Trattamento chirurgico mininvasivo robot-assistito degli aneurismi viscerali: una nuova prospettiva di cura?

Introduzione:Gli aneurismi delle arterie viscerali (AAV) non sono frequenti, ma clinicamente con una notevole incidenza riportata fino al 2% (1-2). Essi sono spesso asintomatici. Il rischio di rottura, rispetto agli aneurismi aortici è molto basso, tuttavia, in regime d'urgenza il rischio di mortalità è uguale (2). Con il miglioramento della qualità e l'uso degli ultrasuoni e della tomografia computerizzata (TC), questi aneurismi sono stati rilevati, incidentalmente, più frequentemente in corso di indagini per altre patologie addominali (75-94%) (3). Mentre il trattamento chirurgico di aneurismi viscerali rotti o sintomatici è ben definito, il trattamento degli aneurismi asintomatici è ancora in discussione. La terapia tradizionale per questi aneurismi può essere la resezione chirurgica, la legatura, l’embolizzazione endovascolare o lo stenting (1-3). Materiali e Metodi:Tra settembre 2007 e giugno 2010, dodici pazienti affetti da Aneurismi Arteriosi Viscerali (VAA) sono stati sottoposti ad una procedura mini-invasiva presso il Dipartimento di Chirurgia Generale, dell’ Ospedale Misericordia di Grosseto. Tra questi 9 pazienti erano affetti da aneurisma dell'arteria splenica (ASA) e tre pazienti da aneurisma dell'arteria renale (RAA). Tutti gli interventi sono stati eseguiti utilizzando un approccio mininvasivo robot-assistito. La possibilità di un trattamento laparoscopico robot-assistito è stato discusso con ciascun paziente prima dell’intervento ed eseguito solo dopo opportuno consenso informato. Lo strumento utilizzato è il sistema chirurgico robotico 'da Vinci' (Intuitive Surgical Inc., Sunnyvale, Stati Uniti). Risultati:Tutti i pazienti sottoposti ad intervento chirurgico non hanno avuto bisogno di ricovero in terapia intensiva e dopo l’intervento hanno avuto il decorso nel reparto di degenza.Il tempo medio operatorio di tutti i pazienti è stata 224,16 ± 65,42 minuti (range 90-310). La perdita media di sangue stimata è stata di 173 ± 180,1 ml (range 000-500). Non sono state registrate complicanze intra-operatorie. La degenza media è stata di 7,1 ± 3,9 giorni (range 3-14) e il tempo medio di ritorno ad assumere una normale alimentazione è stato di 1,66 ± 0,65 giorni (range1-3). Discussione:La mia tesi vuole essere uno studio di fattibilità e vuole dimostrare che un trattamento laparoscopico robot-assistito di pazienti asintomatici con questa rare patologia è un'alternativa molto attraente alle strategie di trattamento classico.La tecnologia robotica permette una dissezione estremamente accurata e raffinata così come la facile esecuzione di anastomosi microvascolari. La chirurgia robotica supera i limiti della laparoscopia e permette l'estensione di un approccio chirugico mini-invasivo in chirurgia vascolare

Evaluation of Patients’ Perception of Safety in an Italian Hospital Using the PMOS-30 Questionnaire

Background: In our study, an Italian version of the PMOS-30 questionnaire was used to evaluate its feasibility and to improve health care quality in an Italian hospital. Methods: A cross-sectional study was conducted with 435 inpatients at a hospital in the Campania Region of Southern Italy using the PMOS-30 questionnaire and two other questions to assess patient feedback about the overall perception of safety. Results: The item “I was always treated with dignity and respect” showed the greatest percentage of agreement (agree/strongly agree = 89.2%; mean = 4.24). The least agreement was associated with the four “Staff Roles and Responsibilities” items (agree/strongly agree ranged from 31.5 to 40.0%; weighted mean = 2.84). All other 25 items had over 55.0% agreement, with 19 items over 70%. Moreover, 94.5% of the patients considered the safety of the ward sufficient/good/very good, and 92.8% did not notice situations that could cause harm to patients. Conclusion: Patient perception of safety was found to be satisfactory. The results were presented to the hospital decision makers for suggesting appropriate interventions. Our experience showed that the use of the PMOS-30 questionnaire may improve safety and health care quality in hospital settings through patient feedback

Rare ileal localisation of angiolipoma presenting as chronic haemorrhage and severe anaemia: a case report

<p>Abstract</p> <p>Introduction</p> <p>Angiolipomas are frequently observed benign tumours. They have a typical vascular component and are often located in subcutaneous tissues, and more rarely, in the gastrointestinal tract.</p> <p>Case presentation</p> <p>We report an uncommon case of an angiolipoma found in the lower portion of the small bowel of an 80-year-old man who was undergoing evaluation for chronic anaemia. A standardised diagnostic pathway was followed. Endoscopic and radiological findings were negative. The diagnosis was finally established with the aid of capsule endoscopy. The case we report is the first in the literature of an angiolipoma without specific painful symptoms. In fact, the patient did not complain of abdominal pain or alvus changes, and abdominal examination did not suggest an expansive process. The endoscopic study performed with the capsule identified the lesion as the cause of the ingravescent anaemia. Intra-operative histological examination of the lesion made it possible to avoid a major surgical procedure and assured a short postoperative course for the patient.</p> <p>Conclusion</p> <p>This report focuses on the importance of correct pre- and/or intra-operative histological diagnosis in order to offer the best therapeutic choice. An angiolipoma was suspected in this case, even though they are rarely located in the ileum.</p

Robot-assisted minimally invasive esophagectomy: systematic review on surgical and oncological outcomes

Aim: Esophagectomy is associated with several post-operative complications (50%-70%) due to surgical trauma. Minimally invasive techniques have therefore been applied to decrease mortality and morbidity. Robot-assisted minimally-invasive esophagectomy (RAMIE) was developed to overcome the drawbacks of the thoraco-laparoscopic approach. The objective of this systematic review is to report some recent experiences and to compare RAMIE with other approaches to esophagectomy, focusing on technical and oncological aspects.Methods: Pubmed, Embase and Scopus databases were searched for “robot-assisted esophagectomy”, “minimally invasive esophagectomy” and “robotic esophagectomy” in January 2020. The study was focused on original papers on totally endoscopic RAMIE in the English language. No statistical procedures (meta-analysis) were performed.Results: Three hundred and twenty studies were identified across the database and after screening and reviewing, 14 were included for final analysis. The overall 90-day post-operative mortality after trans-thoracic esophagectomy ranged from 0% to 9% and did not differ between approaches. Post-operative complications ranged between 24% and 60.9%: respiratory (6.25% to 65%), cardiac (0.8% to 32%), anastomotic leak (3.1% and 37.5%) and vocal cord palsy (9.1%-35%) were the most frequent. The evidence for long-term outcomes is weak, with no significant differences in overall survival, disease-free survival and recurrence identified in comparison with other approaches. The selected papers showed that RAMIE had comparable outcomes between the open and thoraco-laparoscopic approaches within a multimodal treatment pathway.Conclusion: RAMIE also seems to be associated with better lymph node dissection, nerve sparing and quality of life, but larger studies are needed to obtain more evidence

Outcomes of robotic liver resections for colorectal liver metastases. A multi-institutional analysis of minimally invasive ultrasound-guided robotic surgery

Background Current evidence supporting robotics to perform minimally invasive liver resection is based on single center case series reporting surgical outcomes in heterogeneous groups of patients. On the contrary, relatively scarce data specifically focusing on secondary hepatic malignancies is available. The objective of this study is to assess short- and long-term outcomes following liver resection for colorectal liver metastasis on a multi-institutional series of patients. Methods All consecutive patients undergoing robotic surgery for colorectal liver metastasis at three different tertiary hospitals over a 10-year time frame were included in this analysis. All patients received ultrasound-guided liver resection according to tumor location following the principle of parenchymal sparing surgery. Perioperative, clinicopathologic and oncological outcomes were assessed. Results A total of 59 patients underwent liver resection. There were 7 cases of conversion to open surgery. The postoperative complication rate was 27%, 5% being the rate of major morbidity. Overall, the mean postoperative hospital stay was 6 days and no mortality occurred. R0 resection was achieved for 92% of lesions. At a mean follow-up of 19 months, the 1-year and 3-year DFS was 83.5% and 41.9%, while the 1-year and 3-year OS was 90.4% and 66.1%, respectively. Conclusions Robotic liver surgery does not impair surgical outcome and oncological results in patients with liver metastases from colorectal cancer