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

Three-row versus two-row circular staplers for left-sided colorectal anastomosis: a propensity score-matched analysis of the iCral 2 and 3 prospective cohorts

Background: Since most anastomoses after left-sided colorectal resections are performed with a circular stapler, any technological change in stapling devices may influence the incidence of anastomotic adverse events. The aim of the present study was to analyze the effect of a three-row circular stapler on anastomotic leakage and related morbidity after left-sided colorectal resections. Materials and methods: A circular stapled anastomosis was performed in 4255 (50.9%) out of 8359 patients enrolled in two prospective multicenter studies in Italy, and, after exclusion criteria to reduce heterogeneity, 2799 (65.8%) cases were retrospectively analyzed through a 1:1 propensity score-matching model including 20 covariates relative to patient characteristics, to surgery and to perioperative management. Two well-balanced groups of 425 patients each were obtained: group (A) – true population of interest, anastomosis performed with a three-row circular stapler; group (B) – control population, anastomosis performed with a two-row circular stapler. The target of inferences was the average treatment effect in the treated (ATT). The primary endpoints were overall and major anastomotic leakage and overall anastomotic bleeding; the secondary endpoints were overall and major morbidity and mortality rates. The results of multiple logistic regression analyses for the outcomes, including the 20 covariates selected for matching, were presented as odds ratios (OR) and 95% confidence intervals (95% CI). Results: Group A versus group B showed a significantly lower risk of overall anastomotic leakage (2.1 vs. 6.1%; OR 0.33; 95% CI 0.15–0.73; P = 0.006), major anastomotic leakage (2.1 vs. 5.2%; OR 0.39; 95% CI 0.17–0.87; P = 0.022), and major morbidity (3.5 vs. 6.6% events; OR 0.47; 95% CI 0.24–0.91; P = 0.026). Conclusion: The use of three-row circular staplers independently reduced the risk of anastomotic leakage and related morbidity after left-sided colorectal resection. Twenty-five patients were required to avoid one leakage

Technique of laparoscopic splenectomy

Background: Indications for laparoscopic splenectomy have rapidly increased and it is now considered the standard approach for almost all diseases requiring splenectomy, including benign and malignant disease. The aim is to evaluate the safety and effectiveness of laparoscopic splenectomy in a large cohort of patients in a laparoscopic referral center. Methods: We retrospectively analyzed 141 patients undergone surgery for spleen-related diseases from 2010 to 2019. All patients underwent laparoscopic splenectomy were selected according to European Association for Endoscopic Surgery guidelines. Exclusion criteria were American Society of Anesthesiologists (ASA) IV and severe portal hypertension and spleen diameter >30 cm. Early and mid-term results have been evaluated. Results: From 2010 to 2019, 108 patients underwent laparoscopic splenectomy. Mean operative time was 70 min (range, 50-120 min) with a conversion rate of 4.6% (5 patients). Among the 105 patients completed laparoscopically, 21 (20.4%) postoperative complications were reported: 2 early hemorrhage (2%), 4 (3.7%) fluid collections in the splenic fossa, 6 (5.5%) pneumonia and atelectasis and 9 (8.3%) cases of transient fever. Sixty-six patients (64.1%) reported mild pain, 22 patients (21.4%) moderate pain and 15 patients (14.6%) had severe pain. The 15 patients (14.6%) undergone specimen extraction through the suprapubic incision reported a higher pain compared with those in which spleen morcellation was performed (6.2 vs. 3.4, P<0.05). The mean hospital stay was 4 days (range, 3-6 days), with a mean time to return to normal activity of 7 days (range, 4-10 days). No late complications during the mean 3 years follow-up (range, 1-4 years) were observed. Conclusions: Laparoscopic splenectomy is safeness and effectiveness despite it requires extensive experience in laparoscopic surgery, adequate patient positioning and trocars positioning

Technique of laparoscopic splenectomy: How I do it

Laparoscopic splenectomy (LS) is the gold standard procedure to remove the spleen in elective patients. The laparoscopic procedure can be performed safely in patients with a massive splenomegaly, too. Despite many authors prefer the lateral approach, we put the patients in a supine position. This position offers good exposition of the splenic vessels and allows for a rapid control of hilar blood flow. Moreover, the supine approach does not require the retraction of the spleen away from hilum, this allows the procedure to be carried out in most cases without the need to insert a fourth trocar. We control the hilum vessels, after closing the main trunk of the splenic artery with a hem-o-lok, with one firing of an endoscopic stapler loaded with a vascular cartridge, providing that the tail of the pancreas is protected and all hilar structures can be included between the jaws of the stapler. We call this method the stapling technique. LS provides the advantages of shorter length of stay, decreased postoperative pain, and morbidity, but it should be performed using standardized technique by skilled and experienced surgeons

Early postoperative administration of probiotics versus placebo in elderly patients undergoing elective colorectal surgery: a double-blind randomized controlled trial.

BACKGROUND: Perioperative prophylactic antibiotic treatment significantly influences intestinal microflora, resulting in impaired bowel functioning in some patients, sometimes requiring further investigations. This may lead to a worse health-related quality of life (HRQoL). Probiotics administrated in the early post-operative period may help avoiding such nuisances in older people. METHODS: We prospectively enrolled patients undergoing laparoscopic colorectal surgery aged over 70 years between 2005 and 2012. The study was approved by IRB. All patients received perioperative antibiotic treatment. Patients were randomized to one of two treatment arms: Group A patients received probiotics after surgery (VSL#3, VSL Pharmaceuticals, Inc. USA - 900 × 10(9 )daily, while Group B patients received a Placebo (cornstarch). Patients were further divided in sub-groups whether ileo-caecal valve was spared or not. Patients were followed-up every 7 days for 4 weeks. Patients daily annotated bowel frequency, stool shape and consistency - according to Bristol's scale. HRQoL was assessed every week by means of SF-36 questionnaire. RESULTS: Group A included 10 while Group B included 8 patients. One patient in each group experienced a postoperative complication. Group A patients had fewer bowel movements than controls, during every week. Stool consistency was higher in patients undergoing resections including ileo-caecal valve receiving VSL#3. HRQoL gradually increased in both groups; Group A patients had higher "social functioning" item scores at week 1 and 4 than controls. CONCLUSIONS: Elderly patients undergoing resection of ileo-caecal valve may benefit from an early probiotics administration pathway after perioperative antibiotic treatment

Gallstone ileus without bilioenteric fistula years after bypass surgery for Crohn’s disease. Case report and clues to etiology of a neglected cause of obstruction

tINTRODUCTION: Gallstone ileus is a very rare cause of bowel obstruction. Patients suffering from Crohn’sdisease are at increased risk of developing gallstone disease, especially when terminal ileum is involved.Gallstone ileus can occur, but etiology remains controversial. We report on a case of such a rare condition,illustrating etiology and treatments.PRESENTATION OF CASE: A patient with long-standing Crohn’s disease, who had undergone ileotransversebypass for ileocaecal involvement 40 years before, presented with cramp-like abdominal pain. Imagingwas consistent with a gallstone ileus with no evidence of bilioenteric fistulae.DISCUSSION: At surgery, we found gallstones stuck at the site of ileotransverse anastomosis. No bil-ioenteric fistulae were found. Due to disease progression, many enteric fistulae were found, requiringa massive bowel resection. The diverted segment may have been responsible of gallstone formation,and etiology is discussed. Recovery after surgery was uneventful, but the patient required continuednutritional support.CONCLUSION: Physicians dealing with Crohn’s disease patients with bypassed segments should keep inmind, the increased risk of gallstone formation, in order to not overlook gallstone ileus. Early suspect anddiagnosis may allow for less aggressive approaches. A diverted segment should always be removed, andlong-term follow-up encouraged

Vascular anomalies of the large bowel

Vascular anomalies of the large bowel, commonly known as vascular malformations of the colon (VMC), constitute a rare but important condition, potentially causing signiicant morbidity and mortality. Our aim is to provide an up-to-date, practical summary evaluating this disease entity, focussing on pathogenesis, as well as diagnostic and therapeutic modalities. We reviewed available data in the literature, and discussed it in the form of a narrative, readily applicable review. Most VMC (over 70%) are detected in the caecum and ascending colon, and affect people aged over 50 years. VMC are almost always symptomatic, presenting with lower bleeding. Endoscopy is crucial to identify and locate VMC, and to treat the lesions. In patients who fail or do not it endoscopic treatment, aggressive approaches (interventional angiology or surgery) are mandatory. Up to 40% of patients may have relapse in the long term. VMC are rare but potentially life-threatening. Advances in endoscopic imaging and therapy have improved the results of treatment. Long-term follow-up after treatment is recommended

Vascular anomalies of the large bowel

Vascular anomalies of the large bowel, commonly known as vascular malformations of the colon (VMC), constitute a rare but important condition, potentially causing significant morbidity and mortality. Our aim is to provide an up-to-date, practical summary evaluating this disease entity, focussing on pathogenesis, as well as diagnostic and therapeutic modalities. We reviewed available data in the literature, and discussed it in the form of a narrative, readily applicable review. Most VMC (over 70%) are detected in the caecum and ascending colon, and affect people aged over 50 years. VMC are almost always symptomatic, presenting with lower bleeding. Endoscopy is crucial to identify and locate VMC, and to treat the lesions. In patients who fail or do not fit endoscopic treatment, aggressive approaches (interventional angiology or surgery) are mandatory. Up to 40% of patients may have relapse in the long term. VMC are rare but potentially life-threatening. Advances in endoscopic imaging and therapy have improved the results of treatment. Long-term follow-up after treatment is recommended