Raffaele Pugliese

Transvaginal endoscopic cholecystectomy in human beings: preliminary results.

INTRODUCTION The exciting concept of performing surgery in the peritoneal cavity without abdominal incisions by means of flexible endoscopes introduced through natural orifices-natural orifice transluminal endoscopic surgery (NOTES) has been widely investigated in recent years in experimental settings. However, experience with this procedure in human beings is still lacking. In this paper, we report the preliminary results of a small consecutive series of transvaginal endoscopic cholecystectomies. METHODS A standard double-channel gastroscope introduced into the abdominal cavity through a posterior colpotomy was used to perform the cholecystectomy. The introduction of a 5-mm trocar in the left-upper abdominal quadrant was mandatory to create and monitor the pneumoperitoneum and allow the application of the standard laparoscopic clips. This port was also used to introduce a grasper that assisted in the exposure of the gallbladder. The gallbladder was removed through the vagina and was protected in a plastic bag. RESULTS Since July 2007, 3 patients were successfully operated on by this approach, including 1 morbidly obese woman with a body mass index (BMI) of 45. The mean operative time was 136 minutes (range, 110-190). No postoperative complications occurred, and the patients did not complain of pain at both access sites. At the 1-month follow-up, none of the patients complained of dyspareunia. CONCLUSIONS The transvaginal cholecystectomy is feasible, safe, and reproducible in women within a wide range of BMI. NOTES might dramatically change the way surgery will be conceived and performed in the future, as it holds the potential to abolish the historic association of surgery with pain and scars.

High expression of dopamine receptor subtype 2 in a large series of neuroendocrine tumors

Background/Aims: Recent data in vitro and in vivo support that dopaminergic drugs might exert an inhibitory effect on hormone secretion and, possibly, on tumor growth in neuroendocrine tumors (NET)s. Their potential therapeutic role needs the demonstration of dopamine receptors (DR) in tumor cells. Little is known on the expression of DR in NETs. Aim: to evaluate by immumohistochemistry the presence of DR subtype 2 (D2R) in well differentiated NETs of different sites and in normal islet cells. Methods: 46 NET samples from 44 patients and normal endocrine pancreatic tissue were studied. D2R-staining was performed on NETs and compared with six non-secreting pituitary adenomas and related to clinical-pathological data. Results: 85% of samples (100% of bronchial carcinoids and 93% of islet cell tumors) showed positivity for D2R; intensity of immunoreaction in NETs was similar or higher than in pituitary (54% and respectively 31% of cases). D2R positivity in more than 70% of tumor cells was observed in 46% of samples. Same intensity of D2R-immunoreactivity was found in pituitary and normal islet cells. No differences in D2R expression were recorded on considering tumor grading, size, proliferative activity, presence of metastases, endocrine activity and gender. A significant difference (62,5% vs 96,4%, P=0,039) was observed in the prevalence of D2R expression between patients with more aggressive tumors and patients without recurrence/progression of disease during follow-up. Conclusion: The present data demonstrate a high expression of D2R in NETs; this finding is of clinical relevance in view of the potential role of dopaminergic drugs in inhibiting secretion and/or cell proliferation in NETs.

Laparoscopic distal pancreatectomy: a retrospective review of 14 cases.

Although the role of minimally invasive techniques in pancreatic surgery remains controversial, resection of the left pancreas for benign or endocrine lesions has been universally adopted as a routine technique over the last few years. This study was undertaken to assess feasibility and safety of minimal access resections of distal pancreas in benign, endocrine, and malignant diseases. Operative time, conversion rate, adequacy of dissection, respect for oncologic principles, morbidity rate, and short-term outcomes were analyzed. From the years 2002 to 2007, 14 patients affected by pancreatic neoplasm of body/tail region were approached by minimally invasive technique. Nine patients were affected by malignant neoplasms and distal splenopancreatectomy was successfully achieved by laparoscopy in 6. Five patients were affected by endocrine neoplasms; distal pancreatectomy with preservation of spleen and splenic vessels was achieved laparoscopically in 3, whereas 2 needed conversion to laparotomy. Four patients developed pancreatic leak after transection by linear cutting stapler plus oversewing, whereas no leak was observed within 30 days from surgery after transection by linear stapler with Seamguard reinforcement of the staple line (P<0.05 with Fisher exact test).

Laparoscopic repair of incisional hernias located on the abdominal borders: a retrospective critical review.

Background The aim of this study was to assess feasibility and results of laparoscopic approach to repair incisional hernias of the abdominal borders, the weakest points of abdominal wall. Methods Since 2002 through 2008 a total of 39 patients with fascial defects of the abdominal borders underwent laparoscopic repair. The defects were suprapubic (n=18), subxiphoidal (n=15), and lateral sided (n=6). The body mass index was ≥30 Kg/m2 in 19 patients. The parietal defects was measured both externally and from within the peritoneal cavity and 56% of meshes were fixed only by tacks, especially in suprapubic site. Results The mean operating time was 161.8±25 minutes. There was 1 intraoperative complication, an intestinal injury repaired laparoscopically. Conversion was needed in 1 patient for massive adhesions. Postoperative early surgical complications were 7 (1 seroma). Morbidity in obese and nonobese patients showed no statistically relevant difference (P>0.05). There was no postoperative death. Mean hospital stay was 5.1±3 days. The mean follow-up was 37 months and recurrence was observed in 3 cases. Conclusions The onlay laparoscopic approach for repair of incisional hernias of the abdominal borders can warrant good results. Obesity is not a contraindication to laparoscopic repair. Anyway, further experiences are necessary to confirm these results.

“High or low Inferior Mesenteric Artery ligation in Laparoscopic low Anterior Resection: study protocol for a randomized controlled trial” (HIGHLOW trial)

BackgroundThe position of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision can affect genito-urinary function, bowel function, oncological outcomes, and the incidence of anastomotic leakage. Ligation to the inferior mesenteric artery at the origin or preservation of the left colic artery are both widely performed in rectal surgery. The aim of this study is to compare the incidence of genito-urinary dysfunction, anastomotic leak and oncological outcomes in laparoscopic anterior rectal resection with total mesorectal excision with high or low ligation of the inferior mesenteric artery in a controlled randomized trial.Methods/designThe HIGHLOW study is a multicenter randomized controlled trial in which patients are randomly assigned to high or low inferior mesenteric artery ligation during laparoscopic anterior rectal resection with total mesorectal excision for rectal cancer. Inclusion criteria are middle or low rectal cancer (0 to 12 cm from the anal verge), an American Society of Anesthesiologists score of I, II, or III, and a body mass index lower than 30. The primary end-point measure is the incidence of post-operative genito-urinary dysfunction. The secondary end-point measure is the incidence of anastomotic leakage in the two groups. A total of 200 patients (100 per arm) will reliably have 84.45 power in estimating a 20% difference in the incidence of genito-urinary dysfunctions. With a group size of 100 patients per arm it is possible to find a significant difference (α = 0.05, β = 0.1555). Allowing for an estimated dropout rate of 5%, the required sample size is 212 patients.DiscussionThe HIGHLOW trial is a randomized multicenter controlled trial that will provide evidence on the merits of the level of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision in terms of better preserved post-operative genito-urinary function.Trial registrationClinicalTrials.gov Identifier: NCT02153801Protocol Registration Receipt 29/5/2014.

Severe Hemobilia from Hepatic Artery Pseudoaneurysm

Background. Hemobilia is a rare, jeopardizing complication of laparoscopic cholecystectomy coming upon usually within 4 weeks after surgery. The first-line management is angiographic coil embolization of hepatic arteries, which is successful in the majority of bleedings: in a minority of cases, a second embolization or even laparotomy is needed. Case Presentation. We describe the case history of a patient in which laparoscopic cholecystectomy was complicated 3 weeks later by massive hemobilia. The cause of haemorrhage was a pseudoaneurysm of a right hepatic artery branching off the superior mesenteric artery; this complication was successfully managed by one-stage angiographic embolization with full recovery of the patient.

Laparoscopic Bilateral Simultaneous Adrenalectomy: Results of 11 Operations

BACKGROUND This study was undertaken to evaluate the outcomes of the simultaneous bilateral laparoscopic adrenalectomy. MATERIALS AND METHODS This was a retrospective study, including 11 patients with bilateral adrenal lesions, affected by Cushings syndrome (n=2), Cushings disease (n=6), pheochromocytoma (n=2), and 1 adrenocorticotrophin-hormone-dependent hypercortisolism of unknown origin. RESULTS Elevan bilateral adrenalectomies were carried out by the laparoscopic approach with no conversions. The operations were performed in 7 cases by the lateral transperitoneal adrenalectomy (LTLA), in 3 by the posterior approach (PRA), and in 1 by the combined approach. The mean size of the masses was 5 cm. (range, 4-13). The average operating time was 245 minutes for LTLA and 218 minutes for PRA (P<0.05). The estimated mean blood loss was 87+/-36 mL (range, 20-150). No patients required transfusions. The mean hospital stay was 5+/-1.8 days (range, 4-7). The mean follow-up was 34 months (range, 2-96). CONCLUSIONS Our study confirms that the bilateral adrenalectomy by the minimally invasive technique is safe and effective, affording acceptable blood loss and morbidity with a short hospital stay.

Efficacy and effectiveness of suture bolster with Seamguard

The idea of reinforcing staple lines by using a material with the purpose of diminishing suture morbidity is not new. Over the last decades many strategies have been adopted, in both gastrointestinal and thoracic surgery. The first bolsters used for staple lines were nonabsorbable (e.g., expanded polytetrafluoroethylene, ePTFE), semi-absorbable (bovine pericardial and collagen strips), and bioabsorbable materials (L-lactic acid-co-epsilon-caprolactone) [1, 2]. The problem has always been to find the optimal material that yields the greatest advantages in terms of reduced incidence of leakage, stricture, and bleeding of the staple line. Gore Seamguard is a bioabsorbable membrane of polyester braided suture, a random-fiber web of a copolymer glycolide (PGA) and trimethylene carbonate (TMC) microporous structure. The advent of Seamguard in reinforcement of linear sutures yielded good results, reducing the rate of clinical leaks and anastomotic bleeding, and offering satisfactory anastomoses [3–5]. The application of Seamguard to circular staplers ensued and yielded the same good results [6]. Further applications in the strategy of reinforcement of linear sutures have been use of Seamguard for lung resections [7], appendectomy [8], bariatric surgery [9], and gastric surgery [10, 11]. In our experience we have observed some advantages after adopting Seamguard biomaterial as staple-line reinforcement when using linear staplers, in particular in laparoscopic surgery of stomach and distal pancreas. On the whole, since June 2000 we have performed 79 laparoscopic gastrectomies for various pathologies: 6 for benign ulcer, 5 for nodular histiocytic (NH) lymphoma, 2 for gastrointestinal stromal tumor (GIST), and 66 for gastric cancer. We registered three duodenal leaks at the beginning of laparoscopic experience (one following gastrectomy for benign ulcer and two for adenocarcinoma) when we used to merely transect the duodenum by a 45-mm linear cutting stapler without enclosing or reinforcing the staple line (20 cases). From 2002 on, after transecting the duodenum laparoscopically with linear stapler, we enclosed the staple line by separated extracorporeal stitches (9 cases), while after 2003 the staple line was routinely protected with Seamguard (50 cases), since which no leaks have been registered [10, 11]. Certainly, a comparison between enclosing suture versus reinforcement of the staple line would have been of great interest, but the leak rate was nil in both groups, hence such a comparison was nonsense. The reason why we prefer BSG bolster now is only because it is less time consuming than tying extracorporeal slipknots on the duodenal stump. On the other hand, reinforcement by BSG bolster is certainly more expensive. Recently, some interesting studies confirmed the effectiveness of Seamguard in reducing the rate of leak after distal pancreatectomy, in both open surgery [12, 13] and laparoscopy [14, 15]. In our experience we registered a statistically relevant difference with Fisher’s exact test between the leak rate (within 30 days) after pancreatic transection by linear staple plus buttress and by BSG reinforcement [15]. This noticeable outcome in our series has confirmed the statistically significant results obtained in open surgery by others [12, 13]. The polyglycolic acid–trimethylene carbonate BSG (Bioabsorbable Seamguard , WL Gore & Associates, Flagstaff, AZ, USA), is a material absorbable within 6 months. In our series one patient experienced a late pancreatic leak 42 days after surgery, probably due to initial absorption of BSG material that disclosed the presence of an underlying leak. R. Pugliese (&) D. Maggioni F. Sansonna G. C. Ferrari S. Di Lernia A. Forgione C. Magistro Divisione di Chirurgia Generale e Videolaparoscopica, Ospedale di Niguarda Ca’ Granda, Piazza Ospedale 3, 20162 Milano, Italy e-mail: chirurgiaurgenza@ospedaleniguarda.it

Protocol-driven approach of bleeding abdominal and pelvic trauma

Control on a priority basis of significant sites of hemorrhage in patients with abdominal trauma and pelvic disruption may be critical for survival. Purpose of this study was to evaluate retrospectively a work-up based on initial pelvic radiograph, abdominal ultrasound (US) and contrast CT (CESCT).

Tumor response evaluation after neoadjuvant chemotherapy in locally advanced gastric adenocarcinoma: a prospective, multi-center cohort study

Background To verify the prognostic value of the pathologic and radiological tumor response after neoadjuvant chemotherapy in the treatment of locally advanced gastric adenocarcinoma. Methods A total of 67 patients with locally advanced gastric cancer (clinical ≥ T2 or nodal disease and without evidence of distant metastases) underwent perioperative chemotherapy (ECF or ECX regimen) from December 2009 through June 2015 in two surgical units. Histopathological and radiological response to chemotherapy were evaluated by using tumor regression grade (TRG) (Beckers criteria) and volume change assessed by CT. Results Fifty-one (86%) patients completed all chemotherapy scheduled cycles successfully and surgery was curative (R0) in 64 (97%) subjects. The histopathological analysis showed 19 (29%) specimens with TRG1 (less than 10% of vital tumor left) and 25 (37%) patients had partial or complete response (CR) assessed by CT scan. Median disease free survival (DFS) and overall survival (OS) were 25.70 months (range, 14.52-36.80 months) and 36.60 months (range, 24.3-52.9 months), respectively. The median follow up was 27 months (range, 5.00-68.00 months). Radiological response and TRG were found to be a prognostic factor for OS and DFS, while tumor histology was not significantly related to survival. Conclusions Both radiological response and TRG have been shown as promising survival markers in patients treated with perioperative chemotherapy for locally advanced gastric cancer. Other predictive markers of response to chemotherapy are strongly required.