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The incidence of colorectal cancer (CRC) is increasing in the population aged ≤ 49 (early-onset CRC-EOCRC). Recent studies highlighted the biological and clinical differences between EOCRC and late-onset CRC (LOCRC-age ≥ 50), while comparative results about long-term survival are still debated. This study aimed to investigate whether age of onset may impact on oncologic outcomes in a surgical population of sporadic CRC patients. Patients operated on for sporadic CRC from January 2010 to January 2022 were allocated to the EOCRC and LOCRC groups. The primary endpoint was the recurrence/progression-free survival (R/PFS). A total of 423 EOCRC and 1650 LOCRC was included. EOCRC had a worse R/PFS (p < 0.0001) and cancer specific survival (p < 0.0001) compared with LOCRC. At Cox regression analysis, age of onset, tumoral stage, signet ring cells, extramural/lymphovascular/perineural veins invasion, and neoadjuvant therapy were independent risk factors for R/P. The analysis by tumoral stage showed an increased incidence of recurrence in stage I EOCRC (p = 0.014), and early age of onset was an independent predictor for recurrence (p = 0.035). Early age of onset was an independent predictor for worse prognosis, this effect was stronger in stage I patients suggesting a potentially—and still unknown—more aggressive tumoral phenotype in EOCRC.

Indocyanine green fluorescence angiography (ICG-FA) has been used in colorectal surgery to assess anastomotic perfusion and reduce the risks of anastomotic leaks. The main objective of this paper is to review the data on the transanal application of ICG-FA for the intraluminal assessment of colorectal anastomosis.A literature search was conducted for articles published between 2011 and 2021 using PubMed and Cochrane databases, related to the application of ICG for the intraluminal assessment of colorectal anastomosis. Original scientific manuscripts, review articles, meta-analyses, and case reports were considered eligible.A total of 305 studies have been identified. After abstract screening for duplicates, 285 articles remained. Of those, 271 were not related to the topic of interest, 4 were written in a language other than English, and 4 had incomplete data. Six articles remained for the final analysis. The intraluminal assessment of colorectal anastomosis with ICG-FA is feasible, safe, and may reduce the incidence of leaks.The intraluminal assessment of anastomotic perfusion via ICG-FA may be a promising novel application of ICG technology. More data is needed to support this application further to reduce leak rates after colorectal surgery, and future randomized clinical trials are awaited.

SummaryGastrointestinal stromal tumours (GISTs) are malignant mesenchymal tumours that originate from the interstitial pacemaker cells of Cajal. They are particularly rare, comprising only 5% of all GISTs, and often present at an advanced stage. Treatment for these tumours is still a topic of debate due to their low incidence and insidious location. A woman in her mid-70s presented with rectal bleeding and anal discomfort. A 4.5×4 cm anal GIST was diagnosed. A local excision was performed and the patient was further treated with tyrosine kinase inhibitors. At a 6-month follow-up, the MRI showed that she was disease free. Anorectal GISTs are unusual and tend to be aggressive. Surgical resection is the first-line treatment for primary, localised GISTs. However, the appropriate surgical technique for these tumours is still a topic of debate. Further studies are needed to fully understand the oncologic behaviour of these rare neoplasms.

Gastric schwannomas (GSs) are rare mesenchymal neoplasms of the gastrointestinal tract. Diagnosis is often achieved postoperatively, based on pathology reports of retrieved specimens. The aim of the present study is to follow up all patients with gastric schwannoma (Gs) undergoing endoscopic, partial, or more extended surgery and to evaluate the appearance of local or distant recurrence. A PubMed, Cochrane, and Embase systematic review of the literature has been performed. Original papers, review articles, and case reports published between 1988 and 2019 were considered eligible. All the studies who met the inclusion criteria were analyzed. Statistical analysis of data has been performed using GraphPad Prism 7 software. Three hundred twenty-eight articles were found, and a total of 102 were included and analyzed in depth. Fifty-three papers reported the follow-up information, ranging from 1 to 417 months across different studies. Among them, 31 patients underwent endoscopic removal of the gastric lesions; 140 patients underwent local surgery, including wedge resection or partial gastrectomy; and 148 patients underwent subtotal or total gastrectomy. The median follow-up was of 27-38-33 months, respectively. No recurrence or distant metastasis was detected in the endoscopy group. Among local surgery group, liver metastasis was reported in one case; in extended surgery group, one patient died for multiple liver metastases. Local or more extended surgery involved a larger cohort of patients and reported satisfactory long-term results compared with endoscopy group. Surgery in absence of a definite preoperative diagnosis is considered the gold standard treatment for resectable Gs.

Highlights • Here we reported a rare case of ileo-ileal intussusception caused by small bowel leiomyosarcoma. • Actually the case reported in literature of ileo-ileal intussusception are rare and mechanism is still unclear. • The cases of leiomyosarcoma present in the literature are few and even rarer those in adults., Introduction Intussusception is the telescoping of one segment of the bowel into an adjacent bowel segment, causing venous congestion, edema, and blood supply reduction. We present a case of ileo-ileal intussusception in an adult patient with intestinal obstruction caused by a rare mesenchymal malignant lesion of the distal ileum: Leiomyosarcoma (LMS). Presentation of case A 90-year-old Caucasian man presented to the hospital with a two-day history of abdominal pain, nausea, and bowel occlusion. Preoperative Computer Tomography (CT) showed a solid mass with stratified walls in the lumen of the cecum with the classics “bulls-eye” appearance with concentric rings, suggestive of intussusception. The patient underwent emergency laparotomy with evidence of a small bowel wall tumor driving ileo-ileal intussusception with ischemic damage. Ileocecal resection was performed without postoperative complications. Histopathological examination showed a tumor on the muscular layer of the small bowel. The definitive diagnosis was LMS. Discussion Adult intussusception is a rare condition, with an incidence of 2/1 000 000 cases per year worldwide. About 60% of patients suffering from this disease require surgery. Clinical presentation can be non-specific because of its no characteristic signs and symptoms. The most common presenting symptom is abdominal pain with bowel obstruction sings. Intussusception can occur anywhere along the small and large intestine and it is typically associated with a Lead Point (LP). The LP may be benign or malignant conditions. Infrequent malignant causes include LMS. Conclusion Diagnosis of intussusception is relatively challenging because of its non-specific symptoms. CT scan is the examimation of choice for the diagnosis because of its peculiar images. In adults, surgical treatment is recommended with laparoscopic or open approach according to surgeon expertise, sometimes in an emergency setting.

To date, the optimal management of patients with inflammatory bowel disease (IBD) and flat low-grade dysplasia (fLGD) of the colon or rectum remains controversial.A systematic review was reported in accordance with PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Patients diagnosed with fLGD on surveillance endoscopy were pooled from studies published between 2000 and 2020. Advanced neoplasia was defined by the presence of HGD, CRC or small bowel adenocarcinoma detected on subsequent surveillance endoscopy or from examination of resection specimens. We estimated the pooled annual incidence rate of colorectal cancer (CRC) and advanced neoplasia, and the risk factors associated with neoplastic progression.We identified 24 articles and 738 IBD patients were diagnosed with fLGD on endoscopy. Two hundred thirty-six patients (32%) underwent immediate surgery with surgical specimens demonstrating CRC in 8 patients (pooled prevalence, 8.66%; 95% CI 3.58-19.46) and HGD (high grade dysplasia) in 11 patients (pooled prevalence, 13.97%; 95% CI 5.65-30.65). Five hundred-two patients (68%) underwent endoscopic surveillance with 63 patients with fLGD progressing to advanced neoplasia during endoscopic surveillance (38 HGD, 24 CRC and one patient developing small bowel adenocarcinoma). The mean duration of follow-up after fLGD diagnosis was 71 months (10.9-212). The pooled incidence of CRC and advanced neoplasia was 0.5 (95% CI 0.23-0.77) and 1.71 per 100 patient-year (95% CI 0.88-2.54) respectively. The use of corticosteroids and location of fLGD in the distal colon were significantly associated with neoplastic progression.This study provides a summary incidence rate of CRC and advanced neoplasia in patients with IBD and fLGD to inform surgeons' and endoscopists' decision-making thus reducing potential ineffective treatments.

Highlights • There are several surgical approaches for patient with rectal cancer, depending on tumor stage and tumor distance from anal verge. Total mesorectal excision (TME) is the gold standard surgical technique for rectal tumors, reducing rectal cancer local recurrence. • Transanal total mesorectal excision (TaTME) has been described in rectal cancer treatment, especially in challenging patients with narrow pelvis, improving not only dissection but also the preservation of autonomic pelvic nerves and the achievement of a restorative procedure. • This case report aims to describe the possible use of TaTME procedure as a rescue also when this approach is not the first choice. In conclusion, we believe that, if performed by experienced surgeons, TaTME is safe and useful and could be used not in his conventional use., Introduction and importance In the last years, transanal total mesorectal excision (TaTME) has been described in rectal cancer treatment, especially in challenging patients, difficulties in pelvic exposure and limitations of instrumentation improving not only dissection but also the preservation of autonomic pelvic nerves and the achievement of a restorative procedure. Here we report a case report of anterior laparoscopic rectal resection for adenocarcinoma of the high-mid rectum converted to transanal approach. Case presentation A 69-year-old male presented hepatic nodules during radiological follow-up for prostate cancer treated with radical prostatectomy and adjuvant radiotherapy (70 Gy). The biopsy of the lesion demonstrated the presence of a metastatic lesion of an adenocarcinoma, with suspected intestinal origin. Then, we perform an endoscopic examination, which showed the presence of a rectal lesion, which cause a bowel stenosis extended from the middle part to the upper part of the rectum. After chemoradiotherapy, an anterior rectal resection was performed. During surgery we could not perform the resection of the rectum due the thickness and fibrosis of the tissue, despite we used different branded mechanical stapler. So, we decided to complete the surgical treatment starting a TaTME procedure with resolution of the problem. Clinical discussion TaTME is a relatively new technique that had already become a valid option in the treatment of low rectal cancer, and, nowadays, also in the treatment of inflammatory bowel disease. As reported in literature, this technique has a number of advantages, especially in narrow pelvis and it is very useful in low rectal surgery. Conclusion This case report aims to describe the possible use of TaTME procedure as a rescue also when this approach is not the first choice.

Surgical site infections (SSIs) are a feared complication following colorectal surgery and have a sizeable economic impact on the healthcare system. The aim of this study is to assess the clinical effectiveness and cost-effectiveness of O-Ring wound protector/retractor in elective laparoscopic colorectal surgery.Data were analyzed from a retrospective colorectal database from January 2015 to June 2018. SSI was defined according to the criteria published by the European Centre for Disease Prevention and Control (ECDC). An economic evaluation was conducted comparing the group in which Alexis® device was used during surgery (Group A) with a control group (Group B) in which Alexis® device was not used.Two hundred fifty-eight consecutive patients were enrolled in our study. Among them, the intervention group (Group A, 154 patients) was compared with the control group (Group B, 94 patients). A total of 8 (5.2%) and 14 (15%) patients with SSIs were identified in groups A and B, respectively (p = 0.008). The economic evaluation showed that there was no difference in terms of costs and returns on comparing both groups.The final costs and profit are similar in both groups, but the use of O-Ring protector reduces SSI rates and may significantly improve patient's quality of life.Colorectal surgery, Cost-effectiveness, Surgical site infection, Length of stay, Wound protector/retractor.Le infezioni del sito chirurgico (ISC) rappresentano ad oggi una temibile complicanza dopo chirurgia colorettale, costituendo un fenomeno dal notevole impatto economico sul sistema sanitario nazionale. Lo scopo di questo studio è quello di valutare l’efficacia clinica ed i costi relativi all’utilizzo del protettore/retrattore di ferita Alexis® in chirurgia elettiva colorettale laparoscopica METODI: I dati relativi ad ogni paziente sono stati raccolti in un database di chirurgia colorettale ed analizzati retrospettivamente, valutando l’arco temporale da Gennaio 2015 a Giugno 2018. L’infezione del sito chirurgico è stata definita in accordo ai criteri pubblicati dal Centro Europeo per la prevenzione e il controllo delle malattie (ECDC). In primo luogo, è stata condotta un’analisi costi-efficacia comparando il Gruppo in cui l’anello di protezione/retrazione della ferita è stato utilizzato intraoperatoriamente (Gruppo A), con un gruppo di controllo (Gruppo B) in cui il dispositivo in esame non è stato utilizzato.Duecentocinquantotto pazienti consecutivi sottoposti a chirurgia elettiva colorettale laparoscopica da Gennaio 2015 a Giugno 2018 sono stati arruolati nel nostro studio. Di questi, il gruppo di intervento (Gruppo A con 154 pazienti) è stato comparato con il gruppo di controllo (Gruppo B, 94 pazienti). Le infezioni del sito chirurgico sono state del 5.2% e del 15%, nel gruppo A e B rispettivamente (p = 0.008). L’analisi economica ha mostrato che non ci sono differenze in termini di costi totali e ricavi totali comparando i due gruppi.I costi totali ed il profitto totale sono simili in entrambi i gruppi oggetto del nostro studio. Non sono state osservate differenze statisticamente significative. Tuttavia, l’utilizzo del dispositivo Alexis® ha mostrato ridurre significativamente i tassi di infezione del sito chirurgico potendo quindi considerevolmente migliorare la qualità di vita del paziente.

Background Transanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA), considering postoperative complications and medium-term functional outcomes. Methods Our Center has experienced the transanal approach for proctectomy and IPAA since August 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Fecal continence, genito-urinary activity and global quality of life at 1 and 6 months after ileostomy reversal have been assessed. Results Until March 2019, 8 patients underwent transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA). In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning loop ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding, not required a re-invertation. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively using previously validated quality of life questionnaires (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, genitourinary and sexual functions were also investigated, showing comparable results with the literature data. Conclusions In our experience, transanal proctocolectomy and ileal pouch-anal anastomosis provided good short and medium-term functional results in UC.

Introduction The current Tumor Node Metastasis staging system (TNM) for gastric cancer classifies the extent of lymph node metastasis based upon the number of lymph nodes involved. Choi et al. have recently proposed a new anatomical classification based upon the regionality of the involved nodes. This new classification seems to have a better predictive prognostic value than the traditional one. We investigated the prognostic role of the new anatomical based classification, reviewing our institutional gastric cancer database. Methods We performed a retrospective chart review of 329 patients who underwent gastrectomy at our Institution from 2003 to 2017. We excluded from data analysis any patient with distant metastases at the time of first diagnosis and or surgery, pathology other than adenocarcinoma, lymphadenectomy less than D2, impossibility to identify location of lymph nodes (LNs) on pathological report and neoadjuvant chemotherapy. The extent of D2 lymphadenectomy was defined according to Japanese Gastric Cancer Association criteria. LN metastasis were reclassified into three topographic groups (lesser, greater curvature, and extraperigastric nodes) and staged according to Choi. The new N stage was combined with the current pT according to the 8th edition of TNM and a new hybrid TNM stage was established. All patients were followed up until June 2019. The prognostic performance of the new stage and of the current anatomical numeric based system (TNM) was analyzed and assessed by the C-index, AIC and likelihood ratio χ2 value. Results In predicting both Overall Survival (OS) and Disease free Survival (DFS) the new N stage and the new TNM staging system had the highest C-index and likelihood ratio χ2 value and the lowest Akaike Information Criterion (AIC), showing a better accuracy and displaying a better prognostic performance. Conclusions Our study is the first from the Western world to compare the new hybrid classification, based on the anatomical location of metastatic nodes, to the 8th of American Joint Committee on Cancer (AJCC) TNM staging system. Our findings on a small, monocentric sample suggest that hybrid topographic lymph node staging system is more accurate than TNM.

Background Gastric schwannomas (Gs) are rare mesenchymal neoplasms of the gastrointestinal tract. Diagnosis is commonly achieved by pathological examination of resected specimen. In most cases surgical resection of submucosal gastric lesions is performed with wide margins. New minimally invasive techniques are described in an increasing number of cases. Methods A Pubmed, Cochrane and Embase systematic review of the literature has been performed. Original papers, review articles, case reports published between 1988 and 2019 were considered eligible. Only papers written in English with full text available have been included. Articles reporting a follow up period, the type of treatment of the primary tumor and the appearance of local or distant recurrence were compared and analysed. Statistical analysis of data has been performed using GraphPad Prism 7 software. Results 328 articles were found and a total of 102 were included in the analysis. Fifty-three papers reported the follow-up information, ranging from 1-417 months across different studies. Among them, 31 patients underwent endoscopic removal of the gastric lesions, 140 patients local surgery, including wedge resection or partial gastrectomy and 148 patients underwent subtotal or total gastrectomy. The median follow-up was of 27-38-33 months respectively. No recurrence or distant metastasis were detected in endoscopic group. Among local surgery group, liver metastasis was reported in one case; in extended surgery group one patient died for multiple liver metastases. Conclusions In comparison with endoscopic group, local or more extended surgery involved a larger cohort of patients and reported satisfactory long-term results. Surgical approach in absence of a definite pre-operative diagnosis is considered the gold standard treatment for resectable Gs due to the excellent long-term outcome. Further studies are warranted to define the role of endoscopic treatment. Keywords : Schwannoma, neurinoma, gastric neurinoma, gastric schwannoma.

Loop stoma reduces the complications related to anastomotic leak. The skin bridge loop stoma is a recently described technique with many potential advantages over the current technique involving a plastic rod. Our experience shows early results (3 weeks after surgery) comparing skin bridge and plastic rod stoma creation. In 45 patients operated from January 2016 to December 2018, a loop ileostomy was performed with the skin bridge technique. We compared functional results with a prospective series of 45 patients on which ileostomy was performed on a plastic rod. The report of the routine stoma care visit at 7 and 15 days was compared, as well as the “Stoma quality of life” questionnaire when available. We observed more inflammatory changes of the skin around the stoma in the group with a plastic rod (33 vs 10 patients). The patient-reported evaluation of quality of life showed a better quality of life in skin bridge group. The rate of exchanged stoma wafers was 2.6 vs 5.2 per week in the skin bridge group (p < 0.05). The skin bridge stoma creation resulted in better early management of the stoma, better adhesion of the stoma appliances, and better quality of life of the patient. As an increased number of stoma appliances are required in the early postoperative period, the economic burden of this treatment is relevant in relation to the major number of medical equipment used in the early period.

Background Surgical-site infections (SSIs) remain a serious complication of colorectal surgery, causing a significant financial burden to the health care system. The aim of this study is to investigate whether the use of an O-ring retractor can be effective in preventing the incidence of wound infections after elective laparoscopic colorectal surgery. Methods A retrospective case-control study from January 2014 to June 2018 was performed. Data were analyzed from a retrospective colorectal database. SSI was defined according to criteria published by the European Centre for Disease Prevention and Control and analyzed as a primary outcome. Results Three hundred twelve consecutive patients (n = 312) were enrolled in our study. Among them, 158 patients (Group A) in which an O-ring retractor device was used during surgery was compared with a control group of 154 patients (Group B) in which an O-ring retractor device was not used. Primary outcome was to determine SSIs rates among the 2 groups. No statistically differences were observed with regard to baseline characteristics between both groups. A total of 9 patients (5.69%) and 24 (15.58%) with SSIs were identified in Group A and B, respectively, and the difference was statistically significant (OR, 0.32; 95% CI, 0.14-0.72; P = .0045). The median postoperative hospital stay length was 6.7 days in group A and 7.6 days in group B (P ≤ .05). Conclusions SSIs infections rates were significantly higher in patients in which an O-ring retractor device was not used. This study suggests that the use of a wound protector device can be considered for routine use in elective colorectal surgery.

The name of the author was incorrectly spelled as "Filippo Carannant". The correct spelling is "Filippo Carannante" and is now presented correctly in this article.