Gianluigi Melotti

Laparoscopic distal pancreatectomy: results on a consecutive series of 58 patients.

Objective:To describe the clinical characteristics, indications, technical procedures, and outcome of a consecutive series of laparoscopic distal pancreatic resections performed by the same surgical team. Summary Background Data:Laparoscopic distal pancreatic resection has increasingly been described as a feasible and safe procedure, although accompanied by a high rate of conversion and morbidity. Methods:A consecutive series of patients affected by solid and cystic tumors were selected prospectively to undergo laparoscopic distal pancreatectomy performed by the same surgical team. Clinical characteristics as well as diagnostic preoperative assessment and intra- and postoperative data were prospectively recorded. A follow-up of at least 3 months was available for all patients. Results:Fifty-eight patients underwent laparoscopic resection between May 1999 and November 2005. All procedures were successfully performed laparoscopically, and no patient required intraoperative blood transfusion. Splenic vessel preservation was possible in 84.4% of spleen-preserving procedures. There were no mortalities. The overall median hospital stay was 9 days, while it was 10.5 days for patients with postoperative pancreatic fistulae (27.5% of all cases). Follow-up was available for all patients. Conclusions:Our experience in 58 consecutive patients was characterized by the lack of conversions and by acceptable rates of postoperative pancreatic fistulae and morbidity. Laparoscopy proved especially beneficial in patients with postoperative complications as they had a relatively short hospital stay. Solid and cystic tumors of the distal pancreas represent a good indication for laparoscopic resection whenever possible.

Laparoscopic surgery for colorectal cancer.

Despite the widespread use of laparoscopic techniques in many fields, in the realm of malignant diseases, a great concern has been raised regarding safety, efficacy, and long-term results. The authors report their experience of 163 patients operated on for colorectal malignancies by minimally invasive access. The conversion rate (20.4%), morbidity (15.1%), and null mortality compare well with other studies published worldwide. The postoperative outcome was characterized by a prompt return to activity (1.3 days) and of bowel movements (2.9 days), while length of stay and an adequate oral resumption were comparable to those of open surgery. Peritoneal lavage did not show tumor cells disseminated during the operative maneuvers. The distance of tumor from resection margins and the number of lymph nodes harvested with the operative specimen did not vary from those obtained in open surgery. Two patients (1.2%) recurred at the mini-laparotomy and port sites, but, in both cases, the traumatic manipulation of the cancer specimen was probably responsible for the event. After a mean follow-up of over 3 years, 34 patients died of neoplastic recurrence, and 17 are alive with disease relapse. The laparoscopic approach to colectomy has not yet gained an unquestioned place in the experience of the colorectal surgeon. However, if sound surgical method and judgement are used to minimize local recurrences, and if a better preservation of postoperative immune function proves to be of clinical significance in the long term, laparoscopic colectomy may prove to be a safe and less stressful approach to colon resection.

Is laparoscopic adrenalectomy safe and effective for adrenal masses larger than 7 cm

BackgroundLaparoscopic adrenalectomy (LA) has become the gold standard treatment for small (less than 6 cm) adrenal masses. However, the role of LA for large-volume (more than 6 cm) masses has not been well defined. Our aim was to evaluate, retrospectively, the outcome of LA for adrenal lesions larger than 7 cm.Patients and methods18 consecutive laparoscopic adrenalectomies were performed from 1996 to 2005 on patients with adrenal lesions larger than 7 cm.ResultsThe mean tumor size was 8.3 cm (range 7–13 cm), the mean operative time was 137 min, the mean blood loss was 182 mL (range 100–550 mL), the rate of intraoperative complications was 16%, and in three cases we switched from laparoscopic procedure to open surgery.ConclusionsLA for adrenal masses larger than 7 cm is a safe and feasible technique, offering successful outcome in terms of intraoperative and postoperative morbidity, hospital stay and cosmesis for patients; it seems to replicate open surgical oncological principles demonstrating similar outcomes as survival rate and recurrence rate, when adrenal cortical carcinoma were treated. The main contraindication for this approach is the evidence, radiologically and intraoperatively, of local infiltration of periadrenal tissue.

Italian Biological Prosthesis Work-Group (IBPWG): proposal for a decisional model in using biological prosthesis

IntroductionIndications for repair of abdominal hernia are well established and widely diffused. Controversies still exist about the indication in using the different prosthetic materials and principally about the biological ones.Material and methodsIn February 2012, the Italian Biological Prosthesis Work-Group (IBPWG), counting a background of 264 biologic implants, met in Bergamo (Italy) for 1-day meeting with the aim to elaborate a decisional model on biological prosthesis use in abdominal surgery.ResultsA diagram to simplify the decisional process in using biologics has been elaborated.ConclusionThe present score represents a first attempt to combine scientific knowledge and clinical expertise in order to offer precise indications about the kind of biological mesh to use.

Weakly acidic refluxes have a major role in the pathogenesis of PPI-resistant reflux oesophagitis.

Aliment Pharmacol Ther 2011; 33: 601–606

Laparoscopic Distal Pancreatectomy in Children: Case Report and Review of the Literature

BackgroundLaparoscopic resection of benign tumors of the pancreas has been reported in adults, but only four cases of partial laparoscopic pancreatectomy in children have been described in the English-language literature.MethodsWe describe the case of an 11-year-old girl with a solid pseudopapillary tumor who was treated with a laparoscopic, spleen-preserving, distal pancreatectomy. The specimen was extracted in an endoscopic bag retrieval system through a Pfannenstiel incision. Operative time was 120 minutes, and minimal blood loss occurred. The literature is reviewed.ResultsThe postoperative course was uneventful. Twenty-two months after the operation, clinical follow-up (including assessment of exocrine and endocrine pancreatic function) revealed nothing abnormal. The functional and aesthetic results were satisfactory.ConclusionsThe technique used for our case is simple and reproducible, was completed safely within a reasonable operative time, and yielded a good result.

Laparoscopic fundoplication for gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor (PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total (360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior (Toupet) fundoplication, and the anterior (Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.

Bioabsorbable synthetic plug in the treatment of anal fistulas.

BACKGROUND: Management of anal fistulas is challenging, because surgeons must aim to obtain complete healing while sparing the sphincter and avoiding fecal incontinence. The optimal treatment method remains unknown. OBJECTIVE: This study assessed the safety and effectiveness of the use of a new synthetic fistula plug made of bioabsorbable polymers in the treatment of cryptoglandular anal fistulas. DESIGN: This study is a retrospective review of a database of patient records. SETTING: Patients were treated at a general hospital in Italy. PATIENTS: Forty-eight patients (39 men and 9 women; mean age, 49.9 years) with 49 fistulas were treated with the synthetic plug between November 2009 and March 2012. Types of fistula were as follows: 24 superficial transsphincteric, 18 medium transsphincteric, 5 deep transsphincteric, and 1 medium intersphincteric. INTERVENTIONS: The fistula tract was cleaned by using curettage, and a synthetic plug was sized to fit the tract and inserted. A draining seton was used preoperatively in 1 patient. MAIN OUTCOME MEASURES: The outcome measures were complete closure of the fistula, with no discharge/residual fistula (verified by endoanal ultrasonography), perineal pain level (assessed with a visual analog scale), and fecal continence. Follow-up was conducted at 1 week and 1, 3, 6, and 12 months postoperatively. RESULTS: The overall healing rate was 69.3% (34/49 fistulas, 33/48 patients). Eight patients (24.2%) had healing by 3 months after surgery, 21 patients (63.6%) had healed by 6 months, and 4 patients (12.1%) had healed by 12 months. By 3 months, no patient had perineal pain or fecal incontinence. No plug became dislodged, and no patient had the onset of anal stenosis, bleeding, local infection, or any other complication. LIMITATIONS: The number of patients and the retrospective nonrandomized nature of the investigation are limitations of this study. CONCLUSIONS: In patients with cryptoglandular anal fistulas, the use of a bioabsorbable synthetic plug provided a high rate of healing without causing fecal incontinence or other major adverse effects. Larger and randomized studies of this treatment are warranted.

Impairment of chemical clearance is relevant to the pathogenesis of refractory reflux oesophagitis

BACKGROUND The pathophysiological mechanisms underlying proton pump inhibitor-refractory reflux oesophagitis has been scarcely studied. AIMS To assess impedance-pH parameters relevant to the pathogenesis of refractory reflux oesophagitis. METHODS Cases referred for heartburn/regurgitation refractory to high-dosage proton pump inhibitors between January 2008 and December 2012 were reviewed and subdivided into refractory oesophagitis (29 patients, 72% males, median age 50 years), healed oesophagitis (18 patients, 67% males, median age 54 years), and non-erosive reflux disease (49 patients, 53% males, median age 42 years). On-therapy impedance-pH tracings were blindly re-analysed by one observer to assess gastric and oesophageal acid exposure time and chemical clearance as expressed by the post-reflux swallow-induced peristaltic wave index. RESULTS The median gastric and oesophageal acid exposure time did not differ among the three groups (35%, 34%, 41% and 1.2%, 0.7%, 0.8%, respectively; P>0.05 for all comparisons). A normal oesophageal acid exposure time was found in two thirds of patients with refractory oesophagitis. The post-reflux swallow-induced peristaltic wave index was significantly lower in refractory oesophagitis (16%) than in healed oesophagitis (30%) and non-erosive reflux disease (29%) (P=0.003). CONCLUSIONS Refractory reflux oesophagitis is characterized by impairment of chemical clearance. Adequate acid suppression is found in the majority of patients who would likely not benefit from further proton pump inhibitor dose escalation.

Zenker diverticulectomy: first report of robot-assisted transaxillary approach.

Standard surgical treatment of Zenker’s diverticulum consists of open cricopharyngeal myotomy with diverticulectomy. A rigid or flexible endoscopic approach allowing a cricopharyngeal myotomy without diverticulectomy is currently considered as a less invasive alternative to open surgery with reportedly comparable symptom relief at short term follow-up. In recent years, high safety and efficacy of a transaxillary gasless robotic access to the thyroid gland has been shown. The present study describes the feasibility and preliminary results of robot-assisted transaxillary approach for cricopharyngeal myotomy and excision of Zenker’s diverticulum. Patients with troublesome dysphagia and radiological evidence of Zenker’s diverticulum underwent a robot-assisted cricopharyngeal myotomy and diverticulum excision using left transaxillary access with the support of endoscopic assistance. One month after intervention, symptoms were reevaluated and a barium swallow study was performed. Four patients with symptomatic Zenker’s diverticulum were successfully operated. No adverse event was recorded. One month after intervention, total dysphagia remission was declared by all four patients and there was no evidence of diverticulum recurrence at radiology. According to our preliminary data, left transaxillary robot-assisted approach for the surgical management of Zenker’s diverticulum is feasible, safe and effective. Whether our encouraging results will be confirmed in larger patient cohorts with prolonged follow-up, the robot-assisted transaxillary Zenker’s diverticulectomy may represent an alternative to traditional open diverticulectomy when endoscopic interventions cannot be performed or have failed.