Search

Background Achalasia is a rare esophageal motor disorder. Laparoscopic Heller-Dor myotomy (LHD) is among the most effective treatments. The use of nasogastric tube (NGT) following LHD is still controversial. The aim of our study was to evaluate the role of NGT in achalasia patients undergoing LHD. Methods We prospectively enrolled achalasia patients treated with LHD from January 2019 until June 2022 at our institution and randomly assigned them to two groups: one group with NGT and group without (noNGT). Perioperative outcomes were compared between the two groups. ClinicalTrials.gov Identifier: NCT05729971. Results Seventy-nine patients who underwent LHD myotomy were prospectively enrolled. Patients were divided in two groups: 38 with NGT and 41 noNGT. There were no significant differences between two groups in terms of demographic data, preoperative characteristics, length of stay, start of liquid and solid diet, intraoperative and postoperative complications. First flatus was shorter in the noNGT group (p: 0.03). Conclusion Nasogastric tube placement following LHD myotomy does not reduce nausea, vomiting and chest pain, while it increased patients discomfort and time of first flatus.

Background The laparoscopic approach is a very popular technique for many gastrointestinal operations and barbed sutures may improve the difficulties of intracorporeal anastomosis by eliminating the need for knot tying. The aim of this systematic review with a meta-analysis is to explore literature to establish the security profile of barbed suture compared with conventional laparoscopic sutures. Materials and methods A systematic search was performed in all electronic databases (PubMed, Web of Science, Scopus, EMBASE) and 12 studies were included in the analysis, involving 27,133 patients, whereof 3372 cases (patients undergone barbed suture usage) and 23,761 controls (patients undergone conventional suture usage). We found 3 studies discussing differences between barbed and conventional sutures in colorectal surgery and 8 studies presenting results in bariatric surgery, both in Roux-en-y gastric bypass and Mini Gastric/One Anastomosis Gastric Bypass. Results We found comparable rate of leaks, bleedings and stenosis. The meta-regression analysis demonstrated that, both in case of bariatric and colorectal surgery, the demographic characteristic of patients and the oncological features of neoplasms did not impact of these findings. As expected, operative time is significantly shorter when barbed suture is used. Conclusion Our analysis on current literature define an acceptable security profile for barbed suture with effective results particularly in terms of shorter operative time.

Purpose Several risk factors affecting the adequacy of colon cleansing have been proposed during the last decades. However, less is known about the impact that atmospheric aspects could have on adequacy of the bowel cleansing. The study aimed to investigate if the atmospheric temperature could impact on the bowel cleansing during colonoscopy. Methods A prospective maintained database of the colonoscopies performed since 1st August 2017 to 31st March 2020 was retrospective reviewed. The primary outcome of the study was to identify if the atmospheric temperature was associated with inadequate colon cleansing during colonoscopy. Secondary outcome was to identify the other factors associated with an inadequate colon cleansing. Results One thousand two hundred twenty patients were enrolled. High atmospheric temperature (> 25 °C) significantly influenced the colon cleansing (p Conclusion Atmospheric temperature could play an important role in the colon cleansing during colonoscopy, being high temperature (> 25 °C) associated with lower rate of adequate bowel cleansing. However, being this relationship never studied before, these results must be confirmed by other studies.

Introduction: Despite progressive improvements in technical skills and instruments that have facilitated surgeons performing intracorporeal gastro-jejunal and jejuno-jejunal anastomoses, one of the big challenging tasks is handsewn knot tying. We analysed the better way to fashion a handsewn intracorporeal enterotomy closure after a stapled anastomosis. Methods: All 579 consecutive patients from January 2009 to December 2019 who underwent minimally invasive partial gastrectomy for gastric cancer were retrospectively analysed. Different ways to fashion intracorporeal anastomoses were investigated: robotic versus laparoscopic approach; laparoscopic high definition versus three-dimensional versus 4K technology; single-layer versus double-layer enterotomies. Double-layer enterotomies were analysed layer by layer, comparing running versus interrupted suture; the presence versus absence of deep corner suture; and type of suture thread. Results: Significantly lower rates of bleeding (p = 0.011) and leakage (p = 0.048) from gastro-jejunal anastomosis were recorded in the double-layer group. Barbed suture thread was significantly associated with reduced intraluminal bleeding and leakage rates both in the first (p = 0.042 and p = 0.010) and second layer (p = 0.002 and p = 0.029). Conclusions: Double-layer sutures using barbed suture thread both in first and second layer to fashion enterotomy closure result in lower intraluminal bleeding and anastomotic leak rates.

Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p

Background: The risk of conversion to open surgery is inevitably present during any minimally invasive colorectal surgical procedure. Conversions have been associated with adverse postoperative and oncologic outcomes. No previous study has evaluated the specific causes and consequences of conversion during a minimally invasive right colectomy (MIS-RC). Materials and Methods: We analyzed the Minimally invasivE surgery for oncologic Right ColectomY (MERCY) study database including patients who underwent laparoscopic or robotic RC because of colon cancer between 2014 and 2020. Descriptive analyses were performed to determine the different reasons for conversion. Uni- and multivariate logistic regressions were run to identify potential variables associated with this outcome. Cox regression analyses were used to evaluate the impact of conversion on tumor recurrence. Results: Over a total of 1574 MIS-RC, 120 (7.6%) were converted to open surgery. The main reasons for conversion were procedural difficulties related to adherences from previous abdominal surgical procedures (39.2%), or owing to large tumor size or infiltration of adjacent structures (26.7%). Only 16.7% of the conversions were caused by intraoperative medical or surgical complications. Converted patients required longer operative times and developed more postoperative complications, both overall (39.2% versus 27.5%; P = .006) and severe ones (13.3% versus 8.3%; P = .061). Male gender (odds ratio [OR] = 1.89 [95% confidence interval: 1.31-2.71]), obesity (OR = 1.99 [1.4-2.83]), prior abdominal surgery (OR = 1.68 [1.19-2.37]), and pT4 cancers (OR = 4.04 [2.86-5.69]) were independently associated with conversion. Conversion to open surgery was not significantly associated with tumor recurrence (hazard ratios = 1.395 [0.724-2.687]). Conclusions: Although conversion to open surgery during MIS-RC for cancer is associated with worsened postoperative outcomes, it seems not to impact on the oncologic prognosis.

Background Evidence on the efficacy of minimally invasive (MI) segmental resection of splenic flexure cancer (SFC) is not available, mostly due to the rarity of this tumor. This study aimed to determine the survival outcomes of MI and open treatment, and to investigate whether MI is noninferior to open procedure regarding short-term outcomes. Methods This nationwide retrospective cohort study included all consecutive SFC segmental resections performed in 30 referral centers between 2006 and 2016. The primary endpoint assessing efficacy was the overall survival (OS). The secondary endpoints included cancer-specific mortality (CSM), recurrence rate (RR), short-term clinical outcomes (a composite of Clavien-Dindo > 2 complications and 30-day mortality), and pathological outcomes (a composite of lymph nodes removed ≧12, and proximal and distal free resection margins length ≧ 5 cm). For these composites, a 6% noninferiority margin was chosen based on clinical relevance estimate. Results A total of 606 patients underwent either an open (208, 34.3%) or a MI (398, 65.7%) SFC segmental resection. At univariable analysis, OS and CSM were improved in the MI group (log-rank test p = 0.004 and Gray’s tests p = 0.004, respectively), while recurrences were comparable (Gray’s tests p = 0.434). Cox multivariable analysis did not support that OS and CSM were better in the MI group (p = 0.109 and p = 0.163, respectively). Successful pathological outcome, observed in 53.2% of open and 58.3% of MI resections, supported noninferiority (difference 5.1%; 1-sided 95%CI − 4.7% to ∞). Successful short-term clinical outcome was documented in 93.3% of Open and 93.0% of MI procedures, and supported noninferiority as well (difference − 0.3%; 1-sided 95%CI − 5.0% to ∞). Conclusions Among patients with SFC, the minimally invasive approach met the criterion for noninferiority for postoperative complications and pathological outcomes, and was found to provide results of OS, CSM, and RR comparable to those of open resection.

Introduction and importance: Gastric conduit dehiscence after esophagectomy represents a severe complication associated with high mortality. Surgical management is achieved through thoracotomy, but often ends up in conduit sacrifice and diversion. Case presentation: A 59-years-old man underwent minimally invasive McKeown esophagectomy for esophageal adenocarcinoma. After a worsening of the postoperative course and evidence at the CT scan and endoscopy of highly suspect gastric conduit failure, the patient underwent an exploratory thoracoscopy, which revealed a partial dehiscence of the gastric conduit treated with resection of the dehiscent gastric wall by a linear stapler on the guide of a 36-french orogastric tube. Patient had a regular postoperative course without any complications and was discharged on the 6th postoperative day. Clinical discussion: The management of conduit necrosis is extremely challenging. There are several interventional options and it is difficult to decide the most appropriate treatment for each individual patient. In our case we decided to perform a reintervention with a thoracoscopic approach, resecting the dehiscent area of the gastric conduit. Conclusions: Minimally invasive surgery is a valid option for the management of post-operative complications, including those in emergency setting. Re-suturing a partial dehiscence of gastric conduit may be feasible if tissue conditions allow.

Cholangiography with indocyanine green fluorescence (ICG) is increasingly used to visualize the bile duct anatomy during laparoscopic cholecystectomy. Biliary leaks are rare complications after laparoscopic cholecystectomy, result could be lethal. Lesion's site is not always visible. We present an interesting case of a patient with biloma due to an iatrogenic lesion of the biliary tract, treated in urgency using ICG fluorescence. To our knowledge, this is the only case in the literature.A 62-years-old patient after 7 days from laparoscopic cholecystectomy presented abdominal pain and fever. Blood tests showed an increase of inflammation indexes. Abdominal US and abdominal CT revealed a conspicuous right sub-hepatic fluid. We performed a laparoscopy using ICG fluorescence to find the biliary leak. Operative time of surgery was 60 min. There were no complications during this procedure.ICG is a safe and effective procedure that enables real-time visualization of the biliary system. In some cases, it can also be used in urgent surgery, where the biliary anatomy is much more complex.Biloma, Indocyanine green fluorescence, Iatrogenic biliary leaks, Urgent surgery.Le lesioni iatrogene delle vie biliari rappresentano una rara ma temibile complicanza della colecistectomia laparoscopica. In questo lavoro, presentato durante il 39° congresso nazionale ACOI e selezionato per un premio, riportiamo il caso di un paziente con un voluminoso biloma insorto dopo colecistectomia laparoscopica, trattato chirurgicamente con l’ausilio del verde di indocianina. Il paziente si presentava presso la nostra struttura sette giorni dall’intervento con nausea, dolore addominale e febbre. L’ecografia e la TC addominali mostravano una voluminosa raccolta in loggia colecistica. Durante una laparoscopia esplorativa eseguita in urgenza, il leak sul letto epatico è stato evidenziato e riparato dopo la somministrazione del verde di indocianina. Il decorso postoperatorio è stato regolare e il paziente dimesso in decima giornata. In conclusione, l’ICG, già utilizzato in chirurgia epatica per prevenire e identificare lesioni biliari, potrebbe costituire un valido supporto anche nella gestione di tali complicanze insorte tardivamente post-colecistectomia.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They are 1% of all gastrointestinal cancer and 60% of them affects the stomach. Up to 10% to 30% of GISTs are malignant. They occur in people over the age of 50 in both sexes. The most common symptoms of gastric GIST are bleeding, dyspepsia, vague abdominal pain or discomfort, and mass palpation. Some are asymptomatic and diagnosed incidentally. The first choice of treatment for primary localized gastric GISTs is surgery. The most suitable type of resection is not yet clear and it depends on size and location of tumor, especially for difficult localizations, such as subcardial, posterior wall and less curvature GISTs.We report a rare case of a patient with subcardial gastric GIST treated with laparoscopic atypical quadrangular resection guided by intraoperative endoscopy. Furthermore, we performed a review of the literature about this topic.Despite the difficult localization an atypical resection of the gastric GIST was performed without breaking the lesion but preserving the lumen of the esofagogastrich junction.An atypical quadrangular resection for subcardial gastric GISTs, located along the posterior wall and lesser curvature, can be a safe and reliable alternative technique. However, we believe that it should be performed by an experienced surgeon and endoscopist to decrease the risk of mass's break and the narrowing of the cardial region's lumen. In our literature's knowledge there aren't cases treated with this technique.Gastric GIST, Gastrointestinal stromal tumors, Intraoperative endoscopy, Laparoscopic resection, Minimally invasive surgery.I tumori stromali gastrointestinali (GIST) sono i tumori mesenchimali più comuni del tratto gastrointestinale, il 60% dei GIST interessa lo stomaco. La prima scelta di trattamento per i GIST gastrici primari localizzati è la chirurgia. La resezione laparoscopica del GIST gastrico rispetto alla chirurgia a cielo aperto ha migliorato i risultati a breve termine con risultati simili a lungo termine. Tuttavia, non ci sono indicazioni assolute sul tipo di resezione in base alle dimensioni e alla posizione del tumore. Riportiamo un raro caso di un paziente di 53 anni con un GIST gastrico localizzato in una posizione sfavorevole (sottocardiale, lungo la parete posteriore della piccola curvatura dello stomaco) trattato con resezione laparoscopica atipica supportata da un’endoscopia intraoperatoria. La TC addominale nel giugno 2021 mostrava una grossa massa (59x35x39 mm) che occupava parte del lume, il fondo e il corpo gastrico a partenza dalla componente muscolare della piccola curvatura. La gastroscopia, tuttavia non era diagnostica per GIST ma rilevava solo papule erose in sede antrale e prepilorica, come da gastrite cronica. Ad agosto un’acoendoscopia (US) con biopsia ha diagnosticato un GIST gastrico sottocardiale lungo la piccola curva di circa 5 cm di diametro. Dopo una valutazione multidisciplinare il paziente è stato sottoposto ad intervento chirurgico di resezione laparoscopica del GIST gastrico. La visione laparoscopica iniziale non è stata in grado di identificare la massa tranne che per una leggera impronta sulla parete anteriore dello stomaco nella regione sottocardiale, che si estendeva lungo la piccola curva. Pertanto, è stata eseguita una gastroscopia intraoperatoria che ha mostrato inaspettatamente una massa di circa 5cm ulcerata, sulla parete posteriore dello stomaco, sotto il cardias, lungo la piccola curva. La lesione è stata visualizzata endoscopicamente grazie alla compressione ab-estrinseco laparoscopica sulla parete posteriore dello stomaco e la crescita intraluminale probabilmente era dovuta al tempo intercorso tra la gastroscopia preoperatoria e quella intraoperatoria. Grazie alla visione laparoscopica ed endoscopica combinata mediante l’utilizzo di due monitor, il chirurgo è stato in grado di comprendere i margini superiore, inferiore e laterale della lesione. È stata eseguita una resezione atipica che ha consentito l’asportazione della lesione nonostante la difficile localizzazione. È stata realizzata un’asportazione quadrangolare utilizzando una suturatrice lineare su tre lati: la prima sutura sul margine caudale della lesione, la seconda sul margine laterale verso l’alto. Le prime due suture hanno consentito una maggiore mobilizzazione dello stomaco recuperando il range di movimento per l’ultima sutura, che è stata eseguita sul margine prossimale della massa con l’endoscopio posizionato in modo tale da preservare il lume della giunzione esofagogastrica. La visione endoscopica ha permesso di rimuovere la parte di stomaco che conteneva l’intera lesione senza romperla e contemporaneamente di preservare il lume della giunzione esofagogastrica lasciando libero il passaggio tra esofago e stomaco. Nonostante la differenza tra le indagini preoperatorie e la reale visione intraoperatoria del GIST, la difficile localizzazione del tumore e l’utilizzo di una tecnica non standardizzata, l’intervento non ha avuto complicanze ed è durato 120 minuti. La resezione quadrangolare atipica laparoscopica per GIST gastrici sottocardiali, situata lungo la parete posteriore e la piccola curvatura, può essere considerata una tecnica sicura, fattibile e riproducibile. Questo approccio potrebbe essere considerato una scelta chirurgica alternativa alla gastrectomia totale o parziale per questo tipo di tumori. Tuttavia, esso richiede sale operatorie integrate con attività endoscopica e dovrebbe essere eseguita da chirurgo ed endoscopista esperti per ridurre il rischio di rottura della massa e il restringimento del lume della regione cardiaca. In base alle nostre conoscenze non ci sono in letteratura casi trattati con questa tecnica. Pertanto, questo ne rappresenta il primo caso.

During the corona virus disease 2019 (COVID-19) pandemic, most of the surgical procedures were performed for emergencies or oncologic reasons to the detriment of the remaining elective procedures for benign conditions. Ileostomy or colostomy creation are sequelae of oncologic or emergency colorectal surgery, but their closure does not fall within the definition of oncologic or emergency surgery. The aim of this retrospective multicentre observational study is to report the impact of COVID-19 pandemic on the ostomy closure rate in Italy. Data regarding ileostomy and colostomy creation and closure from 24 Italian centres, during the study period (March 2020-February 2021) and during the control period (March 2019-February 2020) were collected. Three hospitals (12.5%) were COVID free. The number of colostomies and ileostomies created and closed in the same period was lower ( -18.8% and -30%, respectively) in the study period in comparison to the control period (p = 0.1915 and p = 0.0001, respectively), such as the ostomies closed in the analysed periods but created before (colostomy -36.2% and ileostomy -7.4%, p = 0.2211 and p = 0.1319, respectively). Overall, a 19.5% reduction in ostomies closed occurred in the study period. Based on the present study, a reduction in ostomy closure rate occurred in Italy between March 2020 and February 2021. During the pandemic, the need to change the clinical practice probably prolonged deterioration of quality of life in patients with ostomies, increasing number of stomas that will never be closed, and related management costs, even if these issues have not been investigated in this study.

This is the first Western study presenting short-term results on patients older than 80 years affected by gastric cancer and treated with laparoscopic distal gastrectomy. A multicentre prospective database on patients suffering from distal gastric cancer with age of ≥ 80 undergone to distal gastrectomy was analysed retrospectively. End points were length of hospital stay (LoS) after surgery, and times to stool passage and solid diet initiation, as well as postoperative complications. Univariate analysis of the differences between “laparoscopic” and “open” groups was performed with non-parametric tests. Forty-six patients (median age: 83 years, median CCI: 5) undergone to distal gastrectomy were analysed. Seventeen out 46 patients (36.9%) underwent laparoscopic distal gastrectomy and extended lymphadenectomy was achieved in 25 cases (25/46, 54.3%). Median number of removed and examined nodes was higher in laparoscopic than in open group. Median LoS was significantly lower in the laparoscopic group (8 vs. 11 days). Complications occurred in 12 patients (26.1%): no significant differences between the two groups. There was a significant difference between the two surgical approaches in term of times for stool passage. Laparoscopic approach seems to reduce the effect of the surgical trauma without compromising lymphadenectomy also in octogenarian patients with distal gastric cancer.

The cause of hepatic portal vein gas (HPVG) is variable. Good knowledge of the possible causes, combined with the clinical assessment of the patient and a good quality imaging, is required to correctly identify the underlying cause of HPVG and to best predict the prognosis.

Hepatocellular carcinoma (HCC) is a common malignancy worldwide, recognized as the fourth most common cause of cancer related death. Many risk factors, leading to liver cirrhosis and associated HCC, have been recognized, among them viral hepatitis infections play an important role worldwide. Patients suffering from chronic kidney disease (CKD), especially those on maintenance dialysis, show a higher prevalence of viral hepatitis than the general population what increases the risk of HCC onset. In addition, renal dysfunction may have a negative prognostic impact on both immediate and long-term outcomes after malignancy treatment. Several interventional procedures for the treatment of HCC are currently available: thermal ablation, transcatheter arterial chemoembolization, liver surgery or even liver transplantation. The Barcelona Clinic Liver Cancer system provides an evidence-based treatment algorithm to address different categories of patients to the most-effective treatment in consideration of the extension of disease, liver function and performance status. Liver resection and transplantation are usually reserved to patients with early stage HCC and acceptable performance status, while the other treatments are more indicated in case of impaired liver function or locally advanced or unresectable tumors. However, there is no validated treatment algorithm for HCC in CKD patients, mainly due to the rarity of reports in this cohort of patients. Hereby we discuss the available evidences on interventional HCC treatments in CKD patients, and briefly report up-to-date pharmacological therapy for HCC patients affected by viral hepatitis.

Background: Laparoscopic adrenalectomy (LA) is considered the "gold standard" treatment of adrenal lesions that are often coincidentally diagnosed during the radiologic workup of other diseases. This study aims to evaluate the intraoperative role of indocyanine green (ICG) fluorescence associated with preoperative 3-dimensional reconstruction (3DR) in laparoscopic adrenalectomy in terms of perioperative outcomes. To our knowledge, this is the first prospective case-controlled report comparing these techniques. Materials and Methods: All consecutive patients aged≥18 and undergoing laparoscopic transperitoneal adrenalectomy for all adrenal masses from January 1, 2019 to January 31, 2022 were prospectively enrolled. Patients undertaking standard LA and those undergoing preoperative 3D reconstruction and intraoperative ICG fluorescence were matched through a one-on-one propensity score matching analysis (PSM) for age, gender, BMI, CCI score, ASA score, lesion histology, tumor side, and lesion diameter. Differences in operative time, blood loss, intraoperative and postoperative complications, conversion rate, and length of stay were analyzed. Results: After propensity score matching analysis, we obtained a cohort of 36 patients divided into 2 groups of 18 patients each. The operative time and intraoperative blood loss were shorter in patients of the 3DR group (P=0,004 and P=0,004, respectively). There was no difference in terms of length of stay, conversion rate, and intraoperative and postoperative complications between the 2 groups. Conclusions: The use of intraoperative ICG in LA and preoperative planning with 3DR images is a safe and useful addition to surgery. Furthermore, we observed a reduction in terms of operating time and intraoperative blood loss.

Italian Research Group for Gastric Cancer (GIRCG), during the 2013 annual Consensus Conference to gastric cancer, stated that laparoscopic or robotic approach should be limited only to early gastric cancer (EGC) and no further guidelines were currently available. However, accumulated evidences, mainly from eastern experiences, have supported the application of minimally invasive surgery also for locally advanced gastric cancer (AGC). The aim of our study is to give a snapshot of current surgical propensity of expert Italian upper gastrointestinal surgeons in performing minimally invasive techniques for the treatment of gastric cancer in order to answer to the question if clinical practice overcome the recommendation. Experts in the field among the Italian Research Group for Gastric Cancer (GIRCG) were invited to join a web 30-item survey through a formal e-mail from January 1st, 2020, to June 31st, 2020. Responses were collected from 46 participants out of 100 upper gastrointestinal surgeons. Percentage of surgeons choosing a minimally invasive approach to treat early and advanced gastric cancer was similar. Additionally analyzing data from the centers involved, we obtained that the percentage of minimally invasive total and partial gastrectomies in advanced cases augmented with the increase of surgical procedures performed per year (p = 0.02 and p = 0.04 respectively). It is reasonable to assume that there is a widening of indications given by the current national guideline into clinical practice. Propensity of expert Italian upper gastrointestinal surgeons was to perform minimally invasive surgery not only for early but also for advanced gastric cancer. Of interest volume activity correlated with the propensity of surgeons to select a minimally invasive approach.

Gastric sleeve stenosis (GSS) is described in 1%-4% of patients.To evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach according to the characteristic of stenosis.Retrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center.We enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach was used.We found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%.GSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of the stenosis should guide the most suitable endoscopic approach. (Surg Obes Relat Dis 2022;X:XXX-XXX.) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.

The current COVID-19 pandemic has considerably stressed ordinary medical resources. In such a contest, Telemedicine (TM) was relevantly recommended by several surgical societies. A specific TM-based pathway was developed emergently to care outpatients with ileo- or colostomy living on a minor island of Southern Italy (Ischia (Naples)). We retrospectively analysed a short prospective series of 23 ileo- or colostomized patients referring to a single coloproctology out-patient clinic. Patients were followed up using TM from March 3rd to April 5th 2020, when local and national policy postponed any non-emergent and non-oncologic in-patient visit to a future date. Seventeen patients were eligible for observation. Tele-consulted patients were overall satisfied, with 14 of them choosing TM as their first option for a future consultation. All medical staff gave a positive feedback about TM project. The use of TM in stoma care was easily feasible in an emergent global context. To the best of our knowledge, this is the first reported experience of remote stoma care services during COVID-19 pandemic. The next challenge is to turn emergent actions into daily outpatient practice.

Introduction We report the case of a successful management with combined aggressive surgery and negative pressure therapy, to treat a severely ill-septic patient, affected by multiple chronic enterocutaneous fistulas. Presentation of case A 26-year-old female patient presented with multiple pelvic and intra-abdominal abscesses, enterocutaneous fistulas and central venous catheter-related bacteraemia in extremely poor general conditions. The patient underwent both an abdominal CT which showed multiple digestive loops stuck and apparently fistulised and an abdominal-pelvic MRI, confirming the CT findings, and demonstrating a third fistula involving the Pouch and responsible for a pelvic and retroperitoneal chronic abscess. Given the patient's septic condition, despite several attempts of conservative therapies, an aggressive surgical approach was adopted. After temporary abdominal wall closure, the patient underwent Vacuum Assisted Closure therapy in order to close the abdominal wall and drain the residual abscess. The patient was discharged at the 35th post-operative day in good general conditions. Discussion This case is about a complex, long-lasting clinical scenario, progressively leading a young woman to death despite several attempts of conservative therapy, sometimes allowed to treat enterocutaneous fistulas. The use of negative pressure therapy to manage open abdomen is still controversial. Patients affected by enterocutaneous fistulas are in need of adequate nutritional support due to their hypercatabolic state, secondary both to the fluid loss and the concomitant inflammatory status. Conclusion When conservative management fails and the patient shows septic complications, a multidisciplinary aggressive approach, including surgery, negative-pressure therapy and hyperbaric oxygen therapy is required to treat this life-threatening condition., Highlights • Using negative pressure therapy to deal with difficult abdominal wall closure. • Multidisciplinary team work is essential to optimize patients' surgical outcomes. • Highly-demolitive surgery can benefit from the use of negative pressure therapy.

Background Laparoscopic Adjustable Gastric Banding (LAGB) has been widely performed in the past at our university bariatric center. Aim of this study was to retrospectively assess long term outcomes of LAGB at our university hospital, with special regard to non-response (EWL Methods Retrospective search of prospectively maintained database of our university bariatric center was carried out to find all consecutive patients that had undergone LAGB at our department with a minimum follow-up of 10 years. Collected data were sex, age, body mass index (BMI), obesity related diseases remission, complications and weight loss. Results After 10 years, patients with the band (n = 144) in place had a BMI of 35.2 ± 7.5 kg/m2, while %EWL and % TWL were 40.8 ± 52.4 and 18.9 ± 20.7. Seventy-four (41.6%) achieved a success (%EWL > 50), while 38 (21.3%) were non-responders (%EWL Conclusion LAGB is a safe and moderately effective bariatric procedure but it showed disappointing rates of removal, non-response and remission from comorbidities. However, LAGB could still be proposed for selected/motivated patients.

The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.

Complete transection of the main bile duct (CTMD) is a major complication during hepato-bilio-pancreatic (HBP) surgery and is associated with high morbidity and mortality. In recent years, a combined endoscopic-radiological approach (CERA) for minimally invasive treatment of CTMD has been introduced, but evidence on its long-term outcomes is limited. Our aim is to report efficacy, safety, and long-term outcomes of CERA for the management of post-surgical CTMD in a tertiary referral center.All consecutive patients referred for CTMD after HBP surgery between February 2012 and January 2021 were included in this study. CERA was first performed to re-establish biliary tree continuity, and then multiple biliary plastic stents were deployed to guarantee biliary tree reconstruction. Anthropometric, clinical, procedural (endoscopic/radiologic/surgical), and follow-up data were collected and analyzed. Each lesion was classified according to Strasberg classification.Overall, 60 patients (age 60.5 years, range 28-91), 38 F (61.7%), underwent CERA. Mean interval from surgery to endoscopic treatment was 13.2 days. Mean treatment duration was 526 days (SD ± 415) with a median number of 8 endoscopic sessions (range 1-33). Mean length of the biliary defect was 17.6 mm (SD ± 11.5). Long-term clinical success was achieved in 33/49 (67.3%) of patients. Treatment failure was experienced in 16/49 (32.7%) patients, while after an average follow-up of 41 months, stricture recurrence was observed in 3/36 (8.3%) patients.CERA is a minimally invasive and effective technique to re-establish the continuity of the biliary tract after CTMD, achieving permanent restoration in over half of treated patients.

Background Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached. Methods The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications’ occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item. Results 1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery. Conclusions Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.

Aim: Pilonidal sinus or Pilonidal Disease (PD) is a relatively common, benign but challenging condition. Although commonly encountered in practice, its ideal treatment is controversial. One of the most validated treatments is video-assisted surgery. In this context, very similar endoscopic techniques have been published under different names. The aim of this systematic review is to assess the differences among these proposed techniques and their outcomes. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during all stages of this systematic review. A systematic search of the English literature was performed on multiple databases from 1 January 2014 to 3 April 2022. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measures were the adherence to the IDEAL reporting guidelines, the Blencowe framework and the core outcome set (COS) for studies evaluating the introduction and evaluation of novel surgical techniques, the qualitative assessment using appropriate tools, the procedural variations and outcomes of each technique. Results: A total of 38 articles were included reporting a very similar technique under eight different acronyms. The number of patients varied from 9 to 250. Mean follow-up ranged from 1 to 60 months. There was only one published study of IDEAL 3. The majority (58%) were IDEAL 2a studies. Reporting of domains in the IDEAL reporting guidelines and Blencowe framework was poor, with most studies not reporting the component steps of procedures or efforts to standardize them. Half of COS domains were markedly underreported. The quality of the evidence was categorized as having a risk of bias from moderate to critical level in all nine comparative non-randomized series. Postoperative complications occurred in 0%–6% of cases, including surgical site infection, poor or failed wound healing bleeding, granuloma, haematoma, and pain requiring intervention. The recurrence rate varied from 0% to 22%. Conclusion: The study demonstrates that reporting on technical aspects of interventions for PD is poor, thus warranting a better-quality control of surgical techniques. It is advisable to group all endoscopic procedures under the umbrella term of ‘endoscopic sinusectomy’, thus embracing the two main principles of this technique, that is, video assistance and PD ablation.

Pilonidal Sinus is a benign, chronic disease that affects the hair follicles of the natal cleft of the sacrococcygeal area. Its ideal treatment is controversial, especially in complex or recurrent cases. The aim of this study is to evaluate the use of minimally invasive endoscopic approach in this setting. We enrolled patients affected by complex or recurrent sacrococcygeal pilonidal sinus from January 2015 through December 2020 who underwent Video-Assisted Ablation of Pilonidal Sinus. All patients enrolled were re-evaluated once a year with a standard physical examination. The patients included were 38. Recurrence rate at 1-, 3- and 5-years follow-ups were 28.9%, 22.2% and 38.1% respectively. Of interest, the mean (SD) distance from the most lateral orifice to the midline was higher in group of patients with recurrence and the multivariate analysis demonstrated that it was the limiting factor, which influences the recurrence rate. In complex or recurrent pilonidal sinus disease with pits off the midline the endoscopic approach should not be the first choice. This makes us think that these cases should have their own classification to be identified and guide surgeons in choosing the appropriate approach.

Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms “laparoscopic” and “robotic”. Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons’ expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12–2.10, p = 0.007). The analysis of the procedures performed by “expert surgeons” showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03–2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20–5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.

The functional disease of the esophago-gastric junction (EGJ) is one of the most common health problems. It often happens that patients suffering from GERD need surgical management. The laparoscopic fundoplication has been considered the gold standard surgical treatment for functional diseases of the EGJ. The aim of our meta-analysis is to investigate functional outcomes after robotic fundoplication compared with conventional laparoscopic fundoplication. A prospective search of online databases was performed by two independent reviewers using the search string “robotic and laparoscopic fundoplication”, including all the articles from 1996 to December 2021. The risk of bias within each study was assessed with the Cochrane ROBINS-I and RoB 2.0 tools. Statistical analysis was performed using Review Manager version 5.4. In addition, sixteen studies were included in the final analysis, involving only four RCTs. The primary endpoints were functional outcomes after laparoscopic (LF) and robotic fundoplication (RF). No significant differences between the two groups were found in 30-day readmission rates (p = 0.73), persistence of symptomatology at follow-up (p = 0.60), recurrence (p = 0.36), and reoperation (p = 0.81). The laparoscopic fundoplication represents the gold standard treatment for the functional disease of the EGJ. According to our results, the robotic approach seems to be safe and feasible as well. Further randomized controlled studies are required to better evaluate the advantages of robotic fundoplication.