Laparoscopic colon and rectal resections with intracorporeal anastomosis and trans-vaginal specimen extraction for colorectal cancer. A case series and systematic literature review

PURPOSE

Intracorporeal anastomosis associated to trans-vaginal specimen extraction decreases the extent of colon mobilisation and the number and size of abdominal incisions, improving the benefits of minimally invasive surgery in female patients. The aim of this study was to evaluate the safety and effectiveness of this procedure for colorectal cancer.

METHODS

Between 2009 and 2013, 13 female patients underwent laparoscopic colon and rectal resection for colorectal cancer with intracorporeal anastomosis and trans-vaginal specimen extraction: 2 right colectomies, 1 transverse colon resection, 4 left colectomies and 6 anterior resections were performed. A MEDLINE search of publications on the presented procedure for colon neoplasms was carried out.

RESULTS

There were no intraoperative complications and no conversions. Postoperative visual analogue scale (VAS) score in the pelvis, abdomen and shoulder was moderate. In the postoperative period, we observed two colorectal anastomotic strictures, successfully treated with pneumatic endoscopic dilation. Median length of the specimen was 18.5 cm, with a median tumour size of 5.5 cm in diameter. Median number of retrieved lymph nodes was 12. All circumferential resection margins were negative. During a mean follow-up of 31 months (range, 6-62), there was neither evidence of recurrent disease nor disorders related to the genitourinary system. The aesthetic outcome was considered satisfactory in all patients. Nine studies were identified in the systematic review.

CONCLUSIONS

Our case series, according to the results of the literature, showed that intracorporeal anastomosis associated to trans-vaginal specimen extraction is feasible and safe in selected female patients.

Down-regulated miRs specifically correlate with non-cardial gastric cancers and Lauren's classification system

BACKGROUND AND OBJECTIVES

Gastric cancers are usually characterized using Lauren's classification into intestinal and diffuse types. We previously documented the down-modulation of miR31, miR148a, miR204, and miR375 in gastric cancers. We aimed this manuscript to investigate these miRs with the end-points of diagnosis, Lauren's classification and prognosis.

METHODS

A total of 117 resected non-cardial adenocarcinomas were evaluated for miRs' expressions. The performance of miRs' expressions for cancer diagnosis was tested using ROC curves. Logistic regression was conducted with the end-point of Lauren's classification. Kaplan-Meier and Cox analyses were performed for OS, DFS, and DSS. miRs' targets were reviewed using PRISMA method and BCL-2 was further investigated in cell lines.

RESULTS

ROC curves documented that miRs' down-modulation was significant in differentiating cancer versus normal tissues. Diffuse type cancers were associated with female sex, young age, and miR375 higher expression. We confirmed BCL-2 as a miR204 target. However, survival analyses confirmed the pathologic criteria (advanced stages, LNR, and low LNH) as the significant variables correlated to worse prognosis.

CONCLUSIONS

The down-modulation of miR31, miR148a, miR204, and miR375 is significantly associated with non-cardial gastric cancers and miR375 is specifically linked to Lauren's classification. Nevertheless, standard pathological features display as the independent variables associated with worse prognosis.

Current role of open surgery in adrenal tumors

AIM

The aim of this retrospective evaluation is to assess the current role of open adrenalectomy, in particular in cases of adrenocortical carcinoma (ACC).

MATERIALS AND METHODS

From January 2009 to May 2019, 26 open out of 233 adrenalectomies were performed in our Academic Department. Open adrenalectomy was performed by the anterior approach. A midline abdominal incision or a subcostal surgical incision was used to reach the peritoneal cavity. The resection was defined R0 if the margins of the sample were negative for malignancy.

RESULTS

Open adrenalectomy was performed in 26 patients: 10 men and 16 women with a mean age of 61±25.3 years and a mean BMI of 28.4±2.9. The right adrenal gland was removed in 15 cases Romaand the left in 11 cases.We reported 18 diagnosis of malignant pathology. The other diagnosis concerned 5 cases of pheochromocytoma, 1 case of Cushing's disease and 2 cases of hyperaldosteronism. Mean tumor size was 7.7±5.5. Mean operative time was 160 min (range=110-205 minutes). Mean postoperative stay was 7±2 days. Only 3 (10%) patient showed postoperative grade II complications, according to Clavien-Dindo classification. Midline abdominal incision was used in 18 patients, subcostalsurgical incision in 5 patients and bilateral subcostal surgical incision in 3 patients. 3 right nephrectomy was necessary to remove the entire tumor mass. An en bloc R0 tumor resection was accomplished in all cases.There was no intra and perioperative mortality. All patients recovered well from surgery. The mean follow-up period was 15 (range=6-48) months.

CONCLUSION

In conclusion, our retrospective study points out the role of open adrenalectomy as the treatment of choice in selected cases with known or suspected malignant adrenal tumors and with size greater than 12 cm.

Differential diagnosis in Rosai-Dorfman disease: A rare case of isolated hepatic presentation mimicking a metastatic tumor with positive 18-FDG uptake

Rosai-Dorfman disease (RDD) is also called sinus histiocytosis with massive lymphadenopathy, and it is caused by a histiocytic disorder with unclear etiology. It usually involves cervical lymph nodes, but it may also present with extranodal involvement. We report a rare condition of isolated hepatic RDD without nodal involvement, clinically manifested with three-month abdominal pain and tenderness of the right hypochondrium. CT- and PET-CT scans were compatible with a secondary lesion from an unknown primary tumor. Therefore, the patient underwent an atypical liver resection. Immunohistochemistry and histological results were compatible with a diagnosis of RDD. RDD is characterized by phenomena of emperipolesis, histiocytic proliferation and positive immunostaining for CD14, CD68 and S-100 protein. Cases of isolated gastrointestinal localization of RDD are particularly rare, especially in the liver. Instrumental exams might confuse RDD with other malignancies. RDD is a rare entity, which might be misdiagnosed using PET-CT due to its similarities with malignant tumors. An accurate multidisciplinary approach may help to clear diagnostic clues of this uncommon disease.

[Comparison between two different mesh fixation methods in laparoscopic inguinal hernia repair: tacker vs. Synthetic cyanoacrylate glue.]

AIM

The aim of this retrospective study was to compare the results of two different mesh fixation methods in laparoscopic transabdominal preperitoneal hernioplasty (TAPP): tacker vs. synthetic cyanoacrylate glue.

METHODS

The study group includes 70 patients with bilateral and monolateral recurrent inguinal hernia undergoing transabdominal preperitoneal repair (TAPP) in the period 2011-2013. A polypropylene mesh was fixed in group A (N.=35) with titanium tacks (EndoUniversal stapler, Covidien) or in group B (N.=35) with synthetic cyanoacrylate glue (Glubran-2, GEM). Patient outcome was assessed by the following variables: sex, mean age, ASA score, intra- and postoperative morbidity, hospitalization, postoperative acute and chronic pain, recurrence rate. The observation period was 24 months, with a mean follow-up of 10.5 months (range, 1-23) for Group A and 11 months (range, 2-24) for Group B.

RESULTS

No difference between the two groups was observed with respect to mean operative time and hospitalization. In all cases, surgery was successfully concluded laparoscopically. Intraoperative complications occurred in 1 patient of the group A and consisted of a urinary bladder injury, which was immediately sutured. Postoperative complication rate was 5.7% (4 patients, of whom 3 in group A and 1 in group B). In each group we detected one recurrence within 6 (group A) and 18 months (group B) postsurgery; both patients were treated with a re-TAPP. Postoperative pain at 6 months from surgery, measured by visual analogue score (VAS), was reported by 4 patients in the group A and in no case of the group B (P=0.04).

CONCLUSION

Data from this study demonstrate the advantages of synthetic cyanoacrylate glue for mesh fixation in laparoscopic transabdominal preperitoneal inguinal hernia repair, compared to titanium tacks. The use of this surgical glue was associated with a significantly reduced risk for developing chronic groin pain and a shortened hospital stay. Nevertheless, further studies with longer follow-up periods are needed to confirm our encouraging results.

The role of laparoscopic surgery in isolated adrenal metastasis: our personal experience

BACKGROUND

Over the past 25 years, mini-invasive adrenalectomy has become the treatment of choice for most adrenal diseases, and even adrenal malignancies in selected cases. The aim of this retrospective evaluation is to assess the effectiveness of laparoscopic adrenalectomy as a treatment of choice for adrenal metastases.

METHODS

From 2008 to 2018, 207 laparoscopic adrenalectomies have been performed in our Department of Surgery. Among these, in 12 cases the indication to adrenalectomy was metastatic adrenal lesion.

RESULTS

The right adrenal gland was removed in 8 cases and the left adrenal gland in 4 cases. A complete resection (R0) was achieved in all patients. The median operative time was 130.6 ± 23.3 min. The median postoperative hospitalization was 3.5±2.0 days. Only one patient showed postoperative grade II complications, according to Clavien-Dindo classification. All patients underwent follow-up at 6-12-18 months without showing disease recurrence. There was no intra and perioperative mortality. Conversion to laparotomic surgery has never been performed. Mean tumor size was 2.4 cm ±1.6 cm.

CONCLUSIONS

Laparoscopic adrenalectomy for metastasis permits to achieve similar results to the open approach in term of oncological outcomes, but gaining in terms of postoperative hospitalization, intra and post-operative complications as well a greater patient compliance.

Penile Mondor's disease after open hernia repair surgery: A case report

Background

Penile Mondor's disease (PMD) is a rare syndrome characterized by sclerosis after superficial thrombophlebitis of the superficial penile veins. The most usual appearance of PMD is a tender, palpable, painful, and sometimes visible cord on the dorsal surface of the penis. Its pathogenesis is still unclear, and a standardized treatment has not been established.

Case report

A 54-year-old male patient presented with a left-sided indirect reducible inguinal hernia. The patient underwent Lichtenstein's procedure for inguinal hernia repair. On the tenth postoperative day, he returned with PMD confirmed by Doppler ultrasonography examination. Treatment with 4000 UI low molecular weight heparin (LMWH) daily for three weeks resolved the symptoms, but mild venous ectasia just to the proximal part of the penis remained.

Discussion

The exact cause of PMD is not well understood, but various studies have identified certain factors associated with an increased risk of the condition. Out of various potential factors that could trigger PMD, the repair of an inguinal hernia has been reported only once. Treatment may involve pain management, anti-inflammatory medications, anticoagulants, and, in some cases, surgery.

Conclusion

PMD after open hernia repair surgery is a very rare benign condition. Correct diagnosis and prompt treatment allowed symptom resolution. Residual venous ectasia has no clinical significance other than a cosmetic appearance.