[Show abstract][Hide abstract] ABSTRACT: The treatment of colon cancer located in splenic flexure is not standardized. Laparoscopic approach is still considered a challenging procedure. This study reviews two Institutions experience in laparoscopic treatment of left colonic flexure cancer. Intraoperative, pathologic and postoperative data from patients undergoing laparoscopic splenic flexure resection were analyzed to assess oncological safety as well as early and medium-term outcomes.
From October 2005 to May 2014 laparoscopic splenic flexure resection was performed in 23 patients.
Conversion rate was nihil. In 7 cases the anastomosis was performed intracorporeally. Specimen mean length was 21.2 cm, while the distance of distal and proximal resection margin from tumor site was 6.5 and 11.5 respectively. The mean number of harvested lymph nodes was 20.8. Mean operative time was 190 min and mean estimated blood loss was equal to 55 ml. As regard major postoperative complications, one case of postoperative acute pancreatitis and one case of postoperative bleeding from the anastomotic suture line were reported.
Although our experience is limited and appropriate indications must be set by future randomized studies, we believe that laparoscopic resection with intracorporeal anastomosis appears feasible and safe for patients affected by splenic flexure cancer.
[Show abstract][Hide abstract] ABSTRACT: To study the implementation of an enhanced recovery after surgery (ERAS) program at a large University Hospital from "pilot study" to "standard of care".
The study was designed as a prospective single centre cohort study. A prospective evaluation of compliance to a protocol based on full application of all ERAS principles, through the progressive steps of its implementation, was performed. Results achieved in the initial pilot study conducted by a dedicated team (n = 47) were compared to those achieved in the shared protocol phase (n = 143) three years later. Outcomes were length of postoperative hospital stay, readmission rate, compliance to the protocol and morbidity. Primary endpoint was the description of the results and the identification of critical issues of large scale implementation of an ERAS program in colorectal surgery emerged in the experience of a single center. Secondary endpoint was the identification of interventions that have been proven to be effective for facilitating the transition from traditional care pathways to a multimodal management protocol according to ERAS principles in colorectal surgery at a single center.
During the initial pilot study (March 2009 to December 2010; 47 patients) conducted by a dedicated multidisciplinary team, compliance to the items of ERAS protocol was 93%, with a median length of hospital stay (LOS) of 3 d. Early anastomotic fistulas were observed in 2 cases (4.2%), which required reoperation (Clavien-Dindo grade IIIb). None of the patients had been discharged before the onset of the complication, which could therefore receive prompt treatment. There were also four (8.5%) minor complications (Clavien-Dindo grade II). Thirty days readmission rate was 4%. Perioperative mortality was nil. After implementation of the protocol throughout the Hospital in unselected patients (May 2012 to December 2012; 147 patients) compliance was 74%, with a median LOS of 6 d. Early anastomotic fistulas were observed in 11 cases (7.7%), 5 (3.5%) of which required reoperation (Clavien-Dindo grade IIIb). Two early anastomotic fistulas were treated by radiologic/endoscopic manoeuvres and 4 were treated conservatively. There were also 36 (25.2%) minor complications, 21 (14.7%) of which were Clavien-Dindo grade II and 15 (10.5%) of which were Clavien-Dindo grade I. Only two patients whose course was adversely affected by the development of an anastomotic leak had been discharged before the onset of the complication itself, requiring readmission. Readmission rate within 30 d was 4%. Perioperative mortality was 1%.
Our results confirm that introduction of an ERAS protocol for colorectal surgery allows quicker postoperative recovery and shortens the length of stay compared to historical series.
World Journal of Gastroenterology 12/2014; 20(46):17578-87. DOI:10.3748/wjg.v20.i46.17578 · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic colorectal resections have been shown to provide short-term advantages in terms of postoperative pain, general morbidity, recovery, and quality of life. To date, long-term results have been proved to be comparable to open surgery irrefutably only for colon cancer. Recently, new trends keep arising in the direction of minimal invasiveness to reduce surgical trauma after colorectal surgery in order to improve morbidity and cosmetic results. The few reports available in the literature on single-port technique show promising results. Natural orifices endoscopic techniques still have very limited application. We focused our efforts in standardising a minilaparoscopic technique (using 3 to 5 mm instruments) for colorectal resections since it can provide excellent cosmetic results without changing the laparoscopic approach significantly. Thus, there is no need for a new learning curve as minilaparoscopy maintains the principle of instrument triangulation. This determines an undoubted advantage in terms of feasibility and reproducibility of the procedure without increasing operative time. Some preliminary experiences confirm that minilaparoscopic colorectal surgery provides acceptable results, comparable to those reported for laparoscopic surgery with regard to operative time, morbidity, and hospital stay. Randomized controlled studies should be conducted to confirm these early encouraging results.
Minimally Invasive Surgery 03/2012; 2012(3):482079. DOI:10.1155/2012/482079
[Show abstract][Hide abstract] ABSTRACT: There is a burgeoning use of FDG-PET to stage colorectal cancer, in particular for patients with colorectal liver metastases scheduled for surgical resection. However, the accuracy of such imaging technique for recurrent colorectal liver metastasis is unknown. This report described a case of false-positive FDG-PET uptake of the liver mimicking local recurrence after resection of colorectal liver metastasis.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic rectal resection (LRR) is an oncologically safe procedure. The impact of conversion to open surgery on outcomes has not been fully elucidated. The aim of the study is to compare short- and long-term outcomes of converted (CR) and not converted (NCR) patients undergoing LRR.
Data were drawn from a prospective database of LRR performed between 1999 and 2008. Statistical analysis employed the chi-squared or Wilcoxon test and Kaplan-Meier estimation.
Of 173 patients undergoing LRR, 26 (15%) required conversion. No differences in age, gender, American Society of Anesthesiologists (ASA) score, and T and N stages were observed between CR and NCR patients. Conversion was associated with higher body mass index (BMI) (27.3 versus 24.9 kg/m(2), P < 0.001) and American Joint Committee on Cancer (AJCC) stage IV (26.9% versus 4.8%, P < 0.001), and resulted in longer operative time (342 versus 285 min, P = 0.006) and increased intraoperative complication rate (31% versus 5%, P < 0.001). No differences were observed in postoperative outcome between CR and NCR patients. After a mean follow-up of 46 and 36 months, 5-year disease-free survival was 55.7% in CR group and 79.2% in NCR group (P = 0.007). After exclusion of stage IV patients from the analysis, 5-year disease-free survival was 71.1% in CR group and 85.3% in NCR group (P = 0.17), while the overall recurrence rate was 26.3% in CR patients and 11.4% in NCR patients (P = 0.07).
Our study suggests that conversion to open surgery does not affect postoperative outcome, but could have a negative impact on long-term overall recurrence rate. LRR should be performed by experienced surgeons in selected patients.
[Show abstract][Hide abstract] ABSTRACT: Prosthetic repair is frequently advocated after repair of large hiatal hernias, and biomeshes have been proposed to help reduce the high recurrence rate. All patients undergoing laparoscopic repair of primary or recurrent large hiatal hernia, and with intraoperative finding of weak diaphragmatic pillars, as judged by the surgeon, were included, from June 2004 to July 2005, in a prospective observational study. In these patients, Surgisis biomeshes were employed to assist the repair. Six patients (4 for primary and 2 for recurrent hernia) received biomesh hiatoplasty. Four had mild dysphagia at 1 month that disappeared at the next follow-up. Three had slow radiologic transit through the esophagogastric junction, still present in 1 patient at 1 year. One patient had hernia recurrence 6 months after surgery and 2 other patients had radiologic recurrence of a small hernia at 1-year follow-up; in all 3, the recurrence was small and asymptomatic and none were reoperated. The short-term recurrence rate using biomesh for the laparoscopic repair of large hiatal hernias in patients with weak diaphragmatic pillars was high at 50%. Postoperative morbidity and mesh-related complications were almost absent. Biomeshes can be safely used as on lay reinforcement in hiatoplasty, but do not reduce the hiatal recurrence rate.
[Show abstract][Hide abstract] ABSTRACT: An esophageal mass of more than 20 cm in length was diagnosed in a patient who presented with persistent dysphagia. Diagnosis of an endo-esophageal tumour was made by barium swallow; esophagoscopy confirmed the presence of a capsulated pink endo-esophageal mass. MRI confirmed the presence of a large capsulated mass within the esophagus, that appeared to be adipose tissue; a small stalk originating at the level of the upper esophageal sphincter was described and the polyp extended down to the gastroesophageal junction. Demonstration of the site and length of the stalk allowed a transoral removal of the mass, performed through a Weerda diverticuloscope (Karl Storz Endoskopie Gmbh, Tuttlingen Germany), a technique that has never been described before. Histology confirmed the mass as a fibrolipoma. The authors discuss both the role of MRI in diagnosis and treatment planning and the technique of transoral excision.
[Show abstract][Hide abstract] ABSTRACT: We performed a retrospective analysis of postoperative course and functional outcome after at least six months' follow-up in a series of 400 consecutive patients who underwent stapled anopexy.
All patients were evaluated at one week and one month after surgery and then according to symptoms. A clinical or telephone follow-up was obtained for all patients. The last 50 patients were prospectively evaluated with an obstructive defecation syndrome score and Wexner continence and constipation score before operation and six months after anopexy.
There were no intraoperative complications. Postoperative bleeding that requires reoperation was observed in 11 patients, most cases (9/11) occurring in the early experience (first 50 patients). After a median follow-up of 6.1 years, four patients required reoperation. After anopexy, we observed an improvement in patients who present disturbance in defecation. The difference between the median obstructive defecation syndrome score before and after operation was statistically significant. Wexner score showed improvement without significant difference.
Treatment of hemorrhoids with circular stapler seems to be effective with low morbidity and high satisfaction rate because of reduced postoperative pain and rapid recovery. This technique also allows improvement of obstructive defecation symptoms, which are seldom studied in patients with hemorrhoids.
Diseases of the Colon & Rectum 07/2008; 51(6):950-5. DOI:10.1007/s10350-008-9228-1 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aim of this study was to analyze long-term sequelae, risk factors, and satisfaction after inguinal hernia primary repair.
A postal questionnaire was mailed to all patients operated between January 1997 and December 2004 for inguinal hernia repair. Patients who had a lump in the groin and patients who experienced chronic problems were invited for a physical examination. Patients who reported having chronic pain were asked to fill out the short-form McGill Pain Questionnaire (SF-MPQ).
Chronic pain was present in 18.1% of cases. The strongest risk factors were presence of recurrence, use of heavyweight mesh, and age younger than 66 years. By means of the SF-MPQ, we found that the pain reported by most patients was sensory-discriminative in quality, with "tender" and "aching" being the most common descriptors used. About 71.3% of replies used descriptors typical of nociceptive pain, 8.9% of neuropathic pain, and 19.8% of nociceptive plus neuropathic. Chronic pain was severe in 2.1% of patients and interfered with normal activities, work, and exercise. The cumulative recurrence rate was 2.1%. There was a strong correlation between lump and recurrence. Patients declared themselves satisfied with the result of the operation in 93.1% of cases. Due to chronic pain, 6.5% of patients were unsatisfied.
This study demonstrates that the main problem after inguinal hernia repair remains chronic pain, which was the primary reason of dissatisfaction. The SF-MPQ is feasible and easy to administer to all patients and provides important information about qualitative features of the pain.
[Show abstract][Hide abstract] ABSTRACT: Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively.
Diseases of the Esophagus 02/2008; 21(3):257-61. DOI:10.1111/j.1442-2050.2007.00773.x · 1.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The role of laparoscopic resection in the management of rectal cancer is still controversial. We prospectively evaluated patient survival and outcomes in patients undergoing laparoscopic rectal resection for rectal cancer at a single institution.
From November 1999 to November 2005, 107 patients with rectal cancer were treated by laparoscopy. Exclusion criteria were: metastatic disease, advanced disease with invasion of adjacent structures, clinical or radiologic involvement of the external anal sphincter, previous colonic resection, synchronous colonic adenocarcinoma, and contraindications to laparoscopy. All patients were followed prospectively for survival and complications. Survival was calculated by the Kaplan-Meier method.
A laparoscopic sphincter-saving procedure was performed in 104 patients, 2 patients had a laparoscopic Miles operation, and 1 underwent a laparoscopic Hartmann's procedure. Mean operating time was 278 (range, 135-430) minutes. Conversion to open surgery was required in 20 of 107 patients (18.7 percent). Overall morbidity was 27 percent, anastomotic leakage occurred in 14 of 104 patients (13.5 percent). There was no postoperative mortality. A mean of 18 (range, 1-49) lymph nodes was removed. Mean distance of distal margin from tumor was 2.6 (range, 0.5-10) cm; in two patients there was microscopic invasion of the distal margin. Mean hospital stay was nine (range, 4-43) days. Mean follow-up was 35.8 months. There was local recurrence in 1 of 107 patients (0.95 percent); there were no port site metastases. Actuarial five-year and disease-free survival rates are 81.4 and 79.8 percent, respectively.
Laparoscopic rectal surgery is feasible and oncologically radical but also technically demanding (conversion rate, 18.7 percent), time-consuming (mean operating time, 278 minutes), and associated with specific intraoperative complications. At present, the technique should only be performed in specialist centers by teams experienced in laparoscopic surgery.
Diseases of the Colon & Rectum 01/2008; 50(12):2047-53. DOI:10.1007/s10350-007-9055-9 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although several authors have demonstrated that laparoscopic total mesorectal excision (TME) is feasible, safe, and has short-term benefits over open surgery, evidence about oncological outcome is lacking. Preoperative chemoradiation has been shown to improve local control in locally advanced rectal cancer. Therefore, neoadjuvant treatment followed by laparoscopic TME has become widely used. We reviewed our series of laparoscopic TME focusing on comparison between preoperative chemoradiation therapy and primary surgery.
Out of 59 patients who underwent laparoscopic TME, 20 were submitted to neoadjuvant chemoradiation and represent study population. Twenty-six patients with non-metastatic rectal cancer >T1 on pathologic TNM staging who underwent primary laparoscopic surgery were considered for comparison.
No significant differences were found in operative time, in conversions to open surgery, in intra- and postoperative complications, and in anastomotic leakage rate between the two groups. No isolated local recurrence nor port-site metastases were detected in either group. Cumulative 3-year and 5-year survivals are also similar.
Neoadjuvant treatment does not seem to jeopardize perioperative results of laparoscopic TME. The low incidence of local recurrence reported in both groups may be attributed to a more precise dissection allowed by the endoscopic view. Laparoscopic TME and preoperative chemoradiotherapy may significantly improve oncologic results and quality of life in patients with mid and low rectal cancer. Results should be validated by randomized trials with adequate follow-up.
[Show abstract][Hide abstract] ABSTRACT: Pain remains a significant clinical problem after inguinal hernia repair. We prospectively assessed post-surgical pain following herniorrhaphy in 1,440 operations with the aim of describing the characteristics and identifying predisposing factors for pain.
Pain quality was assessed with the short-form McGill Pain Questionnaire (SF-MPQ); pain character was estimated as either nociceptive or neuropathic in nature.
A total of 38.3% of replies reported pain (acute or chronic), and 18.7% reported chronic pain. Independent risk factors for pain were young age, BMI >25, day surgery, and use of Radomesh. In patients with chronic pain, independent risk factors were young age, BMI >25 and use of Radomesh. Analysis of the SF-MPQ revealed that the pain reported by most patients was sensory-discriminative in quality. The most common descriptors were tender and aching. Patients with chronic pain reported more intense pain and used sensory descriptors of greater mean intensity than patients with acute pain. A total of 73.9% of replies used descriptors typical of nociceptive pain, 6.5% used descriptors typical of neuropathic pain and 19.6% used nociceptive plus neuropathic descriptors. Patients considered to have nociceptive pain used significantly more sensory descriptors than those considered to have neuropathic pain. By contrast patients with neuropathic pain used more affective descriptors than those with nociceptive pain. Neuropathic pain was reported as more difficult to treat with analgesics than nociceptive pain and neuropathic plus nociceptive pain.
Our study confirms that herniorrhaphy frequently produces chronic pain, which can reduce quality of life. The SF-MPQ is a useful instrument to administer to all patients and provides important information about qualitative properties of the pain.
[Show abstract][Hide abstract] ABSTRACT: Patient selection, postoperative monitoring and discharge criteria after outpatient laparoscopic cholecystectomy (LC) are not clearly defined.
Patients scheduled for elective LC who fulfilled socioeconomic requirements for ambulatory surgery were enrolled in an open prospective study. Choledocholithiasis, ASA IV and unstable ASA III patients were excluded. Discharge was allowed after at least 6 hours if patients were conscious, asymptomatic, ambulant, with normal vital signs, no evidence of bleeding, spontaneous micturition and tolerating soft diet.
Of the 250 patients included, 10.4% were admitted due to intraoperative causes. Of the remaining, 92% were discharged on the same day and 8.0% were admitted for pain control or postoperative anxiety/discomfort. Neither mortality or major complications were observed. Ninety-five percent of patients declared themselves satisfied. History of jaundice, common bile duct dilation on ultrasound, microlithiasis, abnormal preoperative alkaline phosphatase levels and surgeon's experience were independent predictors of admission due to intraoperative causes. No predictor of postoperative admission was identified. Cost analysis showed a benefit for ambulatory LC compared to overnight stay.
Outpatient LC is feasible and safe with high patient satisfaction even with broad selection criteria. Improvements may be achieved in postoperative pain management.
[Show abstract][Hide abstract] ABSTRACT: Minimally invasive techniques are increasingly being used for oesophagectomy. Diaphragmatic hernia is a rare complication of gastroplasty in open surgery. One of the advantages of the laparoscopic technique, the lack of peritoneal adhesions, may lead to an increased rate of this complication. We report two cases of diaphragmatic acute massive herniation after laparoscopic gastroplasty for esophagectomy out of a series of 44 laparoscopic gastroplasties performed over 33 months. We discuss some technical aspects related to its occurrence. Prevention should include a limited crural division and fixation of the gastric tube to the diaphragmatic crura at primary surgery.
Diseases of the Esophagus 02/2006; 19(1):40-3. DOI:10.1111/j.1442-2050.2006.00536.x · 1.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In December 2000, the Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) was formally launched under the auspices of the Italian Society for Endoscopic Surgery and New Technologies (SICE). The aim of this multicentre study was to analyse various aspects of the treatment that are still under discussion, such as the extension of the laparoscopic indications in cases of malignancy, independently of the associated splenomegaly, patient selection and operative techniques. A retrospective review of 379 patients undergoing laparoscopic splenectomy for haematological diseases from February 1, 1993, to September 15, 2005, was conducted. Data were collected from the 18 italian centres participating in the IRLSS. The mean length of surgery was 140 minutes (range: 25-420). Conversion was necessary in 25 cases (6.6%), and at least one accessory spleen was found in 30 patients (8%). The mean spleen weight was 1200 g (range: 85-4500). Perioperative death occurred in two cases (0.5%). There were no complications in 312 patients (82.3%), with a mean hospital stay of 5.5 days (range: 2-30). Morbidity occurred in 67 patients (17.8%), mainly consisting in transient fever (n = 22), pleural effusions (n = 16), and actual or suspected haemorrhage (n = 14), requiring re-intervention in 7 patients. This first study carried out on the IRLSS data shows that laparoscopic splenectomy may constitute the gold standard for haematological diseases with a normal-sized spleen. The low morbidity and mortality rates suggest that laparoscopic splenectomy can be successfully proposed also for splenomegaly in haematological malignancies.
[Show abstract][Hide abstract] ABSTRACT: Minimally invasive surgery is currently becoming an accepted approach to esophageal cancer treatment. At the authors' Department laparoscopic gastroplasty is used in combination to either transhiatal or transthoracic esophagectomy, associated with left cervicotomy and right thoracotomy, respectively. Outcomes of laparoscopic and open gastric mobilization during esophagectomy in terms of intra- and postoperative complications are compared. From February 2003 to September 2005 45 patients underwent laparoscopic gastroplasty (group A) and 26 patients underwent open gastroplasty (group B) during esophagectomy. Intraoperative complications were 2% vs. 11.5%; respiratory complications were 2.2% vs. 19%; leakages from the suture lines were 17.7% vs. 7.6% (p = n.s.); major long-term complications were 4.4% vs 3.8% (p = n.s.), respectively. Laparoscopic gastroplasty during esophagectomy was shown to be a safe procedure. Intraoperative splenic lesions were rare; respiratory complications seemed decreased after the laparoscopic approach in comparison to open gastroplasty; major long-term complications were specific to the open or laparoscopic approach.
[Show abstract][Hide abstract] ABSTRACT: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis.
Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed.
Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97).
Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.
[Show abstract][Hide abstract] ABSTRACT: Despite the fact that the incidence and severity of postoperative complications after oesophagectomy have substantially decreased over the past two decades, anastomotic leakage is still a potentially catastrophic event. In this article, the experience of a single surgical unit is analysed. Over the period from 1992 to 2003, 435 oesophagectomies with oesophagogastroplasty were performed at the Milan University Department of Surgery. The overall mortality rate was 1.6%. The incidence of anastomotic leakage was 8.5% (6.5% for intrathoracic anastomoses and 14% for cervical anastomoses), and the mortality rate due to leakage was 13.5%. The authors discuss the factors associated with anastomotic leakage by comparing their personal experience with data from the international literature.