Niccolò Furbetta

Hand-assisted hybrid laparoscopic–robotic total proctocolectomy with ileal pouch–anal anastomosis

PurposeFew studies have reported minimally invasive total proctocolectomy with ileal pouch–anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We herein report a novel hand-assisted hybrid laparoscopic–robotic technique for patients with FAP and UC.MethodsBetween February 2010 and March 2014, six patients underwent hand-assisted hybrid laparoscopic–robotic total proctocolectomy with IPAA. The abdominal colectomy was performed laparoscopically with hand assistance through a transverse suprapubic incision, also used to fashion the ileal pouch. The proctectomy was carried out with the da Vinci Surgical System. The IPAA was hand-sewn through a trans-anal approach. The procedure was complemented by a temporary diverting loop ileostomy.ResultsThe mean hand-assisted laparoscopic surgery (HALS) time was 154.6 (±12.8) min whereas the mean robotic time was 93.6 (±8.1) min. In all cases, a nerve-sparing proctectomy was performed, and no conversion to traditional laparotomy was required. The mean postoperative hospital stay was 13.2 (±7.4) days. No anastomotic leakage was observed. To date, no autonomic neurological disorders have been observed with a mean of 5.8 (±1.3) bowel movements per day.ConclusionsThe hand-assisted hybrid laparoscopic–robotic approach to total proctocolectomy with IPAA has not been previously described. Our report shows the feasibility of this hybrid approach, which surpasses most of the limitations of pure laparoscopic and robotic techniques. Further experience is necessary to refine the technique and fully assess its potential advantages.

Robotic Colorectal Resection With and Without the Use of the New Da Vinci Table Motion: A Case-Matched Study

Background. The da Vinci Table Motion (dVTM) is a new device that enables patients to be repositioned with instruments in place within the abdomen, and without undocking the robot. The present study was designed to compare operative and short-term outcomes of patients undergoing colorectal cancer surgery with the da Vinci Xi system, with or without use of the dVTM. Methods. Ten patients underwent robotic colorectal resection for cancer with the use of dVTM (Xi-dVTM group) between May 2015 and October 2015 at our center. The intraoperative and short-term clinical outcome were compared, using a case-control methodology (propensity scores approach to create 1:2 matched pairs), with a similar group of patients who underwent robotic colorectal surgery for cancer without the use of the dVTM device (Xi-only group). Results. Overall robotic operative time was shorter in the Xi-dVTM group (P = .04). Operations were executed fully robotic in all Xi-dVTM cases, while 2 cases of the Xi-only group required conversion to open surgery because of bulky tumors and difficult exposure. Postoperative medical complications were higher in the Xi-only group (P = .024). Conclusions. In this preliminary experience, the use of the new dVTM with the da Vinci Xi in colorectal surgery, by overcoming the limitations of the fixed positions of the patient, enhanced the workflow and resulted in improved exposure of the operative field. Further studies with a greater number of patients are needed to confirm these benefits of the dVTM-da Vinci Xi robotically assisted colorectal surgery.

Multiple small bowel perforations due to invasive aspergillosis in a patient with acute myeloid leukemia: case report and a systematic review of the literature

PurposeInvasive aspergillosis (IA) represents a major cause of morbidity and mortality in immunocompromised patients. Involvement of the gastrointestinal tract by Aspergillus is mostly reported as part of a disseminated infection from a primary pulmonary site and only rarely as an isolated organ infection.MethodsWe report a case of small bowel perforation due to IA in a patient with acute leukemia under chemotherapy and pulmonary aspergillosis. We performed a systematic review of the literature as well.ResultsA 43-year-old man with acute myeloid leukemia under chemotherapy developed severe neutropenia and pulmonary aspergillosis due to Aspergillus flavus. He developed melena and hemodynamic failure and a contrast-enhanced ultrasound scan suggested active intestinal bleeding. During emergency laparotomy we found multiple intestinal abscesses, several perforations of intestinal loop and Aspergillus flavus was isolated from the abscesses. Resection of the jejunum was performed. The patient received voriconazole and finally recovered. The patient is now alive and in complete disease remission. From literature review we found 35 intestinal IA previously published in single case reports or small case series as well.ConclusionClinical manifestations of gastrointestinal aspergillosis are nonspecific, such as abdominal pain, and only occasionally it presents as an acute abdomen. Antemortem detection of bowel involvement is rarely achieved and, only in cases of complicated gastrointestinal aspergillosis, the diagnosis is achieved thanks to the findings during surgery. Gastrointestinal aspergillosis should be suspected in patients with severe and prolonged neutropenia with or without pulmonary involvement in order to consider the right therapy and prompt surgery.

AB010. S010. Pancreatic cystic lesions’ follow-up with abdominal ultrasound scan: could it play an alternative role to the routine use of MRI?

Background: Pancreatic cystic lesions (PCL) without “worrisome features” (WFs) at the time of diagnosis, usually necessitate a lifetime surveillance. The routine follow-up in these cases comprises a magnetic resonance imaging (MRI) scan every 6 months in the 1st year, then annually for the next 5 years. Since these parameters can also be evaluated with an abdominal ultrasound scan (AUS), we studied the safety, feasibility and economic impact of AUS follow-up, with a delayed use of MRI. Methods: We retrospectively evaluated all patients who had been followed-up with AUS for the presence of “low risk” PCL. All of patients underwent to an AUS every 6 months for the 1st year and then, in case of stable disease, annually from the 2nd to the 5th year. A surveillance MRI scan was routinely executed every 2 years, or according to the presence of considerable modifications at AUS. We compared the two methods regarding sensitivity and specificity in identifying cysts variations. We also focused on a costs-analysis between the theoretical application of the international guidelines follow-up with MRI, and our follow-up strategy with AUS and delayed MRI. Results: Two hundred patients were followed-up with AUS between January 2012 and January 2016 for PCL. Mean follow-up period was 25.1±18.2 months. Surgery was required for 2 patients (1%), due to the appearance of WF at imaging [with concordance among ultrasonography (US) and MRI]. During the follow-up, AUS showed “low grade” modifications in 28 patients (14%), comprising main pancreatic duct dilatation <6 mm and increasing of the main cyst of about 0.5 cm, compared to previous examinations. In all of these cases MRI confirmed AUS findings, without adding more prognostic information. In only 11 patients (5.5%) a routine MRI identified an evolution of the lesions, not showed at AUS, but only related to an increased number of the PCL (P=0.14). Nevertheless, a MRI every 6 months would not have changed in any case the decisional process. The mean cost of surveillance for each patient, in a theoretical application of international guidelines with MRI at our group of patients, should have been 402€±273.7€, while according to our follow-up strategy it was 215.4€±212.6€ (P<0.0001). Conclusions: In patients with PCL without WF, AUS, could be a safe alternative to MRI, reducing the numbers of 2nd level examinations and therefore reducing costs. Long term safety of this approach should be validated on a longer follow-up period, with a larger series of patients and prospective studies.

Long-term, low-dose tigecycline to treat relapsing bloodstream infection due to KPC-producing Klebsiella pneumoniae after major hepatic surgery

A 68-year-old male underwent a right hepatectomy, resection of the biliary convergence, and a left hepatic jejunostomy for a Klatskin tumour. The postoperative course was complicated by biliary abscesses with relapsing bloodstream infections due to Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp). A 2-week course of combination antibiotic therapy failed to provide source control and the bacteraemia relapsed. Success was obtained with a regimen of tigecycline 100mg daily for 2 months, followed by tigecycline 50mg daily for 6 months, then 50mg every 48h for 3 months. No side effects were reported.