Results of medium seventeen years' follow-up after laparoscopic choledochotomy for ductal stones

INTRODUCTION: In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. METHODS: One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. RESULTS: Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. CONCLUSIONS: Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique

Robot-Assisted Colonic Resections for Cancer

Minimally invasive surgery for colon cancer, if compared with open surgery, has shown similar oncologic outcomes, and it has become the standard management for malignant colonic disease. Its benefits appear yet in early post-operative period such as less postoperative pain, earlier recovery of gastrointestinal functions and shorter hospital stay. Robotic surgery was born in the attempt to overcome the intrinsic limitations of laparoscopic technique. It offers the possibility to have a tridimensional magnified view of surgical field and to use wristed instrument to perform an accurate dissection and lymphadenectomy. It provides the possibility to rotate at 360 degrees the instruments, facilitating considerably the performance of intracorporeal ileo-colic anastomosis in right colectomy. We want to illustrate the feasibility and technique to carry out right and left colectomy in a robotic-assisted way and its advantages with respect to laparoscopic surgery

Demonstration in human cadavers of feasibility of ileoproctostomy performed entirely through a transanal route

Innovative surgical techniques are frequently developed in animal models before of trials in surgical patients. However, these experimental approaches do not permit a perfect evaluation of feasibility due to obvious anatomical differences between humans and animals. The Body Donation Program of the University of Padua has recently developed studies of feasibility on human cadavers of new surgical approaches. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an innovative kinf of surgery which utilizes a flexible endoscope to enter the abdominal, pelvic or thoracic cavities through the body’s natural orifices and then through an internal incision. Skin incisions are thus unnecessary and, as a consequence, tissue trauma, postoperative pain, and incision-related complications are minimized and less anaesthesia is required. The aim of the present study was to verify in human cadavers the technical feasibility of a new NOTES technique, i.e., ileoproctostomy performed entirely through a transanal access. This surgical procedure was previously performed only in a porcine model. The procedure was carried out in three human cadavers (two males and a female). One cadaver was fresh. The other cadavers were fixed through infusion of Thiel’s solution through the larger arteries. A Transanal Endoscopic Microsurgery (TEM) device and endoscopic instruments were utilized. The study demonstrated that ileoproctostomy through a transanal access is technically feasible in humans. The principal steps of the procedure were: placement of the TEM device; rectal perforation above the peritoneal reflection; peritoneoscopy using a standard gastroscope; grasping the small bowel with retrieval forceps and pulling it through the rectal hole; suturing the ileum and the rectum together with two semi-circular continuous sutures utilizing the TEM device; opening the ileal loop from the rectal side followed by endoscopic exploration. Although still at an experimental stage, ileoproctostomy through a transanal access is technically feasible in humans. In planning new procedures, a fundamental step is represented by feasibility tests on donated corpse

Colorectal Cancer Stage at Diagnosis Before vs During the COVID-19 Pandemic in Italy

IMPORTANCE Delays in screening programs and the reluctance of patients to seek medical attention because of the outbreak of SARS-CoV-2 could be associated with the risk of more advanced colorectal cancers at diagnosis. OBJECTIVE To evaluate whether the SARS-CoV-2 pandemic was associated with more advanced oncologic stage and change in clinical presentation for patients with colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included all 17 938 adult patients who underwent surgery for colorectal cancer from March 1, 2020, to December 31, 2021 (pandemic period), and from January 1, 2018, to February 29, 2020 (prepandemic period), in 81 participating centers in Italy, including tertiary centers and community hospitals. Follow-up was 30 days from surgery. EXPOSURES Any type of surgical procedure for colorectal cancer, including explorative surgery, palliative procedures, and atypical or segmental resections. MAIN OUTCOMES AND MEASURES The primary outcome was advanced stage of colorectal cancer at diagnosis. Secondary outcomes were distant metastasis, T4 stage, aggressive biology (defined as cancer with at least 1 of the following characteristics: signet ring cells, mucinous tumor, budding, lymphovascular invasion, perineural invasion, and lymphangitis), stenotic lesion, emergency surgery, and palliative surgery. The independent association between the pandemic period and the outcomes was assessed using multivariate random-effects logistic regression, with hospital as the cluster variable. RESULTS A total of 17 938 patients (10 007 men [55.8%]; mean [SD] age, 70.6 [12.2] years) underwent surgery for colorectal cancer: 7796 (43.5%) during the pandemic period and 10 142 (56.5%) during the prepandemic period. Logistic regression indicated that the pandemic period was significantly associated with an increased rate of advanced-stage colorectal cancer (odds ratio [OR], 1.07; 95%CI, 1.01-1.13; P = .03), aggressive biology (OR, 1.32; 95%CI, 1.15-1.53; P < .001), and stenotic lesions (OR, 1.15; 95%CI, 1.01-1.31; P = .03). CONCLUSIONS AND RELEVANCE This cohort study suggests a significant association between the SARS-CoV-2 pandemic and the risk of a more advanced oncologic stage at diagnosis among patients undergoing surgery for colorectal cancer and might indicate a potential reduction of survival for these patients

Randomised clinical trial of endoluminal loco-regional resection versus laparoscopic total mesorectal excision for T2 rectal cancer post neoadjuvant therapy

Introduzione: Nei tumori del retto non avanzato è possibile, in casi selezionati e dopo trattamento neoadiuvante, effettuare una terapia chirurgica alternativa alla Total Mesorectal Excision (TME) come l’escissione loco-regionale mediante TEM. Metodi: Il presente studio analizza i risultati a lungo termine di un trial prospettico randomizzato che confronta due diverse metodiche: l’escissione loco-regionale transanale mediante TEM (Transanal Endoscopic Microsurgery) e la TME (Total Mesorectal Excision) laparoscopica in pazienti con cancro del retto non avanzato. Sono stati selezionati solo pazienti con stadio cT2 N0 M0, G1-2, con un diametro massimo del tumore di 3 cm e a una distanza massima di 6 cm dalla linea pettinata. Tutti i pazienti inclusi sono stati sottoposti a radiochemioterapia neoadiuvante. Risultati: Il 51% dei pazienti ha avuto un downstaging del tumore dopo terapia neoadiuvante e il 26 % una riduzione significativa della massa. Tutti i pazienti hanno avuto un intervento R0 con margini di resezione liberi da malattia. Al follow-up si sono verificate 4 (8 %) recidive locali nel gruppo della TEM e 3 (6 %) in quello della TME (P = 0.972). In entrambi i gruppi 2 (4 %) pazienti hanno sviluppato metastasi a distanza. Nei due gruppi i pazienti liberi da malattia non hanno portato a differenze statisticamente significative. 4 4 Conclusioni: I due gruppi di pazienti trattati mediante TEM e TME laparoscopica dopo terapia neoadiuvante hanno ottenuto risultati oncologici simili.Background: In selected patients with early low rectal cancer, loco-regional excision combined with neoadjuvant therapy may be an alternative treatment option to total mesorectal excision (TME). Methods: This prospective randomized trial compares the results of endoluminal loco-regional resection (ELRR) by Transanal Endoscopic Microsurgery (TEM) versus laparoscopic TME in the treatment of patients with small, non-advanced low rectal cancer. Patients with rectal cancer staged as cT2 N0 M0, G1-2, tumour diameter < 3 cm, located ≤ 6 cm from the anal verge were randomized to ELRR and TME. All patients underwent long course neoadjuvant chemoradiotherapy (NT). Results: Tumour downstaging and downsizing rates after NT were 51.0 % and 26.0 %, respectively, and were similar in both groups. All patients had R0 resection with tumour-free resection margins. At long-term follow-up, 4 local recurrences (8.0 %) occurred after ELRR and 3 (6.0 %) after TME (P = 0.972). Distant metastases were observed in 2 (4.0 %) cases in both groups. There was no statistically significant difference in disease-free survival (P = 0.686). Conclusions: In selected patients, ELRR had similar oncological results to TME. (Study ID Numbers: URBINO-LEZ-1995; ClinicalTrials.gov

Randomised clinical trial of endoluminal loco-regional resection versus laparoscopic total mesorectal excision for T2 rectal cancer post neoadjuvant therapy

Introduzione: Nei tumori del retto non avanzato è possibile, in casi selezionati e dopo trattamento neoadiuvante, effettuare una terapia chirurgica alternativa alla Total Mesorectal Excision (TME) come l’escissione loco-regionale mediante TEM. Metodi: Il presente studio analizza i risultati a lungo termine di un trial prospettico randomizzato che confronta due diverse metodiche: l’escissione loco-regionale transanale mediante TEM (Transanal Endoscopic Microsurgery) e la TME (Total Mesorectal Excision) laparoscopica in pazienti con cancro del retto non avanzato. Sono stati selezionati solo pazienti con stadio cT2 N0 M0, G1-2, con un diametro massimo del tumore di 3 cm e a una distanza massima di 6 cm dalla linea pettinata. Tutti i pazienti inclusi sono stati sottoposti a radiochemioterapia neoadiuvante. Risultati: Il 51% dei pazienti ha avuto un downstaging del tumore dopo terapia neoadiuvante e il 26 % una riduzione significativa della massa. Tutti i pazienti hanno avuto un intervento R0 con margini di resezione liberi da malattia. Al follow-up si sono verificate 4 (8 %) recidive locali nel gruppo della TEM e 3 (6 %) in quello della TME (P = 0.972). In entrambi i gruppi 2 (4 %) pazienti hanno sviluppato metastasi a distanza. Nei due gruppi i pazienti liberi da malattia non hanno portato a differenze statisticamente significative. 4 4 Conclusioni: I due gruppi di pazienti trattati mediante TEM e TME laparoscopica dopo terapia neoadiuvante hanno ottenuto risultati oncologici simili