abnormal ligamentous laxity failing to fixate the spleen in its normal location in the left upper quadrant, thus leading to its migration to the pelvis due to gravity. Such migration leads to an elongated vascular pedicle, which is prone to torsion causing splenic infarction; thus, a prompt surgical intervention is recommended. Since this adverse event affects childbearing women or children, it is crucial to choose the most appropriate surgical strategy, such as splenectomy or splenopexy, both effective and widely diffused options. The aim of this paper is to perform a literature review on WS reports treated by surgery. We also present a case of symptomatic WS migrated in pelvis in a young female treated by splenectomy. Evidence acquisition All relevant articles from 1895 up to December 2017 were identified by literature searches in PubMed, Scopus and Google Scholar. Evidence synthesis A total of 376 patients treated with surgical approach for WS were identified. The most common presentations were abdominal pain and abdominal mass, and approximately half of the patients had an acute clinical onset. Radiology is essential for the diagnosis. Surgical strategy changed over the time; splenectomy is the most reported treatment although in the last years there is an increasing trend towards a more conservative strategy, preferring splenopexy or a laparoscopic approach. Conclusions Surgery is the gold standard strategy, and laparoscopic approach is recommended, for the treatment of wandering spleen. Both splenopexy or splenectomy are effective and safe surgical options.

Laparoscopic thermal ablation is a common alternative to surgical resection in treating hepatic tumors, particularly in those located in difficult-to-reach locations. The aim of this study was to compare the safety and long-term efficacy of laparoscopic radiofrequency ablation (RFA) and microwave ablation (MWA) in treating hepatocellular carcinoma (HCC). From February 2009 to May 2015, data from patients with HCC nodules who had undergone either laparoscopic MWA or laparoscopic RFA were examined. Complications, complete ablation rates, local tumor progression (LTP) rates, and disease-free and cumulative survival rates were compared between the two treatment groups. A total of 154 patients with HCC (60 MWA and 94 RFA) were treated via the laparoscopic approach. Major complication rates were identified as 1 and 2 % in the RFA and MWA groups, respectively (p = 0.747). Complete ablation rates were 95 % for both treatment groups (p = 0.931), and LTP rates were 21.2 % for RFA and 8.3 % for MWA (p = 0.034). Disease-free survival rates at 5 years were 19 % in the RFA group and 12 % in the MWA group (p = 0.434), while cumulative survival rates at 5 years were 50 % in the RFA group and 37 % in the MWA group (p = 0.185). Laparoscopic RFA and MWA appear to be safe in the treatment of early-stage HCC. The LTP rates were lower in the laparoscopic MWA group compared with the laparoscopic RFA group, but their respective overall and disease-free survival rates remained similar.

PURPOSE Prolonged Postoperative Ileus (PPOI) after abdominal surgery may affect unfavourably the patient recovery. The aim of this study was to estimate the incidence of PPOI in patients elective for colorectal resection and investigate perioperative variables associated with PPOI. METHODS A consecutive series of 428 patients undergoing colorectal resection (median age 72, range 24-92, years; men/women ratio 1.14) were analyzed. Data were extracted retrospectively throughout a five-year period from an electronic prospectively maintained database. PPOI was defined as the need for postoperative insertion of a nasogastric tube in a patient experiencing nausea and two episodes of vomiting and further showing absence of adequate bowel function (absence of flatus/stool) with lack of bowel sounds and abdominal distension. RESULTS Incidence of PPOI was 7% [95% confidence interval (95%CI), 4.8-9.9%]. Mean hospital stay was 8 days longer in patients with PPOI. Male gender, cancer, cardiac and respiratory co-morbidity, rectal resection, open/converted access, duration of operation, stoma formation and body mass index were associated with PPOI at univariate analysis (0.001< P< 0.048). PPOI was independently associated with male gender [adjusted odds ratio (OR), 4.2; 95%CI, 1.5-11.5], stoma formation (OR, 2.8; 95%CI, 1.2-6.8) and obesity (OR of obese vs. normal weight patients, 3.8, 95%CI, 1.2-12.0). CONCLUSION After colorectal resection, PPOI leads to a prolonged hospital stay and slower patient's recovery. An international standardized definition of PPOI is strongly needed to make comparable results from researches and to reliably identify patients with increased risk, also to improve the therapeutic preventive policies in these patients.

INTRODUCTION: Self-expandable metal stents are the gold standard for palliation of malignant dysphagia. Stent-associated esophagealrespiratory fistulas developed in 4% of patients causing a potentially life threatening emergency. When a fistula occurs, stent removal can be very challenging and related to increased risk for further complications. The aim of this paper was to perform a literature review on previous overtube-assisted reports for difficult esophageal stent removal. We also describe a safe method to remove a fully covered self-expandable metal stent prolapsing into the tracheal lumen by using a new type of overtube to reduce the risk of major injury. EVIDENCE ACQUISITION: All relevant articles were extracted up to December 2017 based on the results of searches in PubMed, Scopus and Google Scholar. EVIDENCE SYNTHESIS: A total of 6 case reports and 2 case series were included, for a total of 14 patients. The most frequent indications to stent placement were malignant strictures due to esophageal cancer or cardiac gastric cancer. The complications for which it was necessary to remove the stent were: occlusion, migration, strangulation, tissue overgrowth or ingrowth, embeeding, and epidural abscess and diskitis. In all cases at the time of stent removal no procedure related complications occurred. CONCLUSIONS: Using an overtube during removal of the stent increased patients safety during the procedure, reducing the risk of trauma and protecting the oesophageal wall.

Radiofrequency ablation (RFA) is widely used as a first-line option in patients with hepatocellular carcinoma (HCC). However, since percutaneous approach of RFA may be, in some cases, unfeasible by the tumor size and its location, laparoscopic ablation therapies (LATs) were used as an alternative. Objective of the present study was to assess the efficacy of laparoscopic ultrasound examination in addition to LATs in the treatment of HCC in patients not eligible for percutaneous RFA or surgical resection. Four hundred and twenty-six patients who underwent LATs were analyzed. Laparoscopic approach was offered to patients fulfilling at least one of the following criteria: (a) patients with a single nodule or up to three nodules smaller than 3 cm not suitable for liver transplantation or not eligible for HR because of severe portal hypertension, impaired liver function, or coexistent comorbidities; (b) patients not suitable for percutaneous RFA because of inconvenient tumor location; and (c) short-term recurrence of HCC (

Contrast-enhanced computed tomography colonography (CE-CTC) is a useful guide for the laparoscopic surgeon to avoid incorrectly removing the colonic segment and the failure to diagnose of synchronous colonic and extra-colonic lesions. Lymph node dissection and vessel ligation under a laparoscopic approach can be time-consuming and can damage vessels and organs. Moreover, mesenteric vessels have extreme variations in terms of their courses and numbers. We describe the benefit of using an abdominal vascular map created by CE-CTC in laparoscopic colorectal surgery candidates. We describe patients with different diseases (colorectal cancer, diverticular disease, and inflammatory bowel disease) who underwent CE-CTC just prior to laparoscopic surgery.

The increased invasiveness of endoscopic procedures and complex surgical interventions has resulted in an increased number of gastrointestinal iatrogenic defects, such as perforations, leak and fistulas. The conventional treatment for these gastrointestinal defects is surgery, with considerable risks especially in emergency situations and in patients with comorbidities. The Ovesco over-the- scope clip (OTSC) system (Ovesco Endoscopy AG, Tübingen, Germany) and more recently, the Padlock ClipTM (Aponos Medical, Kingston, NH, United States) have shown promising results in the treatment of gastrointestinal defects. Several case reports and case series have demonstrated the efficacy of the OTSC system for the closure of full-thickness defects. Clinical success is best achieved in patients undergoing closure of a perforation or a leak. Closure of fistulas remains a clinical challenge since fibrosis or necrotic and inflamed tissue surrounding lesions may cause clip failure. Over-the-scope clips are a less invasive endoscopic option for managing patients with gastrointestinal defects before a more invasive surgical approach is attempted. Moreover, a failed attempt of OTSC deployment does not preclude subsequent surgical treatment.

Background The aim of this study was to compare the outcomes of physician-controlled, using both long and short endoscopic-retrograde-cholangiopancreatography wire systems, and assistant-controlled guide-wire biliary cannulation techniques, and to perform a literature review on this topic. Methods The endoscopic databases of three Endoscopic Centers were reviewed to identify all consecutive patients with an intact papilla who, between July 2013 and December 2014, underwent an endoscopic-retrograde-cholangiopancreatography. A total of 240 patients (80 for each group) were matched 1:1, by gender, age and indications for procedure and were included in the analysis. All articles of physician-controlled vs. assistant-controlled guide-wire biliary cannulation techniques, were extracted up to December 2016, and included in the review. Results There were no statistically significant differences in primary and final (using rescue technique) cannulation rate between the three groups. The mean primary cannulation time and overall cannulation time were shorter in the two groups of physician-controlled guide-wire compared to the assistant-controlled guide-wire group, but the difference was not statistically significant. The total procedure time did not differ significantly between the three groups, but the physician-controlled guide-wire using short wire system was associated with a trend toward a shorter time compared to the other two techniques. There were no statistically significant differences in complication rates between the three groups. Three pertinent articles were included in the review. The mean procedure success and complication rates were 92% and 7%, respectively. Conclusions The literature review and our results show that all these techniques have equally efficacy and safety for guide-wire cannulation.

Mesh repair has significantly reduced recurrence rate after groin hernia surgery. Recently, attention has shifted to issues such as chronic pain and discomfort, leading to development of lightweight and partially re-absorbable meshes. The aim of the study was to evaluate the effect of lightweight mesh vs heavyweight mesh on post-operative pain, discomfort and quality of life in short and medium term after inguinal hernia surgery. Eight hundred and eight patients with primary inguinal hernia were allocated to anterior repair (Lichtenstein technique) using a lightweight mesh (Ultrapro(®)) or a heavyweight mesh (Prolene(®)). Primary outcomes were incidence of chronic pain and discomfort at 6-month follow-up. Secondary endpoints were quality of life (QoL), pain and complication at 1week, 1 and 6months. At 6months, 25% of patients reported pain of some intensity; severe pain was reported by 1% of patients in both groups. A statistically significant difference in favour of lightweight mesh was found at multivariable analysis for pain (1week and 6months after surgery: p=0.02 and p=0.04, respectively) and QoL at 1month and 6months (p=0.05 and p=0.02, respectively). There was no difference in complication rate and no hernia recurrences were detected. The use of lightweight mesh in anterior Lichtenstein inguinal hernia repair significantly reduced the incidence of pain and favourably affected the perceived quality of life at 6months after surgery compared to heavyweight mesh.

Thanks to technical advancement in surgery for hepatocellular carcinoma (HCC), hepatic resection (HR) for elderly HCC patients has become safer. However, elderly patients may have shorter long-term survival after surgery if compared with younger patients because of their expected life span. The aim of the present study was to evaluate clinical outcomes and safety after HR in HCC patients aged >75 years (older) compared with HCC patients aged

Background Hemospray is a new endoscopic haemostatic powder that can be used in the management of upper gastrointestinal bleedings. Aims To assess the efficacy and safety of Hemospray as monotherapy for the treatment of acute upper gastrointestinal bleeding due to cancer. Methods The endoscopy databases of 3 Italian Endoscopic Units were reviewed retrospectively and 15 patients (8 males; mean age 74 years) were included in this study. Results Immediate haemostasis was achieved in 93% of cases. Among the successful cases, 3 re-bled, one case treated with Hemospray and injection had a good outcome, while 2 cases died both re-treated with Hemospray, injection and thermal therapy. No complications related to Hemospray occurred. Finally, 80% of patients had a good clinical outcome at 30 days and 50% at six months. Conclusion Hemospray may be considered an effective and safe method for the endoscopic management of acute neoplastic upper gastrointestinal bleedings.

Bile duct injuries (BDIs) are the most serious complications after hepatobiliary surgery and are associated with high morbidity and mortality. The incidence of iatrogenic injuries of bile ducts has increased after the advent of laparoscopic cholecystectomy. BDIs present with biliary leak or biliary obstruction or a combination of both. Successful treatment of these complications requires a multidisciplinary team that includes biliary endoscopists, interventional radiologists and hepatobiliary surgeons. Endoscopic treatment is the main option for biliary leak. Depending on colangiographic appearance of the biliary damage, several endoscopic techniques (naso-biliary drainage, biliary sphincterotomy, placement of prosthesis) are used, allowing to achieve the leak sealing in most cases. In complex biliary fistulas the use of covered self-expandable metal stents is another therapeutic option with high success rates. The most common endoscopic therapy for biliary strictures involves balloon dilation and placement of multiple plastic stents followed by the periodic exchange of the stents. This is usually performed every three months by placing an increasing number of stents each time, until complete resolution of the stricture. Self-expandable metal stents have a larger diameter compared to plastic stents and therefore, higher patency rate. Covered self-expandable stents are an alternative option with the advantage of providing better permeability, preventing occlusion, and reducing the number of the required procedures. The aim of this paper was to review the endoscopic management of patients with bile duct injuries after hepatobiliary surgery.

Hamartoma is a rare splenic benign tumor usually accidentally detected as a radiologic finding. Preoperative diagnosis poses a challenge and thus surgery becomes necessary to confirm the clinical suspicion. Laparoscopic splenectomy has gained consensus as a standard surgical procedure particularly for autoimmune hematological diseases. This former experience has allowed this technique to be extended to other splenic pathologies. Here we report a case of total laparoscopic splenectomy for a bulky splenic hamartoma in a young male patient.

Although cystic colorectal metastases are rare (1.8%), they are still a crucial challenge for the surgeon especially in terms of detection and differential diagnosis. Since prognosis after resection is very good (40% 5-year survival), early diagnosis is essential. A 55-year-old man was admitted to our hospital with a suspected diagnosis of multiple small liver metastases. He had previously undergone left sided-cholectomy followed by chemotherapy for colonic carcinoma. Computed tomography (CT) revealed multiple small (

Our aim was to assess the capability of Barcelona Clinic Liver Cancer (BCLC) staging system in allocating stage A patients to hepatic resection (HR) and the effect on survival. We enrolled 132 patients with hepatocellular carcinoma (HCC) amenable to HR. All patients underwent ultrasound (US)-guided anatomical resection (≤2 segments) and then postoperative results were evaluated. Results showed 95% of patients were Child A, 49% in BCLC A1, 21% in A2, 6% in A3, and 24% in A4. No 30-day mortality occurred. Overall survival got worse from A1 to A4 (P = 0.0271), while no differences were found in Childs A patients with or without portal hypertension (P = 0.1674). Multivariate analysis (Cox model) shows that only AFP (

This study was designed to compare our laparoscopic ultrasonography (LUS) experience in the resectability evaluation of pancreatic or periampullary cancers (PAC) in two different periods: before and after the introduction of multidetector CT (MDCT). We prospectively enrolled 104 CT-resectable patients with PAC. During Step 1 (1995–1999), we performed LUS on all patients, whereas during Step 2 (2002–2007), LUS was performed selectively according to Pisters’ criteria. LUS was satisfactorily performed in all cases. At Step 1 accuracy of LUS in predicting pancreatic resectability was high (96%) but it was markedly lower in a subgroup of patients with close contact between tumor and portal vein (sensibility of 57%). At Step 2, selective LUS was performed on 9 of 64 patients (14%). LUS confirmed the MDCT finding of unresectability in 8 of 9 cases, and allowed curative resection in 1 case. Only 1 of 55 of the patients who did not undergo LUS would have benefited from the procedure. The yield of LUS decreased from 45% before to 1.8% after MDCT. In resectable-MDCT patients, routine LUS is unjustified. However, in doubtful MDCT cases, LUS has yet a good yield. In the event of close vascular contact, neither MDCT nor LUS seem to be conclusive, and laparotomy is still the only solution.

The optimal treatment for hepatocellular carcinoma (HCC) is surgical resection. However, only a small percentage of patients are operative candidates. The authors aimed to assess a novel operative combination of laparoscopic radiofrequency (LRF) with a selective intrahepatic vascular occlusion (SIHVO) to obtain an increased rate of total necrosis and a reduced rate of local HCC recurrences. For this study, 37 patients with HCC in liver cirrhosis were submitted to LRF with SIHVO. An LRF was indicated for patients not amenable to liver resection who evidenced at least one of the following criteria: severe impairment of the coagulation tests, large tumors (but

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. This mainly includes diagnostic procedures, interstitial therapies, and treatment of liver cysts. However, the authors believe there is room for a laparoscopic approach to the liver in selected cases.A prospective study of laparoscopic liver resections was undertaken with patients who had preoperative diagnoses of benign lesion and hepatocellular carcinoma with compensated cirrhosis. The inclusion criteria required that hepatic involvement be limited and located in the left or peripheral right segments (segments 2-6), and that the tumor be 5 cm or smaller. The location of the tumor and its transection margin were defined by laparoscopic ultrasound (LUS).From December 1996, 17 (5%) of 313 liver resections were included in the study. There were 5 benign lesions and 12 hepatocellular carcinomas in cirrhotic patients. The mean age of the study patients was 59 years (range, 29-79 years). The LUS evaluation identified the presence of new hepatocellular carcinoma nodules in two patients (17%). The resections included 1 bisegmentectomy, 8 segmentectomies, 3 subsegmentectomies, and 3 nonanatomic resections. The mean operative time, including laparoscopic ultrasonography, was 156 +/- 50 min (median, 150 min; range, 60-250 min), and the perioperative blood loss was 190 +/- 97 ml. There was no mortality. Conversion to laparotomy was necessary for two patients. Postoperative complications were experienced by 3 of 15 patients, all of them cirrhotics. One of the patients had a wall hematoma, and the remaining two patients had bleeding from a trocar access requiring a laparoscopic reexploration. The mean hospital stay for the whole series was 6.9 +/- 4.9 days (median, 6 days; range, 2-25 days) and 5.6 +/-1.4 days (median, 6 days; range, 2-8 days) for the 15 laparoscopic patients.Laparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver. Evaluation by LUS is indispensable to guarantee precise determination of the segmental tumor location and the relationship of the tumor to adjacent vascular or biliary structures, excluding adjacent or adjunctive new lesions. The evolution of laparoscopic hepatectomies probably will depend on the development of new techniques and instrumentations.

Background The treatment of colon cancer located in splenic flexure is not standardized. Laparoscopic approach is still considered a challenging procedure. This study reviews two Institutions experience in laparoscopic treatment of left colonic flexure cancer. Intraoperative, pathologic and postoperative data from patients undergoing laparoscopic splenic flexure resection were analyzed to assess oncological safety as well as early and medium-term outcomes. Methods From October 2005 to May 2014 laparoscopic splenic flexure resection was performed in 23 patients. Results Conversion rate was nihil. In 7 cases the anastomosis was performed intracorporeally. Specimen mean length was 21.2 cm, while the distance of distal and proximal resection margin from tumor site was 6.5 and 11.5 respectively. The mean number of harvested lymph nodes was 20.8. Mean operative time was 190 min and mean estimated blood loss was equal to 55 ml. As regard major postoperative complications, one case of postoperative acute pancreatitis and one case of postoperative bleeding from the anastomotic suture line were reported. Conclusions Although our experience is limited and appropriate indications must be set by future randomized studies, we believe that laparoscopic resection with intracorporeal anastomosis appears feasible and safe for patients affected by splenic flexure cancer.

Rectal syphilis is a rare expression of the widely recognised sexual transmitted disease, also known as the great imitator for its peculiarity of being confused with mild anorectal diseases because of its vague symptoms or believed rectal malignancy, with the concrete risk of overtreatment. We present the case of a male patient with primary rectal syphilis, firstly diagnosed as rectal cancer; the medical, radiological, and endoscopic features are discussed below.

A systematic literature review was carried out to evaluate best existing evidence on prognostic factors for progression of childhood optic pathway glioma. Databases were searched for relevant articles and articles selected independently by two authors. Information about study design, population, treatment, outcome and prognostic analysis were abstracted and the quality of each article was assessed. A total of 23 articles met the inclusion criteria. Many studies had important methodological limitations, regarding external and internal validity. Eleven studies evaluated possible prognostic factors in a multivariate analysis. Three high-quality studies indicated age < 1 year as an independent prognostic factor for a worse progression-free survival. Three studies with multivariate analysis, including one high-quality study, found that children with neurofibromatosis type 1 (NF-1) have a better progression-free survival than those without NF-1. Two studies with multivariate analysis found tumour site to be a prognostic factor, both with some methodological limitations. In conclusion, this systematic review demonstrates that only a few of the prognostic factors proposed have been proven to be clinically relevant. Age < 1 year is a clear and independent prognostic factor for progression-free survival. Other prognostic factors, such as NF-1, tumour site and others, are suggested, but are still without solid evidence and need further high-quality studies to be clearly proven.

A prospective study of laparoscopic ultrasound (LUS) for evaluation of the common bile duct during laparoscopic cholecystectomy was started in October 1993. LUS during cholecystectomy was performed routinely to preoperatively identify unsuspected stones. Three-hundred thirty patients with symptomatic cholelithiasis were included in the study. The preoperative work-up included endoscopic retrograde cholangiopancreatography in 49 patients. Common bile duct (CBD) stones were found in 22 cases; in 19 cases the stones were removed successfully by endoscopic sphincterotomy. LUS successfully visualized the CBD in all but 10 patients (3%). CBD stones were found in 17 patients and confirmed by preoperative cholangiography and/or CBD exploration. There were two false-negative and one false-positive result for LUS. In 47 patients (14.2%) LUS detected CBD sludge as low-amplitude echoes without acoustic shadowing. The presence of CBD sludge was correlated with some biochemical and clinical variables. A significant correlation was identified between the absence or presence of CBD sludge and endoscopic retrograde cholangiopancreatography, acute pancreatitis, gallbladder sludge, age, and the levels of serum bilirubin and alkaline phosphatase. A significant difference was recorded between CBD diameter and the presence or absence of stones or sludge (p = 0.00001). In our experience, LUS allowed good diagnosis of CBD stones during laparoscopic cholecystectomy. The clinical significance of CBD sludge remains to be elucidated.

Bluerubberblebnevussyndrome(BRBNS) is a rare disease associated with multiple venous malformations in the skin, gastrointestinal tract, and other organs [1], which usually presents with extensive hemorrhage or anemia [2]. Different therapeutic strategies havebeen proposed. We describe a case of BRBNS involving the small bowel, which was treated using a combined surgical and endoscopic approach. A 34-year-old woman with a diagnosis of BRBNS and a history of severe iron deficiency anemia was admitted for a small-bowel capsule endoscopy, which showed multiple vascular nodular lesions with signs of recent bleeding in the jejunum and proximal ileum (● " Fig.1). The patient was treated with blood transfusions and iron supplementation. A double-balloon enteroscopy was performed 2 months later because of new episodes of severe anemia (● " Fig.2), and visible proximal and distal vascular malformations were marked with ink (● " Fig.3). Computed tomography enterography revealed multiple vascular malformations also in the distal tract of the small bowel. Finally, we used a rendezvous approach with surgery and intraoperative enteroscopy. During the laparotomy, the parts of the ileal tracts with the majority of vascular lesions were identified. Two enterotomies were then performed, through which an endoscope was introduced to allow elastic band ligation to be carried out, whether upstream or downstream, of the remaining vascular lesions (● " Fig.4a,b). Surgical segmental resection of the two previously identified ileal tracts was performed (● " Fig.5). The postoperative course was normal. A follow-up small-bowel capsule endoscopy showed only three jejunal and two ileal vascular lesions, which were not bleeding. The patient remains in good clinical condition and has had no need for further blood transfusions. The treatment of BRBNS is mainly conservative. Antiangiogenic agents [3], endoscopic therapy (laser photocoagulation, sclerosis, band ligation, and polypectomy) [4], and surgery [5] have been utilized to reduce bleeding episodes. Laparotomy with intraoperative endoscopy could be used as an alternative approach in selected patients with refractory anemia and multiple lesions in the gastrointestinal tract.

Background: The laparoscopic resection of gastric stromal tumors is being performed with increased frequency. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. Methods: We report three cases of gastric submucosal tumors treated by a laparoscopic wedge resection of the stomach. All lesions were localized anterior gastric wall by intraoperative ultrasound on the. In the first patient the resection was performed with an endoscopic stapler; in the other patients, ultrasonic coagulation in association with an intracorporeal suture has been used. Results: All patients were successfully treated laparoscopically; there were no conversions to open surgery. In all cases the operative course was uneventful. The postoperative hospital stay ranged from 6 to 8 days. Conclusions: The results suggest that laparoscopic surgery is an adequate strategy for gastric submucosal neoplasms including gastrointestinal stromal tumors (GIST). Intraoperative ultrasound is very useful in the selection of the technical approach with or without the endoscopic stapler.

Hepatocellular carcinoma (HCC) is associated with a high incidence of postoperative recurrence, despite high rates of complete necrosis with radiofrequency ablation (RFA) and curative hepatic resections (HR). The aim of this study was to identify intraoperative ultrasound patterns observed during HR or RFA that predicting intrahepatic HCC recurrence.From January 1997 through August 2008, we treated 377 patients with HCC (158 with HR and 219 with surgical RFA). All patients underwent intraoperative ultrasound (IOUS) examination. Primary HCCs was classified according to diameter, HCC pattern (nodular or infiltrative), echogenicity (hyper- or hypo-), echotexture (homogeneous or inhomogeneous), capsular invasion, mosaic pattern, nodule-in-nodule appearance, and infiltration of portal vessels. Number of HCC nodules was also considered. Comparisons between the groups of possible factors for intrahepatic recurrence of treated tumors were performed using the Kaplan-Meier method and compared using the log-rank test.Patients were followed for 9-127 months (median: 18.6 months), and intrahepatic recurrence was observed in 198 (52.5%). In 138 patients (36.5%), recurrences were located in different segments with respect to the primary tumor. In 60 HCC tumors (16%), local recurrences were found in the same segment as the primary tumor. At univariate analysis, primary HCC echogenicity and mosaic pattern were the only factors not significant associated with intrahepatic recurrences.IOUS is an accurate staging tool for use during "surgical" resection or RFA. This study shows that IOUS patterns can also be used to estimate the risk of post-treatment HCC recurrence. In patients at high risk for this outcome, closer follow-up and use of adjuvant therapies could be useful.Sommario INTRODUZIONE: L’epatocarcinoma (HCC) è associato con una elevata incidenza di recidive post-trattamento, nonostante l’elevata incidenza di necrosi totali dopo radiofrequenza (RFA) o una ben riuscita resezione epatica (HR). Scopo dello studio è quello di identificare alcuni patterns ecografici intraoperatori quali fattori predittivi di recidiva. MATERIALI E METODI: Dal 1/97 al 8/2008, sono stati trattati 377 pazienti con HCC (158 HR e 219 RFA per via chirurgica). Tutti i pazienti sono stati sottoposti a valutazione ecografica intraoperatoria. Il nodulo primario è stato classificato nel seguente modo: diametro, pattern (nodulare o infiltrativo), ecogenicità (iper- o ipo-ecogeno), eco-struttura (omogeneo o disomogeneo), invasione capsulare, pattern a mosaico, aspetto di nodulo nel nodulo e infiltrazione dei rami portali. Venivano registrati anche il numero di noduli sospetti per HCC. Il confronto fra gruppi dei possibili fattori predittivi di recidiva dei tumori trattati veniva eseguito utilizzando il metodo di Kaplan–Meier con l’uso del log-rank test. RISULTATI: I pazienti avevano un range di follow-up di 9–127 mesi (follow-up mediano di 18.6 mesi). In 198 casi (52,5%) sono state risonosciute delle recidive intra-epatiche. Recidive intra-epatiche a distanza (cioè in segmenti differenti da quello trattato) sono state rinvenute in 138 pazienti (36,5%) mentre recidive locali sono state evidenziate in 60 casi (16%). All’analisi univariata, solo l’ecogenicità e il pattern a mosaico si sono rivelati fattori predittivi non significativi di recidiva intra-epatica. CONCLUSIONI: L’ecografia intraoperatoria consente un accurato staging intraepatico durante le procedure chirurgiche. Questo studio ha dimostrato un ulteriore vantaggio di questa metodica: permette di identificare dei patterns ecografici che possono predire i casi ad alto rischio di recidiva di HCC. In questi pazienti potrebbe essere utile proporre un follow-up di osservazione più stringato e anche delle terapie adiuvanti.

Background and aims The aim was to externally validate the capability of a simplified Barcelona Clinic Liver Cancer (s-BCLC) staging system in allocating patients to hepatic resection (HR) and the effect on survival: S-BCLC was defined by only 2 groups: AA included BCLC A1 + A2 classes with alpha-fetoprotein (AFP) ≤ 20 ng/ml and AB included A1 + A2 with AFP > 20 ng/ml plus A3 + A4 subgroups. Methods This study compared a training group (TG) with hepatocellular carcinoma (HCC) submitted to hepatic resection (HR) in Milan with another group of patients, the validation group (VG) in Creteil. All patients underwent ultrasound-guided anatomical resection ( Results Overall survival got worse from A1 to A4 ( p = 0.0271) in TG ( n = 132), as well as in VG ( n = 100) ( p = 0.0044) with a more important overlapping of each curves. According s-BCLC classification, the survival curves of TG ( p = 0.0001) and VG ( p = 0.0250) showed a definitive separation in two different staging groups. The s-BCLC provided the best predictive accuracy and it also presented the highest separability index and C-statistics in both TG and VG. On the other hand, in the evaluation of discriminatory ability for death, measured by ROC curve areas, the s-BCLC system gave better results than the others. Conclusion This experience stressed the high value of BCLC system in staging of HCC, but the s-BCLC system seems to be more useful for therapeutic decision making.

Background: According to international guidelines (European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD)), portal hypertension (PHTN) is considered a contraindication for liver resection for hepatocellular carcinoma (HCC), and patients should be referred for other treatments. However, this statement remains controversial. The aim of this study was to elucidate surgical outcomes of minor hepatectomies in patients with PHTN (defined by the presence of esophageal varices or a platelet count of

4110 Background: Surgical resection alone is the standard of care for patients with resectable intrahepatic cholangiocarcinoma (IHC). This study evaluates the benefit of adjuvant chemotherapy (AdjCTx) following curative intent hepatectomy for IHC. Methods: Clinicopathologic and long-term outcome data of 575 consecutive patients treated with curative intent hepatectomy for IHC (1995-2011) were extracted from a multi-institutional registry. After excluding operative mortality and M1 (n=46), Cox regression analysis was used to identify independent determinants of early recurrence (i.e., within 3 years). Propensity scores, which are used in observational studies to reduce selection bias by equating groups on the basis of relevant covariates, were calculated and utilized to match patients who had or had not AdjCTx (one-to-one match). Cases whose propensity score deviated more than 0.10 were considered unmatched and excluded from the analysis. Primary end-point was recurrence-free survival (RFS) at 3-years. Results: At a median FU of 42 months, 247 patients had recurred. Predictors of recurrence were LN metastases (HR 1.83 [1.36-2.44]), radical resection (HR 0.64 [0.45-0.9]), an elevated preoperative CA19.9 (HR 1.54 [1.15-2.07]), vascular invasion (HR 1.97 [1.49-2.61]), multiple tumors (HR 2.21 [1.71-2.86]), and size (analysed as continuous variable) (HR 1.01 [1.01-1.01]). After matching, no difference was observed between patients who had or had not AdjCTx (n=155 per group; 3-yrs RFS 28.3% vs. 38.0%, respectively; p=NS). When the analysis was restricted to patients who had gemcitabine, GEMOX or FOLFOX for 3 or more cycles (n=64 per group) again no difference emerged between patients who had or had not AdjCTx (3-yrs RFS 27.7% vs. 40.0% respectively, p=NS ). Conclusions: Our data suggest that AdjCTx following resection of IHC does not increase 3-years RFS.

Aggressive treatment of intrahepatic recurrence of hepatocellular carcinoma (HCC) increases patients’ survival. This study aimed to evaluate laparoscopic thermal ablation (TA) in the treatment of intrahepatic HCC recurrences. A retrospective analysis was performed on 88 patients (REC group) who underwent laparoscopic TA after prior TA (66 patients.) or partial hepatic resection (HR) (22 patients) as initial local treatment. Another 170 patients with primary HCC tumors (PRIM group) were regarded as the control group. The postoperative morbidity rates were similar for the patients with prior TA (18%) and those with prior HR (21%) (nonsignificant difference [NS]). The overall survival rates were not significantly different between the two groups (3-year survival rates of 59 and 78%, respectively; P = 0.1662). Moreover, the disease-free survival (DFS) rates did not differ significantly between the patients with prior TA and those with prior HR (3-year DFS of 21 and 8%, respectively; P = 0.1911). The incidences of morbidity in the whole REC (21%) and PRIM (20%) groups were similar (P = NS), and no mortality occurred in either group (0%). The cumulative 3-year survival rate was 63% in the REC group and 59% in the PRIM group (P = 0.5739), whereas the 3-year DFS rate was 17% in the REC group and 22% in the PRIM group (P = 0.5266). Laparoscopic TA can be performed safely and may be effective for intrahepatic HCC recurrence after prior TA or HR. It leads to survival and DFS rates similar to those obtained using laparoscopic TA for primary HCC without increasing morbidity. Laparoscopic TA could be proposed as first-line treatment of intrahepatic HCC recurrence for selected patients.

Background Little is known about the visual outcome of children affected by an optic pathway glioma (OPG). Procedures We evaluated the long-term visual outcome of 32 consecutive children affected by OPG without neurofibromatosis type-1 referred to the Pediatric Department of Padua University and managed according to standardized strategies. Results Eight children received chemotherapy, 10 radiotherapy, 7 both chemotherapy and radiotherapy, whereas 7 were untreated. At presentation, visual acuity (VA) was normal in 22 children (13 unilaterally and 9 bilaterally), and reduced in 10. At follow-up, VA had improved in 6 patients; it was stable in 8 and worse in 18. Visual field, assessed in 29 children, was normal in 9 and reduced in 20. The number of children with some grade of visual impairment increased from 7 to 10 during follow-up. Of the 17 children in whom the tumor became significantly smaller, VA improved in 6, was stable in 3, and worse in 8. Of the 6 children with improved VA, 5 received radiotherapy, and their papilla was normal or mildly pale. After a median follow-up of 6 years, 26 patients are alive with stable disease. Conclusions The visual prognosis of children with OPG is unsatisfactory. Older children treated with radiotherapy seem to have a better visual outcome than younger children. Severe optic pallor at diagnosis or during follow-up may be indicative of a negative prognosis. Pediatr Blood Cancer. 2010;55:1083–1088. © 2010 Wiley-Liss, Inc.

This study compared two homogeneous groups of patients submitted to either surgical resection (HR) or laparoscopic radiofrequency ablation (LRFA) for the treatment of hepatocellular carcinoma (HCC). When compatible with the liver functional reserve, HR remains the treatment of choice for HCC, while LRFA seems to be a promising, less invasive alternative. We thus compared HR or LRFA for short- and long-term outcomes in patients with a single HCC nodule and Child-Pugh class A liver cirrhosis.We enrolled 152 cirrhotic patients out of 372 cases consecutively evaluated for HCC. Enrolled patients with similar baseline characteristics underwent HR (n = 78) or LRFA (n = 74), in both cases with intraoperative ultrasonography, and they were then followed for similar durations (mean +/- standard deviation, 36.2 +/- 23.5 months for HR vs. 38.2 +/- 28.4 for LRFA). Outcomes included short- and long-term morbidity, HCC recurrence, and overall survival.Short-term morbidity was far higher in the HR group while, during follow-up, HCC recurrence (mainly local) was more frequent in patients treated with LRFA. More importantly, baseline alfa-fetoprotein levels and early HCC recurrence after treatment greatly influenced overall survival, while the use of HR or LRFA did not predict it. On the other hand, HCC recurrence was found to be determined by the surgical approach and ultrasound characteristics of the tumor.Our data were obtained from a large number of HCC cases and support similar survival rates after HR or LRFA for single HCC nodules on Child-Pugh class A liver cirrhosis, despite a marked increase in HCC recurrence rates after LRFA.

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection. A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound. From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50-79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 +/- 69 min (median, 220; range, 80-300). Perioperative blood loss was 183 +/- 72 ml (median, 160; range, 80-400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 +/- 4.3 days (median, 5; range, 4-25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 +/- 1 (median, 5; range, 4-8). Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.

The treatment of choice for hepatocellular carcinoma (HCC) is surgical resection but only a small percentage of patients are operative candidates. Percutaneous radiofrequency interstitial thermal ablation (RFA) has proved to be effective in the treatment of unresectable HCC. However, there is a sub-group of patients who may benefit from a laparoscopic rather than a percutaneous approach. Laparoscopic RFA offers the combined advantages of improved tumor staging based on the intracorporeal ultrasound examination and safer access to liver lesions that are difficult or impossible to treat with a percutaneous approach. The aim of our review was to evaluate the advantages and limitations of the laparoscopic approach, according to the criteria of evidence-based medicine.Laparoscopic RFA of HCC proved to be a safe and effective technique, at least in terms of the short- and mid-term results. This technique may be indicated in selected cases of HCC when percutaneous RFA is very difficult or contraindicated.Sommario BACKGROUND: Il trattamento ottimale dell'epatocarcinoma è la resezione epatica. Tuttavia, solo una piccola percentuale di pazienti può essere sottoposta a intervento. La termoablazione mediante radiofrequenza per via percutanea si è dimostrata efficace nel trattamento degli epatocarcinomi non resecabili. Tuttavia, esiste un sottogruppo di pazienti che potrebbe essere adatto a un approccio per via laparoscopica. Il razionale di questa tecnica è quello di associare i vantaggi di una miglior stadiazione assicurata dalla valutazione ecografica intraoperatoria con un sicuro approccio alle lesioni epatiche difficili o impossibili da trattare per via percutanea. Lo scopo di questa revisione critica del tema è quello di valutare vantaggi e limiti dell'approccio laparoscopico secondo i criteri di una medicina basata sull'evidenza. CONCLUSIONI: La radiofrequenza per via laparoscopica del'epatocarcinoma si è dimostrata una metodica sicura ed efficace almeno a medio-termine. Questa tecnica può essere indicata in casi selezionati quando l'approccio percutaneo alla lesione da trattare è molto difficile o controindicato.