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

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

Transanal Endoscopic Microsurgery after the attempt of endoscopic removal of rectal polyps

none6The incidence of rectal polyps has steadily increased in recent decades and will continue to rise. [1] The introduction of endoscopic screening programs has probably contributed to the improved detection of rectal polyps and early malignant lesions [2, 3]. With the aim to reduce morbidity and mortality of rectal surgery, in 1983, Gerhard Buess introduced Transanal Endoscopic Microsurgery (TEM) [4]. He conceived a novel endoscopic technology to facilitate the excision of rectal polyps through the anus [5]. This revolutionary technique enabled superfcial or full-thickness excision of large adenomatous lesions. It soon became apparent that indications to TEM could be successfully extended to early malignant polyps [6, 7]. However, in the late nineties, endoscopy was advocated as a diagnostic technique and a therapeutic method. First, large piecemeal snare ablations were reported. Then, the use of endoscopic electrosurgical knives made it possible to achieve en bloc resection, known as Endoscopic Submucosal Dissection (ESD) [8–11]. The sharp increase in endoscopic resection of rectal polyps made the indications for TEM questioned [12]. This unresolved debate confuses the choice of the optimal treatment for complex rectal polyps. Concerns mainly arise where there is uncertainty around early malignancy or where complete resection of an adenomatous polyp is not obtained following endoscopic attempts [13–15]. Accurate prognostic information is not always available after endoscopic removal, mainly when the specimen is fragmented. [16] Additionally, fbrotic tissue growth at the polypectomy site could invalidate the already sub-optimal accuracy of pre-operative imaging techniques. Therefore, endoscopic ultrasound and/or Magnetic Resonance Imaging staging are often misleading [17]. The indication to resect the site of a previous endoscopic resection with a full-thickness technique has been recommended in cases of unexpected malignancy. However, the overall beneft remains unclear [13, 18]. This study aims to evaluate the outcomes of TEM following endoscopic resection of rectal polyps performed at two diferent centres, assess the value of further local excision, and identify features that may contribute to the decisionmaking process.openMonica Ortenzi, Alberto Arezzo, Roberto Ghiselli, Marco Ettore Allaix, Mario Guerrieri, Mario MorinoOrtenzi, Monica; Arezzo, Alberto; Ghiselli, Roberto; Ettore Allaix, Marco; Guerrieri, Mario; Morino, Mari

Nationwide analysis of laparoscopic groin hernia repair in Italy from 2015 to 2020

Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward

Nationwide analysis of inpatient laparoscopic ventral hernia repair in Italy from 2015 to 2020

Since 2010, several guidelines and consensus papers have been proposed to support surgeons in the decision-making process (Cuccurullo et al. in Hernia 17(5):557-566, 2013; Silecchia et al. in Surg Endosc 29:2463-2484, 2015; Bittner et al. in Surg Endosc 33(11):3511-3549, 2015) with the conclusion that laparoscopic repair (LR) has gained popularity in the treatment of IH.To date, however, it is not yet clear as to the uptake of LR for IH on national basis. Only dated studies encompassing of all types of incisional hernia repairs are available in literature (Bisgaard et al. in Br J Surg 96:1452-1457, 2009). The aim of our study is to present a snapshot of Italian data for LR of ventral hernias, over a 6 years period, including volume of LR, procedural features and major postoperative outcomes. Data were extracted from the Italian Hospital Information System (HIS) that collects clinical and administrative information regarding each hospital admission of every patient discharged from any hospital in Italy. Using Hospital Discharge records regional Databases (HDD), all laparoscopic ventral hernia procedures carried out in public and private hospitals between 2015 and 2020, in patients over 18 years and resident in Italy, were collected based on diagnosis and procedure codes. The National Agency for Regional Health Services (AgeNaS) oversees the management and analysis of data. All hospital admissions that occurred between 2015 and 2020 were analyzed.A total of 154,546 incisional hernia repairs were performed in Italy from 2015 to 2020. Of these, 20,789 (13.45%) were minimally invasive repairs. The number of procedures performed increased significantly over time, constituting 11.96 and 15.24% of all procedures performed in 2015 and 2020 respectively. However, considering the whole period, the mean annual change was-5.58% (CI - 28.6% to 17.44%; p < 0.0001).Urgent minimally invasive repairs were performed in 1968 cases (1.27%). The absolute rate of laparoscopically treated patients needing an urgent surgical procedure increased overtime (from 7.36% in 2015 to 13.418% in 2020). The mean annual change registered over the whole period was 7.42%. 92% (CI - 0.03 to 14.09%; p < 0.0001). However, when considering the period from 2015 to 2019, the mean annual change was 10.42% (CI 6.35 to 14.49%; p < 0.0001). To our knowledge this is the first nationwide Italian report presenting the national workload of surgical units and the main perioperative features of minimally invasive surgery for ventral hernia repairs

A multi-sensor approach for volcanic ash cloud retrieval and eruption characterization: the 23 November 2013 Etna lava fountain

Volcanic activity is observed worldwide with a variety of ground and space-based remote sensing instruments, each with advantages and drawbacks. No single system can give a comprehensive description of eruptive activity, and so, a multi-sensor approach is required. This work integrates infrared and microwave volcanic ash retrievals obtained from the geostationary Meteosat Second Generation (MSG)-Spinning Enhanced Visible and Infrared Imager (SEVIRI), the polar-orbiting Aqua-MODIS and ground-based weather radar. The expected outcomes are improvements in satellite volcanic ash cloud retrieval (altitude, mass, aerosol optical depth and effective radius), the generation of new satellite products (ash concentration and particle number density in the thermal infrared) and better characterization of volcanic eruptions (plume altitude, total ash mass erupted and particle number density from thermal infrared to microwave). This approach is the core of the multi-platform volcanic ash cloud estimation procedure being developed within the European FP7-APhoRISM project. The Mt. Etna (Sicily, Italy) volcano lava fountaining event of 23 November 2013 was considered as a test case. The results of the integration show the presence of two volcanic cloud layers at different altitudes. The improvement of the volcanic ash cloud altitude leads to a mean difference between the SEVIRI ash mass estimations, before and after the integration, of about the 30%. Moreover, the percentage of the airborne “fine” ash retrieved from the satellite is estimated to be about 1%–2% of the total ash emitted during the eruption. Finally, all of the estimated parameters (volcanic ash cloud altitude, thickness and total mass) were also validated with ground-based visible camera measurements, HYSPLIT forward trajectories, Infrared Atmospheric Sounding Interferometer (IASI) satellite data and tephra deposits

White-to-brown transdifferentiation of omental adipocytes in patients affected by pheochromocytoma

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Defining Prostatic Vascular Pedicle Recurrence and the Anatomy of Local Recurrence of Prostate Cancer on Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography.

Background The term local recurrence in prostate cancer is considered to mean persistent local disease in the prostatic bed, most commonly at the site of the vesicourethral anastomosis (VUA). Since the introduction of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging for assessment of early biochemical recurrence (BCR), we have found histologically confirmed prostate cancer in the prostatic vascular pedicle (PVP). If a significant proportion of local recurrences are distant to the VUA, it may be possible to alter adjuvant and salvage radiation fields in order to reduce the potential morbidity of radiation in selected patients. Objective To describe PVP local recurrence and to map the anatomic pattern of prostate bed recurrence on PSMA PET/CT. Design setting and participants This was a retrospective multicentre study of 185 patients imaged with PSMA PET/CT following radical prostatectomy (RP) between January 2016 and November 2018. All patient data and clinical outcomes were prospectively collected. Recurrences were documented according to anatomic location. For patients presenting with local recurrence, the precise location of the recurrence within the prostate bed was documented. Intervention PSMA PET/CT for BCR following RP. Results and limitations A total of 43 local recurrences in 41/185 patients (22%) were identified. Tumour recurrence at the PVP was found in 26 (63%), VUA in 15 (37%), and within a retained seminal vesicle and along the anterior rectal wall in the region of the neurovascular bundle in one (2.4%) each. Histological and surgical evidence of PVP recurrence was acquired in two patients. The study is limited by its retrospective nature with inherent selection bias. This is an observational study reporting on the anatomy of local recurrence and does not include follow-up for patient outcomes. Conclusions Our study showed that prostate cancer can recur in the PVP and is distant to the VUA more commonly than previously thought. This may have implications for RP technique and for the treatment of selected patients in the local recurrence setting. Patient summary We investigated more precise identification of the location of tumour recurrence after removal of the prostate for prostate cancer. We describe a new definition of local recurrence in an area called the prostatic vascular pedicle. This new concept may alter the treatment recommended for recurrent disease