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Background: Pancreatic ductal adenocarcinoma (PDAC) has an extremely poor prognosis. The outcomes of patients with cancer are determined not only by tumor-related factors but also by systemic inflammatory response. The objective of the study was to identify whether the preoperative neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are associated with the prognosis of PDAC of the pancreas head after curative pancreatoduodenectomy. Materials and Methods: Seventy-six patients were enrolled in this prospective, observational clinical study. The optimal NLR and PLR cut-off values were calculated using a receiver operating characteristic (ROC) curve analysis. ROC curve analysis revealed an optimal NLR and PLR cut-off point of 5.41 and 205.56, respectively. Consequently, the NLR and PRL scores were classified as NLR Results: Low preoperative NLR and PLR levels both correlated with better pathological features, including decreased depth of invasion (p < 0.001), less lymph node metastasis (p < 0.001), earlier stage (p < 0.001), and lymphovascular invasion (p = 0.004). Kaplan-Meier plots illustrated that higher preoperative NLR and PLR had does not influence OS and DFS. Univariate analysis revealed that depth of invasion, lymph node metastasis, stage, PLR, and NLR are risk factors affecting OS and DFS. Multivariate analysis revealed that only stage was independently associated with OS and DFS. Conclusions: NLR and PLR measurements cannot provide important prognostic results in patients with resectable PDAC.

Introduction Intra-abdominal abscesses complicating Crohn’s disease (CD) present an additional challenge as their presence can contraindicate immunosuppressive treatment whilst emergency surgery is associated with high stoma rate and complications. Treatment options include a conservative approach, percutaneous drainage, and surgical intervention. The current multicentre study audited the short-term outcomes of patients who underwent preoperative radiological drainage of intra-abdominal abscesses up to 6 weeks prior to surgery for ileocolonic CD. Methods This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing ileocolic resection for primary or recurrent CD from June 2018 to May 2019. The outcomes of patients who underwent radiological guided drainage prior to ileocolonic resection were compared to the patients who did not require preoperative drainage. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. Results Amongst a group of 575 included patients who had an ileocolic resection for CD, there were 36 patients (6.2%) who underwent abscess drainage prior to surgery. Postoperative morbidity (44.4%) and anastomotic leak (11.1%) were significantly higher in the group of patients who underwent preoperative drainage. Conclusions Patients with Crohn’s disease who require preoperative radiological guided drainage of intra-abdominal abscesses are at increased risk of postoperative morbidity and septic complications following ileocaecal or re-do ileocolic resection.

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann-Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann-Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.

Sclerotherapy with 3% polidocanol foam is becoming increasingly popular for the treatment of symptomatic I-II or III degree haemorrhoidal disease (HD). However, there are no studies that have reported a follow-up of more than 1 year. The purpose of this study was to analyse the long-term outcomes of sclerotherapy with 3% polidocanol foam in the treatment of II-degree HD.This was an open label, single-arm, phase 2b trial conducted in 10 tertiary referral centres for HD. A total of 183 patients with II-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification and unresponsive to medical treatment, were included in the study and underwent sclerotherapy with 3% polidocanol foam. The efficacy was evaluated in terms of bleeding score, haemorrhoidal disease symptom score (HDSS) and short health scale for HD (SHS-HD) score. Successful treatment was defined as the complete absence of bleeding episodes after 7 days (T1) according to the bleeding score.The overall success rate ranged from 95.6% (175/183) at 1 year to 90.2% (165/183) after the final 3 year follow-up. The recurrence rate, based on the primary outcome, ranged from 12% (15/125) to 28% (35/125). The greatest increase in recurrence (15) was recorded between 12 and 18 months of follow-up, then another five between 18 and 24 months. Both the HDSS and the SHS score remained statistically significant (p 0.001) from a median preoperative value of 11 (10-13) and 18 (15-20) to 0 (0-2) and 4 (0-4), respectively. Symptom-free (HDSS = 0) patients, excluding patients converted to surgery, increased from 55.5% (101/182) at 1 year to 65.1% at 3 years (110/169). There were no intraoperative complications in redo-sclerotherapy nor additional adverse events (AEs) compared to the first 12 months.Sclerotherapy with 3% polidocanol foam is gradually establishing itself in the treatment of bleeding HD due to its repeatability, safety, convenience in terms of direct and indirect costs with the absence of discomfort for the patient as well as AEs rather than an excellent overall success rate.

Introduction In the past decade, minimally invasive pancreaticoduodenectomy has been gaining interest. However, minimally invasive pancreaticoduodenectomy remains technically challenging and is associated with a steep learning curve. Additionally, the operating surgeon should be cognizant of replicating the same oncological steps as observed in the typical open approach. In view of this, there exist various maneuvers that are designed to achieve negative margins and a safer mesopancreatic dissection. One of these techniques is the superior mesenteric artery first approach, which is garnering interest among pancreatic surgeons. Material and Methods According to existing literature, there are several superior mesenteric artery dissections approaches. We describes 5 different minimally invasive approaches. Results This multimedia manuscript provide, for the first time in literature, a comprehensive step-by-step overview of the superior mesenteric artery first approach for minimally invasive pancreaticoduodenectomy by a team of expert surgeons from various international institutions. Conclusions Through the tips and indications presented in this article, we aim to guide the choice of this approach according to tumor location, type of minimally invasive approach and the operating surgeon's experience and increase familiarity with such a complex procedure.

Objectives. The prevalence of morbid obesity has dramatically increased over the last several decades worldwide, currently reaching epidemic proportions. Gastric leak (GL) remains the potentially fatal main complication after sleeve gastrectomy (SG) for morbid obesity. To our knowledge, there are no standardized guidelines for GL treatment after laparoscopic sleeve gastrectomy (LSG) yet. The aim of this study was to represent our institutional preliminary experience using the endoscopic double-pigtail catheter (EDPC) as the method of internal drainage and propose it as first-line treatment in case of GL after LSG. Methods. One hundred and seventeen patients were admitted to our surgical department and underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity from March 2014 to June 2019. In 5 patients (4.3%) of our series, GL occurred as a complication of LSG. EPDC was the stand-alone procedure of internal drainage and GL first-line treatment. The internal pig tail was endoscopically removed from 30th to 40th POD in all cases. Results. Present data (clinical, biochemical, and instrumental tests) showed a complete resolution of GL, with promotion of a pseudodiverticula and complete re-epithelialization of leak. Follow-up was more strict than usual (clinical visit and biochemical test on 7th, 14th, and 21st day after discharge; a CT scan with gastrografin on 30th day from discharge if clinical visit and exams were normal). Conclusion. This was a preliminary retrospective observational study, conducted on 5 patients affected by GL as a complication of LSG for morbid obesity. EDPC maintains the safety, efficacy, and nonexpensive characteristic and may be proposed as better first-line treatment in case of GL after bariatric surgery.

Highlights • Acute abdomen is any acute abdominal condition requiring a quick response. • The abdominal discomfort associated with extra-abdominal pathologies could mimic acute abdomen. • Cardiac tamponade is a medical emergency. • The differential diagnosis could be kept in mind to avoid a delayed treatment., Introduction Acute abdomen is any acute abdominal condition requiring a quick response. The incidence varies according to age and disease aetiology. The abdominal discomfort associated with extra-abdominal pathophysiology and thoracic conditions could mimic acute abdomen. In this case we report a rare case of a young patient with cardiac tamponade masquerading as acute abdomen. Presentation of case A 25-years-old African man presented to the Emergency Department with abdominal pain. An EKG was performed, which revealed sinus tachycardia, with electrical alternans and borderline reduced voltage. At the time of the admission to our unit, he had a clinical worsening and a CT scan of abdomen was performed, which demonstrated hepatomegaly, abundant pericardial effusion and thin right pleural effusion at the lung bases. An echocardiogram confirmed a circumferential pericardial effusion with initial collapse of the right ventricular free wall. It was decided to immediately transport the patient to the Cardiosurgery Unit of another hospital to undergo pericardiocentesis. Discussion Our experience with this case underlines the important point that patients with a large pericardial effusion may present with the clinical features of acute abdomen and peritonitis. Abdominal pain was the primary symptom that prompted this patient to seek medical attention. Conclusion Acute abdomen is any acute abdominal condition requiring a rapid, often surgical, treatment. Cardiac tamponade is a medical emergency. The differential diagnosis could be kept in mind by any emergency physician, surgeon and anaesthesiologist, because an incorrect diagnosis and therefore an incorrect treatment or a delay in pericardial evacuation can be life-threatening.

Funder: Università degli Studi dell'Insubria, INTRODUCTION: This How-I-Do-It article presents a modified Deloyers procedure by mean of the case of a 67-year-old female with adenocarcinoma extending for a long segment and involving the splenic flexure and proximal descending colon who underwent a laparoscopic left extended hemicolectomy (LELC) with derotation of the right colon and primary colorectal anastomosis. BACKGROUND: While laparoscopic extended right colectomy is a well-established procedure, LELC is rarely used (mainly for distal transverse or proximal descending colon carcinomas extending to the area of the splenic flexure). LELC presents several technical challenges which are demonstrated in this How-I-Do-It article. TECHNIQUE AND METHODS: Firstly, the steps needed to mobilize the left colon and procure a safe approach to the splenic flexure are described, especially when a tumor is closely related to it. This is achieved by mobilization and resection of the descending colon, while maintaining a complete mesocolic excision to the level of the duodenojejunal ligament for the inferior mesenteric vein and flush to the aorta for the inferior mesenteric artery. Subsequently, we depict the adjuvant steps required to enable a primary anastomosis by trying to mobilize the transverse colon and release as much of the mesocolic attachments at the splenic flexure area. Finally, we present the rare instance when a laparoscopic derotation of the ascending colon is required to provide a tension-free anastomosis. The resection is completed by delivery of the fully derotated ascending colon and hepatic flexure through a suprapubic mini-Pfannenstiel incision. The primary colorectal anastomosis is subsequently fashioned in a tension-free way and provides for a quick postoperative recovery of the patient. RESULTS: This modified Deloyers procedure preserves the middle colic since the fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump. Also, by eliminating the need for a mesenteric window and the transposition of the caecum, we allow the small bowel to rest over the anastomosis and the mobilized transverse colon and reduce the possibility of an internal herniation of the small bowel into the mesentery. CONCLUSIONS: Laparoscopic derotation of the right colon and a partial, modified Deloyers procedure preserving the middle colic vessels are feasible techniques in experienced hands to provide primary anastomosis after LELC with improved functional outcome. Nevertheless, it is important to consider anatomical aspects of the left hemicolectomy along with oncological considerations, to provide both a safe oncological resection along with good postoperative bowel function.

Esophago-jejunostomy leakage (EJL) it the most dreaded septic complication after total gastrectomy for gastric cancer. Early detection and treatment of this complication may improve outcomes. Systemic Inflammation Response Index (SIRI) is a marker that reflects systemic inflammation.The SIRI was developed in a training cohort of 180 patients who underwent elective open total gastrectomy with esophago-jejunal anastomosis for gastric cancer from January 2009 to December 2013. To verify the prognostic value of SIRI score we recruited 192 patients treated from January 2014 to December 2021 as the validation cohort. The optimal cut-off value of SIRI was determined by receiver operating characteristic curve. Univariate and multivariate analysis was performed.An optimal cut-off point for the SIRI of 0.82 divided the patients into a low SIRI group and high SIRI group in the training cohort. Patients with a SIRI ≥0.82 was found to be significantly associated with EJL. Univariable analysis showed that NLR, PLR, MLR, SII, and SIRI were prognostic factors for EJL in the training cohort. In multivariable analysis, EJL high level of SIRI was identified as independent prognostic factor.Preoperative SIRI may be helpful in identifying patients at greater risk for developing EJL after total gastrectomy.

PURPOSE Minimally invasive surgery has been universally accepted as a valid option for the treatment of diverticular disease, provided specific expertise is available. Over the last decade, there has been a growing interest in the application of robotic approaches for diverticular disease. We aimed at evaluating whether robotic colectomy may offer some advantages over the laparoscopic approach for surgical treatment of diverticular disease by meta-analyzing the available data from the medical literature. METHODS The PubMed/Medline, EMBASE, and Web Of Sciences electronic databases were searched for literature up to December 2020. Inclusion criteria considered all comparative studies evaluating robotic versus laparoscopic colectomy for diverticulitis eligible. The conversion rate to the open approach was evaluated as the primary outcome. RESULTS The data of 4177 patients from nine studies were included in the analysis. There were no significant differences in the baseline characteristics. Patients undergoing laparoscopic colectomy compared to those who underwent surgery with a robotic approach had a significantly higher risk of conversion into an open procedure (12.5% vs. 7.4%, p

Background The laparoscopic approach in the treatment of mid- or low-rectal cancer is still controversial. Compared with open surgery, laparoscopic resection of extraperitoneal cancer is associated with improved short-time non-oncological outcomes, although high-level evidence showing similar short- and long-term oncological outcomes is scarce. Objective The aim of our paper is to study the oncological and non-oncological outcomes of laparoscopic versus open surgery for extraperitoneal rectal cancer. Data sources A systematic review of MedLine, EMBASE, and CENTRAL from January 1990 to October 2020 was performed by combining various key words. Study selection Only randomized controlled trials (RCTs) comparing laparoscopic versus open surgery for extraperitoneal rectal cancer were included. The quality of RCTs was assessed using the Cochrane reviewer's handbook. This meta-analysis was based on the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Intervention(s) This study analyzes laparoscopic versus open surgery for extraperitoneal rectal cancer. Main outcome measures Primary outcomes were oncological parameters. Results Fifteen RCTs comprising 4,411 patients matched the selection criteria. Meta-analysis showed a significant difference between laparoscopic and open surgery in short-time non-oncological outcomes. Although laparoscopic approach increased operation time, it decreases significantly the blood loss and length of hospital stay. No significant difference was noted regarding short- and long-term oncological outcomes, but 4 and 5 years disease-free survival were statistically higher in the open group. Limitations There are still questions about the long-term oncological outcomes of laparoscopic surgery for extraperitoneal rectal cancer being comparable to the open technique. Conclusions Considering that all surgical resections have been performed in high volume centers by expert surgeons, the minimally invasive surgery in patients with extraperitoneal cancer could still be not considered equivalent to open surgery in terms of oncological radicality.

Minimally invasive pancreaticoduodenectomy (PD) is attracting increased interest in the pancreatic surgical community with more and more teams reporting their experience worldwide. The pancreatic anastomosis (PA) is one of the key steps and challenging manoeuvre of this procedure. Since the introduction of the minimally invasive approach for PD, several PA types have been proposed, ranging from high to low complexity, but none of them have been proven unequivocally superior to the others. Therefore, definitive consensus has not been reached yet. In the present multimedia manuscript, we report the most commonly adopted minimally invasive PA and we propose a "complexity classification" to guide the choice accordingly to different characteristics of the pancreatic stump. We describe five possible different PA that might be tailored to each different case, depending mainly on texture of pancreatic stump (soft/hard, lean/fatty) and the size and visibility of main duct. This manuscript presents a step-by-step portfolio of the most commonly used mini-invasive PA. This technique requires experience in pancreatic surgery and advanced minimally invasive skills. Knowledge of and proficiency in different types of PA could help reducing the incidence of postoperative pancreatic fistula.

Background/objectives: Reports about the implementation of recommendations from acute pancreatitis guidelines are scant. This study aimed to evaluate, on a patient-data basis, the contemporary practice patterns of management of biliary acute pancreatitis and to compare these practices with the recommendations by the most updated guidelines. Methods: All consecutive patients admitted to any of the 150 participating general surgery (GS), hepatopancreatobiliary surgery (HPB), internal medicine (IM) and gastroenterology (GA) departments with a diagnosis of biliary acute pancreatitis between 01/01/2019 and 31/12/2020 were included in the study. Categorical data were reported as percentages representing the proportion of all study patients or different and well-defined cohorts for each variable. Continuous data were expressed as mean and standard deviation. Differences between the compliance obtained in the four different subgroups were compared using the Mann-Whitney U, Student's t, ANOVA or Kruskal-Wallis tests for continuous data, and the Chi-square test or the Fisher's exact test for categorical data. Results: Complete data were available for 5275 patients. The most commonly discordant gaps between daily clinical practice and recommendations included the optimal timing for the index CT scan (6.1%, χ2 6.71, P = 0.081), use of prophylactic antibiotics (44.2%, χ2 221.05, P < 0.00001), early enteral feeding (33.2%, χ2 11.51, P = 0.009), and the implementation of early cholecystectomy strategies (29%, χ2 354.64, P < 0.00001), with wide variability based on the admitting speciality. Conclusions: The results of this study showed an overall poor compliance with evidence-based guidelines in the management of ABP, with wide variability based on the admitting speciality. Study protocol registered in ClinicalTrials.Gov (ID Number NCT04747990).

Background Jejunal feeding is an invaluable method by which to improve the nutritional status of patients undergoing neoadjuvant and surgical treatment of oesophageal malignancies. However, the insertion of a feeding jejunostomy can cause significant postoperative morbidity. The aim of this study is to compare the outcomes of patients undergoing placement of feeding jejunostomy by conventional laparotomy with an alternative laparoscopic approach. Methods A retrospective review of data prospectively collected at the Oxford Oesophagogastric Centre between August 2017 and July 2019 was performed including consecutive patients undergoing feeding jejunostomy insertion. Results In the study period, 157 patients underwent jejunostomy insertion in the context of oesophageal cancer therapy, 126 (80%) by open technique and 31 (20%) laparoscopic. Pre-operative demographic and nutritional characteristics were broadly similar between groups. In the early postoperative period jejunostomy-associated complications were noted in 54 cases (34.4%) and were significantly more common among those undergoing open as compared with laparoscopic insertion (38.1% vs. 19.3%, P = 0.049). Furthermore, major complications were more common among those undergoing open insertion, whether as a stand-alone or at the time of staging laparoscopy (n = 11/71), as compared with insertion at the time of oesophagectomy (n = 3/86, P = 0.011). Conclusions This report represents the largest to our knowledge single-centre comparison of open vs. laparoscopic jejunostomy insertion in patients undergoing oesophagectomy in the treatment of gastroesophageal malignancy. We conclude that the laparoscopic jejunostomy insertion technique described represents a safe and effective approach to enteral access which may offer superior outcomes to conventional open procedures.

Ingested toothpicks are a relatively rare event, but they may cause serious gut injuries and can be listed among rare causes of perforation, peritonitis, sepsis or death. Unless the foreign bodies were intentionally swallowed, many patients who ingested them fail to remember the event and they do not refer it during the medical history collection; this makes diagnosis problematic. In this work, a case of perforation of the sigmoid colon is described, caused by a toothpick ingestion. The patient had to be surgically treated because of a complication: the formation of an entero-iliac fistula with subsequent development of a pseudoaneurysm of the right external iliac artery. Vascular perforation due to toothpick ingestion has rarely been reported. In similar cases, it could be difficult to establishing the correct diagnosis because of the low sensitivity and accuracy rates of diagnostic investigations. The ingestion of foreign bodies should be kept in mind as an important differential diagnosis in patients with acute abdomen or chronic abdominal pain of unknown origin., Highlights • Ingested toothpicks are a relatively rare event. • These can be listed among rare causes of perforation, peritonitis, sepsis or death. • It could be difficult to establishing the correct diagnosis because of the low sensitivity of diagnostic investigations. • Vascular perforation due to toothpick ingestion has rarely been reported. • The ingestion of foreign bodies should be kept in mind as an important differential diagnosis.

Highlights • Agenesis of the dorsal pancreas is a rare congenital anomaly. • The possibility of finding this disorder is increasing with the use of advanced radiological techniques. • Some patients experience no symptoms. • Rarely, they may also develop pancreatic exocrine insufficiency or pancreatic adenocarcinoma. • This diagnosis could be missed by US, due to difficulty on visualization of body and tail of pancreas., Introduction Agenesis of the dorsal pancreas (ADP) is a rare congenital anomaly resulting in missing corpus and cauda of the pancreas. The possibility of finding this disorder is increasing with the use of advanced radiological techniques like CT scan or MRI. Presentation of case We reported 2 cases of a partial ADP as radiological finding: the first one was a 79-year-old asymptomatic patient who presented to perform a CT staging scan for bladder tumor, while the second case was a 73-year-old patient with obstructive jaundice and with suspected common bile duct calculi. In the second patient US, CT scan and MRI were performed, and after that also an ERCP was scheduled. Discussion The prevalence of agenesis of the dorsal pancreas is not exactly known; in the literature, only 50 cases have been reported. Its cause and pathogenesis are not fully understood. Some patients experience no symptoms, while others may develop hyperglycemia, diabetes mellitus, bile duct obstruction, abdominal pain, pancreatitis, or other conditions. Conclusion Considering that dorsal agenesis is sporadically found, often do not have related symptoms and it does not require a specific treatment, whether further examinations are needed to determine the type of agenesis remains questioned.

It is known that Duodenal adenocarcinoma (DA) is a rare malignant solid tumor that cause occlusion symptoms with orthodox dysphagia when locally advanced. Pancreatic neuroendocrine tumors (PanNETs) account for about 2% of all pancreatic neoplasms. The combination of these two lesions, with the synchronous presence of ectopic pancreatic tissue (EPT) of the duodenum, has never been described in literature, to our knowledge. Here we report a case of combined DA, EPT and PanNET affecting a 71-year-old woman., Highlights • Simultaneous presence of Duodenal adenocarcinoma pancreatic neuroendocrine tumor ectopic pancreatic tissue of duodenum. • Biochemical tests did not reveal abnormalities: CA 19-9 was normal, CEA was 153 U/L. • Ultrasonography confirmed a nodule dislocating pancreas investigated with contrast-enhanced CT and esophagogastroduodenoscopy. • The association between duodenal adenocarcinomas, PanNET and ectopic pancreatic tissue (EPT) of the duodenum is really rare.

Highlights • Metastatic involvement of peripheral nerves by perineural invasion from an adjacent cancer is not uncommon. • Nerve root metastasis without extension from an adjacent process has been seldom reported in case of solid tumors. • No cases of gastric adenocarcinoma metastasis to the nerves have been reported to date. • In case of known malignancy and refractory pain, the possibility of a nerve root metastasis should be considered., Introduction Nerve root metastasis without extension from an adjacent process has been seldom reported in case of solid tumors. We describe a case of solitary nerve root metastasis of gastric adenocarcinoma, likely due to hematogenous spread. Case presentation A 75-year-old man presented with radiculopathy refractory to medical treatment. MRI and CT demonstrated a right-sided S1 nerve root mass involving the spinal ganglion in its intra-foraminal region with avid enhancement, initial erosive bone changes on sacral foramina and focal hyperaccumulation on 18F – FDG CT-PET, suspicious for metastasis. The histopathological examination confirmed a metastasis of gastric adenocarcinoma. Discussion A review of the current literature revealed only ten cases of hematogenous metastases to spinal nerve root ganglia; the primary lesions in those cases were an oat cell carcinoma of the lung, two cases of colonic adenocarcinoma, a case of uterine adenocarcinoma, a ductal breast carcinoma, a Ewing’s sarcoma, a Renal Cell Carcinoma, a gastro-intestinal stromal tumor, a follicular thyroid carcinoma, a pulmonary adenocarcinoma. Conclusion In the setting of a known malignancy, a nerve root metastasis should be considered in the differential diagnosis of a nerve root mass, although it occurs very rarely.

Lymphangiomatosis is a benign proliferation of lymph vessels. Lymphatic diseases can vary from small lymphangioma to generalized lymphangiomatosis, which is a rare condition and can have several clinical manifestations. The gastrointestinal tract may be affected, but the incidence in the intestinal wall is very low. We propose in our study a case of ileal lymphangiomatosis presenting with perforation, in which the diagnosis was made after the pathological analysis of the resected intestinal tract. Although rare and not described in the literature, intestinal lymphangiomatosis could manifest itself with acute abdomen and could be a surgical urgency. This disease should be considered when intestinal perforation is observed., Highlights • Lymphangiomatosis is a multisystemic disorder. • The GI tract may be affected, but the incidence of lymphangioma of the intestinal wall is very low. • Lymphangiomatosis of the small bowel is a rare disease, so it is easy for a clinician to make a misdiagnosis. • Intestinal lymphangiomatosis could manifest itself with an acute abdomen and surgical urgency. • The pathologist should keep it in mind in the differential diagnosis, when he analyses a case of perforation.

The aim of this prospective multicentric study was to compare the accurate colonic lesion localization ratio between CT and colonoscopy in comparison with surgery. All consecutive patients from 1st January to 31st December 2019 with a histologically confirmed diagnosis of dysplastic adenoma or adenocarcinoma with planned elective, curative colonic resection who underwent both colonoscopy and CT scans were included. Each patient underwent conventional colonoscopy and CT to stage the tumour, and the localization results of each procedure were registered. CT and colonoscopic localization were compared with surgical localization, adopted as the reference. Our analysis included 745 patients from 23 centres. After comparing the accuracy of colonoscopy and CT (for visible lesions) in localizing colonic lesions, no significant differences were found between the two preoperative tools (510/661 vs 499/661 correctly localized lesions, p = 0.518). Furthermore, after analysing only the patients who underwent complete colonoscopy and had a visible lesion on CT, no significant difference was observed between conventional colonoscopy and CT (331/427 vs 340/427, p = 0.505). Considering the intraoperative localization results as a reference, a comparison between colonoscopy and CT showed that colonoscopy significantly failed to correctly locate the lesions localized in the descending colon (17/32 vs 26/32, p = 0.031). We did not identify an advantage in using CT to localize colonic tumours. In this setting, colonoscopy should be considered the reference to properly localize lesions; however, to better identify lesions in the descending colon, CT could be considered a valuable tool to improve the accuracy of lesion localization.

Introduction Single-incision laparoscopic surgery (SILS) aims to minimize the surgical access trauma by reducing the number of abdominal incisions to a single site, potentially offering better cosmetic results and decreased postoperative pain. In this study, we compare the results of SILS ileocolic resection for Crohn’s disease (CD) to conventional laparoscopy and open surgery using a propensity score–matched analysis in a retrospective national multicentre study. Methods All consecutive patients undergoing elective SILS ileocaecal or redo ileocolic resection for primary and recurrent CD from 1 June 2018 to 31 May 2019 were included. Patients were matched 1:1:1 with laparoscopy and open surgery according to perianal disease, recurrent disease, penetrating phenotype of CD, history of previous abdominal surgery, preoperative medical treatment with steroids and anti-TNF. Postoperative morbidity within 30 days of surgery was the primary endpoint. Results Fifty-eight patients were included in each group, for a total of 174 patients. The conversion rate for SILS and laparoscopy was 10.3% and 12%, respectively, with no difference in the incidence of postoperative complications (13.8% and 12%, p = 0.77), whilst open surgery demonstrated a worse morbidity profile, with a complication rate of 25.9% (p < 0.0001). Median length of hospital stay following SILS ileocolic resection was 5 days, significantly shorter compared to 7 days for laparoscopy and 9 for open surgery (p < 0.0001). Conclusions SILS ileocolonic resection for CD demonstrated a comparable morbidity profile compared to laparoscopy in selected patients, with a reduced length of postoperative hospital stay.

The aim of this study is to evaluate the cost-effectiveness of different modifications of the trans-abdominal pre-peritoneal (TAPP) repair of groin hernia. Data were collected prospectively for all consecutive patients who underwent TAPP unilateral inguinal hernia repair between November 2017 and March 2019, and who completed a minimum of 1 year of follow-up. Costs and quality adjusted life year (QALY) gained were collected. Three TAPP variations were assessed: mesh fixation and peritoneal closure with staples (group 1); mesh fixation with fibrin glue and peritoneal closure with sutures (group 2); and mesh fixation and peritoneal closure with fibrin glue (group 3). A matched group of open repairs was established. The incremental cost-effectiveness ratio (ICER) and main intra-operative and post-operative outcomes were assessed. Overall 120 patients were included (group 1 n = 31; group 2 n = 27; group 3 n = 33; open group: 29). Operative time was shorter for groups 2 and 3, and the main post-operative outcomes were similar. The overall mean total cost of the open group (1185.95€) was lower compared with the laparoscopic group (group 1: 1682.39; group 2: 1538.54€; group 3: 1510.1€) (p = 0.026). However, the mean ICERs of groups 2 and 3 were significantly higher compared with group 1 (p = 0.021) and the open group (p = 0.032). At simulations analysis, the probability of cost-effectiveness was 33.32%, 36.26%, and 36.7% in TAPP groups 1, 2, and 3. In the long term, laparoscopic repair of groin hernia is cost-effective compared with open surgery. The use of fibrin glue for mesh fixation and/or for closing the peritoneum is the most cost-effective option and shortens operative times.

Introduction: The laparoscopic approach has become the gold standard for cholecystectomy. However, it could have some major complications. Among them, it can be considered postoperative pseudoaneurysms of the cystic or hepatic arteries. Haemobilia secondary to a cystic artery pseudoaneurysm is extremely rare. Case Report: Here we present a case from our centre of haemobilia in association with a cystic artery pseudoaneurysm, as a late complication of VLC. An 18-year-old girl underwent laparoscopic cholecystectomy; during surgery, due to viscero-perietal tight adhesions and due to the close proximity of the cystic duct to the biliary ducts, we suspected a bile duct injury. So, decision was taken to convert to open surgery: a suture was performed to repair the coledocic duct injury and an endoscopic papillotomy was performed with subsequent positioning of an endoscopic plastic biliary endoprothesis at the hepatocholedochus. One month after surgery, the patient showed clinical signs of hypovolemic shock. She underwent Computed Tomography Angiography, showing a possible arterial lesion, just adjacent to surgical clip. Therefore, patient underwent angiographic examination, which confirmed an 8 mm pseudoaneurysm arising from cystic artery, just adjacent to surgical clips. Superselective catheterization of vessel was performed, and two coils were released, until obtaining complete exclusion of the vascular lesion. The patient was discharged five days after procedure, with good general condition. Conclusion: Pseudoaneurysms of the cystic artery are uncommon entities, rarely reported in the literature, and often caused by cholecystitis or iatrogenic biliary injury. All conditions that are responsible for vessels’ injuries could also cause haemobilia. Even if pseudoaneurysm of cystic artery with haemobilia is a rare event, it has to be considered as a complication of VLC. Angiographic approach should be the treatment of choice.

Laparoscopic Nissen fundoplication (LNF) is considered the surgical treatment of choice for gastroesophageal reflux disease (GERD). However, persistent dysphagia (PD) occurs in up to 20% of patients. The aim of this study was to evaluate the incidence of PD after LNF, the causes, and the methods of prevention and management. This study was a retrospective analysis of prospectively collected data. From April 1994 to November 2019, 868 patients underwent laparoscopic short-floppy Nissen fundoplication (LSFNF). A postoperative dysphagia score was obtained by using the “difficulty swallowing” question from the GERD-Health Related Quality of Life. The postoperative clinical outcomes were obtained from 822 to 868 patients (94.7%) after LSFNF. The mean follow-up period was 17.3 years (range 1–26). Only 12 patients (1.4%) with PD were treated. Seven patients (0.8%) required endoscopic dilatation. Too tight fundoplication was the most frequent cause of dysphagia. Dysphagia was resolved completely in all patients. Five patients (0.6%) required reoperation for prolonged dysphagia (three for a tight wrap and two for a tight esophageal hiatus) after failed dilatation attempts. All underwent laparoscopic conversion from Nissen procedure to Toupet with enlargement of hiatal opening in two. Dysphagia was resolved completely in all patients. Postoperative esophageal manometry was performed in all patients with PD. Pre- and postoperative manometric data were not significantly different between patients with moderate-severe PD, mild PD, and without dysphagia. PD is a common complication after LNF. The most frequent cause is too tight fundoplication. The LSFNF could prevent postoperative dysphagia.

Neuro-anatomy of the perineum has gained renewed attention due to its significance in the transanal procedures for rectal cancer (eg TaTME). Surgeons embarking on this technique must have sophisticated knowledge and a precise anatomical understanding of the perineum before proceeding with this reversed rectal approach. We report anatomical observations deriving from a relevant experience in the colorectal surgery field. The collective multicenter experience of the present study is clinically relevant and based on the rectal and transanal resections performed in colorectal centers of excellence from Greece, UK, and Italy over the last 10years (2011–2020). From the original anatomical and intraoperative observations derived from collective cases operated by this multicenter group of colorectal surgical centers in three Europeancountries, data were retrieved and analyzed in collaboration with specialist researchers of human anatomy and interpreted for their clinical significance and potential use for preoperative planning and intraoperative guidance during TaTME. This descriptive article demonstrates in detail the neurogenic pathways encountered in the perineum and pelvic cavity during transanal procedures. Specific anatomical and topographic implications are also included serving as a guide for colorectal surgeons to perform a nerve-sparing procedure. transanal approach for rectal excision offers new insights into the complex pelvic and perineal neuroanatomy while the procedure itself remains a challenge for surgeons. Preoperative anatomical planning and 3D reconstruction may help in anticipating technical difficulties, resulting in more precise surgical dissections and decreased postoperative complications.