A major factor in the development of morbidity after surgery is the surgical stress response. The aim of this interventional multicenter randomized open label, parallel group trial is to evaluate the possible lower inflammatory stress response induced by robot-assisted versus laparoscopic surgery for colorectal resections. A total of 593 patients diagnosed with colorectal cancer planned for elective, curative surgery was screened for eligibility. 314 patients planned for right colectomy, left colectomy or rectal resection were randomly assigned 1:1 to robotic (n = 161) or laparoscopic group (n = 153). The primary endpoint was the 24-hours postoperative ∆% change of IL-6 serum levels. Subgroup analyses included the assessment of IL-6 ∆% changes stratified according to age, obesity, comorbidities, tumor staging and resection type have been also performed. In conclusion robotic surgery was associated to a lower surgical stress after colorectal surgery and this finding may help in decision-making regarding when to proceed to robotic approach for colorectal cancer, especially in selected high risk clinical settings.

Purpose This study aimed to determine whether the benefits of robotic surgery can be applied to the treatment of colon cancer by evaluating short-term outcomes of robotic versus laparoscopic colonic resection. Methods This interim analysis of an interventional multicenter randomized trial was conducted to compare outcomes of robotic and laparoscopic colorectal surgery performed between January 2017 and December 2019. The study specifically assessed short-term outcomes in patients undergoing laparoscopic or robotic right or left colectomy for cancer. In addition, all short-term outcomes were evaluated in separate subgroups of right and left colonic resections through prespecified subgroup analyses. Results A total of 323 patients were analyzed, of whom 142 underwent robotic-assisted surgery and 181 underwent laparoscopic surgery. Overall, 109 complications (33.7%) occurred in the short-term period, 41 (28.9%) in the robotic group and 68 (37.6%) in the laparoscopic group, with no differences between groups in intraoperative or postoperative complications. However, grade III complications were significantly more frequent in the laparoscopic group, with 17 cases (9.4%) compared to 5 cases (3.5%) in the robotic group. Oncological radicality was similar between groups. Functional recovery after surgery was superior in the robotic group, as reflected by a shorter time to mobilization (17.5±10.2 hours vs. 21.1±11.5 hours). In the right colectomy subgroup, rates of grade III complications (1.9% vs. 11.7%) and lymph nodes retrieved (20.3±10.3 vs. 20.2±6.4) favored robotic surgery. In the left colon cancer subgroup, functional recovery was also improved with robotic surgery (44.3±22.2 hours vs. 61.1±31.1 hours, as measured by the composite recovery outcome). Conclusion Robotic surgery is associated with fewer severe complications and improved postoperative recovery following colonic resections. Trial registration ClinicalTrials.gov identifier: NCT02871960

An accurate intraoperative assessment of tissue perfusion in digestive surgery is critical to prevent complications such as anastomotic leakage, an event in which a surgical connection between organs fails to heal properly. However, current fluorescence angiography with indocyanine green (ICG) is still mostly qualitative and affected by surgeon expertise. This study proposes an artificial intelligence (AI)-based framework for quantitative perfusion evaluation using ICG fluorescence imaging. The system combines computer vision (CV) and machine learning (ML) to extract dynamic fluorescence profiles from intraoperative videos, cluster perfusion patterns, and classify tissue, focusing on the quality-related aspects of perfusion, as ideal and non-ideal perfusion. The framework was validated on 20 near-infrared ICG videos acquired during robotic colorectal procedures (including 3 cases with postoperative anastomotic leakage). After the preprocessing stage including stabilization and segmentation, regions of interest (ROIs) were tracked by extracting ICG time–fluorescence curves. The curves were clustered with k-medoids approach to separate optimal from non-ideal perfusion patterns. The resulting labels were used to train a logistic regression classifier, evaluated with stratified 5-fold cross-validation. The unsupervised step achieved a normalized Silhouette score of 0.77, indicating well-separated perfusion clusters. The supervised classifier reached a mean accuracy of (97 ± 2)% in distinguishing optimal from suboptimal perfusion patterns. These findings demonstrate the potential of AI-enhanced fluorescence imaging to provide quantitative intraoperative decision support, reducing reliance on subjective interpretation and improving surgical precision. This approach advances fluorescence-guided surgery, offering a scalable, data-driven solution to minimize surgical complications.

Rectal prolapse or procidentia is a debilitating condition that typically presents in parous older women but can occur in men and women of all ages. Surgery is the mainstay for the treatment of rectal prolapse and can be performed through a transabdominal or a perineal approach. Ventral mesh rectopexy was first described by D’Hoore in 2004 and involves pure anterior rectal mobilization to reduce the risk of autonomic nerve injury and postoperative constipation. The need for dissecting along the rectovaginal (or rectovesical) septum as well as suturing within the confined space of the deep pelvis makes ventral mesh rectopexy a procedure ideally suited for robotic surgery. Data from recent meta-analyses suggest that the robotic platform may reduce intraoperative blood loss, length of hospital stay, and postoperative complication rates when compared with conventional laparoscopy. Prospective data on long-term functional outcomes and recurrence are needed.

Vascular approach during elective laparoscopic left colectomy impacts post-operative outcomes. The aim of our study was to evaluate how different approaches impact positively defecatory, urinary and sexual functions and quality of life during elective laparoscopic left colectomy. A prospective non-randomized controlled trial at two tertiary center was conducted. All patients who underwent elective laparoscopic left colonic resection from January 2019 to July 2022 were analyzed. They were divided into two groups based on Inferior Mesenteric Artery (IMA) preservation with distal ligation of sigmoid branches close to a colonic wall for complicated diverticular disease and IMA high tie ligation for oncological disease. Patients were asked to fulfil standardized, validated questionnaires to evaluate pre and post-operative defecatory, urinary and sexual functions and quality of life. Defecatory disorders were assessed by high-resolution anorectal manometry preoperatively and six months after surgery. A total of 122 patients were included in the study. The 62 patients with IMA preservation showed a lower incidence of defecatory disorders also confirmed by manometer data, minor incontinence and less lifestyle alteration than the 60 patients with IMA high tie ligation. No urinary disorders such as incomplete emptying, frequency, intermittence or urgency were highlighted after surgery in the IMA preservation group. Evidence of any sexual disorders remained controversial. The IMA-preserving vascular approach seems to be an effective strategy to prevent postoperative functional disorders. It is a safe and feasible technique especially for diverticular disease. New prospective randomized and highly probative studies are needed to confirm the effectiveness in specific clinical situations.

Background: Gastrointestinal perforations are a frequent cause of acute abdominal symptomatology for patients in the emergency department. The aim of this study was to investigate the findings of multidetector-row computed tomography of gastrointestinal perforations and analyze the impact of any imaging signs on the presurgical identification of the perforation site. Methods: We retrospectively reviewed emergency MDCT findings of 93 patients submitted to surgery for gastrointestinal perforation at two different institutions. Two radiologists separately reviewed the emergency MDCT examinations performed on each patient, before and after knowing the surgical diagnosis of the perforation site. A list of findings was considered. Positive predictive values were estimated for each finding with respect to each perforation site, and correspondence analysis (CA) was used to investigate the relationship between the findings and each of the perforation types. Results: We did not find inframesocolic free air in sigmoid colorectal perforations, and in rare cases, only supramesocolic free fluid in gastroduodenal perforations was found. A high PPV of perivisceral fat stranding due to colonic perforation and general distension of upstream loops and collapse of downstream loops were evident in most patients. Conclusions: Our data could offer additional information on the perforation site in the case of doubtful findings to support surgeons, especially in planning a laparoscopic approach.

Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.

The Prostate Imaging Reporting and Data System (PI-RADS) classification is based on a scale of values from 1 to 5. The value is assigned according to the probability that a finding is a malignant tumor (prostate carcinoma) and is calculated by evaluating the signal behavior in morphological, diffusion, and post-contrastographic sequences. A PI-RADS score of 3 is recognized as the equivocal likelihood of clinically significant prostate cancer, making its diagnosis very challenging. While PI-RADS values of 4 and 5 make biopsy necessary, it is very hard to establish whether to perform a biopsy or not in patients with a PI-RADS score 3. In recent years, machine learning algorithms have been proposed for a wide range of applications in medical fields, thanks to their ability to extract hidden information and to learn from a set of data without previous specific programming. In this paper, we evaluate machine learning approaches in detecting prostate cancer in patients with PI-RADS score 3 lesions via considering clinical-radiological characteristics. A total of 109 patients were included in this study. We collected data on body mass index (BMI), location of suspicious PI-RADS 3 lesions, serum prostate-specific antigen (PSA) level, prostate volume, PSA density, and histopathology results. The implemented classifiers exploit a patient's clinical and radiological information to generate a probability of malignancy that could help the physicians in diagnostic decisions, including the need for a biopsy.

Introduction: Remote control of surgical robots represents a valuable opportunity for computer-assisted surgery. Since signal latency is still not yet compatible with safe clinical practice, we explored a field of application that is free from patient-safety issues, namely training. Our research aims to demonstrate the feasibility and effectiveness of Remote Surgical Training (ReST) in the cadaver lab or on alternative models. Methods: ReST tests were carried out over a short distance, using the Xi da Vinci dual console and a cable connection. A trainee performed surgical tasks assisted by a trainer, and a tutor was dislocated remotely in an adjacent OR. ReST tests were compared with control events with tutors and trainees in the same robotic OR. Trainee’s performance was evaluated by supervisors using the Global Evaluative Assessment of Robotic Skills (GEARS) score. At the end of each event, all subjects filled in an online Likert scale-based questionnaire to evaluate the educational process. Results: Fifteen ReST tests were successfully completed and compared with fifteen control events. Statistical analysis of questionnaire data showed no significant differences in the educational process between the ReST group and the control group. At GEARS assessment, trainees achieved similar mean performance scores in both groups. Conclusion: Remote surgical training appears to be feasible and effective. Our results support further investigation on more advanced forms of remote training, including remotely displacing the trainee and testing by cable or wireless network connection over a long distance. This research is the first step towards remote robotic surgery.

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Introduction There has been an increasing interest for the laparoscopic treatment of early gastric cancer, especially among Eastern surgeons. However, the oncological effectiveness of Laparoscopic Gastrectomy (LG) for Advanced Gastric Cancer (AGC) remains a subject of debate, especially in Western countries where limited reports have been published. The aim of this paper is to retrospectively analyze short- and long-term results of LG for AGC in a real-life Western practice. Materials and methods All consecutive cases of LG with D2 lymphadenectomy for AGC performed from January 2005 to December 2019 at seven different surgical departments were analyzed retrospectively. The primary outcome was diseases-free survival (DFS). Secondary outcomes were overall survival (OS), number of retrieved lymph nodes, postoperative morbidity and conversion rate. Results A total of 366 patients with stage II and III AGC underwent either total or subtotal LG. The mean number of harvested lymph nodes was 25 ± 14. The mean hospital stay was 13 ± 10 days and overall postoperative morbidity rate 27.32%, with severe complications (grade ≥ III) accounting for 9.29%. The median follow-up was 36 ± 16 months during which 90 deaths occurred, all due to disease progression. The DFS and OS probability was equal to 0.85 (95% CI 0.81–0.89) and 0.94 (95% CI 0.92–0.97) at 1 year, 0.62 (95% CI 0.55–0.69) and 0.63 (95% CI 0.56–0.71) at 5 years, respectively. Conclusion Our study has led us to conclude that LG for AGC is feasible and safe in the general practice of Western institutions when performed by trained surgeons.

Crystalline micrometer size stripes in 2.2 μm thick Ge2Sb2Te5 phase-change material films were produced by irradiation with a Continuous Wave Laser of 405 nm wavelength. The shape and the dimensions of the crystallized regions were investigated by Transmission Electron Microscopy and then compared with simulations based on temperature-crystal growth velocity literature data. The temperature-time profile was determined taking into account the laser power, the optical and thermal properties of both the amorphous and crystalline phase. The mechanical properties of the amorphous and of the crystallized regions were characterized by an ultra nano-indentation technique. This procedure allows a direct and local measurement of hardness and Young's modulus in the amorphous and in the contiguous crystalline regions on the micrometer scale. The following values for Young's modulus and for hardness were obtained: 33±4 GPa and 2.00±0.3 GPa for the amorphous phase, and 51±8 GPa and 2.90±0.45 GPa for the crystalline phase. The stresses induced by the density increase in the crystallized region cause, on the irradiated surface, a series of fracture whose characteristic behavior depends on the laser power and on the spacing between two contiguous scans. These results are of relevance for the mechanical failure mechanisms in potential phase-change devices.

The crystallization behavior of amorphous nano regions (20-100 nm in diameter) embedded in a textured epitaxial Ge2Sb2Te5 (GST) 25 nm thick film grown on a Si (1 1 1) substrate has been investigated in situ by transmission electron microscopy (TEM) analysis. The amorphous regions were obtained by irradiation with 30 keV Ge+ at a fluence of 1.5 x 10(14) ions cm(-2) of masked samples. The adopted configuration simulates the GST structure of a device in the RESET state, it is then of relevance for understanding their data retention characteristics. The in situ TEM analysis indicates that the amorphous to crystal transition for 20 nm dots is characterized by a growth velocity of 3.6 pm s(-1) at 75 degrees C, probably related to the external partially damaged area. At 90 degrees C annealing crystallization is completed for 20 nm dot. In the case of 50 and 100 nm diameter amorphous dots a growth velocity of about 2.6 pm s(-1) was observed at 90 degrees C and of 170 pm s(-1) at 110 degrees C. The transition is governed only by rearrangement (nucleation is absent) of the atoms located at the boundary of the amorphous dot with the surrounding crystalline regions. In some cases a preferential growth along surfaces normal to the [1 1 1] and to the [1 2 1] directions has been found. The crystallographic characterization of the regrowth crystal indicates a good matching with the zone axis of the surrounding material although the seed, a Si (1 1 1) wafer, at the bottom interface is damaged by the implant.

Laparoscopy has gained wide acceptance due its benefits for patients. However, advanced laparoscopic procedures are still challenging. One critical issue is lack of stereoscopic vision. Despite its diffusion, the totally laparoscopic approach for right hemicolectomy (TLRC) is still debated due to its difficulty, particularly for fashioning of the ileocolic anastomosis. The aim of this multicenter study is to investigate whether 3D vision offers any advantages on surgical performance over 2D vision during TLRC. All data of consecutive patients who underwent elective TLRC for cancer at three Italian surgical centers with either 2D or 3D technology from January 2013 to December 2018 were retrieved from a computer-maintained database. A case-matched analysis using the Mantel–Haenszel method was performed. After matching, a total of 106 patients were analyzed with 53 patients in each group. Mean operative time was significantly longer for 2D-TLRC than for 3D-TLRC (153.2 ± 52.4 vs. 131 ± 51 min, p = 0.029) and a statistically significant difference in anastomosing time (p = 0.032, 19.2 ± 5.9 min vs. 21.7 ± 6.2 min for 3D and 2D group, respectively) was also recorded. No difference in the median number of harvested nodes (23 ± 11 vs. 21 ± 7 for 3D and 2D group, respectively; p = 0.48) was found. Neither intraoperative complications nor conversions occurred in the two groups. In conclusion, 3D vision appears to improve the performance of a TLRC by reducing operative time and making intracorporeal anastomosis easier. Prospective randomized studies are required to determine the real beneficial effects.

Tumours of the small intestine are rare and account for about 5% of gastrointestinal tract neoplasms. The angle of Treitz (AT) could be defined as the intestinal loop comprised between the third duodenal portion and the first 10 cm of jejunum. A gold standard surgical treatment for AT neoplasm has not yet been well defined. This paper is focused on a very rare disease and at the best of our knowledge this is the largest case series in the literature about the Laparoscopic Segmental Resection (LSR) of AT tumours. Using a prospectively collected database, all data of consecutive patients, from January 2007 to May 2019, who underwent LSR for AT tumours at two different institutions were analysed. Patients’ demographics, intra and post-operative data, 30-day mortality and overall survival were collected. A total of 16 patients were retrieved from our database. The mean operative time was 206,5 ± 79 min. Conversion to open surgery was needed in two cases due to tumor size and, respectively, invasion of the transverse colon which required a multivisceral resection. The mean distal and proximal resection margins were 7.4 ± 2.2 and 3.9 ± 1.2 cm. The median number of harvested nodes was 9 ± 3. Pathological diagnosis was GIST in 11 cases, adenocarcinoma in 4 and sarcoma in 1 case. In conclusion, in experienced hands, LSR appears to be a safe and effective treatment option for tumours of the AT. Prospective studies are needed to confirm these findings.

Opportunistic modification of the tumour microenvironment by cancer cells enhances tumour expansion and consequently eliminates tumour suppressor components. We studied the effect of fibroblasts on the circadian rhythm of growth and protein expression in colon cancer HCT116 cells and found diminished oscillation in the proliferation of HCT116 cells co-cultured with naive fibroblasts, compared with those co-cultured with tumour-associated fibroblasts (TAFs) or those cultured alone, suggesting that TAFs may have lost or gained factors that regulate circadian phenotypes. Based on the fibroblast paracrine factor analysis, we tested IL6, which diminished HCT116 cell growth oscillation, inhibited early phase cell proliferation, increased early phase expression of the differentiation markers CEA and CDX2 , and decreased early phase ERK5 phosphorylation. In conclusion, our data demonstrate how the cancer education of naive fibroblasts influences the circadian parameters of neighbouring cancer cells and highlights a putative role for IL6 as a novel candidate for preoperative treatments.

Simultaneous occurrence of Morgagni hernia (MH) and paraoesophageal hernia (PH) is an exceedingly rare condition with only nine cases reported in the English-language literature. Only four cases were treated with laparoscopic approach, and in one case, a robotic procedure was performed. To our knowledge, this is the first case presenting with acute small bowel obstruction, and so requiring an urgent laparoscopic surgical procedure. An 80-year-old male patient presented to our emergency department with acute abdominal pain with nausea, vomiting, and abdominal distention. Antero-posterior chest X-ray and computed tomography which confirmed the presence of mechanical ileus show the cause, represented by extrusion in the right hemithorax of a small bowel loop through a large MH. They also showed a hiatal hernia, with entire stomach and the gastroesophageal junction in a retrocardiac position (type III hiatal hernia). The patient was offered an urgent laparoscopic procedure in order to solve the bowel obstruction. In our case experience, laparoscopic repair has showed to be a feasible option also in urgent conditions.

Enhanced Recovery After Surgery (ERAS) pathway is a multi-disciplinary, patient-centered protocol relying on the implementation of the best evidence-based perioperative practice. In the field of colorectal surgery, the application of ERAS programs is associated with up to 50% reduction of morbidity rates and up to 2.5 days reduction of postoperative hospital stay. However, widespread adoption of ERAS pathways is still yet to come, mainly because of the lack of proper information and communication. Purpose of this paper is to support the diffusion of ERAS pathways through a critical review of the existing evidence by members of the two national societies dealing with ERAS pathways in Italy, the PeriOperative Italian Society (POIS) and the Associazione Italiana Chirurghi Ospedalieri (ACOI), showing the results of a consensus development conference held at Matera, Italy, during the national ACOI Congress on June 10, 2019.