Laparoscopic ICG-guided stapled left lateral sectionectomy for HCC on hemochromatosis

A case of a 76-year-old man, with a 10-year history of cirrhosis on a hemochromatosis (HH), CHILD score A, and MELD 10. The diagnosis of S2 and S3 liver mass detected during US surveillance prompted admission for surgery. A preoperative enhanced TC scan confirmed a 4 cm liver mass, highly suspicious for a HCC located in segments S2 and S3 with the involvement of the left hepatic vein and sparing of the main portal pedicle. Indocyanine green (ICG) was intravenously administered 6 hours before surgery and an ICG-guided laparoscopic S2–S3 left lateral sectionectomy was performed

Blood Transfusions and Adverse Events after Colorectal Surgery: A Propensity-Score-Matched Analysis of a Hen-Egg Issue

Blood transfusions are considered a risk factor for adverse outcomes after colorectal surgery. However, it is still unclear if they are the cause (the hen) or the consequence (the egg) of adverse events. A prospective database of 4529 colorectal resections gathered over a 12-month period in 76 Italian surgical units (the iCral3 study), reporting patient-, disease-, and procedure-related variables, together with 60-day adverse events, was retrospectively analyzed identifying a subgroup of 304 cases (6.7%) that received intra- and/or postoperative blood transfusions (IPBTs). The endpoints considered were overall and major morbidity (OM and MM, respectively), anastomotic leakage (AL), and mortality (M) rates. After the exclusion of 336 patients who underwent neo-adjuvant treatments, 4193 (92.6%) cases were analyzed through a 1:1 propensity score matching model including 22 covariates. Two well-balanced groups of 275 patients each were obtained: group A, presence of IPBT, and group B, absence of IPBT. Group A vs. group B showed a significantly higher risk of overall morbidity (154 (56%) vs. 84 (31%) events; OR 3.07; 95%CI 2.13-4.43; p = 0.001), major morbidity (59 (21%) vs. 13 (4.7%) events; OR 6.06; 95%CI 3.17-11.6; p = 0.001), and anastomotic leakage (31 (11.3%) vs. 8 (2.9%) events; OR 4.72; 95%CI 2.09-10.66; p = 0.0002). No significant difference was recorded between the two groups concerning the risk of mortality. The original subpopulation of 304 patients that received IPBT was further analyzed considering three variables: appropriateness of BT according to liberal transfusion thresholds, BT following any hemorrhagic and/or major adverse event, and major adverse event following BT without any previous hemorrhagic adverse event. Inappropriate BT was administered in more than a quarter of cases, without any significant influence on any endpoint. The majority of BT was administered after a hemorrhagic or a major adverse event, with significantly higher rates of MM and AL. Finally, a major adverse event followed BT in a minority (4.3%) of cases, with significantly higher MM, AL, and M rates. In conclusion, although the majority of IPBT was administered with the consequence of hemorrhage and/or major adverse events (the egg), after adjustment accounting for 22 covariates, IPBT still resulted in a definite source of a higher risk of major morbidity and anastomotic leakage rates after colorectal surgery (the hen), calling urgent attention to the implementation of patient blood management programs

Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort

background current evidence concerning bowel preparation before elective colorectal surgery is still controversial. this study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation. methods a prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. the primary endpoints were AL, SSIs, and OM. all the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI). results compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23-2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10-1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25-0.79; p = .008). conclusions MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP

Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort

background: In italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. the aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery. methods: a database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. the primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. the results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i. results: a total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). group a versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). a mean postoperative duration of stay difference of 0.86 days was detected between groups. no difference was recorded between the two groups for all the other endpoints. conclusion: this study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery

How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Il percorso diagnostico-terapeutico nei pazienti con gozzo cervico-mediastinico.Quando è inevitabile la programmazione della sternotomia.

La strategia chirurgica nei gozzi substernali è solitamente dettata da esperienze “aneddotiche” di autorevoli esperti e raramente è basata su parametri decisionali riproducibili. Si è soliti affermare che ogni gozzo substernale può essere operato attraverso l’accesso cervicotomico a patto che l’operatore sia sufficientemente esperto. Tale affermazione rimane valida fino che non ci si imbatte in gozzi per i quali la sternotomia o la toracotomia rappresentano non una scelta ma una necessità. Metodo: Scopo della presente ricerca clinica è stato quello di definire i più importanti aspetti clinici dei gozzi cervico mediastinici e in particolare la loro reale incidenza ed il reale “rischio” di dover effettuare una sternotomia di necessità per la loro exeresi, sulla base della nostra personale esperienza unitamente a quella delle più rappresentative esperienze pubblicate sull’argomento. Risultati: Diciotto pazienti su 355 sottoposti a tiroidectomia dal 1993 al Febbraio 2004 presentavano un gozzo con estensione substernale (5.05%) . In un caso (5.5%) è stata necessaria una sternotomia per poter rimuovere un voluminoso gozzo mediastinico ad “iceberg” con oltre l’80% della massa localizzata in sede intratoracica e meno del 20% in sede cervicale. Dai dati della letteratura è risultato che la frequenza dei gozzi retrosternali varia da un minimo di 4.6% ad un massimo di 15.7% mentre la necessità di dover ricorrere, per la loro rimozione, a sternotomia/toracotomia oscilla tra il 3.3% ed il 12.5%. La definizione di gozzo retrosternale è un punto controverso e cruciale per un corretto planning preoperatorio. Secondo Crile si può parlare di gozzo retrosternale quando il suo margine inferiore si estende sino al livello dell’arco aortico. Per Lindskog il margine inferiore deve essere riferito al livello della T4 mentre per Katlik si può parlare di gozzo retrosternale quando la massa intratoracica ha una estensione > 50% distalmente all’”outlet toracico”. Tutte queste affermazioni danno una definizione approssimativa del fenomeno e non indicano quando la sternotomia è inevitabile. Nella nostra esperienza quando la massa si estende al di sotto dell’arco aortico e la sua morfologia è ad iceberg e con la parte immersa nel torace > dell’80% e con diametro trasversale > 10 cm la sternotomia diventa una necessità assoluta . Occorre sottolineare l’esigenza di rimuovere integralmente la massa mediastinica evitando morcellizzazioni ghiandolari (si ricorda che il 10% di tali masse può ospitare neoplasie occulte) e/o traumi di importanti strutture anatomiche locoregionali (vascolari, nervose e pleuropolmonari). Conclusioni: I dati del nostro studio smentiscono l’affermazione ricorrente ( tra i chirurghi generali), che in mani “veramente” esperte, la necessità di dover ricorrere alla sternotomia per la rimozione dei gozzi immersi sia più un mito che una realtà. In un piccolo ma significativo numero di pazienti portatori di gozzi immersi nel mediastino(3.3%-12.5%) non si deve esitare a rinunciare alla tiroidectomia transcervicale “a tutti i costi” pianificando preoperatoriamente un accesso sternotomico. Questo eclettismo strategico consente al chirurgo di evitare fallimentari acrobazie tecniche ed al tempo stesso riduce i rischi di seri danni iatrogeni per il paziente

Tumori stromali gastrici:su tre casi clinici trattati con resezioni videoassistite

In conclusione riteniamo che: 1) i GIST debbano essere trattati con ampia terapia resettiva in quanto la loro potenziale malignità è imprevedibile utilizzando i tradizionali parametri prognostici; 2) la loro exeresi è notevolmente semplificata dall’ausilio della assistenza videolaparoscopica. 3) lo studio istopatologico definitivo è cruciale per la verifica della adeguatezza della exeresi e per la definizine del successivo follow-up dei pazient

Apulian Autochthonous Olive Germplasm: A Promising Resource to Restore Cultivation in <i>Xylella fastidiosa</i>-Infected Areas

The olive tree (Olea europaea subsp. europaea var. europaea) represents the cornerstone crop of Apulian agriculture, which is based on the production of oil and table olives. The high genetic variability of the Apulian olive germplasm is at risk of genetic erosion due to social, economic, and climatic changes. Furthermore, since 2013, the spread of the Gram-negative bacterium Xylella fastidiosa subsp. pauca responsible for the olive quick decline syndrome (OQDS) has been threatening olive biodiversity in Apulia, damaging the regional economy and landscape heritage. The aim of this study was to investigate the differential response to X. fastidiosa infection in a collection of 100 autochthonous Apulian olive genotypes, including minor varieties, F1 genotypes, and reference cultivars. They were genotyped using 10 SSR markers and grown for 5 years in an experimental field; then, they were inoculated with the bacterium. Symptom assessments and the quantification of bacterium using a qPCR assay and colony forming units (CFUs) were carried out three and five years after inoculation. The study allowed the identification of nine putatively resistant genotypes that represent a first panel of olive germplasm resources that are useful both for studying the mechanisms of response to the pathogen and as a reserve for replanting in infected areas