Antonio A Brescia

Background Implementation of colorectal cancer (CRC) screening programs increases endoscopic resection of polyps with early invasive CRC (pT1). Risk of lymph node metastasis often leads to additional surgery, but despite guidelines, correct management remains unclear. Our aim was to assess the factors affecting the decision-making process in endoscopically resected pT1-CRCs in an academic center. Methods We retrospectively reviewed patients undergoing endoscopic resection of pT1 CRC from 2006 to 2016. Clinical, endoscopic, surgical treatment, and follow-up data were collected and analyzed. Lesions were categorized according to endoscopic/histological risk-factors into low and high risk groups. Comorbidities were classified according to the Charlson comorbidity index (CCI). Surgical referral for each group was computed, and dissociation from current European CRC screening guidelines recorded. Multivariate analysis for factors affecting the post-endoscopic surgery referral was perform...

Gastric pacing to treat morbid obesity has been found to be safe and the implant technique simple to perform. Appetite is reduced and satiety is increased after the implant. There are two components in the Implantable Gastric Stimulation (IGS): (a) an electrical stimulator connected to a (b) bipolar lead that is positioned in the muscle wall of the stomach. We describe the optimal procedure to safely place the components. We present our results after preliminary experiences. From August 2005 to January 2006, 4 patients (F) mean age 44 (33-63) underwent to IGS implant. The mean BMI was 41.8 (378-47), mean weight 117.2 Kg (107-133) . The IGS was activated 30 days after implant. Fasting and postprandial plasma ghrelin concentrations after a test meal were measured before and 1, 2, 3 and 6 months after implanting operation. All procedures were successfully completed laparoscopically. There were no major operative complications. Postoperative course was uneventful in all cases. One patie...

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].

Anastomotic 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. All 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. Of 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. The 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.

The use of laparoscopy to perform lower anterior rectal resection is increasing worldwide because it allows better visualisation and rectal mobilisation and also reduces postoperative pain and recovery. The Contour Curved Stapler (CCS) is a very helpful device because of its curved profile that enables better access into the pelvic cavity and allows rectal closure and section to be performed in one shot. In this paper, we present an original technique to use this device, made for open surgery, in laparoscopy and the results of our experience. We retrospectively evaluated the data of all patients who underwent lower laparoscopic anterior rectal resection and in which the CCS was used to perform section of the rectum between September 2005 and September 2011. To perform section of the rectum a Lapdisc(®) was inserted through a 6-7 cm supra-pubic midline incision to allow placement of the CCS into the pelvic cavity. Patients' biographical and surgical data such as sex, age, indication for surgery, infection, anastomotic leakage or stenosis and staple-line bleeding were prospectively collected in a computerised database and evaluated. Between September 2005 and September 2011, we performed 45 laparoscopic lower rectal resection using CCS, 27 male and 18 female with a mean age of 61 years (range 40-82 years) and a mean body mass index (BMI) of 26.5 kg/m(2) (range 16.5-35 kg/m(2)). In 29 cases a temporary ileostomy was performed. Mean operative time was 131 min (range 97-210 min). In all cases it was possible to perform a lower section of the rectum with CCS. No intraoperative or postoperative staple line bleeding occurred. In two patients we observed anastomotic leaks and in one of these a temporary ileostomy was performed. None of the patients showed an anastomotic stenosis at 1-year follow-up colonoscopy. This study shows that CCS enables section of the lower rectum to be easily performed, especially in adverse anatomical condition, and the technique proposed by us allows the use of this stapler without giving up the benefits of laparoscopic access.

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. 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. Eighty-nine patients underwent STARR as a day-case regimen, and none presented major complications or required an extension of hospital stay or readmission. 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.

Laparoscopic 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. From 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. Evaluation 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. This study shows that prior knowledge of the patient's mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resection.

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. 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. This is a retrospective study. The study was conducted at the One-Day Surgery Unit of St. Andrea Hospital. 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. If identified, the retained staples were removed endoscopically or transanally. After the staple removal, patients were followed with biweekly office visit for 2 months to evaluate the progression of symptoms. 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. 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. The removal of the retained staples is an efficacious and safe procedure to solve or improve postoperative complications and should be always considered.

Postoperative pain after stapled hemorrhoidopexy is cause for considerable concern and may be related to contracture of continence muscles. We compared glyceryl trinitrate 0.4% ointment with lidocaine chlorohydrate 2.5% gel as topical therapy to relieve the pain of anorectal muscular spasm after stapled hemorrhoidopexy. This was a single-blind, parallel-group, randomized controlled trial. The study was conducted at a university teaching hospital in Rome, Italy. Patients with severe postoperative anal pain after stapled hemorrhoidopexy, clinical evidence of anal hypertonia, and elevated anal resting pressure on manometric assessment were enrolled. Patients treated for concomitant anorectal disease were excluded. Participants were randomly assigned to receive twice-daily, local topical application of glyceryl trinitrate or lidocaine for a total of 14 days. Pain intensity was measured on a visual analog scale at baseline and after 2, 7, and 14 days of therapy. Anal resting pressure was measured pre- and postoperatively and after 14 days of therapy. Of 480 patients undergoing stapled hemorrhoidopexy, 121 had severe postoperative pain (score >3) and underwent clinical examination; 45 patients (13 women, 28 men) had clinically evident anal hypertonia and underwent anorectal manometry; 41 patients had elevated anal resting pressure and entered the study. Mean pain scores were significantly lower with glyceryl trinitrate than with lidocaine on day 2 (2.5 ± 1.0 vs 4.0 ± 1.1, p < 0.0001); day 7 (1.4 vs 2.8, p < 0.0001); and day 14 (0.4 vs 1.4, p = 0.003). Anal resting pressure was significantly lower with glyceryl trinitrate than with lidocaine on day 14 (75.4 ± 7.4 mmHg vs 85.6 ± 7.9 mmHg, p < 0.0001). GTN-induced reduction in sphincter tone could not be evaluated during the initial period, when pain was most intense. Because anorectal manometry was performed only in patients with severe pain and clinical evidence of anal hypertonia, firm conclusions cannot be drawn as to frequency of hypertonia after SH. Bias may have been introduced because the surgical team could not be blinded. Topical 0.4% glyceryl trinitrate is effective in relieving pain and reducing anal resting pressure in patients with anal hypertonia after stapled hemorrhoidopexy.

Between September 2014 and December 2015, 32 patients with inguinal hernia were treated using a new 3D mesh in our department. This mesh is characterized by a multilamellar flower-shaped central core with a flat, large-pore polypropylene ovoid disk that has to be implanted preperitoneally. Compared with the traditional Lichtenstein procedure, we observed a shorter mean duration of surgery and a significantly lower mean visual analogue scale (VAS) postoperative pain score recorded immediately after the procedure in the 3D mesh group. The mean VAS score recoded after 4 and 8 postoperative days showed better results in the 3D mesh group than the control group. Moreover, there was reduced postoperative morbidity in the 3D mesh group than the control group, even if no patients experienced severe complications.

Stapled Transanal Rectal Resection (STARR) performed using CCS-30 Contour Transtar™ despite its recent introduction seems to be an effective surgical procedure to treat obstructed defecation syndrome. The major constraint of this procedure is the need to open the prolapse longitudinally using the CCS-30. This is often difficult and can lead to an inadequate or spiralling resection. Our modified technique, presented in this paper, creates the prolapse opening with an electric scalpel between two Kocher clamps, placed to grab the whole prolapsed tissue at 2 and 4 o'clock, respectively. The results of the first 83 procedures confirm that this technique allows the surgeon to simplify the prolapse's longitudinal opening and especially the first loading of the tissue between the CCS-30 jaws, which is necessary to start the circular resection, as confirmed by the absence of spiralling and major complications in this series.

The aim of this study was to compare oncologic outcomes of radical prostatectomy (RP) with brachytherapy (BT). A literature review was conducted according to the 'Preferred reporting items for systematic reviews and meta-analyses' (PRISMA) statement. We included studies reporting comparative oncologic outcomes of RP BT for localized prostate cancer (PCa). From each comparative study, we extracted the study design, the number and features of the included patients, and the oncologic outcomes expressed as all-cause mortality (ACM), PCa-specific mortality (PCSM) or, when the former were unavailable, as biochemical recurrence (BCR). All of the data retrieved from the selected studies were recorded in an electronic database. Cumulative analysis was conducted using the Review Manager version 5.3 software, designed for composing Cochrane Reviews (Cochrane Collaboration, Oxford, UK). Statistical heterogeneity was tested using the Chi-square test. Our cumulative analysis did not show ...

Background: In rectal cancer surgery, anastomotic leakage (AL) remains the most feared complication, with a frequency of up to 30% in non-high-volume centers. The preservation of proper vascularization is a key factor for successful anastomosis. The use of fluorescence with indocyanine green (ICG) as an intraoperative method to verify optimal perfusion is becoming an interesting tool in rectal surgery. Today, robotic surgery, together with the use of the intraoperative evaluation of the perfusion with ICG, could be a real strategy to deal with AL, allowing for a more delicate and less traumatic surgical technique. This strategy may allow for an extremely accurate surgery, and for optimal control of the proper vascularization of the rectum. Methods: The purpose of this descriptive review is to analyze the impact of fluorescence and robotic surgery on short-term surgical outcomes for rectal cancer. Results: We performed a systematic literature search using the PubMed, Embase and Cochr...

In 1988, Longo proposed a new treatment for haemorrhoidal disease. In western countries day surgery procedures are becoming more and more common. We propose a new protocol for outpatient haemorrhoidopexy. From 2003 to 2010, we performed 403 out-patient stapled haemorrhoidopexies under spinal anaesthesia, on patients with symptomatic grade III and IV haemorrhoid disease. We used PPH 01 and PPH 03 staplers (Ethicon Endosurgery, Cincinnati, OH, USA). We assessed early and late postoperative pain with a Visual Analogue Scale (VAS), and clinical postoperative examinations were performed 7 days, 6 months, and 1, 3 and 5 years after surgery. The mean surgery time was about 20 min (range 13-39 min). Out of 403 patients, 41 were not dischargeable as a result of urine retention, severe pain or mild bleeding. Twenty-two patients reported transient faecal urgency, while no patient complained of anal incontinence. Our experience with 403 patients demonstrated that stapled haemorrhoidopexy is feasible and safe as a day surgery procedure. However, careful preoperative planning is necessary in order to evaluate the patients' health status and the consequent perioperative and postoperative risk. Our results are positive in terms of surgical safety and postoperative recovery time.

Laparoscopic low anterior rectal resection (LLAR), allowing better visualization and rectal mobilization, can reduce postoperative pain and recovery. A contour curved stapler (CCS) is a very helpful device because of its curved profile that consents better access into the pelvic cavity and allows to perform rectal closure and section in one shot, especially in the presence of a narrow pelvis, complex anatomy, or large tumors. We developed an original technique of laparoscopic rectal resection using CCS. Between 2005 and 2009, in 36 cases, we performed LLAR with a three-trocar technique, starting with mobilization of left colonic flexure followed by the section of inferior mesenteric vessels. The rectum was prepared up to the levator ani with total mesorectal excision. The Lapdisc was inserted trough a suprapubic midline incision, allowing the CCS stapler placement into the pelvic cavity. After the rectal section, the anastomosis was then performed with a circular stapler. Ileostomy was performed if neoadjuvant radiotherapy and chemotherapy have been carried out or if the anastomosis was below 4 cm from the anal verge. Mean operative time was 135 minutes and no intra- or postoperative bleeding occurred. In 27 patients we performed temporary ileostomy. In two cases we observed anastomotic leakage; one of these patients already had ileostomy. No anastomotic stenosis occurred after one-year follow-up. This procedure simplifies the section of the lower rectum, reduces leaking rate resulting from technical difficulties, and does not nullify the benefits of laparoscopy.