Massimiliano Fabozzi

Laparoscopic gastric bypass performed with the Da Vinci Intuitive Robotic System: preliminary experience

BackgroundThis study aimed to analyze retrospectively the authors’ preliminary experience using the Da Vinci Intuitive Robotic System for gastric bypass in managing morbid obesity, and to determine its efficacy and safety in relation to other standardized laparoscopic surgical techniques.MethodsFrom October 2000 to March 2004 the authors performed 146 laparoscopic gastric bypasses, 17 of which were robot assisted using the Da Vinci Intuitive Robotic System. The last patients were 7 men and 10 women with a mean age of 44 years. The mean weight was 139 kg, and the mean body mass index (BMI) was 49.8 kg/m2 at first postoperative recovery. The mean excess body weight (EBW) was 131%. Follow-up assessment, performed at months 1, 3, 6, and 12, then yearly thereafter, included evaluation of the variations in BMI and the percentage of excess body weight loss (EBWL%). All the patients were informed of the risks inherent with each surgical procedure as well as the potential benefits.ResultsThe mean operative time was 201 min (range, 90–300 min). No intraoperative complications and no conversion occurred in this series. The mean hospital stay was 9 days (range, 6–18 days). The patients in this series experienced a normal postoperative course without anastomotic complications. The mortality rate was zero. No robot-related complications were noted. The analysis of follow-up assessment at months 1, 3, 6, and 12 showed a progressive decrease in BMI and an increment of EBWL%.ConclusionsThe authors’ early experience with robotic surgery suggests that it is safe and could be an effective alternative to conventional laparoscopic surgery. The authors believe that robotic surgery, with its ability to restore the hand–eye coordination and three-dimensional view lost in laparoscopic surgery, could allow complex procedures to be performed with greater precision and better results.

Surgical approach to right colon cancer: From open technique to robot. State of art

This work is a topic highlight on the surgical treatment of the right colon pathologies, focusing on the literature state of art and comparing the open surgery to the different laparoscopic and robotic procedures. Different laparoscopic procedures have been described for the treatment of right colon tumors: Totally laparoscopic right colectomy, laparoscopic assisted right colectomy, laparoscopic facilitated right colectomy, hand-assisted right colectomy, single incision laparoscopic surgery colectomy, robotic right colectomy. Two main characteristics of these techniques are the different type of anastomosis: Intracorporeal (for totally laparoscopic right colectomy, single incision laparoscopic surgery colectomy, laparoscopic assisted right colectomy and robotic technique) or extracorporeal (for laparoscopic assisted right colectomy, laparoscopic facilitated right colectomy, hand-assisted right colectomy and open right colectomy) and the different incision (suprapubic, median or transverse on the right side of abdomen). The different laparoscopic techniques meet the same oncological criteria of radicalism as the open surgery for the right colon. The totally laparoscopic right colectomy with intracorporeal anastomosis and even more the single incision laparoscopic surgery colectomy, remain a technical challenge due to the complexity of procedures (especially for the single incision laparoscopic surgery colectomy) and the particular right colon vascular anatomy but they seem to have some theoretical advantages compared to the other laparoscopic and open procedures. Data reported in literature while confirming the advantages of laparoscopic approach, do not allow to solve controversies about which is the best laparoscopic technique (Intracorporeal vs Extracorporeal Anastomosis) to treat the right colon cancer. However, the laparoscopic techniques with intracorporeal anastomosis for the right colon seem to show some theoretical advantages (functional, technical, oncological and cosmetic advantages) even if all studies conclude that further prospective randomized trials are necessary. Robotic technique may be useful to overcome the problems related to inexperience in laparoscopy in some surgical centers.

Laparoscopic incisional and ventral hernia repair (LIVHR) with PARIETEX™ Composite mesh

Abstract Objectives: Laparoscopic incisional and ventral hernia repair (LIVHR) is widely used although its clinical indications are often debated. The aim of this study was to retrospectively describe the experience of our surgical centre in order to establish the safety, efficacy, and feasibility of LIVHR using PARIETEX™ Composite mesh (Covidien, Mansfield, MA, USA). Material and methods: Between January 2007 and November 2010, 87 patients were admitted to the Division of General Surgery of Aosta, with the diagnosis of abdominal wall hernia and underwent laparoscopic repair using PARIETEX™ Composite mesh. The type and size of surgical defects, mean operative time, morbidity, mortality and rate of recurrence at one-year follow-up were retrospectively analysed. Results: We performed 87 LIVHR: 51.7% for incisional hernia and 48.3% for epigastric or umbilical hernias. Mean operative time was 100 min., conversion rate was 3.4%. The mean size of abdominal defect was 6 cm (range: 2–15); in relation to umbilical hernias, mean size was 5.4 cm (range: 2–8). The mortality rate was 0%; overall morbidity was 16%. At one-year follow-up, we observed two cases of hernia recurrences. Conclusions: LIVHR using PARIETEX™ Composite mesh is an effective and safe procedure with very low morbidity and low rates of postoperative pain and recurrence, especially in hernias with diameter of between 5 and 15 cm and in obese patients without previous laparotomies.

Irreversible electroporation for locally advanced pancreatic cancer through a minimally invasive surgery supported by laparoscopic ultrasound

Highlights • We report on the application of Irreversible electroporation (IRE) on locally advanced pancreatic cancer (LAPC).• We report on a minimally invasive surgical approach supported by laparoscopic ultrasound.• We report on a novel technique the benefits of IRE with the advantages of laparoscopic surgery.• In medical literature is in our knowledge the first experience.

Open vs totally laparoscopic right colectomy: technique and results

BackgroundRight colectomy is the surgical treatment for malignantpathologies involving the intestinal tract between theileocecal Bahuino valve and the colic hepatic flexure.Laparoscopic resection must respect the same oncologi-cal criteria as the open approach including:‘’no-touchisolation technique’’, isolation and ligation of the vascularpedicles at the origin, oncological lymphadenectomy and‘’distal and radial clearance’’ of the neoplasm from resec-tion margins.Two major procedures have been described for thetreatment of right colon tumors: Open right colectomy(ORC) and Totally Laparoscopic resection (TL) in whichvascular ligations, intestinal resection and anastomosis areperformed by laparoscopy (Figure 1).In ORC technique, there is an abdominal right sidelaparotomy; in TL there is a minilaparotomy used only forendobag colon extraction and it is located in parapubicregion.MethodsFrom May 2004 to march 2013, we performed in HighSpecialistic Surgical Centers (Aosta “Parini” Hospital andNaples “Federico II” University) 132 laparoscopic rightcolectomies and 127 open right colectomies of which wehave selected 75 laparoscopic cases of these 11 for benignpathologies and 64 for neoplastic diseases and 75 OpenCases. The M/F rate was 1/1. The mean age was 64.7 ± 7.2.Colonic preoperative washout was performed to allpatients with 2 L for a day of polyethylene glycol (PEG) inthe two days before the operation, associated with a fiber-free diet. The day before operation, we positioned in allpatient antalgic peridural catheter with 0.5% levobupiva-caine (4 ml/h); on the following day, in the operatingroom, after anesthetic induction, we also positioned naso-gastric tube (NG tube) and urinary catheter (UC) and nodrain according to Kehlet protocols (in the last 23 cases).In the TL colectomy, the sovrapubic minilaparotomy of6 ± 2 cm is necessary only for the specimen extractionfrom the parapubic minilaparotomy performed by a 15-mm Endocatch, preventing the peritoneal spreading ofneoplastic cells.The procedures were considered curative only whenthere was no intraoperative evidence of secondarylocations.NG tube was removed after the operation and UC in themorning after surgery. The patients were allowed to drinkliquids with oral assumption of medicines the evening ofthe operation (Table 1) [1]. All the patients underwent acycle of postoperative physiokinesis therapy. Patients weredischarged when they became autonomous in movementsand walking with a restored bowel function without feverand pain.They were followed-up at least 1 year, starting on the30

Clinical efficacy of HBOT(hyperbaric oxygen therapy) in the treatment of foot ulcers in elderly diabetic patient: our experience

Background The development of foot ulcers is a serious complication in elderly diabetic patients. Its treatment is based on the use of different techniques, but when they fail that often lead to limb amputation. The efficacy of treatment with HBOT in diabetic foot ulcer has been evaluated for more than 20 years, but its use has never become routine, its use is a reality that in recent years is increasingly consolidating, especially as an adjuvant to conventional therapies and the NPWT (Negative Pressure Wound Therapy ) and dermal substitutes. Many studies prove its validity, experimentally the beneficial effects consist in the improvement of tissue perfusion, inflammatory cytokines down-regulation, fibroblasts proliferation, edema reduction , angiogenesis promotion and collagen production, it is also proven by the years the favorable effect against infectious component of the lesion [1,2]. In particular, the hyperbaric oxygen increases the bactericidal activity and is particularly toxic to anaerobes [3]. In addition, many studies, including some meta-analyzes, documenting the positive role of HBOT in reducing the risk of amputation, although a recent meta-analysis it is clear the shortterm benefit, but for the long-term studies would be needed to be so designated such as to minimize any bias [4]5. In our center, we evaluated the use of hyperbaric oxygen therapy to reduce limb amputation risk. Methods This observational study, open-label short-term evaluated the clinical efficacy of this method integrated medical therapy, treatment of wound cleansing and debridement, and topical applications of hydrocolloids, alginates, polyacrylates and foams. After obtaining informed consents, 7 diabetic patients with foot ulcers (n = 7) were enrolled and treated with cycles of hyperbaric oxygen therapy (2.4 ATA) for a period of about 85 minutes for 5 days a week, during the period between January and September 2012, with follow-up until May 2013.Among the exclusion criteria we considered: patients with compromised bone and / or Charcot’s foot, Wagner class greater than III, non elegible patients for HBOT (AP chest X-ray, visit ENT, cardiological examination with ECG, laboratory tests to assess feasibility), then patients with severe impairment of arterial district in the affected arm. All patients have done foot X-ray and ECO Color Doppler of lower limb as preliminary study, which showed: four patients Wagner class II, Winsor index between 0.9 and 1, three patients Wagner Class III, with winsor pathological index. The treatment was carried out in two stages: at first, the patients were treated with medical therapy, surgical debridement, exudate management and stimulation of granulation and epithelialization with advanced wound dressings, wound swabs and orthotics , in a second time were matched HBOT cycles. The follow-up was done by clinical and biochemical controls with particular attention to the glycemic profile and obtaining optimal levels of glycated hemoglobin, and taking cilostazol tablets 100 mg, possibly associated with antiplatelets (cardioaspirin, clopidogrel). We established two outcome measures : 1) surgical healing of the lesions, 2) amputation (short-term assessment by the end of treatment until May 2013). * Correspondence: luciano.grimaldi@unina.it Department of Specialized Surgery, Division of Gastrointestinal Surgery Rehabilitation of Election and Emergency. “Federico II” University, Naples, Italy Full list of author information is available at the end of the article Grimaldi et al. BMC Surgery 2013, 13(Suppl 1):A26 http://www.biomedcentral.com/1471-2482/13/S1/A26

Laparoscopic near-total splenectomy: a single-center experience of a standardized procedure

Abstract Background: Near-total splenectomy (NTS) represents an innovative and effective surgery technique for spleen disease, reducing the risk of severe infections and thromboembolic events after total splenectomy. The authors reported a laparoscopic near-total splenectomy (LNTS) surgical experience following the optimal results of the open approach, describing a standardized and effective minimally invasive technique with the purpose of preserving a minimal residual spleen. Material and methods: From November 2006 to September 2016, 15 patients with splenic and hematologic disease underwent LNTS, according to a laparoscopic procedure developed by the authors. The end criterion was to conserve a remanent spleen of 10–15 cm3 in size. Results: Patient age ranged between 18 and 59 years. Mean operative time was 70 ± 20 min. Mean hospital stay was 3.46 (range 3–7) days. One complication occurred during the surgery for a lesion of the inferior polar artery with need of a total splenectomy. No conversion to open surgery was necessary. Conclusions: LNTS is a safe and effective technique for the management of splenic and hematologic disease with a low intra- and post-operative complication rate, and it can minimize the late sequelae of secondary splenectomy. However, it requires further studies with more cases to evaluate its role.

Next-generation sequencing analysis of receptor-type tyrosine kinase genes in surgically resected colon cancer: identification of gain-of-function mutations in the RET proto-oncogene

BackgroundImprovement in genetic characterization of Colon Cancer (CC) patients is required to propose new potential targets, since surgical resection coupled to chemotherapy, presents several limits such as cancer recurrence and drug resistance. Targeted therapies have more efficacy and less toxicity than standard treatments. One of the most relevant cancer-specific actionable targets are receptor tyrosine kinases (RTKs) whose role in CC need to be better investigated.MethodsWe have analysed 37 CC patients using the Ion AmpliSeq™ Comprehensive Cancer Panel (CCP). We have confirmed the somatic nature of RET variants through Sanger sequencing and assessed RET activation status and protein expression by immunofluorescence and western-blot analyses. We have used RET mutant expression vectors to evaluate the effect of selected mutations in HEK293 cells by performing proliferation, migration and clonogenic assays.ResultsAmong the 409 cancer-related genes included in the CCP we have focused on the RTKs. Overall, we have observed 101 different potentially damaging variants distributed across 31 RTK genes in 28 patients. The most frequently mutated RTKs were FLT4, ROS1, EPH7, ERBB2, EGFR, RET, FGFR3 and FGFR4. In particular, we have identified 4 different somatic variants in 10% of CC patients in RET proto-oncogene. Among them, we have demonstrated that the G533C variant was able to activate RET by promoting dimer formation and enhancing Y1062 phosphorylation. Moreover, we have demonstrated that RET G533C variant was able to stimulate anchorage-dependent proliferation, migration and clonogenic cell survival. Notably, the effects induced by the RET G533C variant were abolished by vandetanib.ConclusionsThe discovery of pathogenic variants across RTK genes in 75% of the CC patients under analysis, suggests a previously underestimated role for RTKs in CC development. The identification of a gain-of-function RET mutation in CC highlights the potential use of RET in targeted therapy.

Hernie interne après by pass gastric laparoscopic (BPGL) pour obésité morbide

Introduction Le BPGL peut etre complique par herniation viscerale interne avec une incidence du 1-5 %. Observation A partir de j anvier 2001 jusqu’a d ecembre 2014, 453 patients ont ete operes dans notre centre de BPGL ; le 6 0.9 % avec technique antecolique et le 39 % transmesocolique. Le 5,7 % (26) des patients ont eu symptomes lies a la hernie. Le diagnostic a ete pose par un bilan preoperatoire d’imagerie dans 38 % des cas (10). Dans les autres cas (62 %) seulement la laparoscopie exploratrice a mis en evidence la hernie. Une hernie interne a travers l’orifice de Petersen a ete retrouvee dans le 7 3 % des cas (19), par contre l’herniation viscerale a ete transmesocolique dans le 23 % (6) et transmesenterique dans le 3,8 % (1) des cas. Pour tous les patients operes, on avait explore le trait alimentaire, biliopancreatique et commun avec la fermeture a points non resorbables des breches mesenteriques et mesocoliques. Conclusions La symptomatologie des hernies se presente apres 8-12 mois de l’intervention et dans les cas de perte de poids les plus importantes. Le diagnostic est rarement realise par la radiologie, souvent la coelioscopie est le choix diagnostique-therapeutique. La fermeture des breches doit etre realisee de facon systematique. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.

Échographie cœlioscopique peropératoire routinaire versus cholangiographie pour la détection de la lithiase de la voie biliaire principale pendant vidéolaparocholécystectomie : précision du diagnostic, analyse des coûts et courbe d’apprentissage

Introduction La gestion de la lithiase de la voie biliaire principale en cours de videolaparocholecystectomie est un argument encore bien dibattu. On discute la necessite ou moins d’examens peroperatoires de routine, le choix entre les methodes disponibles et, enfin, les modes et les temps meilleurs pour le traitement. Nous presentons les resultats de l’echographie laparoscopique peroperatoire (ELP) par rapport a la cholangiographie peroperatoire (CP). Methodes Nous avons effectue l’ELP et la CP sur 239 patients consecutifs entre aout 2009 et juin 2013 et nous avons compare les resultats en termes de faisabilite, fiabilite, temps d’execution et couts. Puis nous avons decrit et evalue les courbes d’apprentissage de deux operateurs ayant une experience echographique differente. Observations L’ELP a ete possible dans tous les cas, tandis que la CP dans 87,03 % (allergie au milieu de contraste, difficultes techniques ou indisponibilite du technicien de radiologie). La sensibilite et la specificite de l’ELP ont ete de 100 % et 100 %, le temps d’execution moyen a ete de 10,37 minutes pour l’ELP et de 10,83 pour la CP. Le cout unitaire a ete respectivement de € 115,03 et € 296,80 pour la ELP et la CP. Conclusions L’ELP est une technique faisable, fiable, rapide et peu couteuse, avec une courbe d’apprentissage raisonnable, dont l’utilisation routiniere semble particulierement avantageuse chez les patients presentant un risque preoperatoire de choledocholithiase moyen et bas. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.