Axillary surgery in breast cancer patients has shifted from more extensive to minimalist approaches with re-evaluation of the risks versus benefits of available treatment options which are increasingly tailored to indivi...Axillary surgery in breast cancer patients has shifted from more extensive to minimalist approaches with re-evaluation of the risks versus benefits of available treatment options which are increasingly tailored to individual patient characteristics. A radical axillary node dissection is rarely indicated nowadays due to several factors including screening with detection of small node negative cancers, introduction of targeted node sampling, less reliance on information from nodal staging for adjuvant therapy decision making and evidence that non-surgical treatments such as systemic therapies (chemotherapy, hormonal therapy, biological therapy) together with radiotherapy can safely treat low burden axillary disease. Sentinel lymph node biopsy (SLNB) alone with omission of further axillary surgery for nodal macrometastases (>2 mm) might be sufficiently extirpative to achieve local control when combined with adjuvant treatments. There remain unanswered questions on the safety of SLNB post chemotherapy in patients with biopsy-proven nodal disease at presentation and whether omission of axillary node dissection is feasible in selected cases. Emerging evidence suggests that a complete radiological response with removal of at least 3 nodes (including clipped nodes at time of biopsy) can yield false negative rates of <10% and be a safe option. New technologies involving percutaneous biopsy of sentinel nodes under radiological guidance are under investigation and could potentially replace surgical staging of the axilla in the future. Moreover, omission of any type of node biopsy might be a potential option in more favorable tumors and could herald the beginning of the end for histological axillary sampling in selected cases.
BACKGROUND: Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) represents a treatment option for peritoneal surface malignancies. Even if it has been reported that this new approach...BACKGROUND: Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) represents a treatment option for peritoneal surface malignancies. Even if it has been reported that this new approach improved survival of selected patients, it is still associated with high morbidity and mortality rates. METHODS: From October 1995 to December 2017, over 450 patients affected by peritoneal carcinomatosis (PC) underwent in our Institute CRS associated with HIPEC. For this preliminary analysis we considered 300 patients presenting PC of different origin: pseudomyxoma peritonei (PMP, N.=98), epithelial ovarian cancer (EOC, N.=87), peritoneal mesothelioma (DMPM, N.=49) and colorectal cancer (CRC, N.=66). Postoperative morbidity and mortality were studied in order to identify possible risk factors. RESULTS: The morbidity rate was 36.3% in all procedures (109/300). According to the Clavien-Dindo Classification, 67 cases (22.3%) were associated with grade I-II complications and 35 cases (11.7%) with grade III-IV. Surgical and medical complication rates were 8.3% (25/300) and 11.3% (34/300), respectively. The mortality rate was 2.3%. Reoperation was needed in 28 patients (9.3%). The operative time, the number of anastomosis, of peritonectomy procedures, of visceral resections performed and the PCI value resulted the most statistically significant factors influencing postoperative morbidity and mortality. CONCLUSIONS: The risks of perioperative morbidity and mortality after CRS and HIPEC are analogous to any other major gastrointestinal surgery. CRS and HIPEC should remain a treatment option for highly-selected patients in whom a curative or life prolonging treatment is a pursuit and should be performed in high volume specialized institutions.
Advances in reconstructive breast surgery with new materials and techniques now allow us to offer patients the best possible cosmetic results without the risks associated with oncological control of the disease. These ad...Advances in reconstructive breast surgery with new materials and techniques now allow us to offer patients the best possible cosmetic results without the risks associated with oncological control of the disease. These advances, in both oncological and plastic surgery, have led to a new field, oncoplastic breast surgery, which enables us to undertake large resections and, with advance planning, and prevent subsequent deformities. This is particularly important when more than 30% of the breast volume is removed, as it allows us to obtain precise information for conservative surgery according to the site of the lesion and to set the boundary between conservative surgery and mastectomy.
Augmented reality (AR) enables the superimposition of virtual reality reconstructions onto clinical images of a real patient, in real time. This allows visualization of internal structures through overlying tissues, ther...Augmented reality (AR) enables the superimposition of virtual reality reconstructions onto clinical images of a real patient, in real time. This allows visualization of internal structures through overlying tissues, thereby providing a virtual transparency vision of surgical anatomy. AR has been applied to neurosurgery, which utilizes a relatively fixed space, frames, and bony references; the application of AR facilitates the relationship between virtual and real data. Augmented breast imaging (ABI) is described. Breast MRI studies for breast implant patients with seroma were performed using a Siemens 3T system with a body coil and a four-channel bilateral phased-array breast coil as the transmitter and receiver, respectively. Gadolinium was injected as a contrast agent (0.1 mmol/kg at 2 mL/s) using a programmable power injector. Dicom formatted images data from 10 MRI cases of breast implant seroma and 10 MRI cases with T1-2 N0 M0 breast cancer, were imported and transformed into augmented reality images. ABI demonstrated stereoscopic depth perception, focal point convergence, 3D cursor use, and joystick fly-through. ABI can improve clinical outcomes, providing an enhanced view of the structures to work on. It should be further studied to determine its utility in clinical practice.
BACKGROUND: The aim of this study was to evaluate the safety and efficacy of percutaneous ablation for hepatocellular carcinoma (HCC) hepatic recurrence along surgical resection margins to achieve complete cure or bridge...BACKGROUND: The aim of this study was to evaluate the safety and efficacy of percutaneous ablation for hepatocellular carcinoma (HCC) hepatic recurrence along surgical resection margins to achieve complete cure or bridge for additional treatment. No current recommendations exist for these lesions. METHODS: Retrospective review of post-surgical recurrent HCC located along surgical margins treated by percutaneous ultrasound-guided ablation from 2006-2014. Ablation was performed by radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI), selected for recurrence in proximity to extrahepatic organs. RESULTS: In total, nine patients (49-82 y, mean 73.8±8.3) were treated for 13 recurrent HCC nodules (9-35 mm, mean 21.5±8.1) located along resection margins by RFA (11 nodules) and PEI (2 nodules). Mean time between surgery and percutaneous ablation was 64 months (range 10-149). At a mean follow-up of 17 months (±9), complete ablation was achieved in 9 nodules (69.2%, 8 after RF, 1 after PEI) and partial ablation was achieved in 4 nodules (3 after RFA, 1 after PEI). Complications were limited to minor abdominal pain in 2 patients requiring medical therapy (15.3%). Of the 4 partially ablated nodules, subsequent therapy achieved complete response in 3 nodules (1 patient with TACE, 1 patient with stereotactic radiotherapy, and one with liver transplantation), while the last nodule progressed despite subsequent TACE. CONCLUSIONS: HCC recurrence along the surgical margin can be safely and effectively treated by percutaneous therapy, despite the misconception of the surgical margin as a hostile location. Percutaneous treatment may bridge the patient for additional therapy.
Laparoscopic and endoscopic colorectal intervention and operations have their basis in real-time, image-based decision-making and step-by-step sequenced technical progress. The capacity to visualize accurately malignant...Laparoscopic and endoscopic colorectal intervention and operations have their basis in real-time, image-based decision-making and step-by-step sequenced technical progress. The capacity to visualize accurately malignant disease wherever it may be including within the primary lesion and its draining lymph node basin as well as at potential sites of metastatic harbor (i.e. peritoneum, liver and lung) would allow more accurate surgery at the time of operation and enable personalized, stratified surgical intervention. In addition, such capacity could efficiently compress the diagnostic and therapeutic stages of a patient's progress from presentation, through work-up and onto appropriate treatment, important in this era of restricted resource and increased user demand. Near-infrared endolaparoscopic illumination enables broad spectral imaging of tissue in situ, most often, at present, in conjunction with the approved safe and low-cost fluorophore indocyanine green. While additional targeted agents are in development, here we detail how this developed and available technology may be used as a visual probe of neoplasia to inform surgeons regarding functional, tissue characterization through the direct observation of metabolic and metabolomic processes within the area under inspection perhaps helping in the distinction between invasive cancer and non-invasive dysplastic lesions. This understanding can inform and accelerate development of specific agents and techniques that can better advance surgical practice into the era of surgical data science and true precision surgery.
Anastomotic leakage (AL) is a serious complication in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. Adequate bowel perfusion h...Anastomotic leakage (AL) is a serious complication in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. Adequate bowel perfusion has been stressed as one of the key elements for suture healing. Currently, there is no widespread method to assess and quantify the perfusion of gastrointestinal anastomoses intraoperatively, besides the subjective evaluation by the surgeon. The aim of this paper is to describe the basis of Indocyanine Green (ICG) fluorescence guided surgery applied to assessment of bowel perfusion and to highlight studies on the use of fluorescence angiography (FA) in laparoscopic rectal surgery. ICG fluorescence guided surgery has increasingly been used as a tool for intraoperative diagnostics to assess microperfusion and viability of tissues by means of a real-time FA; this technique has achieved the role of major contribution to intraoperative decision making during surgical procedures, especially in order to assess bowel perfusion before anastomosis creation in colorectal surgery. Several studies in literature already reported that ICG FA as a feasible technique to decrease AL rate in colorectal surgery; to date no randomized controlled trials have been completed but large series and prospective studies that focus on fluorescence perfusion assessment in rectal surgery have been published. Real time intraoperative ICG fluorescent angiography (FA) is a safe and feasible technique to guide the surgeon in intraoperative decision-making process. ICG FA seems to reduce AL rates following rectal surgery for cancer. However large well-designed RCTs are needed to provide evidence for its routine use.
The management of rectal cancer has considerably changed over the last decades and complete response to neoadjuvant chemoradiotherapy is becoming a common clinical entity. There is still no consensus on the definition of...The management of rectal cancer has considerably changed over the last decades and complete response to neoadjuvant chemoradiotherapy is becoming a common clinical entity. There is still no consensus on the definition of complete response to neoadjuvant treatment prior to surgery. Treatment programs are mostly heterogeneous and non-randomized. In addition, techniques to diagnose complete response are still unclear and there is no uniformity in surveillance modality of those patients managed without operative intervention. We review the most recent evidences reported in literature.
Once considered an incurable disease, the continuous evolution of technologies and techniques has improved both oncological outcomes and quality of life for patients with rectal cancer. Multiport laparoscopic surgery for...Once considered an incurable disease, the continuous evolution of technologies and techniques has improved both oncological outcomes and quality of life for patients with rectal cancer. Multiport laparoscopic surgery for rectal cancer is the standard of care in many institutions and countries and is the approach that has been most subjected to controlled trial. Following a number of randomized trials as well as large series and registry reports and several Cochrane reviews, there is no evidence of any oncological disadvantage to laparoscopic surgery compared with the open approach and there is good evidence of improved short-term outcomes and some evidence of improved long-term outcomes. We describe the "standard" approach to multiport, laparoscopic low anterior resection.
BACKGROUND: Bleeding and staple-line leak, are the most common complications of laparoscopic sleeve gastrectomy. To decrease the incidence of this complications, a variety of intraoperative reinforcement of staple line i...BACKGROUND: Bleeding and staple-line leak, are the most common complications of laparoscopic sleeve gastrectomy. To decrease the incidence of this complications, a variety of intraoperative reinforcement of staple line is used. Reinforced GIA™ is a new automatic suture device with pre-attached synthetic tissue reinforcement, but no study has evaluated its use in sleeve gastrectomy. The objective of this study is to evaluate the efficacy and safety of this new staple line reinforcement technique in laparoscopic sleeve gastrectomy. METHODS: We conducted a retrospective review of 290 patients who underwent laparoscopic sleeve gastrectomy between January 2013 and January 2016 in which reinforced GIA™ or standard GIA™ was used. Patients preoperative characteristics, Operative time, staple line leaks, staple line bleeds, stenosis, and complications requiring reoperation were collected. RESULTS: A total of 187 laparoscopic sleeve gastrectomy were performed with standard GIA and 103 with reinforced GIA™. Patient characteristics were not significantly different between the groups. The average operating time in the standard GIA group is 57.41±16.44 min against 50.9±14.12 min in the reinforced GIA group (P=0.006). Two staple line leaks developed in the standard GIA group and reoperated against no patients in the reinforced GIA group, without significant difference between the both groups (P=0.66). Staple line bleeds are less in the reinforced GIA group, only 23 (22.3%) against 78 (41.7%) cases in the standard GIA group (P=0.001). No patients of both groups developed gastric sleeve stenosis. CONCLUSIONS: During laparoscopic sleeve gastrectomy, the use of a reinforced stapler significantly reduces the operative time and staple line bleeding. No significant difference is evidenced in terms of reduction of staple line leaks with this reinforced stapler.
BACKGROUND: The aim of this study was to compare OTSC® proctology and fistulectomy with primary sphincter reconstruction results as treatment strategies for anorectal low trans-sphincteric fistula. METHODS: Between Febru...BACKGROUND: The aim of this study was to compare OTSC® proctology and fistulectomy with primary sphincter reconstruction results as treatment strategies for anorectal low trans-sphincteric fistula. METHODS: Between February 2012 and March 2013, patients affected by trans-sphincteric anal fistula were consecutively enrolled in the trial. Patients were randomized to receive fistulectomy with primary sphincter reconstruction or OTSC® Proctology. Demographic characteristics, comorbodities, previous anorectal treatments, and recurrent fistula data were acquired. Postoperative therapy data and pain and Wexner scores (30 and 60 dd) were acquired during follow-up. Furthermore, patients were contacted by telephone after six months, and were visited both one year and three years after surgery. RESULTS: Thirty consecutive patients were included in the study. 15 patients underwent the OTSC® Proctology procedure and 15 underwent the standard fistulectomy. The success rate was 93.3% in the OTSC group. The mean postoperative stay was 1.3 days in the OTSC® patients and 3.6 days in the fistulectomy group patients. The mean medications required for complete healing was 3.2 in the OTSC group and 8.9 in the FIPS group. CONCLUSIONS: Our results suggest that OTSC® Proctology is an effective and safe treatment in achieving permanent closure of the internal fistula opening in selected patients, with excellent results in terms of pain, postoperative incontinence, healing time, and days of hospitalization.
BACKGROUND: Liver resection may be complicated by unpredictable intraoperative bleeding. Pringle's maneuver was the first attempt to control bleeding, but the main problem is the duration of ischemia. Robotic surgery tha...BACKGROUND: Liver resection may be complicated by unpredictable intraoperative bleeding. Pringle's maneuver was the first attempt to control bleeding, but the main problem is the duration of ischemia. Robotic surgery thanks to the magnified view, three-dimensional visualization associated and fine movement allow to perform good parenchymal dissection and identification of vascular structure. Aim of study is to evaluate blood loss and the need to perform Pringle maneuver in patients underwent robotic liver resection. METHODS: Thirty-three patients underwent robotic liver resections were analyzed, 16 (48%) male and 17 (52%) female, with median age of 64 years. Seven (21%) patients had benign lesions and twenty-six (79%) malignant tumor. RESULTS: Seventeen (52%) patients had anatomical resections, while sixteen (48%) patients had non anatomical resection. Operative time was 270 minutes. Estimated blood loss was 100 mL and Pringle maneuver was carried out on seven patients. Median hospital stay was 4 days. CONCLUSIONS: Our results show that liver resections with robotic technique can be performed safely even without systematic Pringle maneuver.
BACKGROUND: Previous studies have suggested that variation in results of lumbar discectomy depends on careful selection of patients. Numerous factors have been suggested to explain this variation with no direct examinati...BACKGROUND: Previous studies have suggested that variation in results of lumbar discectomy depends on careful selection of patients. Numerous factors have been suggested to explain this variation with no direct examinations on this issue. The objective was to examine the use of pain medication before and after lumbar discectomy in patients with back pain. METHODS: Prospective occupational cohort study (N.=151,618) with linkage to national registers. Of the cohort members, 1538 (age 44 years) underwent discectomy. Records from purchases of pain medication were obtained during a 3-year period before and after hospital discharge. RESULTS: Purchases of pain medication increased during the follow-up period from 9.7±28.7 to 17.3±17.3 defined daily doses. Three groups were identified: 1) with constant, relatively low pain medication use; 2) with high use combined with further increases in purchases until the time of surgery and only a slight decrease thereafter; and 3) with a sharp rise in medication use before surgery and a return to no pain medication use approximately six months after the discharge. Non-manual profession (OR=1.34, 95% CI: 1.06 to 1.69) and open surgery technique increased (OR=1.32, 95% CI: 1.04 to 1.67) the probability of being included into the third group. CONCLUSIONS: The greater decline in the use of pain medication after discectomy was associated with a sharp rise of that use within six months before surgery. This suggests that lumbar discectomy may benefit especially those with acute or subacute pain within the six-month window.
BACKGROUND: To assess outcomes of patients operated on for rectal cancer (RC) by analysing the trends of disease free survival curves (DFSc) after a very long-term follow-up. METHODS: All patients treated with curative i...BACKGROUND: To assess outcomes of patients operated on for rectal cancer (RC) by analysing the trends of disease free survival curves (DFSc) after a very long-term follow-up. METHODS: All patients treated with curative intent for RC from 1986 to 2005 were retrospectively analyzed. Other than demographics, disease characteristics and treatment-related factors were considered. The DFSc were compared between patients who had neoadjuvant therapy (NAT) and those who had surgery alone. RESULTS: Median age of 319 patients included in the study was 66.3 years (range 23-89) and 140 (57.6%) of them were males. Moreover, NAT was given in 24 (11.8%) patients, and adjuvant therapy in 40 (19.7%) patients. Median follow-up was of 150 months (60-240). In patients who had NAT the mean age was higher (P=0.05), RC were located lower (P=0.009) and higher positive lymph-nodes were found (P=0.003), whereas the number of both local (P=0.4) and distant recurrences (P=0.7) was not significantly lower, compared to the other group. Comparing trends of DFSc a more progressive decrease was shown in patients treated with surgery alone. Even if the differences of DSFc between groups at the end of follow-up were not significant (95% CI: 0.609-2.963, P=0.46), patients who had NAT displayed better survival up to 180 months. CONCLUSIONS: Overall, these results showed comparable outcomes between both groups over such a long lasting follow-up. This time frame might be used more extensively for increasing our knowledge of RC biological behaviour as well.
BACKGROUND: Actual cure rate and patterns of recurrence after cytoreductive surgery (CRS) associated to hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with colorectal peritoneal carcinomatosis (PC) are no...BACKGROUND: Actual cure rate and patterns of recurrence after cytoreductive surgery (CRS) associated to hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with colorectal peritoneal carcinomatosis (PC) are not yet well explored. Moreover, the selection policy to this resource-consuming treatment is still a matter of debate. METHODS: From a dataset of 400 CRS+HIPEC performed between October 1996 and December 2015, we selected 54 consecutive patients with colorectal PC. Exclusion criteria were age>70, PS>2, or disease progression during chemotherapy. From 2004, we also excluded patients with both PCI>16 and poor prognostic factors of primary tumor (i.e. T4, N2 and G3) and only proceeded to HIPEC in case of optimal cytoreduction. Prognostic factors, cure rate and patterns of recurrence were investigated, comparing the two time periods. RESULTS: After 2004, median overall survival was 52 months, with a 40% 5-year survival. Completeness of cytoreduction, primary tumor histology and time period were independent prognostic factors. Median recurrence-free survival was 16 months. A relapse was detected in 41 out of 46 patients with optimal cytoreduction. Main sites of first relapse were peritoneum (73%), and distant metastases (37%), mainly to liver and lungs. Peritoneal and liver/lung metastases presented as isolated recurrence in 73% and 58% of cases, respectively. CONCLUSIONS: By a selection policy based on patient, disease extension and primary tumor factors, a median survival higher than 50 months can be expected. Most patients will eventually recur, mainly in the peritoneum. The pattern of recurrence suggests a potential role for more effective intraperitoneal therapies and repeat surgical treatments.