Dario Sirimarco

Robotic right colectomy: A worthwhile procedure? Results of a meta-analysis of trials comparing robotic versus laparoscopic right colectomy

Background: Robotic right colectomy (RRC) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach is worthwhile in enhancing patient recovery and reducing post-operative complications, compared with laparoscopic right colectomy (LRC). Literature is still fragmented and no meta-analyses have been conducted to compare the two procedures. This work aims at reducing this gap in literature, in order to draw some preliminary conclusions on the differences and similarities between RRC and LRC, focusing on short-term outcomes. Materials and Methods: A systematic literature review was conducted to identify studies comparing RRC and LRC, and meta-analysis was performed using a random-effects model. Peri-operative outcomes (e.g., morbidity, mortality, anastomotic leakage rates, blood loss, operative time) constituted the study end points. Results: Six studies, including 168 patients undergoing RRC and 348 patients undergoing LRC were considered as suitable. The patients in the two groups were similar with respect to sex, body mass index, presence of malignant disease, previous abdominal surgery, and different with respect to age and American Society of Anesthesiologists score. There were no statistically significant differences between RRC and LRC regarding estimated blood loss, rate of conversion to open surgery, number of retrieved lymph nodes, development of anastomotic leakage and other complications, overall morbidity, rates of reoperation, overall mortality, hospital stays. RRC resulted in significantly longer operative time. Conclusions: The RRC procedure is feasible, safe, and effective in selected patients. However, operative times are longer comparing to LRC and no advantages in peri-operative and post-operative outcomes are demonstrated with the use of the robotic surgical system.

Retroperitoneal schwannomas: advantages of laparoscopic resection. Review of the literature and case presentation of a large paracaval benign schwannoma (with video)

Retroperitoneal schwannomas represent 0.5%–3% of all retroperitoneal tumors. Complete surgical removal is the treatment of choice because it permits a correct histological diagnosis and prevents eventual degeneration. Laparoscopic surgery has been reported as safe and effective by several authors. We present a comprehensive review of the literature regarding the role of laparoscopy in surgical resection of retroperitoneal schwannomas, and we present a case showing the technique (with video). Laparoscopic resection in experienced hands is safe and effective, and guarantees excellent postoperative results in terms of patient recovery.

Dedifferentiated Liposarcoma of the Retroperitoneum With Osteosarcomatous Component

We commend Iwasa and Nakashima for their brilliant work on dedifferentiated liposarcoma (DDL). In particular, we really appreciated the differentiations the authors assessed between high-grade (HDDL) and low-grade DDL (LDDL), as well as conventional and comingling types of DDL (where the transition from well-differentiated liposarcoma (WDL) to DDL is abrupt in the former and intermingled in the latter). Furthermore, since LDDL proved to have metastatic capability, we concur with them on the concern of using mitotic count as one of the criteria for dedifferentiation, whereas advocate for retroperitoneal localization as a prognostically unfavorable feature of DDL. Recently, we had to deal with a 69-year-old man affected by a very rare form of DDL, that is, DDL with osteosarcomatous component (ODDL) occurring in the left retroperitoneum. A curative excision of the neoplasm was conducted along with en bloc resection of the greater omentum, spleen, left colon, left adrenal gland, and kidney. The patient did well after the intervention and was scheduled for adjuvant radiochemotherapy with epirubicin and ifosfamide; nevertheless, at 4-month follow-up he developed multiple supracentimetric intraand retroperitoneal metastases. Only 17 cases of ODDL are reported in the world medical literature. Of these, 13 occurred in the retroperitoneum. Retroperitoneal ODDL seems to have a predilection for male patients (8 men, 3 women, undeclared gender in 2 instances) ranging in age from 40 to 61 years; of interest, our patient aged 69 years is the oldest to be affected by retroperitoneal ODDL. Ten patients (77%) were Asian (9 from Japan and 1 from South Korea), whereas only 3 patients were Occidental (2 from the United States and 1 from England); hence, our patient is the second to be recorded in Europe and the first from Italy. The tumor size data were available for 8 cases (range = 7-40 cm craniocaudally), whereas the retroperitoneal side was revealed only in 5 instances (2 lesions were right-sided, 2 were left-sided whereas 1 occupied the entire retroperitoneum). Our patient suffered from a 19 cm × 16 cm left-sided retroperitoneal ODDL. Eleven patients underwent surgical treatment, and a percutaneous biopsy of the lesion was conducted with diagnostic intention for two patients with widespread disease. Macroscopically, ODDL commonly appears as unior multinodular fatty mass with inner well-defined bony component. Histologically, it is composed of WDL intermingled with osteosarcomatous foci; the interface between the 2 components may be gradual, abrupt, or less frequently, mosaic. The most common pattern was that of a high-grade osteosarcomatous dedifferentiation (6 cases), followed by 3 low-grade cases, whereas in the remaining 4 cases this information was unreported. High-grade osteosarcoma was found also in our patient. The longest follow-up reported for a patient previously operated for ODDL and free from disease (only 2 cases) is of 7 years and 11 months; besides these, 1 patient died from cancer, 4 cases developed local recurrence and distant metastases, and in 5 cases this topic was not clearly described. Concerning the prognostic significance, the anatomic location seems to be the most important factor for DDL, with the retroperitoneal compartment imparting the worst behavior; on the contrary, the tumor size, expression of MDM2 and CDK4, and histological grade have led to heterogeneous results. In summary, DDL with osteosarcomatous dedifferentiation represents a very rare and complex form of DDL; the information about its main features come from very few case reports and are extrapolated with difficulty from larger series on DDL. Hence, more dedicated reports are required to better assess the anatomopathobiological features of this disease.

Transthoracically or transabdominally: how to approach adenocarcinoma of the distal esophagus and cardia. A meta-analysis

Esophageal carcinoma is the eighth most frequent cancer worldwide and the sixth cancer-related cause of death. Here we propose a new meta-analysis to identify the most appropriate approach for resectable adenocarcinoma of the distal esophagus and cardia (Siewert 1-2). A systematic literature search was performed independently by 2 of the manuscripts authors using PubMed, EMBASE, Scopus and the Cochrane Library Central. The following criteria were set for inclusion in this meta-analysis: 1) studies comparing transthoracic esophagectomy and transhiatal esophagectomy for adenocarcinoma of the esophagus; 2) studies reporting at least 1 perioperative outcome; and 3) if more than 1 study was reported by the same institute, only the most recent or the highest quality study was included. A total of 6 articles dated between 1996 and 2012 fulfilled the selection criteria and were therefore included in this meta-analysis; this pool of articles consisted of 2 prospective and 4 retrospective studies. A statistically significant difference favoring the transthoracic procedure was noted regarding the number of retrieved lymph nodes, 5-year disease-free survival rate and 5-year overall survival rate (p = 0.001, p = 0.05 and p = 0.03, respectively). In conclusion, transthoracic esophagectomy for adenocarcinoma of the distal esophagus and esophagogastric junction (Siewert 1-2) appears to be superior to the transhiatal approach in terms of oncological outcomes.

Inferior vena cava resection with prosthesis replacement for recurrent leiomyosarcoma (with video)

Inferior vena cava (IVC) leiomyosarcoma (LY) is a rare tumor with poor prognosis and recurring in one third of patients, radical surgery represents the only chance of cure. Whether caval flow has to be re-established with IVC reconstruction is a matter of debate as well as neoadjuvant therapy. We herein present a case of recurrent IVC LY managed with caval resection and reconstruction with polyethylene terephthalate (PET) prosthesis and left lateral liver resection for suspected metastases. Although the patient experienced a prosthesis occlusion and transient renal failure, at 24 months’ follow-up is recurrence free with a normal renal function and no sign of lower limbs edema.