Fabio Staderini

Totally Laparoscopic Versus Open Gastrectomy for Gastric Cancer: A Matched Cohort Study

BACKGROUND The role of laparoscopic surgery for the treatment of gastric cancer is still controversial, particularly in terms of oncologic efficacy. The aim of this study was to compare short-term outcomes of laparoscopic and open resection for gastric cancer at a single Western institution. SUBJECTS AND METHODS This study was designed as a matched cohort study from a prospective gastric cancer database. Forty-one patients undergoing laparoscopic gastrectomy for gastric cancer between June 2008 and January 2012 were matched with 41 patients undergoing open gastrectomy in the same time period. Patient pairing was done according to age, gender, type of gastrectomy (subtotal or total), and tumor stage via a randomized statistical method. The short-term outcomes and oncologic adequacy of the laparoscopic and open procedures were compared. A D2 lymph node dissection was performed in the majority of patients in both groups. RESULTS The two study groups were similar with respect to patient and tumor characteristics. Laparoscopic procedures were associated with a decreased blood loss (118.7 versus 312.4 mL, P<.005), incidence of surgery-unrelated complications (3 versus 9 patients, P<.05), and duration of hospital stay (8.1 versus 11.5 days, P<.05) but increased operative time for both subtotal (223.5 versus 158.2 minutes, P<.001) and total (298.1 versus 185.5 minutes, P<.001) gastrectomies. The mean number of retrieved lymph nodes after D2 dissection was similar: 30.0 for laparoscopic and 29.7 for open patients. CONCLUSIONS Within the limitations of a nonrandomized analysis, this study shows that the laparoscopic approach is a safe and oncologically adequate option for the treatment of gastric cancer, which compares favorably with open gastrectomy in short-term outcomes.

Robotic rectal surgery: State of the art

Laparoscopic rectal surgery has demonstrated its superiority over the open approach, however it still has some technical limitations that lead to the development of robotic platforms. Nevertheless the literature on this topic is rapidly expanding there is still no consensus about benefits of robotic rectal cancer surgery over the laparoscopic one. For this reason a review of all the literature examining robotic surgery for rectal cancer was performed. Two reviewers independently conducted a search of electronic databases (PubMed and EMBASE) using the key words “rectum”, “rectal”, “cancer”, “laparoscopy”, “robot”. After the initial screen of 266 articles, 43 papers were selected for review. A total of 3013 patients were included in the review. The most commonly performed intervention was low anterior resection (1450 patients, 48.1%), followed by anterior resections (997 patients, 33%), ultra-low anterior resections (393 patients, 13%) and abdominoperineal resections (173 patients, 5.7%). Robotic rectal surgery seems to offer potential advantages especially in low anterior resections with lower conversions rates and better preservation of the autonomic function. Quality of mesorectum and status of and circumferential resection margins are similar to those obtained with conventional laparoscopy even if robotic rectal surgery is undoubtedly associated with longer operative times. This review demonstrated that robotic rectal surgery is both safe and feasible but there is no evidence of its superiority over laparoscopy in terms of postoperative, clinical outcomes and incidence of complications. In conclusion robotic rectal surgery seems to overcome some of technical limitations of conventional laparoscopic surgery especially for tumors requiring low and ultra-low anterior resections but this technical improvement seems not to provide, until now, any significant clinical advantages to the patients.

Robotic vs laparoscopic distal gastrectomy with D2 lymphadenectomy for gastric cancer: a retrospective comparative mono-institutional study

BackgroundRobotic surgery has been developed with the aim of improving surgical quality and overcoming the limitations of conventional laparoscopy in the performance of complex mini-invasive procedures. The present study was designed to compare robotic and laparoscopic distal gastrectomy in the treatment of gastric cancer.MethodsBetween June 2008 and September 2015, 41 laparoscopic and 30 robotic distal gastrectomies were performed by a single surgeon at the same institution. Clinicopathological characteristics of the patients, surgical performance, postoperative morbidity/mortality and pathologic data were prospectively collected and compared between the laparoscopic and robotic groups by the Chi-square test and the Mann-Whitney test, as indicated.ResultsThere were no significant differences in patient characteristics between the two groups. Mean tumor size was larger in the laparoscopic than in the robotic patients (5.3 ± 0.5 cm and 3.0 ± 0.4 cm, respectively; P = 0.02). However, tumor stage distribution was similar between the two groups. The mean number of dissected lymph nodes was higher in the robotic than in the laparoscopic patients (39.1 ± 3.7 and 30.5 ± 2.0, respectively; P = 0.02). The mean operative time was 262.6 ± 8.6 min in the laparoscopic group and 312.6 ± 15.7 min in the robotic group (P < 0.001). The incidences of surgery-related and surgery-unrelated complications were similar in the laparoscopic and in the robotic patients. There were no significant differences in short-term clinical outcomes between the two groups.ConclusionsWithin the limitation of a small-sized, non-randomized analysis, our study confirms that robotic distal gastrectomy is a feasible and safe surgical procedure. When compared with conventional laparoscopy, robotic surgery shows evident benefits in the performance of lymphadenectomy with a higher number of retrieved and examined lymph nodes.

A unique presentation of a renal clear cell carcinoma with atypical metastases

Highlights • Management of advanced renal cancer.• Role of multidisciplinary approach in atypical metastatic renal cancer.• Cytoreductive surgery and metastasectomy improving effectiveness of multi-targeted therapies.• Disease free progression after surgery and multi-targeted therapies in advanced renal clear cell carcinoma.

Survival after laparoscopic and open surgery for colon cancer: a comparative, single-institution study

BackgroundSome recent studies have suggested that laparoscopic surgery for colorectal cancer may provide a potential survival advantage when compared with open surgery. This study aimed to compare cancer-related survivals of patients who underwent laparoscopic or open resection of colon cancer in the same, high volume tertiary center.MethodsPatients who had undergone elective open or laparoscopic surgery for colon cancer between January 2002 and December 2010 were analyzed. A clinical database was prospectively compiled. Survival analysis was calculated by using the Kaplan-Meier method.ResultsA total of 460 resections were performed. There were no significant differences between the laparoscopic (n = 227) and the open group (n = 233) apart from tumor stage: stage I tumors were more frequent in the laparoscopic group whereas stage II tumors were more frequent in the open group. The mean number of harvested lymph nodes was significantly higher in the laparoscopic than in the open group (20.0 ± 0.7 vs 14.2 ± 0.5, P < 0.01). The 5-year cancer-related survival for patients undergoing laparoscopic resection was significantly higher than that following open resections (83.1% vs 68.5%, P = 0.01). By performing a stage-to-stage comparison, we found that the improvement in survival in the laparoscopic group occurred mainly in patients with stage II tumors.ConclusionsOur study shows a survival advantage for patients who had undergone laparoscopic surgery for stage II colon cancer. This may be correlated with a higher number of harvested lymph nodes and thus a better stage stratification of these patients.

Cost–benefit analysis of the intraoperative parathyroid hormone assay in primary hyperparathyroidism

The purpose of this study was to evaluate the usefulness of the routine intraoperative intact parathyroid hormone (IOPTH) assay, the role of unilateral and bilateral cervical exploration and of preoperative imaging, and to do a cost–benefit analysis in parathyroidectomy for primary hyperparathyroidism.

Prevenzione e trattamento della ipocalcemia precoce e tardiva dopo tiroidectomia

Gran parte delle circa 40000 tiroidectomie annuali in Italia prevede un ricovero di una sola notte con grado di efficacia ed efficienza elevate, consentito dalla percentuale modesta di complicanze, dal dolore post operatorio contenuto e dal rapido recupero dei pazienti [1, 2]. A fronte di indubbi vantaggi socio-economici e sulla qualità di vita del paziente, la maggiore riserva riguarda la difficoltà di prevedere e trattare le eventuali complicanze tardive. Le tre complicanze maggiori post-tiroidectomia possono alterare in modo severo le condizioni del paziente fino a metterne a rischio la sopravvivenza (Tabella 1).

Reply to Letter to Editor regarding “Economic impact of intraoperative parathyroid hormone assay in primary hyperparathyroidism”

Dear Editor, We read with interest the comments of de la Plaza Llamas et al. on our published manuscript “Cost-benefit analysis of the intraoperative parathyroid hormone assay in primary hyperparathyroidism.” Our analysis was based exclusively on the cost of parathyroid hormone assay and the operating room costs because they were objectively determined measures. The length of hospital stay was not considered because all patients stayed 1 night in the hospital, with the exception made for some patients of group A, who stayed more than 1 night due to long operating room time. We never affirmed that one of the benefits of using intraoperative intact parathyroid hormone (IOPTH) is that it shortens the length of stay in the hospital. Re-reading our article, we noticed that our conclusions can lead to a misunderstanding: when we state “this approach can decrease costs...” we meant “our approach,” without IOPTH assay. We think that the case of reoperation in group A reinforces our thesis about the overuse of IOPTH; nevertheless, we performed IOPTH and if we did not find the adenoma, we would have obtained the same result even without IOPTH essay, this is the reason why we think this case influenced the costs of group A. We explained why delayed IOPTH was performed in group B1: it was our control group: “the B1 group was considered our control group because the results of PTH intraoperative sampling could not change the surgeon’s strategy during the operation and it was used to better understand if IOPTH would be helpful in guiding the surgeon’s intraoperative decisions.” The IOPTH was performed in all patients of group A, even in those 29 patients who underwent an associated thyroidectomy because at the beginning of our experience we planned to perform IOPTH to all patients. In addition, group B includes patients who underwent a thyroidectomy and a bilateral exploration. We think that the kind of intervention does not impact the diagnostic accuracy of IOPTH. We do not perform minimally invasive video-assisted parathyroidectomy (MIVAP) with the patients under local anesthesia, in our experience, MIVAP is not longer than conventional or minimally invasive parathyroidectomy. Hence, MIVAP did not negatively influence operative time. This is an observational-retrospective study. The slight dishomogeneity of the 2 groups is intrinsic in the study design but it did not affect costs because we considered homogeneous and objective parameters for the cost analysis. We thank our colleagues for their comments from “the use of IOPTH produced false negative in twelve.....” up to the end of the letter; we appreciated them but we do not think they are related to the primary purpose of our study: cost benefits.

Lymph node mapping with near-infrared fluorescence imaging during robotic surgery for gastric cancer: a pilot study

Lymphadenectomy for gastric cancer is considered to be technically difficult to perform in conventional laparoscopic surgery. The robotic system has been introduced to overcome some of these technical limitations of laparoscopy. The daVinci robotic platform allows near-infrared fluorescence imaging (NIFI) with indocyanine green (ICG) to be integrated into the surgical field. This pilot study aimed at investigating whether the use of NIFI with ICG may improve the intraoperative visualization of lymph nodes and help to identify complete lymph node removal during robotic gastrectomy. Fourteen patients underwent robotic distal gastrectomy with D2 lymph node dissection for gastric cancer. A 0.2% ICG solution was injected into the submucosa endoscopically at four sites around the tumor. Fluorescence imaging with ICG was carried out with a robotic infrared camera system. Fluorescent lymph nodes were both dissected out intraoperatively and isolated in the dissected specimen with the help of the robotic camera. Eight males and 6 females were enrolled in the study. No adverse effects of the ICG were observed. The mean total number of examined lymph node was 43.3 (range, 27–78). The mean number of fluorescent lymph nodes was 19.4 (range, 1–36). Seven patients were found to have metastatic lymph nodes: in 3 patients, all the metastatic lymph nodes were fluorescent, in 3 they were non-fluorescent and in 1 patient they were both fluorescent and non-fluorescent. NIFI is a promising method of lymphatic mapping during robotic gastrectomy and may provide a valuable adjunct for identification of complete D2 lymphadenectomy.

Can 3D imaging really help the surgeon perform laparoscopic gastric surgery

One of the major limitations of conventional laparoscopy is the lack of depth perception due to the planar image from two-dimensional (2D) monitors.