ACTH-Independent Cushing's Syndrome Associated with Left Adrenocortical Oncocytoma of Uncertain Malignant Potential

Adrenocortical oncocytomas are rare and mostly nonfunctioning neoplasms. We report the case of a 27-year-old woman diagnosed with an ACTH-independent Cushing's syndrome due to left adrenal oncocytoma. She underwent laparoscopic adrenalectomy. Histopathological examination revealed an oncocytoma of uncertain malignant potential with a low Ki-67 proliferation index, inhibin A positivity, and chromogranin A negativity. Electron micrographs confirmed adrenal oncocytoma cells, characterized by the presence of a large amount of mitochondria. The postoperative course was uneventful, and the patient experienced a progressive regression of Cushing-related symptoms. Periodical follow-ups with MRI and cortisol dosage are required due to the neoplasm's uncertain malignant potential. Considerations on the diagnosis, pathology findings, clinical remarks, and interventions are made

3D Laparoscopy. A potential cutting edge in minimal invasive digestive surgery

Laparoscopic surgery has changed surgical landscape, providing reduced surgical trauma, shorter hospital stays, less postoperative pain and better outcomes than open surgery. Since its first development in the 90’s, 3D technology applied to laparoscopic surgery has had several technical improvements and now it represents, together with high definition technology, the best option in minimal invasive digestive surgery, providing shorter operative times and lower blood loss, making easier to perform surgical tasks both for trainees than for skilled surgeons. It remains a little bit more expensive than standard 2D laparoscopic devices but even cheaper than robotic equipment

National variations in perioperative assessment and surgical management of Crohn's disease: a multicentre study

Aim: Crohn's disease (CD) requires a multidisciplinary approach and surgery should be undertaken by dedicated colorectal surgeons with audited outcomes. We present a national, multicentre study, with the aim to collect benchmark data on key performance indicators in CD surgery, to highlight areas where standards of CD surgery excel and to facilitate targeted quality improvement where indicated. Methods: All patients undergoing ileocaecal or redo ileocolic resection in the participating centres for primary and recurrent CD from June 2018 to May 2019 were included. The main objective was to collect national data on hospital volume and practice variations. Postoperative morbidity was the primary outcome. Laparoscopic surgery and stoma rate were the secondary outcomes. Results: In all, 715 patients were included: 457 primary CD and 258 recurrent CD with a postoperative morbidity of 21.6% and 34.7%, respectively. Laparoscopy was used in 83.8% of primary CD compared to 31% of recurrent CD. Twenty-five hospitals participated and the total number of patients per hospital ranged from 2 to 169. Hospitals performing more than 10 primary CD procedures per year showed a higher adoption of laparoscopy and bowel sparing surgery. Conclusions: There is significant heterogeneity in the number of CD surgeries performed per year nationally in Italy. Our data suggest that high-volume hospitals perform more complex procedures, with a higher adoption of bowel sparing surgery. The rate of laparoscopy in high-volume hospitals is higher for primary CD but not for recurrent CD compared with low-volume hospitals

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population. Trial registration: ClinicalTrials.gov NCT04509986

The use of positron emission tomography with [18F] 2-fluoro-D-2-deoxyglucose (FDG-PET) in Hodgkin and non-Hodgkin's lymphoma.

Positron emission tomography (PET) has obtained a place in the management of patients with hematologic disease particularly those with lymphoproliferative disorders. In the staging and monitoring of cancer, the use of PET in combination with fluorine-18 fluorodeoxyglucose (FDG) has already demonstrated its benefit when compared with conventional imaging modalities. One such area which has already profited from the use of PET is Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). Computed tomography and magnetic resonance imaging are equivalent in staging and monitoring disease, while gallium-67 imaging is more useful in HD and high grade NHL for studies of response to therapy.Paul et al. in 1987 were the first to describe PET imaging in patients with lymphoma; since this time a number of studies have demonstrated that PET technique is superior to 67 Ga imaging in staging lymphoma before therapy and is useful in the evaluation and the prediction of relapse after high dose therapy with stem cell transplantation.PET is based on the utilisation of positron emitting radiopharmaceuticals and the detection in coincidence of the two nearly collinear 511-keV photons emitted following positron annihilation with an electron in vivo. By surrounding the patients with detectors, a large number of acquired coincident events can lead to the construction of an image of the in vivo radioisotope distribution

Laparoscopic Treatment of Bouveret's Syndrome Presenting as Acute Pancreatitis

Gastric outlet obstruction as a result of gallstone (Bouveret's syndrome) is a rare but serious complication of cholelithiasis. Although patients present with persistent vomiting, colicky epigastric pain and dehydration, the clinical features of the Bouveret's syndrome are not pathognomonic. Due to its rarity, the diagnosis and treatment represent a challenge for the surgeon. In most of the reported cases, the diagnosis was made at the time of laparotomy. We report an unusual clinical presentation of Bouveret's syndrome with mild acute pancreatitis that was treated laparoscopically. To our knowledge, this is the first described case. Cause, clinical presentation, methods of diagnosis, and options for management of Bouveret's syndrome are also discussed

Ambulatory Surgery for Perianal Disease

The gold standard in the diagnosis and treatment of proctological diseases is the exploration of the anal canal and distal rectum under anaesthesia (EUA), routinely performed as day case surgery. In selected cases it can be conducted as an outpatient exploration (OE) during a specialist surgical consultation. In the outpatient setting it is possible and safe to perform rubber band ligation, sclerotherapy and infrared coagulation for the treatment of haemorrhoidal disease, excision and incision of thrombosed external haemorrhoids, abscess drainage, setonage and fistulotomy also in case of perianal Crohn’s disease, anal warts and skin tags removal. In terms of patients’ satisfaction and success rate OE is comparable to EUA. All procedures can be performed under local anaesthesia. Pain control after the procedure is provided by oral pain killers

Interleukin-34 Enhances the Tumor Promoting Function of Colorectal Cancer-Associated Fibroblasts

In colorectal cancer (CRC), cancer-associated fibroblasts (CAFs) promote tumor growth and progression through the synthesis of various molecules targeting the neoplastic cells. Here, we demonstrate that IL-34, a cytokine highly expressed in CRC tissue, regulates the function of CAFs in a paracrine and autocrine manner. Specifically, IL-34 induces normal fibroblasts (NFs) to acquire a cellular phenotype resembling that of CAFs, while IL-34 knockdown in CAFs reduces their tumorigenic properties and proliferation. Moreover, IL-34 stimulates NFs to produce netrin-1 and b-FGF—two factors that enhance CRC cell growth and migration. Altogether, our data support the involvement of IL-34 in CRC. Abstract The stromal compartment of colorectal cancer (CRC) is marked by the presence of large numbers of fibroblasts, termed cancer-associated fibroblasts (CAFs), which promote CRC growth and progression through the synthesis of various molecules targeting the neoplastic cells. Interleukin (IL)-34, a cytokine over-produced by CRC cells, stimulates CRC cell growth. Since IL-34 also regulates the function of inflammatory fibroblasts, we hypothesized that it could regulate the tumor promoting function of colorectal CAFs. By immunostaining and real-time PCR, we initially showed that IL-34 was highly produced by CAFs and to lesser extent by normal fibroblasts isolated from non-tumoral colonic mucosa of CRC patients. CAFs and normal fibroblasts expressed the functional receptors of IL-34. IL-34 induced normal fibroblasts to express α-SMA, vimentin and fibroblast activation protein and enhanced fibroblast growth, thus generating a cellular phenotype resembling that of CAFs. Consistently, knockdown of IL-34 in CAFs with an antisense oligonucleotide (AS) decreased expression of such markers and inhibited cell proliferation. Co-culture of CRC cells with IL-34 AS-treated CAFs supernatants resulted in less cancer cell proliferation and migration. Among CAF-derived molecules known to promote CRC cell growth/migration, only netrin-1 and basic-fibroblast growth factor were induced by IL-34. Data suggest a role for IL-34 in the control of colorectal CAF function

ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study

Background Enhanced recovery after surgery (ERAS) programs influence morbidity rates and length of stay after colorectal surgery (CRS), and may also impact major complications and anastomotic leakage rates. A prospective multicenter observational study to investigate the interactions between ERAS program adherence and early outcomes after elective CRS was carried out. Methods Prospective enrolment of patients submitted to elective CRS with anastomosis in 18 months. Adherence to 21 items of ERAS program was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints [major morbidity (MM) and anastomotic leakage (AL) rates] were identified through logistic regression analyses including all significant variables, presenting odds ratios (OR). Results Institutional ERAS protocol was declared by 27 out of 38 (71.0%) participating centers. Median overall adherence to ERAS program items was 71.4%. Among 3830 patients included in the study, MM and AL rates were 4.7% and 4.2%, respectively. MM rates were independently influenced by intra- and/or postoperative blood transfusions (OR 7.79, 95% CI 5.46-11.10; p < 0.0001) and standard anesthesia protocol (OR 0.68, 95% CI 0.48-0.96; p = 0.028). AL rates were independently influenced by male gender (OR 1.48, 95% CI 1.06-2.07; p = 0.021), intra- and/or postoperative blood transfusions (OR 4.29, 95% CI 2.93-6.50; p < 0.0001) and non-standard resections (OR 1.49, 95% CI 1.01-2.22; p = 0.049). Conclusions This study disclosed wide room for improvement in compliance to several ERAS program items. It failed to detect any significant association between institutionalization and/or adherence rates to ERAS program with primary endpoints. These outcomes were independently influenced by gender, intra- and postoperative blood transfusions, non-standard resections, and standard anesthesia protocol