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Minimally invasive surgery (MIS) is a widespread approach in general surgery. Computer guiding software, such as the augmented reality (AR), the virtual reality (VR) and mixed reality (MR), has been proposed to help surgeons during MIS. This study aims to report these technologies' current knowledge and diffusion during surgical training in Italy. A web-based survey was developed under the aegis of the Italian Society of Endoscopic Surgery (SICE). Two hundred and seventeen medical doctors' answers were analyzed. Participants were surgeons (138, 63.6%) and residents in surgery (79, 36.4%). The mean knowledge of the role of the VR, AR and MR in surgery was 4.9 ± 2.4 (range 1-10). Most of the participants (122, 56.2%) did not have experience with any proposed technologies. However, although the lack of experience in this field, the answers about the functioning of the technologies were correct in most cases. Most of the participants answered that VR, AR and MR should be used more frequently for the teaching and training and during the clinical activity (170, 80.3%) and that such technologies would make a significant contribution, especially in training (183, 84.3%) and didactic (156, 71.9%). Finally, the main limitations to the diffusion of these technologies were the insufficient knowledge (182, 83.9%) and costs (175, 80.6%). Based on the present study, in Italy, the knowledge and dissemination of these technologies are still limited. Further studies are required to establish the usefulness of AR, VR and MR in surgical training.

Introduction: Today average life expectancy in Western Countries has reached 80 years. At the same time, colorectal cancer (CRC) ranks first on both cancer incidence and related mortality. Therefore we face the problem of treating colorectal cancer occurring in elderly patients. Over the last years, there has been growing evidence in the literature that this population should be offered life-prolonging radical surgeries. The aim of the study is to assess clinical features and postoperative outcomes in 80 years old and older patients treated for CRC. We focused on safety (complication rates and operative mortality) and oncological results (radical excision and number of isolated lymph nodes). Methods: From September 2011 to May 2015, 455 resections for CRC with curative intent were performed: 148 patients were over 80 years old (GroupA), 307 patients were younger than 80 years (GroupB). Patients’ demographic, clinical and histo-pathological parameters, as well as intra- and perioperative results were analysed. Results: In GroupA 72 patients underwent emergency procedures (49%) and 76 underwent elective procedures (51%); conversely in GroupB 85 patients underwent emergency procedures (53%) and 76 underwent elective procedures (47%), respectively (p

Introduzione Indications for elective surgery in diverticular disease are sill debated and recent findings suggest a conservative approach since most patients present complicated diverticulitis as the first manifestation of diverticular disease. In our study we analyze the result in term of postoperative morbidity and mortality in patiets who underwent elective surgery for diverticular disease. Pazienti e metodi From September 2011 to May 2015 we perfomerd 170 surgical interventions for diverticular disease in our unit. Of these, 51 resection were performed in elective setting. Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative events. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05. Risultati Male:Female ratio was 1:1 with mean age of 5914 years. 44 patients was younger than 75 years. 54.9% of patients had one or more comorbidities and 12 patients (23.5%) had ASA score >2. Most patients had only one previous hospital admission (28 patients, 54.9&) while 9 patients reported two or more admissions. 2 patient underwent surgery for the development of colo-vescical or colovaginal fistula and 2 patient for paracolic or pelvic abscess refractory to medical therapy. In 70.6% (36 patients) of cases a laparoscopic approach was performed with a conversion rate of 16.7%. No postoperative in-hospital mortality was recorded. Postoperative complication rate was 31.4% (16 patients) according Clavien-Dindo Classification. Anyway 14 patients had grade I or II complication with mild clinical impairment. Multivariate analysis did not find any independent predictive factor for overall and surgical complications. On the other hand presence of diabetes mellitus (DM) and ASA score > 2 was associated with increased risk of medical complication (OR 16.7; 95%CI 1.1-259.9 P=0.044 and OR 8.5; 95%CI 1.1-62.6 P=0.036 respectively). A T-test was performed to compare mean of postoperative stay within the two variables. Patients with ASA score > 2 were found to have longer postoperative stay respect to those with ASA score 1-2 (13,5 vs 8,4 P=0.008). No significant difference was found in patients with or without DM (9.0 vs 9.6 P=0.818). Conclusioni In our experience, elective surgery for diverticular disease can be performed safely and often with mini-invasive approach, with accetable rate of significant postoperative event. Anyway we need powerful studies providing strong evidence to identify patients who could really take advantage of elective surgical intervention.

Introduzione There is lack of consensus whether to consider acute diverticulitis in younger patients a more aggressive disease than in other. While some authors considered diverticulitis in younger worst than in older patients, others suggested similar outcomes. In this study we evaluate differences between patients  45 years old and > 45 who underwent surgery for acute diverticulitis. Pazienti e metodi From September 2011 to May 2015 119 patients underwent emergency surgical intervention for acute diverticulitis in our unit. Pre-, intra- and postoperative findings were collected in a prospective database. 12 patients (Group A, 10,1%) were  45 years old. We compared clinical and pathological data between Group A patients and the remaining 145 (Group B 89.9) to find out any difference for characteristics of patients, clinical presentation, operative and short-term results. Uni- and multivaiate analysis were performed with SPSS v. 13.0 and satistical significance considered with p value < 0.05. Risultati Slight difference between Group A and Group B was found about presence of males (75.0% vs 43.9%; p=0.065). Significant differences were found for patients with one ore more comorbidities (16.7% vs 86.9%; p

Background: It is a commonly held belief that in emergency surgery is not rare an inadequate lymphadenectomy resulting in pathologically understaged or indeterminate staging of the patient. Consequently some patients may not receive a necessary adjuvant chemotherapy or be subjected to unnecessary therapy. Methods: From September 2011 to May 2015, 483 patients were admitted in our Unit with the diagnosys of colo-rectal cancer. Four-hundred and fifty-five underwent to radical resection and were enrolled in this study. One-hundred and fifty-seven patients (35%) required an emergency operation (Group 1) and 298 (65%) had elective surgery (Group 2). Patients information were entered into a database: age and sex, tumor site, type of resection, laparoscopic versus open approach, stage, number of nodes and adequacy of lymph-node harvest (adequacy >= 12 lymph-nodes harvested). Statistical analysis was performed with SPSS v13; significance was defined as p< 0,05. Results: In Group 1, tumor sites were: right-sided 46%, left sided 45% and 9 % rectum. In Group 2, tumor sites were right-sided 38%, left sided 31% and 31 % rectum. These differences were statistically significant. The number of nodes harvested was similar in the two groups (Group 1: 18,3±9,2 nodes; Group 2: 18,7±10,1 nodes, p=0,97). The adequacy of lymph node harvest was 95% in Group 1 and 89% in Group 2. Thus the adequacy of lymphadenectomy was better in Group 1, however these differences were not statistically significant (p=0,60). The number of nodes harvested and the adequacy of lymphadenectomy were not influenced by the type of surgical approach (laparoscopic versus open surgery). Group 1 patients had a more advanced cancer stage (stage III/IV 47,1% vs. 36,0%, p=0,0006), but the need for enlarged resection was not significantly different in the two groups. Conclusions: Our data didn’t show significant differences in nodes harvesting in emergency colo-rectal surgery compared to elective surgery. Adequacy of lymphadenectomy is comparable in the two settings.

Introduzione Right sided colonic diverticulitis is a rare condition in Western countries while is common in Asian ones. In most cases, right colonic diverticulitis mimicks an acute appendicitis and it is often diagnosed when explorative laparoscopy excludes the presence of appendicits. We report our experience in the treatment of right-side diverticulitis. Pazienti e metodi From September 2011 to May 2015 170 patients underwent surgical intervention for diverticular disease in our unit, both in emergency or elective setting. Pre- intra- and postoperative data of patients were prospectively registered. Uni and multivariate analysis was performed both for factors associated with postoperative morbidity and conversion to laparotomy. Statistical analysys was performed with SPSS v. 13.0. Significance was considered for p value < 0.05. Risultati 17 patients (10%) was affected by right colonic diverticulitis and only 3 of them (17.6%) came from Asian countries. Male/female ratio was 1:1 with mean age of 5115 years, statistically lower respect to our cohort of patients with left side diverticulitis (6714 years; P

Introduzione Complicated acute diverticulitis (CAD) occurs in approximately 10 to 25 percent of patients affected by diverticular disease and a surgical treatment is often necessary. Postoperative morbidity and mortality are still high, up to 40% of cases in patients with generalized peritonitis. The purpose of this study is to identify predictive prognostc factor for postoperative morbidity and mortality in patients requiring surgical intervention for CAD. Pazienti e metodi From September 2011 to May 2015 170 patients underwent surgical intervention for diverticular disease in our unit. Of these, 119 patients required urgent surgery for complicated acute diverticulitis (CAD). Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative morbidity and mortality. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05. Risultati There were 56 males and 63 females with mean age of 68 ± 15 years. 100 patients (84.0%) were at first hospital admission for diverticular disease and in 16 cases (13.4%) the disease was localized at right colon or ceacum. A stomy was required in 84 patients (70.6%) and postoperative morbidity rate was 52,9% according Clavien–Dindo Classification. Anyway only 10.9% of patients were affected by grade III or IV complication with a mortality rate of 16.8%. At multivariate analysis the presence of a postoperative medical complication was the only predictive factor for mortality (OR 10.3; 95%CI 2.1-51.3 p=0.004) while the presence of COPD and purulent or fecal peritonitis were not statistically significant (OR 3.3; 95%CI 0.9-12.2 p=0.073 and OR 3.1 95%CI 0.8-11.6 p=0.099 respectively). For postoperative morbidity the logistic regression showed that patients ≥75 years and with ASA score > 2 were independently associated with postoperative morbidity (OR 2.8; 95%CI 1.1-7.2 p=0.028 and OR 5.3 95%CI 2.0-13.9 p=0.001 respectively). The same factors were independent prognostic factor associated with medical complication with OR 3.0; 95%CI 1.1-7.8 p=0.028 and OR 6.5 95%CI 2.0-21.3 p=0.002 respectively. Multivariate analysis of factor predicting surgical morbidity showed that age ≥75 was the only predictive factor for postoperative surgical morbidity (OR 3.1; 95%CI 1.1-8.8 P=0.027). Conclusioni In our experience the majority of patients who require surgery for CAD are at the first episode of acute diverticulitis. Medical complication after surgery for CAD is the only factor associated with mortality while surgical complications do not seem to have the same weight. Age≥75 years and ASA score >2 are independent predictive factors for postoperative medical complications while only age seems to have a significant effect on surgical morbidity.

Aim of study: Metastatic involvement of the small bowel by melanoma is rare. The average time from the excision of the primary cutaneous melanoma to the occurrence of intestinal metastases tends to be between 3 and 5 years; one case of recurrence after 15 years is described. The most common kind of lesion is polypoid: this can cause intussusception and intestinal occlusion. We report a case of intestinal occlusion by an ileal metastasis of a melanoma occurred 7 years earlier. Materials and Methods: Case Report: The patient was a 57-year-old female who was admitted to our hospital for persistent abdominal pain and sub-occlusion. The patient's past medical history included cutaneous malignant melanoma 7 years before and lobular breast adenocarcinoma 10 years before. During the previous three months, she had intermittent abdominal pain and a weight loss of about 7 kg. Abdominal-US, EGDS and colonoscopy were all negative for pathologic findings. During the hospital stay, a CT enterography revealed lower intestinal intussusception, and enlarged lymph nodes both in the abdominal cavity and in the retroperitoneum. Intraoperatively we found an ileal invagination due to a polypoid mass of the ileal tract. Segmental ileal resection was performed; wide mesenteric lymph node dissection was not possible because of large and extended retroperitoneal lymphadenopathies. Histological examination showed epithelioid and spindle tumor cells with obvious cytoplasmic melanin deposition. Immunohistochemical staining revealed that tumor cells were positive for S-100, HMB-45 and vimentin, confirming the diagnosis of melanoma. Main results and conclusions: Appearance of GI metastases is reported up to 15 years after the inital diagnosis of melanoma. Reported clinical signs and symptoms generally include chronic abdominal pain, occult or gross bleeding and, as in this case, weight loss. Aspecificity of symptoms may impede early diagnosis and treatment of the disease. As in this case, where curative surgery is impossible because of the extent of disease, metastatic tumor resection or GI tract bypass surgery is recommended to relieve symptoms or avoid future complications. Early diagnosis of metastases requires adequate imaging (CT) and prolonged follow up.

Aim: To identify prognostc factor for postoperative complications in patients who underwent surgery for complicated acute diverticulitis (CAD). Method: From September 2011 to March 2016 we operated 136 patients for CAD. Multivariate analysis with logistic regression was performed for postoperative morbidity and mortality. Results: Mean age was 68 15 years. In 17 cases (12.5%) the disease was localised at right colon. Postoperative morbidity was 53.7%. According Clavien-Dindo classi- fication, 12.5% of patients had grade III-IV complications with mortality at 15.4%. At multivariate analysis, age  80, chronic renal failure and diffuse peritonitis were independent factors for mortality (respectively; OR 2.8, 95% CI 1.00–8.2; P = 0.005, OR 5.4, 95% CI 1.6–18.3; P = 0.007, OR 2.4, 95% CI 1.2–4.9; P = 0.014). For postoperative morbidity, the only independent factor was left side disease (OR 4.2, 95% CI 1.1–16.0; P = 0.033), while chronic renal failure did not reach significance (OR 3.8, 95% CI 0.9–15.9; P = 0.062). Conclusion: Surgery for CAD has high rate of postoperative adverse events. Partic- ular care must be taken in patients’  80 years, with renal impairment and with Hinchey III-IV disease. Right colonic CAD seems to have a milder postoperative course.

Aim: In elective surgery, the recommended oncologic criteria include en-bloc resection of invaded organs and structures, free margins and an adequate number of lymph nodes yielded. The aim of this study was to analyse whether the above criteria were met in emergency surgery. Method: From September 2011 to January 2016 494 patients underwent colonic resection for CRC. Data were collected and statistical analysis was performed with SPSS v13.0; significance was defined as P < 0.05. Results: In the Emergency Group patients had a more advanced cancer stage (51.4% vs 36.0%, P = 0, 0002), but the need for enlarged resection was not significantly different. The number of radical resections (R0) was greater for elective patients (93.4% vs 79.7%, P < 0.001), but the numbers of free distal margins and of excised nodes was similar in two groups. Emergency procedures had a higher morbidity (34.2% vs 31.9%, P = 0.67) and mortality (12.4% vs 1.3%, P < 0.001). Multivariate analysis showed that emergency presentation is an independent predictor both for mortality and morbidity (P = 0.0001~OR = 7.6; p = 0.0220~OR = 1.7), and for R0 resection (P = 0.0002~OR = 3.5) but it is not an independent prognostic factor for distal margins involved and lymph nodes harvest (P = n.s.). Conclusion: Adherence to guidelines for CRC surgery is safe and feasible, but the emergency setting is an independent risk factor for postoperative morbidity and mortality; and is associated with a lower R0 resection rate.

Aim: The aim of the study is to assess clinical features and postoperative outcomes in older patients treated for CRC. Method: 494 patients who underwent curative resection for CRC were enrolled in this study. 159 patients were over 80 years-old (GroupA), 335 patients were younger (GroupB). Patients’ demographic, clinical and histo-pathological parameters, intra- and perioperative results were entered into a database and analysed. Statistical analysis was performed with SPSS v13.0; significance was defined as P < 0.05. Results: In GroupA 83 patients underwent emergency procedures (52%), in GroupB 104 patients (31%) (P < 0.001). We observed significant differences between the two groups in comorbidities, emergency presentation, intraoperative blood transfusions, laparoscopic approach and mortality (P < 0.001). There were no differences in the number of radical resection and number of lymph-nodes isolated. However, multivariate logistic regression analysis showed that age ≥80 is an independent predictor of mortality (P = 0.004 OR 5.394) but not an independent predictor of morbidity (P = 0.6 OR 1.109). Conclusion: Old age ≥80 does not represent a contraindication for CRC surgery though associated with higher morbidity and mortality, in particular in emergency setting. It is advisable to reduce emergency procedures with multidisciplinary approach (enlargement of screening in old patients and stenting as-bridge-to-surgery in obstructions).

Aim: To evaluate differences between patients 45 who underwent surgery for acute diverticulitis (AD). Method: From September 2011 to May 2015 119 patients underwent surgery for AD. 12 patients (Group A, 10.1%). Results: Group A had less patients with comorbidities (16.7% vs 86.9%; P < 0.001), in particular cardiovascular (0% vs 67.3; P < 0.001) with ASA 1–2 in 91.7% of patients (vs 29.0%, P < 0.001). Right colonic disease was found in 41.7% of Group A (vs 10.3%; P = 0.010). Group A patients were at first admission in 91.7% of cases respect to 83.2% (P = 0.688) and laparoscopy was performed in 50% of patients (vs 20.6%; P = 0.033). The majority of Group A patients did not required ostomy respect to Group B (33.3% vs 74.8%; P = 0.006) with no difference for incidence of purulent / faecal peritonitis (33.3% vs 57.9%; P = 0.131). Morbidity and medical complications were lower in Group A (8.3% vs 57.9%; P = 0.001 and 8.3% vs 44.9%; P = 0.015). The groups did not differ for mortality (8.3% vs 17.8% ; P = 0.688). Hospital stay was shorter in Group A (6.3 2.0 vs 15.3 14.6; P = 0.002). Multivariate analysis showed only higher, not significant, incidence of ostomy group B (HR 4.0; 95% CI 0.85–19.0; P = 0.08). Conclusion: AD in young patients does not seem to be more aggressive. Surgical intervention should be taken into account not considering age.