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Background: Technological development has offered laparoscopic colorectal surgeons new video systems to improve depth perception and perform difficult task in limited space. The aim of this study was to assess the cognitive burden and motion sickness for surgeons during 3D, 2D-4 K or 3D-4 K laparoscopic colorectal procedures and to report post-operative data with the different video systems employed., Methods: Patients were assigned to either 3D, 2D-4 K or 3D-4 K video and two questionnaires (Simulator Sickness Questionnaire-SSQ- and NASA Task Load Index -TLX) were used during elective laparoscopic colorectal resections (October 2020-August 2022) from two operating surgeons. Short-term results of the operations performed with the three different video systems were also analyzed., Results: A total of 113 consecutive patients were included: 41 (36%) in the 3D Group (A), 46 (41%) in the 3D-4 K Group and 26 (23%) in the 2D-4 K Group (C). Weighted and adjusted regression models showed no significant difference in cognitive load amongst the surgeons in the three groups of video systems when using the NASA-TLX. An increased risk for slight/moderate general discomfort and eyestrain in the 3D-4 K group compared with 2D-4 K group (OR = 3.5; p = 0.0057 and OR = 2.8; p = 0.0096, respectively) was observed. Further, slight/moderate difficulty focusing was lower in both 3D and 3D-4 K groups compared with 2D-4 K group (OR = 0.4; p = 0.0124 and OR = 0.5; p = 0.0341, respectively), and higher in the 3D-4 K group compared with 3D group (OR = 2.6; p = 0.0124). Patient population characteristics, operative time, post-operative staging, complication rate and length of stay were similar in the three groups of patients., Conclusions: 3D and 3D-4 K systems, when compared with 2D-4 K video technology, have a higher risk for slight/moderate general discomfort and eyestrain, but show lower difficulty focusing. Short post-operative outcomes do not differ, whichever imaging system is used., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Aim: Prognostic Nutritional Index (PNI) is a useful tool to predict short-term results in patients undergoing surgery for gastrointestinal cancer. Few studies have addressed this issue in colorectal cancer or specifically in rectal cancer. We evaluated the prognostic relevance of preoperative PNI on morbidity of patients undergoing laparoscopic curative resection for rectal cancer (LCRRC)., Methods: PNI data and clinico-pathological characteristics of LCRRC patients (June 2005-December 2020) were evaluated. Patients with metastatic disease were excluded. Postoperative complications were evaluated using the Clavien-Dindo classification., Results: A total of 182 patients were included in the analysis. Median preoperative PNI was 36.5 (IQR 32.8-41.2). Lower PNI was associated with females (p=0.02), older patients (p=0.0002), comorbidity status (p<0.0001), and those who did not receive neoadjuvant treatment (p=0.01). Post-operative complications occurred in 53 patients (29.1%), by the Clavien-Dindo classification: 40 grades I-II and 13 grades III-V. Median preoperative PNI was 35.0 (31.8-40.0) in complicated patients and 37.0 (33.0-41.5) in uncomplicated patients (p=0.09). PNI showed poor discriminative performance regarding postoperative morbidity (AUC 0.57) and was not associated with postoperative morbidity (OR 0.97) at multivariable analysis., Conclusions: Preoperative PNI was not associated with postoperative morbidity after LCRRC. Further research should focus on different nutritional indicators or hematological/immunological biomarkers., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The importance of body composition, in particular skeletal muscle mass, as risk factor affecting survival of cancer patients has recently gained increasing attention. The relationship between sarcopenia and oncological outcomes has become a topic of research in particular in patients with gastrointestinal cancer. However, there are few studies addressing this issue in colorectal cancer, and even less specifically focused on rectal cancer, in particular in Western countries. The aim of this study was to evaluate the prognostic relevance of preoperative skeletal mass index (SMI) on long-term outcomes in patients undergoing laparoscopic curative resection for rectal cancer., Methods: SMI data and clinicopathological characteristics of rectal cancer patients in a 15-year period (June 2005-December 2020) were evaluated; patients with metastatic disease at surgery were excluded; overall and disease-free survival as well as recurrence were evaluated., Results: Hundred and sixty-five patients were included in the study. Sarcopenia was identified in 30 (18%) patients. Multivariate analysis identified sarcopenia (HR = 3.28, CI = 1.33-8.11, P = 0.015), along with age (HR = 1.06, CI = 1.02-1.10, P = 0.002) and stage III (HR = 2.63, CI = 1.13-6.08, P < 0.03) as independent risk factors for overall survival., Conclusion: Long-term results of rectal cancer patients undergoing curative resection are affected by their preoperative skeletal muscle status. Larger studies including comprehensive data on muscle strength along with SMI are awaited to confirm these results on both Eastern and Western rectal cancer patient populations before strategies to reverse muscle depletion can be extensively applied., (© 2023 Royal Australasian College of Surgeons.)

Background: Sarcopenia is a useful tool in predicting short-term results in patients undergoing surgery for gastrointestinal cancer. However, there are few studies addressing this issue in colorectal cancer, and even less specifically focused on rectal cancer. We evaluated the prognostic relevance of preoperative skeletal mass index on postoperative morbidity in patients undergoing laparoscopic curative resection for rectal cancer. Methods: Skeletal mass index data and clinicopathological characteristics of rectal cancer patients in a 15-year period (June 2005-December 2020) were evaluated; patients with metastatic disease at surgery were excluded; postoperative complications within 30 days were evaluated using the Clavien-Dindo classification. Results: A total of 166 patients were included in the study. The overall prevalence of sarcopenia was 60%. BMI, Hb, or albumin were not associated with sarcopenia. Hospital stay was not correlated with sarcopenia. Postoperative complications occurred in 51 patients (31%); by the Clavien-Dindo classification 31 (61%) grade I, 10 (14.5%) grade II, and 10 (14.5%) grade III. Overall complications were not significantly different in sarcopenic and nonsarcopenic patients ( P  = .10). Considering only patients with complications, sarcopenia was found to be a predictor of more severe postoperative morbidity (odds ratio 12.7, P  = .021). On multivariable analysis, sarcopenia was not associated with postoperative morbidity. Conclusions: Skeletal muscle status in rectal cancer patients undergoing curative resection was not associated with overall postoperative morbidity, although there was a correlation between sarcopenia and more severe complications. Further studies in a larger cohort of patients are needed before conclusions can be drawn on the relationship between muscular depletion and surgical outcomes in rectal cancer patients.

Purpose: Left hemicolectomy is the standard surgical operation for a variety of colonic diseases, both benign and malignant. When colonic resection is extended, relocation of the small bowel loops can be difficult. Several techniques have been described to reposition the small intestine. Welti's technique consists in the passage of the entire small bowel to the left side of the abdomen, below the descending colon that is positioned on the right side. Methods: We retrospectively evaluated 23 patients who underwent extended left hemicolectomy and reconstruction according to the Welti's technique at our hospital. We assessed the recovery of intestinal function and the length of hospital stay; in the mid-term follow-up we searched for episodes of acute or chronic intestinal obstruction. Results: Median operative time was 215 minutes; median resumption of gas and stool emission were, respectively, 3 days (interquartile range [IQR]: 2-6) and 4 days (IQR: 2-9) after surgery. Median hospital stay was 8 (IQR: 5-37) day. After a median follow-up of 15 months (IQR: 3-132) we did not observe any episode of acute or chronic bowel obstruction. Conclusions: Welti's technique is safe and does not cause a delay in resumption of bowel functions or a delayed hospital discharge; it is a useful technique that the colorectal surgeon can use when needed.

Background: Inflammation plays an important role in tumor growth. Novel serum blood biomarkers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), have been proposed as useful prognostic indexes in cancer patients. However, their role in rectal cancer is controversial., Methods: A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, and the Cochrane Database of Systematic Reviews through May 2022. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) tool. Aim of the study was to summarize available literature on PLR, NLR, and LMR in patients with rectal cancer undergoing resection., Results: Forty-seven observational studies (14,205 patients) were included; there were 42 retrospective and 5 prospective cohort studies with an average MINORS score of 14.6 (range: 12-18). Worse overall survival was associated with high NLR (HR 1.81; 95%CI 1.52-2.15; p < 0.001), high PLR (HR 1.24; 95%CI 1.06-1.46; p = 0.009), and low LMR (HR 0.67; 95%CI 0.49-0.91; p = 0.01). High NLR and low LMR were also associated with disease-free-survival (HR 1.68; 95%CI 1.35-2.08; p < 0.001 and HR 0.71; 95%CI 0.58-0.87; p < 0.001, respectively)., Conclusions: NLR, PLR, and LMR are independent clinical predictors for overall survival in patients with rectal cancer treated with curative surgery. NLR and LMR are also good predictors for disease free survival. These biomarkers, which are readily available, appear optimal prognostic indexes and may help clinicians predict the prognosis of rectal cancer and develop individualized treatment strategies., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Standard laparoscopic colorectal surgery relies on 2D image systems in most centers. However, 3D vision has gained popularity and is used nowadays in a constantly rising number of units. Right hemicolectomy with intracorporeal anastomosis and lymph node dissection represents a surgical procedure that may benefit the most from 3D vision. The aim of the study was to summarize the available literature on the use of 2D vs. 3D video imaging in patients undergoing laparoscopic right hemicolectomy., Methods: A comprehensive literature review was conducted including Medline/PubMed, Embase, and Scopus (PROSPERO registration number CRD 42022344764) through October 2022. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The risk of bias was evaluated using the ROBINS-I tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines and GRADEpro to develop a summary of evidence tables. Random-effects meta-analyses were conducted., Results: Five observational retrospective studies (496 patients, 275 2D and 216 3D) were included. One study was rated as having a critical risk of bias; the remaining had low to moderate risk. 2D laparoscopic right hemicolectomy patients showed longer anastomotic time in 3/3 studies (MD = 3.32; 95%CI, 1.58-5.05; p = 0.002) and an upward trend in operative time in 4/5 studies (MD = 9.98; 95%CI, -1.42, 21.37; p = 0.086) compared to 3D. The two image video systems had similar short-term outcomes, including the number of lymph nodes harvested (MD =  -0.67; 95%CI, -2.47, 1.13; p = 0.47), morbidity (OR post-operative complications = 1.12; 95%CI, 0.71-1.77; p = 0.62), and length of stay (MD = 0.27; 95%CI, -0.59, 1.13; p = 0.9)., Conclusions: 2D and 2D laparoscopic right hemicolectomy had similar complications rate, with a shorter anastomotic time along with a downward trend in overall operative time for 3D. Larger prospective randomized trials are awaited before definitive conclusions can be drawn., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: There are few studies focused on the short-term results of laparoscopic right hemicolectomy performed with 2D (two-dimension) or 3D (three-dimension) video technology and none on the oncologic effects. The aim of the study was to assess the long-term results of laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis using 3D or 2D video in patients with right colon cancer with at least three years of oncologic follow-up., Methods: Data from patients undergoing laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis for cancer in an 11-year period (June 2008-June 2019) and ≥ 3 years of follow-up were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons., Results: 111 patients were included in the study: 56 (50.5%) in the 3D group and 55 (49.5%) in the 2D group. Tumor stage and number of lymph nodes harvested were similar. Overall and disease-free survival were not different in the two groups. Local recurrence occurred in none of the patients, and distant metachronous metastases were similar in the two groups. A propensity score weighting approach was used to account for potential confounding related to patients' nonrandom allocation to the 2 groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach., Conclusions: Laparoscopic 3D technology allows similar oncological results as 2D vision in LRH with intracorporeal anastomosis. Larger prospective randomized studies might confirm these results in the long-term follow-up., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Infra-ampullary duodenal lesions are rare and surgical management is controversial. The commonly accepted treatment, which allows radical resection, is pancreaticoduodenectomy, but segmental duodenal resection has been considered as alternative. Aim of the study was to describe the effectiveness of minimally invasive resection of the third/fourth portion of the duodenum for both benign and malignant lesions, with pancreas preservation and reconstruction through end-to-side duodenojejunostomy. Methods: Data from patients undergoing elective laparoscopic curative duodenal resection with pancreas preservation between June 2005 and June 2019 were prospectively collected. Results: A total of 5 patients were identified (3M/2F), median age 73 years (range: 54-83). Lesions were all located in the third or fourth portion of the duodenum and were adenocarcinoma in 2 patients (pT2N0 and pT3N2, both 3 cm in diameter) and gastrointestinal stromal tumor in 3 patients (two pT1N0 and one pT2N0, low-risk according to Miettinen, of 3, 2, and 5 cm in diameter, respectively). The operations lasted a median of 225 minutes (range: 180-300). Digestive continuity was restored with fully laparoscopic side-to-side duodenojejunostomy in all cases. One patient developed pneumonia after surgery (20%) and required also postoperative blood transfusions. Reoperation and mortality rate was nil. Median postoperative stay was 11 days (range: 10-13). The median follow-up was 30 months. Conclusions: Fully laparoscopic pancreas-preserving duodenal resection with duodenojejunal reconstruction can be a safe and feasible option for both benign and malignant lesions of the third and fourth portion of the duodenum. It brings good oncological results, but it needs to be validated with larger number of patients.

Background: Internal hernia (IH) after laparoscopic colorectal surgery is a potentially severe complication. It may go undiagnosed in patients having their abdominal CT scan during oncologic follow-up. We evaluated the occurrence of IH on CT scans after laparoscopic curative resection for rectal cancer (LRRC) and routine closure of the mesenteric defect., Methods: Data from 189 consecutive patients undergoing elective curative LRRC in a 14-year period (June 2005-june 2019) were prospectively collected. Only patients with abdominal CT scans, performed as routine oncologic follow-up, between 3 months and 7 years post-operatively were included in the study and reviewed by a surgeon and a radiologist., Results: A total of 161 patients were eligible for the study with a median age of 69 years (IQR: 59-77) at surgery. They had abdominal follow-up CT scans at a median of 39.5 months (IQR: 12.8-62.7) after surgery. The prevalence of IH was 11.2% (18/161 patients). Of the 18 patients, 15 (83.3%) were fully asymptomatic, 2 (11.1%) reported chronic abdominal discomfort (including mostly nausea and colicky pain) during their oncologic follow-up (however, IH was not suspected neither prompted additional investigations), and 1 (5.6%) was reoperated elsewhere for IH and acute small bowel obstruction., Conclusions: IH following LRRC is not uncommon, with a prevalence > 10% in our experience. Most of these patients remain fully asymptomatic, but in a few patients, IH might be responsible for some symptoms or require reoperation. Awareness of this complication is important, given the potential risk of acute small bowel obstruction., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

In this video, we present the laparoscopic technique of pancreas-preserving segmental resection for GISTs of the 4th portion of the duodenum. A 54-year-old male presented with a polypoid mass of about 3 cm in diameter with a large base, in the 4th portion of the duodenum, about 4 cm from the ampulla. Multiple endoscopic biopsies were taken, and all were negative for adenocarcinoma. CT scan of the abdomen confirmed that the mass, suggestive of GIST, was limited to the duodenum, a limited part intraluminal and the vast majority in the duodenal wall. A laparoscopic segmental resection with a 3D video system was accomplished. The operation lasted 160 min. Recovery was uneventful., (© 2021. The Society for Surgery of the Alimentary Tract.)

Laparoscopic and thoracoscopic surgery often require extraction of surgical specimens. The use of standard retrieval bag can be expensive, especially in case of multiple specimens during the same operation. We describe the use of a folded glove-finger as cheap alternative and easily reproducible means of specimen extraction. The medium finger of a glove, cut at its base, was used to locate several types of specimens. The edge of the glove was folded to allow an easier insertion and retrieval of the specimens. Using this technique in the last 5 years, we have retrieved hundreds of different types of specimens (including omentum, lymph nodes, appendix, peritoneal or pleural biopsies) during laparoscopic and thoracoscopic procedures. All the retrieval fingers were safely pulled outside and were intact when extracted through the ports with no fragmentation of the specimens. In conclusion, we suggest that a folded glove-finger can be used as an easy, quick and cheap strategy for specimen extraction during laparoscopic and thoracoscopic surgery.

Background: There are few reports comparing safety and efficacy of 2-D and 3-D video technology in laparoscopic right hemicolectomy. The aim of the study was to assess the short-term results of laparoscopic right hemicolectomy (LHR) with intracorporeal anastomosis with 2-D/3-D video in patients with right colon cancer., Methods: Data from 239 patients undergoing LRH for cancer in a 14-year period (June 2005-January 2020) were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons., Results: One hundred and fourteen patients were included in the study: 55 (48.2%) operated with 2-D and 59 (51.8%) with 3-D video. Tumor site and postoperative stage distribution were similar. Mean operative time was comparable in the two groups (159.0 ± 48.8 min vs. 17.06 ± 36.0 min, p = ns, group 2-D and 3-D, respectively). Group 3-D patients had a similar percentage of associated procedures (44.1% vs. 29.1%, p = ns). Intraoperative complications were nil in both groups, while postoperative complications were similar (30.9% 2-D vs 25.4% 3-D, p = ns). The mean number of lymph nodes retrieved was similar in group 3-D (26.0 ± 14.6 vs. 22.9 ± 9.3, p = ns) and the length of stay was comparable in 3-D and 2-D patients (8.4 ± 2.6 vs. 9.1 ± 3.3 days, respectively, p = ns)., Conclusions: Laparoscopic 3-D vision is as equally effective as 2-D vision in LRH with intracorporeal anastomosis, with a similar proportion of associated procedures and number of lymph nodes retrieved in the same operative time. Further prospective larger randomized studies are necessary to verify if LRH with 3-D video can reduce postoperative complications, compared to 2-D video., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

We developed a new technique to reduce the length of the enteric defect to be closed during intracorporeal anastomosis in laparoscopic right hemicolectomy (LRH), also avoiding the need to suture the first part of the anastomosis in a deep space with an acute angle. From January 2017, after the ileo-colic anastomosis was completed, an additional stapler cartridge was applied starting at the colonic rim and including the small bowel part of the anastomosis. The isoperistaltic fashion of the ileo-colonic anastomosis was maintained. The remaining defect left to be closed was 2-3 cm. We compared the results of the novel technique with those of the 'standard' closure (full-length enterotomy). In the last 30 months, this technique was successfully used in 32 patients (Group A), compared with 33 patients (2012-2016) operated with 'standard' closure (Group B). Age, BMI and post-operative stage distribution were similar. The mean operative time was 175.2 min (± 36.7) in Group A and 165.9 min (± 42.5) in Group B (p = ns), with 53.1% and 27.3% of associated procedures (cholecystectomy, ovariectomy, etc.), respectively (p < 0.05). Overall morbidity rate was 28.1% and 30.3% (Group A vs Group B, p = ns), with no anastomotic bleeding/leak in either group. This technique, which simplifies the closure of the enteric defect after LRH with intracorporeal anastomosis is safe, reproducible and easy to learn. It might help more surgeons to perform a fully laparoscopic procedure in right hemicolectomy, offering the advantages of intracorporeal anastomosis to their patients., (© 2021. Italian Society of Surgery (SIC).)

Background: Internal hernia (IH) is an infrequent complication following colorectal resection with minimally invasive technique. The real prevalence is difficult to define and there are only few large series reporting data on this complication, often focusing only on left-sided resections. Aim of the study was to evaluate the occurrence of IH following laparoscopic colorectal resection (LCR), reporting clinical presentation and treatment., Methods: Data from 1297 patients undergoing elective LCR for cancer or benign disease in a 15-year period (June 2005-March 2020) were prospectively collected. A database query was performed to search for small bowel obstructions requiring reintervention., Results: Five patients presented symptomatic IH (prevalence = 0.38%) and required reintervention. The preceding surgical procedure was left hemicolectomy for diverticular disease in all patients. The mesenteric defect had been originally closed in 4/5 patients. The median time interval between initial surgery and the occurrence of IH was 1 (range: 0.3-10) month. In all cases a small bowel loop was found herniating through the mesocolic defect. Small bowel resection was required in one patient only. The median hospital stay following reintervention was 7 (range: 4-17) days., Conclusions: IH following LCR is a rare but severe complication, potentially leading to death, if not promptly diagnosed and treated. Awareness of this complication, early recognition, and proper diagnostic and therapeutic management is mandatory allowing laparoscopic approach and often avoiding small bowel resection.

Purpose: The advantages of biological meshes for ventral hernia repair are still under debate. Given the high financial cost, the proper indications for biological meshes should be clarified to restrict their use to properly selected patients., Methods: A retrospective database was instituted to register all cases of abdominal wall defect treated with biological meshes from 1/2010 to 3/2016., Results: A total of 227 patients (mean age: 64 years) whose ventral abdominal defects were reconstructed with a biological mesh were included in the study. Patients were divided according to the 2010 four-level surgical-site complication risk grading system proposed by the Ventral Hernia Working Group (VHWG): Grade 1 (G1, 12 cases), Grade 2 (G2, 68 cases), Grade 3 (G3, 112 cases), and Grade 4 (G4, 35 cases). The surgical site complication rate was higher in patients with one or more risk factors (33.6% vs 19% in patients with no risk factors) (P = 0.68). Statistically significant risk factors associated with the onset of one or more postoperative surgical site complications included: diabetes, coronary artery disease, immunosuppression, and obesity. Recurrence was more common in patients with surgical site complications and mainly associated with infection (38.9%) and wound necrosis (44.4%), and in cases of inlay positioning of the mesh (36%)., Conclusions: Due to their high costs, biological mesh should not be used in G1 patients. In infected fields (G4), they should only be used if no other surgical solution is feasible. There is a clear need to prospectively evaluate the performance of biological meshes.

Anastomotic stenosis after colorectal surgery is usually considered low-rate complication and often is under-reported in most studies. Few data are available on management strategies. The aim of the study was to assess the prevalence of stenosis after stapled colorectal anastomosis, performed either in elective or emergent setting, for benign or malignant disease, and to evaluate treatment profiles. This retrospective study was a survey conducted in a large Italian North-Eastern area including three regions (Triveneto), over a 12-month period (January-December 2015). Patients' characteristics and surgical technique details were recorded, along with data on the prevalence of stenosis and its treatment. Patients with mid or low rectal resection and/or neoadjuvant chemo-radio therapy and/or diverting stoma were excluded. The study was promoted by the Italian Association of Hospital Surgeons (ACOI) and the Society of Surgeons of the Triveneto Region. Twenty-eight surgical units were enrolled in the survey, accounting for over 1400 patients studied. Fifty percent of the units performed laparoscopically > 70% of the colorectal resections and 7.5% of the procedures were emergent. Less than 60% of the units planned regular endoscopic follow-up after colorectal resection. Anastomotic stricture was recorded in 2% of the patients; 88% of the stenoses were diagnosed within 6 months from surgery. Only one anastomotic stricture required re-do surgery. The CANSAS study confirms that colorectal anastomotic stenosis is low-rate-but still present-complication. Treatment strategies vary according to surgeons' and endoscopists' preferences. Commonly endoscopic dilatation is preferred, but re-do surgery is required in some cases.

Background and Aim: Conflicting findings have been reported in older patients undergoing laparoscopic surgery for rectal cancer. The aim of this study was to evaluate the effects of age and comorbidities on short- and long-term results of patients undergoing laparoscopic curative resection for rectal cancer (LCRRC)., Materials and Methods: We retrospectively evaluated all 173 consecutive patients undergoing LCRRC at our unit (June 2005-September 2015). They were divided into two age groups as follows: <75 (n = 122) and ≥75 (n = 51) years. Comorbidities were evaluated using American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), and age-related Charlson Comorbidity Index (ACCI)., Results: Tumor characteristics were similar in the two groups. Comorbidity status (ASA, CCI, ACCI) was worse in elderly patients. Type of surgery performed was similar in the two groups. Medical complications were significantly higher in elderly (10.7% versus 29.4%, P = .006), while surgical complications were similar. Postoperative stay was longer in older patients (13 days versus 9 days, P = .0007). Multivariable analysis identified older age, higher CCI, and longer operative time as independent predictors of morbidity. Five years overall survival and disease-free survival were 49% and 43% in older and 84% and 77% in younger group (P < .0001). Multivariable analysis identified age, CCI, tumor, node, metastasis stage, and postoperative morbidity as independent risk factors for overall and disease-free survival., Conclusions: LCRRC achieves excellent short- and long-term results, but age and comorbidities may significantly affect postoperative morbidity and survival.

The aim of the present study was to evaluate the long-term results of laparoscopic curative resection for rectal cancer. We included all patients who underwent laparoscopic curative resection for rectal cancer from June 2005 to September 2015. A total of 159 patients were included; 33.9% received neoadjuvant chemoradiotherapy. Thirty-day mortality and morbidity rates were 0.6% and 26.4%, respectively. Pathologic stage was 0 in 12%, I in 39%, II in 24.5%, and III in 24.5%. The median number of lymph nodes harvested was 16. In 5% of patients, mesorectal excision was incomplete. Median follow-up was 59 months. Overall 5-year survival was 80%. Multivariable analysis identified older age, higher Charlson Comorbidity Index, advanced tumor stage, and postoperative morbidity as independent risk factors for overall/disease-free survival. Local/distant recurrence rate was 4.4%/17.6%. Deaths during follow-up were 33/159 (20.8%): cancer related 54.6% and non cancer related 45.4% of patients. Laparoscopic curative resection for rectal cancer can yield prolonged survival and low recurrence.

Background: Actual predictors of survival and recurrence for rectal cancer patients undergoing curative resection mostly come from pathological data of surgical specimen. Recently, novel blood biomarkers have been proposed as useful tools in cancer patient management, but few and conflicting data have been reported in rectal cancer. We evaluated the prognostic relevance of preoperative platelet-to-lymphocyte (P/L) ratio and neutrophil-to-lymphocyte (N/L) ratio on survival and recurrence in patients undergoing laparoscopic curative resection for rectal cancer., Methods: All consecutive patients who referred for primary rectal disease to the Department of General Surgery in Cittadella (Italy) from June 2005 to September 2015 were retrospectively evaluated. Patients with metastatic disease at surgery were excluded. P/L and N/L ratios were calculated. For patients undergoing neoadjuvant chemo-radiotherapy, pre-treatment data were considered. Follow-up data were updated at December 2016., Results: One hundred fifty-two patients were included in the study, 49 (32%) received neoadjuvant chemo-radiotherapy. Both P/L and N/L ratios showed poor discriminative performance on 5-year OS and DFS. Time-dependent ROC curves showed no improvements in discriminative performance of P/L and N/L ratios when considering different time endpoints. Multivariable analysis identified CEA-rather than P/L or N/L ratios-as independent predictor of OS and DFS, adjusting for age, tumor stage, and postoperative morbidity., Conclusion: Neither P/L nor N/L ratios were associated with survival after rectal cancer surgery. Further studies on large series might provide insights on the role of these inexpensive blood biomarkers in rectal cancer.

Introduction: Schwannomas are slow-growing tumors, rarely occurring in the GI tract. When found, their location is mostly in the stomach. Presentation in the small bowel is extremely rare, anecdotal., Case Report: We present the case of a 47-year old male who underwent laparoscopic elective left hemicolectomy for recurrent diverticulitis., Results: At surgery an exophytic mass originating from the first jejunal loop was identified and resected, under the suspicion of a GIST. Post-operative pathologic report was consistent with the diagnosis of jejunal schwannoma. Unfortunately resection margins were positive and the patient was taken back to the OR for an additional jejunal segmental resection., Conclusions: GI schwannomas have excellent prognosis after surgical resection. It is important to differentiate them from GISTs, which may have a malignant behavior in 10-30% of the cases. To ensure complete surgical resection with negative margins is mandatory and is the curative treatment of choice., Key Words: GIST, Jejunum, Submucosa Minimally-invasive surgery, Schwannoma, Small bowel.

Optimal treatment of splenic flexure (SF) colon cancer-less than 10% of all colorectal cancers is a matter of debate, in particular with regard to the optimal extent of radical surgery, according to the oncological principles of curative resection. Aims of this study were to assess the clinicopathological characteristics and report operative data and survival of patients with SF colon cancers. Short- and mid-term outcome of patients undergoing laparoscopic curative resection for SF colon cancer between June 2005 and September 2011 was assessed. The analysis considered 16 patients: 10 underwent segmental resection, 4 left hemicolectomy and 2 subtotal colectomy. There were no intraoperative deaths or major morbidity. The median operative time was 185 min. The median number of lymph nodes harvested was 17. Disease-free survival rate at 30-month follow-up was 75%. Laparoscopic resection of SF cancer is feasible and safe. Oncological principles of disease-free margins and minimum node harvest can be respected even with segmental resection.

Reestablishing continuity after a Hartmann's procedure is considered a major surgical procedure with high morbidity/mortality. The aim of this study was to assess the short-/long-term outcome of laparoscopic restoration of bowel continuity after HP. A prospectively collected database of colorectal laparoscopic procedures (>800) performed between June 2005 and June 2013 was used to identify 20 consecutive patients who had undergone laparoscopic reversal of Hartmann's procedure (LHR). Median age was 65.4. Ten patients (50 %) had undergone surgery for perforated diverticulitis, 3 (15 %) for cancer, and 7 (35 %) for other reasons (volvulus, posttraumatic perforation, and sigmoid perforation from foreign body). Previous HP had been performed laparoscopically in only 3 patients. Median operative time was 162.5 min. All the procedures were completed laparoscopically. Intraoperative complication rate was nil. Post-operative mortality and morbidity were respectively 0 and 10 % (1 pneumonia, 1 bowel obstruction from post-anastomotic stenosis which required resection and redo of the anastomosis). Median time to first flatus was 3 days, to normal diet 5 days. Median hospital stay was 9 days without readmissions. We followed up the patients for a median of 44 months: when asked, all 20 (100 %) said they would undergo the operation (LHR) again; 3 (15 %) had been re-operated of laparoscopic mesh repair for incisional hernia. When performed by experienced surgeons, LHR is a feasible, safe, reproducible operation, which allows early return of bowel function, early discharge and fast return to work for the patient. It has a low morbidity rate.

Right diaphragmatic hernia after abdominal trauma is a rare injury. Most patients can be asymptomatic, and the diagnosis may be delayed for several years. The treatment of choice involves surgical repair via laparotomy. The authors treated a young patient with transdiaphragmatic herniation of the right hepatic lobe and delayed diagnosis using a laparoscopic approach and accomplished a successful complete repair. The 6-month radiologic follow-up assessment confirmed good results.

Background: Laparoscopic total gastrectomy for adenocarcinoma is a widely diffused operation in eastern countries, but there are only a few reports from western centers. We assessed a single surgeon's experience at a single, nonacademic, community hospital., Methods: Short-term outcome of patients undergoing laparoscopic total gastrectomy for adenocarcinoma (June 2005-March 2010) was assessed., Results: Fourteen patients (5 males, 9 females; median age, 66.8 years [interquartile range, 59.7-71.8]) underwent laparoscopic total gastrectomy. The median operative time was 240 min. There were five stage 1 patients, five stage 2, and four stage 3; R0 resection was obtained in all 14 patients, and the median number of lymph nodes retrieved was 38. Mortality and overall morbidity rates were 0% and 35.7%, respectively., Conclusions: The outcomes of laparoscopic total gastrectomy for adenocarcinoma performed by a well-trained laparoscopic surgeon working in a community hospital are good in terms of safety for the patients and response to the oncological criteria used in open surgery.

Background: Several studies have addressed the issue of the feasibility of laparoscopic colorectal surgery in elderly patients, usually by choosing an arbitrary cut-off age limit, and retrospectively evaluating patient outcomes. The aim of this study was to assess the effects of age on the outcome of laparoscopic colorectal surgery for cancer in a single department, by comparing younger and older patients, matched by ASA score and type of operation., Methods: The perioperative outcome of patients ≥75 years old who underwent laparoscopic colorectal surgery for cancer between June 2005 and January 2009 were compared with findings in younger patients, matched by ASA score and type of operation., Results: The study included 100 patients, fifty <75 years old (Group A) and fifty ≥75 (Group B) years old. There were 18 right hemicolectomies, 16 left hemicolectomies, 4 anterior resections, 9 low anterior resections, 2 Miles' operations and 1 segmental resection in each group. We observed a significantly higher overall morbidity rate among elderly patients than among younger patients (24 vs. 8%)., Conclusions: Short-term results after laparoscopic colorectal surgery for cancer in patients ≥75 years old reveal that they have higher postoperative risk compared to their younger counterparts, even when matched by ASA score and type of operation. It suggests that although advanced age, per se, is not a contraindication, it is a risk for patients who undergo laparoscopic colorectal surgery for cancer. This surgery in elderly patients should be performed by experienced surgeons in specialized centers to keep postoperative risk to a minimum.

Spontaneous rupture of the esophagus (so-called Boerhaave's syndrome) is considered a medical emergency. It carries a significant mortality rate and requires prompt treatment. The treatment of choice involves surgical repair of the esophageal defect, usually accomplished via laparotomy, thoracotomy, or both to accomplish esophageal repair and mediastinal debridement. We have treated an elderly patient with severe comorbidities with a minimally invasive approach, achieving a successful complete repair. Long-term endoscopic and radiologic follow-up confirm the good results.

Aims and Background: Aging of the population and a longer life expectancy have led to an increased number of elderly patients presenting with colorectal cancer and searching for treatment. The aim of the study was to assess the effects of age on the outcome of laparoscopic colorectal surgery for cancer at a single department., Methods: Perioperative outcome of patients > or =75 years old undergoing laparoscopic colorectal surgery between June 2005 and January 2009 for colorectal cancer were compared with findings in younger patients., Results: The analysis considered 134 patients <75 years and 82 patients > or =75 years of age. There was a significant difference in perioperative risk factors, as reflected by different ASA scores and a significantly higher postoperative 'medical' morbidity, but 'surgical' morbidity was similar in the two groups and remained low., Discussion: Surgical morbidity rate was not affected by age. Cardiovascular and pulmonary comorbid conditions were mainly responsible for the higher morbidity rate reported in the elderly patients, although advanced age, per se, should not be considered a contraindication to laparoscopic colorectal surgery for cancer.

Spontaneous rupture of gastrointestinal stromal tumor (GIST) with hemoperitoneum is an extremely rare clinical presentation of this mesenchymal tumor. We report the unusual case of a 68-year-old man who was admitted to the hospital with abdominal pain. While waiting for the results of his laboratory tests the patient became pale and tachycardic and his abdomen distended with generalized rebound tenderness. A CT scan suggested rupture of a cavernous angioma of the liver and the patient was brought to the operating room for an explorative laparoscopy, which revealed hemoperitoneum from a ruptured giant gastric GIST. After conversion to laparotomy, the tumor was excised: it was 11 x 10 x 5 cm in size, with massive necrosis and clotted blood inside. Immunohistochemical examination revealed reactivity to c-KIT and CD34, consistent with the diagnostic criteria for GIST, with low mitotic activity (< 5/50 HPF). The postoperative course was uneventful, and the clinical and radiological follow-up at 6 months is negative for recurrence.

Pulmonary hernias--defined as protrusions of the lung parenchyma and pleural membranes through a defect in the thoracic wall--are rare. They are usually congenital, spontaneous or traumatic iatrogenic lung herniations are extremely rare and secondary to thoracoscopic procedures or minimally invasive cardiothoracic surgery. There are very few reports of surgical repair of this iatrogenic condition and, to date, no reports of thoracoscopic repair of such defects of the thoracic wall have been reported. We present a case of a young patient with iatrogenic lung herniation in which a thoracoscopic approach was attempted and complete repair successfully accomplished.

Background: We assessed a single surgeon's experience on laparoscopic colorectal surgery (LCR) at a single non academic, community hospital. The surgeon was trained in minimally-invasive techniques and robotic surgery with >500 procedures at another non-university hospital, either as operating surgeon or as assistant., Methods: Short-term outcome of patients undergoing LCR for benign/neoplastic disease (June 2005-September 2007) was assessed., Results: A total of 208 patients (104 males, 104 females; median age 69.1 years, Interquartile Range (IQR):59.3-76.6) underwent LCR. Over 70% of the operations were performed for cancer. Left hemicolectomy was performed in 102 patients (49.1%), right hemicolectomy in 50 (24%), anterior resection in 40 (19.2%), other procedures in 16 (7.7%). One-hundred-ninety (91.3%) operations were elective. The median operative time was 180 min (IQR:150-210). Conversion rate was 4.8%: 3.4% for benign and 5.4% for neoplastic disease (p = n.s.). The median lymph node harvest in cancer patients was 16 (IQR:12-20). Mortality and overall morbidity rates were 0.5% and 13%, with no significant difference between benign and malignant disease, colon and rectum, elective and non elective operations., Conclusions: The outcomes of LCR surgery performed by a well-trained laparoscopic surgeon working in a community hospital are comparable with results from academic health science centers.

Esophageal perforations with a mediastinal abscess are medical emergencies with a significant mortality rate. Prompt management is mandatory, and a variety of treatment strategies have been advocated. In the case of a spontaneous rupture of the esophagus (the so-called Boerhaave's syndrome), the treatment of choice involves the surgical repair of the esophageal defect, usually accomplished through a laparotomy or thoracotomy. In this paper, we present a case of an elderly patient with severe comorbidities, in which a minimally invasive approach was attempted and a complete repair was successfully accomplished.

Background: The use of laparoscopy for colorectal cancer resection is still controversial., Methods: We prospectively analyzed the outcome of minimally invasive resection for colorectal cancer, performed at our institution from 1998, when laparoscopic surgery became the treatment of choice for colorectal cancer, until 2004. All patients undergoing elective resection were assessed in terms of perioperative results (duration of surgery, number of lymph nodes removed, length of specimen, rate of conversion, complications) and survival. Patients were assessed yearly with follow-up visits and telephone interviews., Results: In the study period, 302 patients (mean age 66.1 years; range, 32-93 years) underwent 114 left hemicolectomies, 108 low anterior resections, 61 right hemicolectomies, 12 Miles procedures, 4 subtotal colectomies, and 3 transverse colon resections. Surgery took an average of 226 minutes (SD=71 min). The number of lymph nodes removed was 14+/-8. The conversion rate was 10%; most of the conversions were due to locally advanced cancer (15 cases) and bowel distension (7 cases). Fifteen anastomotic leaks were observed (5%). Twenty patients needed reoperation and two died: one of septic shock due to an anastomotic leak; the other of electrolyte imbalance and dehydration after peritonitis due to a bowel loop injury. Follow-up was available for 91% of patients. Cancer-related survival curves showed a 90% survival for stage II, 85% for stage III, and 10% for stage IV disease, 30 months after surgery., Conclusions: Minimally invasive laparoscopic resection for colorectal cancer enables an oncologically adequate resection with complication and survival rates that are no worse than are to be expected after traditional open surgery. Locally advanced tumor and bowel distension are the most frequent reasons for conversion to open surgery.

Purpose: In the last ten years, several robotic systems have been developed to overcome the loss of the three-dimensional view and dexterity characteristic of laparoscopic surgery. The aim of this study was to compare the traditional laparoscopic approach and robotic techniques in the treatment of colorectal diseases., Methods: The study compares a consecutive series of patients treated surgically for colorectal disease from June 2001 to May 2003 with the da Vinci robotic system (Intuitive Surgical) and a matched number of patients who underwent conventional laparoscopy during the same time interval. The factors analyzed were the time required to prepare the patient and the room, total time of surgery, length of specimens, number of lymph nodes retrieved, blood loss, complications, and postoperative results., Results: The study included 106 patients (53 in each group). No differences were observed in total time of surgery (laparoscopic group, 222 +/- 77 minutes vs. robotic group, 240 +/- 61 minutes), specimen length (laparoscopic group, 29 +/- 11 cm vs. robotic group, 27 +/- 13 cm), or number of lymph nodes retrieved (laparoscopic group, 16 +/- 9 vs. robotic group, 17 +/- 10). It took significantly longer to prepare the operating room and patient in the robotic group (24 +/- 12 minutes) than in the laparoscopic group (18 +/- 7 minutes). There were three conversions to laparotomy in the laparoscopic group; in the robotic group, two cases were converted to laparoscopy and three to hand-assisted laparoscopy. No significant differences were observed between the two groups in terms of recovery of bowel function and postoperative hospital stay., Conclusions: Robot-assisted surgery proved to be as safe and effective as laparoscopic techniques in the treatment of colorectal diseases. Because of its dexterity and three-dimensional view, the da Vinci system was particularly useful in specific stages of the procedure, e.g., takedown of the splenic flexure, dissection of a narrow pelvis, identification of nervous plexus, and handsewn anastomosis. The cost-effectiveness of the procedure still needs to be evaluated.