Marcello Gasparrini

Role of CT angiography with three-dimensional reconstruction of mesenteric vessels in laparoscopic colorectal resections: a randomized controlled trial

BackgroundLaparoscopic surgery, despite its well-known advantages and continuous technological innovations, still has limitations such as the lack of tactile sensation and reduced view of the operative field. These limitations are particularly evident when performing laparoscopic colorectal resection due to the variability of the number and course of mesenteric vessels. Today, the patient’s vascular anatomy can be mapped using computed tomography (CT) angiography and processing of the images with rendering software to reconstruct a three-dimensional model of the mesenteric vessels. To assess how prior knowledge of the patient’s mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resections, we conducted a randomized, parallel, single-blinded controlled trial.MethodsFrom January 2010 to January 2012, all patients with surgical indication to undergo standardized right or left hemicolectomy and anterior rectal resections were randomly assigned to two groups and subjected to CT angiography with three-dimensional reconstruction of mesenteric vessels. In the first group the surgeon was able to view the 3D reconstruction before and during surgery, while in the second group the surgeon was only able to view the 3D reconstruction after surgery.ResultsEvaluation of data from 112 patients shows statistically significantly lower operative time, episodes of difficult identification of right anatomy, and incidence of intraoperative and postoperative complication related to difficult or erroneous identification of mesenteric vessels in the group in which the surgeon was able to view the 3D reconstruction before and during surgery compared with the control group.ConclusionThis study shows that prior knowledge of the patient’s mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resection. Registration number NCT01540448 (http://www.clinicaltrials.gov).

Laparoscopic cholecystectomy in day surgery: Feasibility and outcomes of the first 400 patients

BACKGROUND The aim of this study was to evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in a day surgery setting in Italy. MATERIAL AND METHODS Between March 2003 and June 2011, in our institution 439 patients were selected for day surgery LC. To evaluate the efficacy and safety of the procedure, postoperative complications, pain, nausea and vomiting were monitored at 4, 8, and 24 h after surgery. Patients admitted for an overnight stay or readmitted after discharging were also monitored. RESULTS Over 8 years we performed 400 LC in day surgery setting and no conversion or major intraoperative complication were detected. A total of 387 patients (96.7%) were successfully discharged after 8-10 h of observation. Postoperative monitoring showed good pain control (mean VAS score 1.5) and only 3 (0.7%) of the 7 patients who experienced major pain were admitted. Twenty-seven patients (6.7%) experienced PONV and 9 (2.2%) of these required admission. None of the patients needed to be readmitted after discharging. The satisfaction questionnaire administered at 1 month office visit showed that 380 patients (95%) were satisfied with day surgery LC. CONCLUSIONS Our success rate of 96.7% can be attributed to strict adherence to the patient selection criteria. The main reasons for hospital admission were pain and PONV; adequate control of these represents the key of success for day surgery LC. This study confirms the feasibility and safety of LC performed in day surgery setting.

Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity.

BACKGROUND: Obstructed defecation syndrome is a widespread and disabling disease. OBJECTIVE: We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome. DESIGN: A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted. SETTINGS: The entire study was conducted at a university hospital. PATIENTS: All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol. INTERVENTIONS: All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them. MAIN OUTCOME MEASURES: Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated. RESULTS: The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure. LIMITATIONS: Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias. CONCLUSIONS: The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.

Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial

AbstractBackgroundAnastomotic leakage following anterior rectal resection is the most important and most commonly faced complication of laparoscopy and open surgery. To prevent this complication, the construction of a preventing stoma is usually adopted. It is not easy to decide whether to construct a protective stoma in patients with a medium risk of anastomotic leakage. In these patients, ghost ileostomy (GI), a pre-stage ileostomy that can be externalized and opened if needed, has proved useful. We conducted a prospective, randomized, controlled study to evaluate the advantages of GI in laparoscopic rectal resection.MethodsAll patients with surgical indications for laparoscopic rectal resection who were at medium risk for anastomotic leakage from January 2007 to January 2013 were included and were randomly divided in 2 groups. All of the patients were subjected to laparoscopic anterior rectal resection with the performance of GI (group A) or without the construction of any protective stoma (group B). The presence and severity of clinically evident postoperative anastomotic leakage and other postoperative complications and reinterventions were investigated.ResultsOf the 55 patients allocated to group A, 3 experienced anastomotic leakage compared with 4 in group B. The patients with GI experienced a lower severity of anastomotic leakage and shorter hospitalization compared with the patients in group B. None of the patients with GI and anastomotic leakage required laparotomy to treat the dehiscence.ConclusionsThe use of GI in laparoscopic rectal resections in patients at medium risk for anastomotic leakage was useful because it allowed for the avoidance of stoma creation in all of the patients, thus reducing the number of stomas performed, improving the quality of life of the patients and preserving, in most cases, the benefits gained by laparoscopy.

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.

Feasibility and safety study of day-case Transtar™ procedure.

BACKGROUND Short hospitalization surgery is cost effective and convenient for both patients and healthcare system. Stapled transanal rectal resection (STARR) conducted with the new curved device, Contour Transtar, has proved an effective and safe procedure for treatment of obstructed defecation syndrome. The aim of this study was to determine the safety and feasibility of STARR, performed as a day-case procedure. MATERIAL AND METHODS Retrospective review was performed of all STARR performed as day-case surgery between September 2009 and February 2011. The entire study (intervention, data collection and data analysis) was conducted at the One-day Surgery Unit of the St. Andrea Hospital, Rome, Italy. All patients with surgical indication to STARR for the presence of an obstructed defecation syndrome were included in the study. We excluded from day-case protocol, patients over 65 years old, with an ASA score of III-IV or with a BMI over 35. The surgical technique reflects the original technique proposed by Antonio Longo with the exception of the longitudinal prolapse opening, which was created with the use of an electric scalpel between two Kocher clamps and not by an application of Transtar stapler. To evaluate the feasibility and safety of performing this procedure with short hospitalization, we investigated the presence and the time of presentation of post-operative complications. RESULTS Eighty-nine patients underwent STARR as a day-case regimen, and none presented major complications or required an extension of hospital stay or readmission. CONCLUSIONS STARR performed with Contour Transtar, in selected patients, is safe and feasible in day-case regimen if performed by expert surgeons and in a structure that allows the physician to keep the patient hospitalized or to re-admit and promptly treat those patients who present major surgical complication.

Does the removal of retained staples really improve postoperative chronic sequelae after transanal stapled operations

BACKGROUND: Transanal stapled procedures are increasingly being used. Several postoperative complications can be referred to their application, including those related to the presence of retained staples at the level of the staple line. OBJECTIVE: This study was conducted to assess whether the removal of the retained staples is a useful approach to improve some of the most common postoperative complications of these surgical techniques. DESIGN: This is a retrospective study. SETTINGS: The study was conducted at the One-Day Surgery Unit of St. Andrea Hospital. PATIENTS: All of the patients who underwent a stapled transanal procedure from January 2003 to December 2011 were included in the study. Patients included in the study were followed postoperatively for 1 year after surgery to identify the presence of retained staples. INTERVENTIONS: If identified, the retained staples were removed endoscopically or transanally. MAIN OUTCOME MEASURES: After the staple removal, patients were followed with biweekly office visit for 2 months to evaluate the progression of symptoms. RESULTS: From the 566 patients included in the study, 165 experienced postoperative complications, and in 66 of these cases, retained staples were found and removed. With the removal of retained staples, symptoms were almost all resolved or improved. In only 1 case did the retained staples removal not modify the symptoms. LIMITATIONS: The study design may have introduced potential selection bias. In addition, the study was limited by the lack of a specific questionnaire for the evaluation of symptoms improvement. CONCLUSIONS: The removal of the retained staples is an efficacious and safe procedure to solve or improve postoperative complications and should be always considered.

Indocyanine green fluorescence angiography: a new ERAS item

ERAS protocol and indocyanine green fluorescence angiography (ICG-FA) represent the new surgical revolution minimizing complications and shortening recovery time in colorectal surgery. As of today, no studies have been published in the literature evaluating the impact of the ICG-FA in the ERAS protocol for the patients suitable for colorectal surgery. The aim of our study was to assess whether the systematic evaluation of intestinal perfusion by ICG-FA could improve patients outcomes when managed with ERAS perioperative protocol, thus reducing surgical complication rate. This is a retrospective case–control study. From March 2014 to April 2017, 182 patients underwent laparoscopic colorectal surgery for benign and malignant diseases. All the patients were enrolled in ERAS protocol. Two groups were created: Group A comprehended 107 patients managed within the ERAS pathway only and Group B comprehended 75 patients managed as well as with ERAS pathway plus the intraoperative assessment of intestinal perfusion with ICG-FA. Two board-certified laparoscopic colorectal surgeons jointly performed all procedures. Six (5.6%) clinically relevant anastomotic leakages (AL) occurred in Group A, while there was none in Group B, demonstrating that ICG-FA integrated in the ERAS protocol can lead to a statistically significant reduction of the AL. Mean operative time between the two groups was not statistically significant. In five cases (6.6%), the demarcation line set by the fluorescence made the surgeon change the resection line previously marked. The prevalence of all other complications did not differ statistically between the two groups. Our study confirms that combination between ICG and ERAS protocol is feasible and safe and reduces the anastomotic leakage, possibly leading to consider ICG-FA as a new ERAS item.

STARR and TRANSTARR Procedures

Obstructed defecation syndrome (ODS) is characterized by a multifactorial etiology, resulting from the interaction of functional and anatomical factors that influence the rectoanal mechanism of evacuation [1]. The most common anatomical changes associated with ODS are rectocele and rectal intussusception [2].

Comments on Long-term outcome after transanal rectal resection in patients with obstructed defecation syndrome.

To the Editor—the authors thank Dr francesco saverio mari and his colleagues for commenting on our article in the february 2013 issue of Diseases of the Colon & Rectum. We concur with them that the rate of incontinence that we observed postoperatively was rather high, with a new onset in 13% of patients at 4 weeks after the operation. however, of the 16 patients that reported an impairment of continence initially, only 3 (4%) remained incontinent at the end of follow-up. in many patients, continence was restored solely by reducing the laxatives that had been taken since before the operation. the rate of incontinence and how this is measured differs in the literature. other authors report persisting incontinence problems of up to 10% of their patients after more than 1 year after the operation. the development of incontinence after a staRR operation is therefore a serious problem, and patients should be carefully informed about this specific complication before giving their consent. We agree that a thorough preoperative evaluation is crucial to selecting the right patients for the staRR procedure. our patients were investigated profoundly and selected carefully according to the guidelines of the staRR pioneers, as we stated. this included routine anal manometry. all the same, even with such investigations, a new onset of postoperative incontinence cannot be avoided completely. furthermore, some desperate cases with already preexisting incontinence and additional obstructed defecation problems were included in our series. the staRR procedure helped most of those patients, but, in some cases, only after a second, previously anticipated procedure (eg, sacral neuromodulation) was performed. other authors also have reported Comments on Long-term Outcome After Transanal Rectal Resection in Patients With Obstructed Defecation Syndrome