Luigi Brusciano

Background: The optimal surgical approach for perforated sigmoid diverticulitis (PSD) remains debated. Hartmann’s procedure (HP) is the standard, but often leads to a permanent stoma, while primary resection with anastomosis and diverting loop ileostomy (PADLI) may offer better functional recovery. This prospective multicenter study compared PADLI and HP in terms of stoma reversal, complications, and long-term quality of life (QoL) in hemodynamically stable patients with Hinchey III–IV diverticulitis. Materials and Methods: From January 2017 to December 2022, 664 consecutive patients with Hinchey III–IV PSD were enrolled across six high-volume tertiary referral centers in an international multicentric collaboration. The primary endpoint was stoma reversal rate at 24 months. Secondary endpoints included early (≤90 days) and late (>90 days) complications, stoma closure outcomes, long-term morbidity, and QoL assessed with the Short Form-36 Health Survey (SF-36) and EQ-5D-5L questionnaires at 3, 6, 12, and 24 months. Kaplan–Meier survival analysis and multivariable Cox proportional-hazards regression were performed to identify independent predictors of stoma-free survival. Results: A total of 265 patients underwent PADLI and 399 HP; 536 patients (80.7%) constituted the per-protocol population analyzed for the primary outcome (210 PADLI, 326 HP); the 19 patients re-operated within 30 days were analyzed separately in a sensitivity analysis. PADLI achieved significantly higher stoma reversal rates at 24 months (91.6% vs 57.8%; P < 0.00001), with shorter median time to closure (64 vs 178 days; P < 0.001). In-hospital mortality was comparable between groups (1.2% vs 1.8%; P = 0.747). Major complications (Clavien–Dindo ≥ IIIb) were comparable (6.1% vs 8.5%), while early readmissions were more frequent in PADLI (17.9% vs 12.3%; P < 0.05) and late readmissions in HP (12.8% vs 7.2%; P < 0.05). PADLI patients demonstrated superior QoL after 6 months, with SF-36 scores at 24 months of 80.1 ± 6.5 vs 72.3 ± 6.8 ( P < 0.001) and EQ-5D-5L of 0.90 ± 0.05 vs 0.75 ± 0.06 ( P < 0.001). Parastomal hernia rates at 24 months were lower in PADLI (43.7% vs 72.9%; P < 0.00001). PADLI independently predicted stoma-free survival at 24 months (HR, 2.63; 95% CI: 1.84–3.77; P < 0.001), while ASA III–V, age ≥70 years, and higher APACHE II scores were negative predictors. Conclusion: In stable patients with Hinchey III–IV PSD, PADLI is associated with higher rates of and faster stoma reversal, superior long-term QoL, and fewer late stoma-related complications compared with HP, at the expense of increased early readmissions. These findings, derived from a large international, multicenter cohort, support PADLI as a preferred strategy in selected patients, provided there is structured perioperative care and follow-up.

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) on the diagnosis and management of obstructed defecation syndrome (ODS), with the purpose of guiding physicians in the selection of the most appropriate treatment option. A panel of experts was appointed by the Board of the SIUCP to develop key questions addressing the main topics related to the management of ODS and to perform an accurate literature search for each topic, in order to provide evidence-based answers and to summarize them in structured statements. All clinical questions were discussed by the expert panel over multiple rounds using the Delphi approach, and consensus among the experts was achieved for each statement. The questions were formulated according to PICO (patients, intervention, comparison, outcome) criteria, and the statements were developed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In patients with ODS refractory to first-line medical therapy, rehabilitation may be considered as a therapeutic option, particularly in cases of dyssynergic defecation, whereas a surgical approach may be indicated in patients with a high symptom score and an Oxford prolapse grade system score ≥3 on defecography (using magnetic resonance imaging or another modality). Surgical options include stapled transanal rectal resection and ventral mesh rectopexy, eventually combined, respectively, with pelvic organ prolapse suspension and sacrocolpopexy in the presence of multicompartment pelvic prolapse. A transverse perineal support procedure may be considered in the presence of excessive perineal descent. In patients with recurrent symptoms after surgery, transanal irrigation may represent a useful therapeutic option.

Purpose: To evaluate the safety and long-term efficacy of stapled transanal rectal resection (STARR) combined with the transverse perineal support (TPS) procedure in the surgical treatment of obstructed defecation syndrome (ODS) associated with internal rectal prolapse and excessive perineal descent (PD).Methods: This multicenter observational case-control study involved 7 European centers. During the initial study period, patients underwent STARR alone (group 1), while in the subsequent period, patients received STARR combined with TPS (group 2). All patients were followed clinically at 6, 12, 36, and 60 months, and were offered radiological evaluation between 3 and 5 years postoperatively.Results: The median postoperative ODS score was similar between groups at 6 months (6 [range, 2–15] vs. 5 [range, 2–13]; P=0.16, Mann-Whitney U-test), but at 36 months, it was significantly lower in group 2 compared to group 1 (11 [range, 5–16] vs. 5 [range, 2–15]; P<0.001, Mann-Whitney U-test), with stable results maintained through 5 years. The success rate followed a similar trend. Postoperative maximum PD during straining remained unchanged in group 1, whereas it significantly decreased compared to preoperative values in group 2.Conclusion: The addition of TPS to STARR in the surgical treatment of ODS associated with internal rectal prolapse and excessive PD appears to significantly improve long-term success rates and correct descending perineum.

Purpose: Laparoscopic right hemicolectomy can be performed via intracorporeal ileocolic anastomosis (ICA) or extracorporeal ileocolic anastomosis (ECA). Prior studies have emphasized ICA’s advantages in hospital stay and postoperative pain. This multicenter study aimed to compare the 2-year incidence of incisional hernia between ICA (using a suprapubic Pfannenstiel incision) and ECA (using a pararectal incision) and assess perioperative outcomes.Methods: We retrospectively analyzed patients undergoing laparoscopic right hemicolectomy between 2019 and 2020, divided into 2 groups: ICA with a Pfannenstiel incision and ECA with a pararectal incision.Results: The mean operative time was longer in the ICA group (190 minutes vs. 170 minutes, P=0.004). Despite requiring advanced surgical skills and prolonged operative time, ICA was associated with superior short-term outcomes and a significantly lower incisional hernia rate compared to ECA (1.2% vs. 14.7%, P=0.044) at 24-month follow-up.Conclusion: ICA is linked to longer operative times, but shorter hospital stays, fewer wound complications, and reduced incisional hernia rates compared to ECA.

Background: Sphinkeeper™ (SK) implantation has emerged as a minimally invasive option for patients with fecal incontinence (FI) who fail to respond to conservative therapies. While preliminary outcomes have been encouraging, robust mid-term data remain limited. This study aimed to evaluate the safety, efficacy, and quality-of-life outcomes of SK implantation in a large, multicenter European cohort. Materials and methods: This retrospective cohort study included patients with FI who underwent SK implantation between 2017 and 2022 across seven tertiary referral centers in Europe. Eligible patients had failed pharmacological and pelvic floor rehabilitation therapies and completed at least 3 years of follow-up. Primary outcomes included changes in the Cleveland Clinic Incontinence Score (CCIS), Vaizey score, weekly incontinence and soiling episodes, and the ability to postpone defecation. Secondary outcomes assessed changes in the fecal incontinence quality of life (FIQoL) scale. All patients underwent standardized clinical, ultrasonographic, and manometric evaluations preoperatively and at 3 months postoperatively. Results: A total of 111 patients (61.2% female; median age 59.4 years) were included. Median CCIS decreased from 12 (range: 6–18) at baseline to 7 (1–10) at 12 months, with sustained improvement at 3 years ( P < 0.0001). Vaizey scores and weekly incontinence episodes significantly declined, while the ability to postpone defecation improved from 8 to 18 seconds ( P < 0.001). All FIQoL domains showed significant enhancement by 12 months and remained stable through 36 months. No major complications were reported, and implant positioning was confirmed as adequate in 91.9% of cases. Conclusion: SK implantation is a safe and effective treatment for refractory FI, offering durable improvements in continence, urgency control, and quality of life over a 3-year follow-up period. These findings support its role as a viable minimally invasive alternative in the contemporary management of FI.

Purpose: This study was conducted to evaluate the validity of a new imaging-guided, anatomy-based classification of anorectal fistulas in defining disease severity and predicting surgical outcomes.Methods: This multicenter, retrospective cohort study analyzed data from patients with perianal fistulas who underwent surgery between 2017 and 2023. All patients underwent preoperative 3-dimensional endoanal ultrasound, with adjunctive magnetic resonance imaging performed if ultrasound indicated a complex fistula. Imaging examinations were retrospectively evaluated to categorize fistulas according to the Garg classification and the newly proposed classification system. The new classification included 6 severity grades based on the characteristics of the primary tract: submucosal, intersphincteric, low transsphincteric, high transsphincteric, multiple, and suprasphincteric/extrasphincteric. Each grade was further subdivided into 3 subtypes (A, B, C) based on the extension of secondary tracts.Results: When compared with the new classification, the Garg classification demonstrated a slightly lower ability to predict the feasibility of fistulotomy in simple fistulas (94.2% vs 99.1%; Fisher exact test, P=0.006). A strong positive correlation was found between the surgery failure rate and the severity grade of the new classification (Spearman rho, 0.90; P<0.001), whereas the Garg classification showed a nonsignificant positive correlation with surgical failure rate (Spearman rho, 0.90; P=0.08).Conclusion: The new imaging-guided, anatomy-based classification of anorectal fistulas demonstrates high accuracy in defining disease severity. It represents a valuable tool for preoperative grading of anal fistulas, standardizing the reporting of diagnostic imaging, and improving the communication of findings among healthcare professionals.

Background and Objectives: With the increasing life expectancy, the frequency of total thyroidectomies in elderly patients has risen, raising concerns regarding hemorrhage and recurrent laryngeal nerve palsy compared to the general population. Therefore, considering the frequent alteration of the coagulation status in such patients, innovative methods able to reach an accurate hemostasis appear highly desirable. This retrospective multicentric study aimed to compare the postoperative outcomes of patients treated with conventional hemostasis with patients treated with the Harmonic Scalpel (HS) and gelatin–thrombin matrix (Floseal). Materials and Methods: Patients undergoing total thyroidectomy were retrospectively enrolled and categorized into two groups: Group A patients underwent surgery with the Harmonic Scalpel and Floseal, while Group B underwent traditional hemostasis surgery with ligations and monopolar electrocautery. The primary endpoint was the drain output after 24 and 48 h and the presence of significant blood loss. Secondary endpoints included the presence of seroma, wound infection, hematoma, laryngeal nerve palsy, surgery duration, and onset of post-surgical hypocalcemia. Results: From January 2014 to January 2024, 870 individuals participated in the study. Group A (gelatin–thrombin and HS) comprised 502 patients, while Group B (Standard Hemostasis—control group) comprised 368 patients. The 24 h drain output was 52 ± 25 mL in Group A vs. 113 ± 27 mL in Group B, p = 0.003, while the 48 h drain output was 95 ± 29 mL in Group A and 113 ± 27 mL in Group B (p = 0.002). Significant blood loss occurred in eight patients (2.2%) of Group B vs. three cases (0.6%) in Group A (p = 0.039). Also, neck hematoma (p = 0.012), seroma (p = 0.005), and reoperation (p = 0.052) values were significantly lower in Group A. Conclusions: Surgery aided with HS, and gelatin–thrombin was associated with lower major and minor complications compared to the conventional approach, guarantying reduced operative time, ensuring hemostasis, and preserving parathyroid glands, even in elderly patients.

Introduction: Robot-assisted minimally invasive gastrectomy (RAMIG) represents a significant advancement in the surgical management of gastric cancer, offering superior dexterity, enhanced visualization, and improved ergonomics compared to laparoscopic gastrectomy (LG). This review systematically evaluates the current evidence on perioperative outcomes, oncological efficacy, learning curves, and economic considerations, providing insights into RAMIG’s potential role in modern gastric cancer surgery. Methods: A thorough analysis of retrospective, prospective, and meta-analytic studies was conducted to compare RAMIG with LG. Key outcomes, including operative time, intraoperative blood loss, lymph node retrieval, postoperative complications, learning curve duration, and cost-effectiveness, were assessed. Emphasis was placed on both short-term and long-term oncological outcomes to determine the clinical value of RAMIG. Results: Evidence indicates that RAMIG is associated with reduced intraoperative blood loss, lower morbidity rates, and a shorter learning curve, with proficiency achieved after 11–25 cases compared to 40–60 cases for LG. The robotic platform’s articulated instruments and enhanced three-dimensional visualization enable more precise lymphadenectomy, particularly in complex anatomical regions. Despite these advantages, operative time remains longer, and costs remain higher due to system acquisition, maintenance, and consumable expenses. However, emerging data suggest a gradual narrowing of cost disparities. While short-term outcomes are favorable, further high-quality, multicenter studies are needed to validate long-term oncological efficacy and survival outcomes. Conclusion: RAMIG offers significant technical and clinical advantages over conventional LG, particularly in terms of precision and learning efficiency. However, the long-term oncological benefits and economic feasibility require further validation. Future research should focus on cost optimization, advanced technological integration such as near-infrared fluorescence and artificial intelligence, and multicenter trials to solidify RAMIG’s role as a standard approach for gastric cancer surgery.

Background: Esophageal cancer, the seventh most common malignancy globally, requires esophagectomy for curative treatment. However, esophagectomy is associated with high postoperative morbidity and mortality, highlighting the need for minimally invasive approaches. Robotic-assisted surgery has emerged as a promising alternative to traditional open and minimally invasive esophagectomy (MIE), offering potential benefits in improving clinical and oncological outcomes. This review aims to assess the postoperative morbidity and outcomes of robotic surgery. Methods: A comprehensive review of the current literature was conducted, focusing on studies evaluating the role of robotic-assisted surgery in esophagectomy. Data were synthesized on the clinical outcomes, including postoperative complications, survival rates, and recovery time, as well as technological advancements in robotic surgery platforms. Studies comparing robotic-assisted esophagectomy with traditional approaches were analyzed to determine the potential advantages of robotic systems in improving surgical precision and patient outcomes. Results: Robotic-assisted esophagectomy (RAMIE) has shown significant improvements in clinical outcomes compared to open surgery and MIE, including reduced postoperative pain, less blood loss, and faster recovery. RAMIE offers enhanced thoracic access, with fewer complications than thoracotomy. The RACE technique has improved patient recovery and reduced morbidity. Fluorescence-guided technologies, including near-infrared fluorescence (NIRF), have proven valuable for sentinel node biopsy, lymphatic mapping, and angiography, helping identify critical structures and minimizing complications like anastomotic leakage and chylothorax. Despite these benefits, challenges such as the high cost of robotic systems and limited long-term data hinder broader adoption. Hybrid approaches, combining robotic and open techniques, remain common in clinical practice. Conclusions: Robotic-assisted esophagectomy offers promising advantages, including enhanced precision, reduced complications, and faster recovery, but challenges related to cost, accessibility, and evidence gaps must be addressed. The hybrid approach remains a valuable option in select clinical scenarios. Continued research, including large-scale randomized controlled trials, is necessary to further establish the role of robotic surgery as the standard treatment for resectable esophageal cancer.