Stefano De Carli

Azienda Ospedaliera Niguarda Ca' Granda, Milano, Lombardy, Italy

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Publications (9)17.18 Total impact

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    ABSTRACT: The value of fast-track (FT) multimodal recovery programs in improving hospitalization of surgical patients has been widely proved. The application of FT protocols to laparoscopic colorectal surgery seems to maximize the effects of the minimally invasive approach. The objectives of this randomized-controlled trial are to compare the short-term outcomes (bowel function, return to oral nutrition, day of discharge, fatigue, time to resume normal activities, functional capabilities, and readmission rate) of patients undergoing elective laparoscopic high anterior resection (HAR) following either a FT or a standard program. The prospective randomized-controlled trial included 52 consecutive patients undergoing elective laparoscopic HAR. Group 1 was treated with a FT rehabilitation program, and group 2 was treated with a standard care (SC) program. Patients were interviewed 14 and 30 days postoperatively. One patient in each group was excluded from the study. Mean hospital stay, time of first bowel movement, and bowel function resumption were significantly shorter in the FT group (P<0.05). Patients in the FT group referred more pain in day 0 versus patients in the SC group (P<0.05) even though the difference disappeared from day 1. Fatigue was significantly reduced at day 14 in the FT group compared with the SC group (P<0.01). Similarly, ability to resume the normal preoperative attitude (walking stairs, cooking, housekeeping, shopping, and walking outdoors) was significantly better at day 14 in the FT group (P<0.005). There was no significant difference between the 2 groups at day 30 for the same parameters. There were no readmissions in both the groups and no need for consultations from general practitioners. FT multimodal program is a safe approach effective on postoperative short-term outcome significantly reducing hospital stay. Early postoperative pain control needs to be optimized.
    Surgical laparoscopy, endoscopy & percutaneous techniques 04/2014; 24(2):118-21. · 0.88 Impact Factor
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    ABSTRACT: BACKGROUND: Several techniques are described in the literature about laparoscopic treatment of the right colon. Among them, laparoscopic-assisted colectomy (LAC) with creation of an extracorporeal ileocolonic anastomosis remains the favourite approach in most centers. So far, total laparoscopic colectomy (TLC) with intracorporeal anastomosis is not widely performed, because it requires adequate skills and competence in the use of mechanical linear staplers and laparoscopic manual sutures. The purpose of this study was to determine prospectively if TLC offers some advantages in short-term outcomes over LAC. METHODS: A prospective comparative study was designed for 80 consecutive patients who were alternatively treated with TLC and LAC for right colon neoplasms. The following data were collected: operative time, intra- and postoperative complication rate, time to bowel movement, hospitalization time, length of minilaparotomy, number of harvested lymph nodes, and specimen length. RESULTS: Operative time in TLC resulted significantly longer than in LAC (230 vs. 203 min), complication rate was similar in both groups, with no case of anastomotic dehiscence, two anastomotic bleedings in TLC vs. three in LAC and one case of postoperative ileus for each group. One case of death occurred in LAC patient developing a postoperative severe cardiopulmonary syndrome. Time to first flatus was in favour of TLC (2.2 vs. 2.6 days), whereas hospitalization was comparable. As regards to the oncological parameters of radicality, the specimen length was superior in TLC group, but the number of lymph nodes excised was equivalent. The length of the minilaparotomy was clearly shorter in TLC group (5.5 vs. 7.2 cm). CONCLUSIONS: No evidence of relevant differences in terms of functional and safety outcomes between the two laparoscopic procedures. TLC determines less abdominal manipulation and shorter incision length, but clear advantages must be still demonstrated. Larger series are necessary to test the superiority of totally laparoscopic procedures for right colectomy.
    Surgical Endoscopy 02/2013; · 3.43 Impact Factor
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    ABSTRACT: Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival. Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up. Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not (p=0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48+/-33 months (range 0.1-120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%. Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.
    European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 01/2009; 35(5):497-503. · 2.56 Impact Factor
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    ABSTRACT: This study was undertaken to evaluate the outcomes of the simultaneous bilateral laparoscopic adrenalectomy. This was a retrospective study, including 11 patients with bilateral adrenal lesions, affected by Cushing's syndrome (n=2), Cushing's disease (n=6), pheochromocytoma (n=2), and 1 adrenocorticotrophin-hormone-dependent hypercortisolism of unknown origin. Elevan bilateral adrenalectomies were carried out by the laparoscopic approach with no conversions. The operations were performed in 7 cases by the lateral transperitoneal adrenalectomy (LTLA), in 3 by the posterior approach (PRA), and in 1 by the combined approach. The mean size of the masses was 5 cm. (range, 4-13). The average operating time was 245 minutes for LTLA and 218 minutes for PRA (P<0.05). The estimated mean blood loss was 87+/-36 mL (range, 20-150). No patients required transfusions. The mean hospital stay was 5+/-1.8 days (range, 4-7). The mean follow-up was 34 months (range, 2-96). Our study confirms that the bilateral adrenalectomy by the minimally invasive technique is safe and effective, affording acceptable blood loss and morbidity with a short hospital stay.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 09/2008; 18(4):588-92. · 1.07 Impact Factor
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    ABSTRACT: The aim of this study was to analyze feasibility and outcomes of laparoscopic adrenalectomy (LA). Pathology, size and bilateral site of lesions were considered. Between December 1998 and May 2007 in our institution a total of 68 patients of mean age of 53 years underwent unilateral (n=57) or bilateral (n=11) LA. Adrenal masses averaged 5.4cm in size (range 1.2-13cm) and 56.7g in weight (range 10-265) including 71 benign and 8 malignant lesions. A total of 79 adrenal glands were resected, 44 right sided and 35 left sided. Removal was complete in 77 cases and partial (sparing adrenalectomy) in 1 patient affected by bilateral pheochomocytoma. Three left adrenalectomies for pheochromocytoma were robot-assisted. The transperitoneal lateral approach was preferred and the posterior retroperitoneal approach was adopted in 5 patients. The mean duration of surgery for each LA was 138+/-90min and 3.8 trocar were used on average (range 3-6). Conversion was needed in 3 cases owing to difficult dissection of large masses. Estimated mean blood loss for each LA was 95+/-30ml and it was greater for bilateral LA. Mortality was nil and morbidity was 5.8%. The average length of hospital stay (LOS) in surgical unit was 4+/-2.4 days (range 2-8). Patients affected by hormone secreting or bilateral lesions, by unilateral or bilateral pheochromocytoma and by bilateral Cushing's disease were transferred to the endocrinological ward so that their overall hospital stay was prolonged to 9+/-2.8 days on average (range 7-17). Mean duration of follow-up of patients was 38 months (range 2-100) and demonstrated acceptable endocrine results. Three primary cortical carcinomas were discovered as chance findings on histologic examination. While long-term results after LA for cortical carcinomas were poor and LA is not recommended in such cases, long-term results after LA for adrenal metastases were encouraging.
    Surgical Oncology 08/2008; 17(1):49-57. · 2.14 Impact Factor
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    ABSTRACT: Laparoscopic excision of rectal tumors has gained favor in the last decade and several issues have reported encouraging results: still, the use of laparoscopy remains open to debate. The aim of the current study is to assess the reliability of laparoscopic anterior resection (LAR) for rectal cancer analyzing short-term outcomes and long-term survival. The charts of 157 patients were reviewed retrospectively after anterior resection for rectal adenocarcinoma performed by minimal access. Patients undergoing emergency surgery were excluded. LAR was excluded in presence of preoperative features at computed tomography (CT) scan suggesting bulky tumors unresectable by laparoscopy or in case of anesthesiologic contraindications. Conversion rate and functional and oncologic outcomes were analyzed. Data on long-term results and survival were evaluated. LAR was performed in 157 patients, and conversion to laparotomy was required in 12 cases. Mean operation time for nonconverted patients was 229 minutes (overall 238 minutes). Total mesorectal excision (TME) was performed in tumors of the mid and low rectum and a temporary ileostomy was performed in 56 patients. The mean length of hospital stay (LOS) was 10.5 days. Morbidity of anterior resection included 17 anastomotic leaks after laparoscopic surgery (LS; 5 in the converted patients). Conversion increased significantly the risk of leak (P < .005). Two leaks caused death. The mean number of nodes collected was 12. The incidence of local relapse was 4%, and the rate of anastomotic recurrence was nil. Survival probability with LS was .73 at 5 years. Patients in stage III took advantage of adjuvant treatment and had a better survival than patients in stage II (P = not significant [NS]). The outcomes of this study suggest that LAR for rectal cancer is a reliable procedure. Oncologic requirements were respected; parameters such as length of specimen, distal margin, and number of nodes retrieved were quite acceptable. Incidences of local recurrence and long-term survival were comparable with those of other series.
    American journal of surgery 02/2008; 195(2):233-8. · 2.36 Impact Factor
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    ABSTRACT: Hemorrhoidal disease is one of the most common anorectal disorders, from 10% to 20% of all patients admitted at a clinical investigation need to undergo surgery, stapled haemorrhoidopexy is gaining wide acceptance as an interesting, safe and less painful technique, but hemorrhage is one of the most serious early complications and is a severe complication in day surgery. In our day surgery proctology, surgical procedures represent about 32%. Of these, 24% are for hemorrhoidal disease, we present our protocol and experience for early and safe discharge, 6h after stapled hemorrhoidopexy surgery.
    Surgical Oncology 01/2008; 16 Suppl 1:S173-5. · 2.14 Impact Factor
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    ABSTRACT: Minivasive techniques for excision of low rectal tumours have spread worldwide with good results, but their employment is still under discussion. The purpose of this study is to assess short term results and survival of laparoscopic abdominoperineal resection (LAPR) in very low rectal cancers. The charts of 32 patients undergoing LAPR for very low rectal adenocarcinoma (0-2cm from dentata line) were reviewed retrospectively. Outcomes were evaluated considering surgical procedure, short and long-term results and survival. A thorough LAPR was performed in 31 patients and conversion to laparotomy was required in 1 patient. Mean operating time was 244min. The length of hospital stay (LOS) was 13,3days. The mean number of nodes collected was 12 and the distal margin was 3,6cm on average. There was 1 post-operative death. In the follow up no pelvic recurrence was observed, while metachronous metastases were observed in 5 patients and peritoneal carcinosis in 2 patients. No port site metastasis was registered. Cumulative 5year survival probability was 0,50. The outcomes of this study suggest that LAPR in very low rectal cancer is a reliable procedure, operating time and LOS were acceptable. Oncologic principles were respected: length of specimen, distal margin and number of nodes retrieved were quite acceptable. Pelvic recurrence frequency was nil. Long term results were comparable with those of other series.
    European Journal of Surgical Oncology 03/2007; 33(1):49-54. · 2.61 Impact Factor
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    ABSTRACT: The Authors present a case of thoracoabdominal trauma from a road accident in a young woman who received care initially in a level II hospital. She was then transferred to a level I Trauma Centre with the onset of haemorrhagic shock due to haemopericardium and haemoperitoneum from liver injuries. A chest CT scan led to the suspicion of aortic dissection, hence a cardiopulmonary bypass (CPB) for life support was instituted just before laparotomy through the femoral vessels. Exploration of the peritoneal cavity was performed as a first step because haemoperitoneum was deemed to be the main cause of shock. One litre of blood was aspirated and hepatosplenic tears were sutured to obtain haemostasis. Subsequently, aortic dissection was ruled out by median sternotomy, while a right atrial disruption was identified and repaired by stitches and a pericardial homologous patch. Nevertheless, the ascending aorta was explored by transverse arteriotomy. The postoperative course was uneventful and the woman has never presented cardiac or abdominal symptoms as a result of trauma or surgery.
    Chirurgia italiana 58(3):397-401.