Laparoscopic right hemicolectomy: a SICE (Società Italiana di Chirurgia Endoscopica e Nuove tecnologie) network prospective study on the approach to right colon lymphadenectomy in Italy: is there a standard?—CoDIG 2 (ColonDx Italian Group)

Background: Colon cancer is a disease with a worldwide spread. Surgery is the best option for the treatment of advanced colon cancer, but some aspects are still debated, such as the extent of lymphadenectomy. In Japanese guidelines, the gold standard was D3 dissection to remove the central lymph nodes (203, 213, and 223), but in 2009, Hoenberger et al. introduced the concept of complete mesocolic excision, in which surgical dissection follows the embryological planes to remove the mesentery entirely to prevent leakage of cancer cells and collect more lymph nodes. Our study describes how lymphadenectomy is currently performed in major Italian centers with an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH). Methods: CoDIG 2 is an observational multicenter national study that involves 76 Italian general surgery wards highly specialized in colorectal surgery. Each center was asked not to modify their usual surgical and clinical practices. The aim of the study was to assess the preference of Italian surgeons on the type of lymphadenectomy to perform during RH and the rise of any new trends or modifications in habits compared to the findings of the CoDIG 1 study conducted 4 years ago. Results: A total of 788 patients were enrolled. The most commonly used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%), side-to-side (98.7%), or isoperistaltic (96.0%) anastomosis. The lymph nodes at the origin of the vessels were harvested in an inferior number of cases (203, 213, and 223: 42.4%, 31.1%, and 20.3%, respectively). A comparison between CoDIG 1 and CoDIG 2 showed a stable trend in surgical techniques and complications, with an increase in the robotic approach (7.7% vs. 12.3%). Conclusions: This analysis shows how lymphadenectomy is performed in Italy to achieve oncological outcomes in RH, although the technique to achieve a higher lymph node count has not yet been standardized. Trial registration (ClinicalTrials.gov) ID: NCT05943951

Diagnostic difficulties and therapeutic choices in intrapancreatic accessory spleen: case reports

Marco Massani,1 Paola Maccatrozzo,1 Giovanni Morana,2 Luca Fabris,3 Cesare Ruffolo,1 Luca Bonariol,1 Bruno Pauletti,1 Nicolò Bassi1 1IV Department of Surgery, Regional Center for HPB Surgery, 2Diagnostic and Interventional Radiology, Regional Hospital of Treviso, Treviso, 3Molecular Medicine Department, University Hospital, Padua, Italy Introduction: Accessory spleen has a worldwide prevalence of 10%–30% and is defined as intrapancreatic accessory spleen (IPAS) when it locates within the pancreas. This occasional finding can raise difficulties in differential diagnosis with hypervascular pancreatic lesions, such as pancreatic neuroendocrine tumor. Presentation of cases: We present five cases in which a mass of the pancreatic tail was found on radiologic investigations. The first case was a young female patient who underwent a distal pancreatectomy because of a mass of the pancreatic tail misdiagnosed as a pancreatic neuroendocrine tumor due to its radiologic features on computed tomography and magnetic resonance imaging (MRI) (small, ovoidal, and well defined). Misdiagnosis also occurred in the second case, in which an 82-year-old woman was referred to our hospital because of a pancreatic mass of uncertain diagnosis. She also underwent an operation, and pathologic examination showed splenic parenchyma. A correct diagnosis was achieved in the remaining three cases that are still under radiologic monitoring. Discussion: IPAS is a benign entity and therefore does not require surgical treatment. We discuss the best diagnostic options that have recently been experienced, focusing on diffusion-weighted and superparamagnetic iron oxide MRI, which in our experience seem to be the safest and most easily accessible diagnostic tools. Conclusion: We suggest that a multidisciplinary approach should guide the diagnosis. When a pancreatic mass with specific features (round, ovoid, and well defined) is detected by computed tomography or MRI, an IPAS should be suspected. Keywords: intrapancreatic accessory spleen, superparamagnetic iron oxide, diffusion-weighted images, neuroendocrine tumor, neoplas

Acute appendicitis: what is the gold standard of treatment?

cBurney's procedure represented the gold-standard for acute appendicitis until 1981, but nowadays the number of laparoscopic appendectomies has progressively increased since it has been demonstrated to be a safe procedure, with excellent cosmetic results and it also allows a shorter hospitalization, a quicker and less painful postoperative recovery. The aim of this editorial was to perform a review of the literature in order to address controversial issues in the treatment of acute appendicitis

Strategies to Increase the Resectability of Patients with Colorectal Liver Metastases: A Multi-center Case-Match Analysis of ALPPS and Conventional Two-Stage Hepatectomy.

Background: Two-stage hepatectomy (TSH) is well established for the treatment of patients who have colorectal cancer liver metastases (CRLM) with a small liver remnant. The technique of associating liver partitioning and portal vein occlusion for staged hepatectomy (ALPPS) has been advocated as a novel tool to increase resectability. Using a case-match design, this study aimed to compare TSH and ALPPS for patients with CRLM. Methods: All patients undergoing ALPPS for CRLM at three major hepatobiliary centers in Italy (ALPPS group) were compared in a case-match analysis with patients undergoing TSH (TSH group) at a single institution. The groups were matched with a 1:3 ratio using propensity scores based on covariates representing severity of metastatic disease. The main end points of the study were feasibility of complete resection and intra- and postoperative outcomes. Results: The two treatments did not differ significantly in feasibility. Two patients in the TSH group dropped out compared with no patients in the ALPPS group. A comparable volume gain in future liver remnant (FLR) was obtained in the ALPPS and TSH groups (47 vs. 41 %, nonsignificant difference) but during a shorter interval in ALPPS group. The overall and major complication rate was significantly higher after stage 2 in the ALPPS group (Clavien 65 3a: 41.7 vs. 17.6 % in TSH group; p = 0.025). Conclusion: The feasibility of resection using ALPPS compared with TSH for CRLM was not significantly greater, but perioperative complications were increased. Therefore, ALPPS should be proposed to patients with caution and warnings. Currently, TSH remains the standard approach for performing R0 resection in patients with advanced CRLM and inadequate FLR. \ua9 2014 Society of Surgical Oncolog

Liver transplantation. A summary of our surgical practice.

At the turn of the new century, liver transplant procedures can finally be considered an efficient treatment option. Technology has helped transplant intervention become a preferred treatment for patients with progressive and irreversible liver failure. New immuno-suppressive drugs have been introduced which reduce the patient's immunological reaction to the implanted organ, entail minimal side effects and improve practical applications of liver transplantation. As a result of these technological advanced and proper disease management, liver transplant procedures are no longer thought of as an elite therapy, reserved for selected patients with end stage liver disease. In our opinion, it is now a sound and valid surgical option with strictly defined characteristics, indications and well-understood limits. Throughout the past decade, we have studied and applied this type of intervention and have come to terms with its rapid expansion at both the theoretical and practical levels. The most significant obstacle remaining today is the discrepancy between the ever increasing demand and limited supply of organs. The future of liver transplant lies in overcoming this obstacle. Liver transplant practice began at our Institute on 23 November 1990 with the first surgical intervention to replace an organ. In the past 10 years, we have exceeded 200 liver transplant procedures