Mariano Cesare Giglio

Meta-analysis of drain amylase content on postoperative day 1 as a predictor of pancreatic fistula following pancreatic resection

Drain amylase content in the days immediately after major pancreatic resection has been investigated previously as a predictor of postoperative pancreatic fistula (POPF). Its accuracy, however, has not been determined conclusively. The purpose of this study was to evaluate the accuracy of drain amylase content on the first day after major pancreatic resection in predicting the occurrence of POPF.

Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study

Background Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, “learning curve” experience, implementing a well standardized operative technique and recovery protocol. Methods The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed. Results Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo–Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission. Conclusion Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.

Confocal laser endomicroscopy in breast surgery: a pilot study

BackgroundBreast neoplasms include different histopathological entities, varying from benign tumors to highly aggressive cancers. Despite the key role of imaging, traditional histology is still required for a definitive diagnosis. Confocal Laser Endomicroscopy (CLE) is a new technique, which enables to obtain histopathological images in vivo, currently used in the diagnosis of gastrointestinal diseases. This is a single-center pilot feasibility study; the main aim is to describe the basic morphological patterns of Confocal Laser Endomicroscopy in normal breast tissue besides benign and malignant lesions.MethodsThirteen female patients (mean age 52.7, range from 22 to 86) who underwent surgical resection for a palpable breast nodule were enrolled. CLE was performed soon after resection with the Cellvizio® Endomicroscopy System (Mauna Kea Technologies, Paris, France), by using a Coloflex UHD-type probe; intravenous fluorescein was used as contrast-enhancing agent. The surgical specimen was cut along the main axis; dynamic images were obtained and recorded using a hand-held probe directly applied both to the internal part of the lesion and to several areas of surrounding normal tissue. Each specimen was then sent for definitive histologic examination.ResultsHistopathology revealed a benign lesion in six patients (46%), while a breast cancer was diagnosed in seven women (54%). Confocal laser endomicroscopy showed some peculiar morphological patterns. Normal breast tissue was characterized by a honeycomb appearance with regular, dark, round or hexagonal glandular lobules on a bright stroma background; tubular structures, representing ducts or blood vessels, were also visible in some frames. Benign lesions were characterized by a well-demarcated “slit-like” structure or by lobular structures in abundant bright stroma. Finally, breast cancer was characterized by a complete architectural subversion: ductal carcinoma was characterized by ill-defined structures, with dark borders and irregular ductal shape, formingribbons, tubules or nests; mucinous carcinoma showed smaller cells organized in clusters, floating in an amorphous extracellular matrix.ConclusionsThis is the first pilot study to investigate the potential role of confocal laser imaging as a diagnostic tool in breast diseases. Further studies are required to validate these results and establish the clinical impact of this technique.

In vivo assessment of tumour angiogenesis in colorectal cancer: the role of confocal laser endomicroscopy.

Tumour neoangiogenesis is a key factor in tumour progression and metastatic spread and the possibility to assess tumour angiogenesis might provide prognostic information. The aim of this study was to establish the role of probe‐based confocal laser endomicroscopy (p‐CLE) in the identification of vascular architecture and specific morphological patterns in normal colorectal mucosa and malignant lesions during routine endoscopy.

Kono-type anastomosis in a patient with severe multi-recurrent Crohn's disease.

Dear Editor: Despite significant advances in medical therapy, around 70– 80 % of patients with Crohn’s disease (CD) still require surgeries in their lifetime. New drugs and biologics have also demonstrated to be crucial in reducing post-operative recurrences; nevertheless, the fact that most of them appear at the anastomotic site emphasizes the importance of surgical approach in the management of these patients. Different ileocolic anastomotic configurations have been described, none of them demonstrating to be superior in terms of recurrence prevention. Data from post-operative endoscopic follow-up shows that, in absence of medical treatment, the post-operative endoscopic recurrence rate varies from 65 to 90 % within 12 months and 80–100 % within 3 years; on the other hand, the clinical recurrence rate is around 20–25 %/year. Many studies investigate on the potential prognostic role of some factors for the onset of CD recurrence, such as the operative technique (i.e., end-to-end anastomosis vs side-to-side anastomosis), patient’s risk profile (i.e., smoking, young age of onset, penetrating CD behavior), and prophylactic medical therapy. Early (6–12 months) ileocolonoscopy is a crucial tool for diagnosing post-operative CD recurrence, also being able to predict the subsequent course of CD in terms of clinical/ surgical recurrence. In 2011, Kono and coll. [a new antimesenteric functional end-to-end hand-sewn anastomosis: surgical prevention of anastomotic recurrence in Crohn’s disease. Dis Colon Rectum 2011; 54: 586–92] developed a new combined stapled and hand-sewn antimesenteric functional end-to-end anastomosis (Kono-S anastomosis) to minimize surgical recurrence in CD. Preliminary retrospective results comparing Kono-S anastomosis with conventional surgical techniques appear interesting and encouraging. We here share the case of a severe recurrent CD, which was successfully treated with the Kono-S anastomosis after a redo ileocolic resection. In 2009, a 24-year-old-patient, smoker, with a sister suffering from severe Crohn’s disease, received the diagnosis of penetrating ileal CD complicated by abdominal abscess. For

Confocal laser endomicroscopy in ulcerative colitis: beyond endoscopic assessment of disease activity

AbstractBackground The aim of this study was to investigate the role of confocal laser endomicroscopy (CLE) in the assessment of disease activity in ulcerative colitis (UC).Methods Consecutive patients with UC referred to our inflammatory bowel disease unit for colonoscopy were enrolled. Patients without UC were used as controls. UC activity was evaluated by white light endoscopy and classified according to the Mayo Ulcerative Colitis Endoscopic Score of Severity. Endoscopic biopsies were also taken for histological assessment of disease activity and then assessed with CLE. Three parameters were evaluated; crypt architecture (crypt diameter, inter-crypt distance, presence of fused crypts, crypts regularity), microvascular pattern (regular, dilated, irregular and deformed), fluorescein leakage.ResultsFifty patients with UC and 10 controls were enrolled. At colonoscopy, 11 patients (22%), 19 patients (38%), 12 patients (24%) and 8 patients (16%) presented a Mayo score of 0, 1, 2 and 3, respectively. At CLE, fused crypts were present in all the patients with UC and absent in controls. Crypt diameter and inter-crypt distance showed a parallel increase with the Mayo score. Fluorescein leakage and irregular vessels were more frequently found in case of a high level of endoscopic severity, but were also identified in about 20% of UC patients with normal mucosa. Biopsies also demonstrated the presence of histological activity in 4 patients with endoscopically inactive colitis.ConclusionsCLE might be a useful tool to determine inflammatory activity in UC. Fused crypts appeared to be a CLE marker of UC, while other abnormalities, like microvascular alteration and fluorescein leakage, have also been identified in patients with mucosal healing at endoscopy. Larger series are required to validate these results and the advantages of a CLE-based assessment of UC activity.

Detection of colonic dysplasia in patients with ulcerative colitis using a targeted fluorescent peptide and confocal laser endomicroscopy: A pilot study

Aim Targeted molecular probes have been used to detect sporadic colonic dysplasia during confocal laser endomicroscopy (CLE) with promising results. This is a feasibility pilot study aiming to assess the potential role of CLE combined with a fluorescent-labeled peptide to stain and detect dysplasia associated with Ulcerative Colitis. Method A phage-derived heptapeptide with predicted high binding affinity for dysplastic tissue, was synthesized and labeled with fluorescein. Eleven lesions with suspected dysplasia at endoscopy were excised from nine patients with long-standing ulcerative colitis. Specimens were sprayed with the peptide and examined by CLE. The CLE images were then compared to the corresponding histological sections. Results At definitive histology, 4 lesions were diagnosed as inflammatory polyps, 6 as dysplastic lesions and one as invasive cancer. In inflammatory polyps, the fluorescence signal came from peri-cryptal spaces and crypt lumen due to passive accumulation of the peptide in these areas. Dysplasia was associated with active binding of the peptide to dysplastic colonocytes. Conclusion Ex vivo staining of ulcerative colitis-associated dysplasia using a fluorescent labeled molecular probe and CLE is feasible. In vivo studies on larger populations are required to evaluate the safety and the effective contribution of molecular probes in cancer surveillance of ulcerative colitis.

Recurrent, spontaneous, postoperative small bowel perforations caused by invasive candidiasis

Dear Editor: Postoperative bowel perforations represent a serious medical condition with high morbidity and mortality. They are usually related to surgery itself; the anastomosis breakdown being considered the most common cause after bowel surgery; incidence maywidely vary, depending on type of primary surgery, anastomosis level and comorbidities. Iatrogenic injuries after abdominal surgery are also well-recognised causes of postoperative perforations; prompt diagnosis of such situations and eventually early reoperation are key factors for better prognosis. On the other hand, spontaneous and no-traumatic perforations may represent evenmore challenging clinical conditions, due to both difficulties in diagnosis and management. Underlying medical conditions are usually recognised as predisposing factors of spontaneous bowel perforations, such as ulcerative colitis, Crohn’s disease, jejunal perforation in celiac disease (if complicated by lymphoma or collagenous sprue), other than metabolic and vascular diseases; thus, even more uncommon conditions associated with spontaneous bowel perforation have been described such as Ehlers-Danlos syndrome. In recent years, the wide adoption of biological medications, such as monoclonal antibodies, has also led to new records of spontaneous bowel perforations, the most emblematic example being represented from bevacizumab, an inhibitor of vascular endothelial growth factor, used for several malignancies; few reports sent a warning on the possibility of bowel perforation after bevacizumab adoption, with an estimated incidence of about 3 %. A further chapter to be considered is represented by the infectious-related perforation: Cytomegalovirus (CMV) infection has been recognised has a cause of bowel perforation especially in immunocompromised patients, other than other bacterial, parasitic or fungal infections [1]. We here describe the case of a 76-year-old woman, who underwent a right hemicolectomy for a colon cancer and then developed multiple spontaneous postoperative small bowel perforations, requiring multiple reoperations: the only suspected cause of this being represented by a Candida infection which finally led to death. The patient had no significant comorbidities; the only anamnestic record being represented by a gallbladder resection plus biliary tract exploration for gallstones, 30 years before. A right hemicolectomy was performed by our surgical team to treat the cancer; it was a straightforward procedure and an ileocolic stapled end-to-end anastomosis was fashioned in a standard manner. The only immediate complication was represented by a pneumothorax due to CVC insertion by the anaesthesiologist team, requiring a thoracic tube insertion and ICU admission. On the third postoperative day, a bilious-enteric fluid became apparent from surgical drain, associated with fever; after a CT scan, the patient was reoperated for a generalised peritonitis, due to a proximal ileal perforation which was taken out as an ileostomy; it was a small perforation (around 1.5 cm diameter), with raised edges, while all the surrounding gut wall seemed to be healthy. G. Luglio (*) :G. D. De Palma : F. Liccardo :M. C. Giglio : V. Sollazzo : L. Bucci Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy e-mail: gaetano.luglio@gmail.com

Madelung disease : report of a case and review of the literature.

Abstract Madelung disease is a rare disorder characterized by the presence of multiple, symmetric, nonencapsulated fatty accumulations diffusely involving the cheeks, the neck, the upper trunk, the shoulder girdle area, and the upper extremities. The cause of this syndrome is unknown, but it has been associated with alcoholism in 60% to 90% of patients. The long-term lipomatous deposits are often large and cosmetically deforming, and the upper aerodigestive tract and great veins may be compressed. We report the case of a man with MD, involving the cervical and upper dorsal regions, who underwent surgical treatment at our Department.

Minimally Invasive Surgery for Complicated Diverticulitis

Dear Editor, We thank Mahmoud N.N. and Riddle E.W. for reviewing the current evidence supporting the use of minimally invasive surgery for the treatment of complicated diverticulitis. Hartmann’s procedure (HP) is the most commonly performed operation for acute diverticulitis complicated by peritonitis or failing to respond to conservative treatment. It is designed to avoid the risk of anastomotic complications and current indications also include obstructing or perforated leftsided colonic tumors and traumatic and ischemic injuries associated with fecal contamination. Laparoscopic approach for HP, in selected patients, has been associated to reduced length of hospital stay and morbidity compared to the open approach, although randomized controlled trials are needed to confirm these results. An additional potential benefit in favor of the use of the laparoscopic technique even in the emergency setting is the increased rate of Hartmann’s reversal (HR), which is successfully completed laparoscopically, when the index procedure is performed with a minimally invasive approach, as we have previously shown. HR restores intestinal continuity and avoids the physical and psychological difficulties associated with a long-term colostomy, but unfortunately almost half of patients do not have their colostomy closed, with reasons for not reversing commonly including age, high-risk status, and patient refusal for fear of postoperative complications. Laparoscopic HR is one of the most technically demanding procedures in colorectal surgery, with further less than 20% of these procedures being attempted laparoscopically 8 and with a high reported rate of conversion to open surgery: mostly due to adhesions, failed identification, or injury of the rectal stump. Our meta-analysis 5 included 862 patients: 403 laparoscopic HR (46.75%) and 459 open HR (53.25%), with conversion to open surgery occurring in 65 patients (mean 16.1%, range 0–50%). Laparoscopic HR was associated with a reduced overall postoperative 30-day morbidity compared to open HR (OR, 0.24; 95% CI, 0.17 to 0.34), with wound infections and postoperative ileus most commonly observed in patients undergoing open surgery. There was no difference in operating time and patients undergoing laparoscopic HR had shorter length of hospital stay. Our findings may lead to an increasing number of reversals being attempted laparoscopically; however, randomized controlled trials, with patients also stratified according to some characteristics of the primary resection (Hinchey grade, type of surgical approach), are mandatory before advising laparoscopic surgery as the gold standard technique for Hartmann’s procedure and for Hartmann’s reversal.