Guglielmo Piozzi | Università degli Studi di Milano - State University of Milan (Italy) (original) (raw)

Papers by Guglielmo Piozzi

Colorectal Disease, Jul 1, 2023

Journal of surgical case reports, Nov 1, 2021

Extensive resection that may be required in locally advanced and recurrent colorectal cancer resu... more Extensive resection that may be required in locally advanced and recurrent colorectal cancer result in formation of empty pelvic cavity that has the potential to cause small bowel descent into the pelvis. In patients with prior history of radiotherapy and multiple abdominal surgery, the risk of adhesion and subsequent small bowel obstruction can lead to increasing need for surgery and its resulting morbidity and mortality. We present five cases of locally advanced and recurrent colorectal cancer requiring laparoscopic and robotic-assisted pelvic closure with Gore-Tex Dual Mesh as prevention of small bowel descent into the pelvis. One out of the five cases had a history of small bowel obstruction after the surgery and wound-related infection occurred in one patient. There was no mesh-related complication or mortality. Pelvic closure using Gore-Tex Dual Mesh is feasible to prevent small bowel descent after surgery for locally advanced and recurrent colorectal cancer.

Ejso, Apr 1, 2022

INTRODUCTION The hepatic flexure and transverse colon have a complex intermingled lymphovascular ... more INTRODUCTION The hepatic flexure and transverse colon have a complex intermingled lymphovascular anatomy crossing between mesocolon and mesogastrium. Few studies have investigated the oncological relevance of metastatic infrapyloric and gastroepiploic lymph nodes (IGLN) from hepatic flexure and transverse colon tumors. This study aimed to evaluate the incidence and risk factors for IGLN metastases, and the indications, surgical morbidities, and oncological outcome following extended lymphadenectomy. MATERIALS AND METHODS According to the PRISMA statement, a systematic review on IGLN lymphadenectomy for colon cancer was conducted into PubMed, Embase, and Cochrane databases. A critical appraisal of study was performed according to the Joanna Briggs Institute Tools. RESULTS Nine studies were included. IGLN metastases incidence ranged 0.7-22%. IGLN positivity for patients with metastatic mesocolic lymph nodes ranged 1.7-33.3%. Postoperative complication rate ranged 8.5-36.9%, mostly low grade according to Clavien-Dindo's classification. Postoperative mortality rate ranged 0-5.4% at 30-days. IGLN metastases were associated with advanced disease with a 5-year progression-free survival rate up to 33.9%. Two authors reported perineural invasion and N stage as risk factors, while another reported endoscopic obstruction, signet ring adenocarcinoma, CEA level ≥17 ng/ml, and M1 stage to be risk factors for IGLN involvement. Apart from one study, all other studies were of moderate/high quality. CONCLUSIONS Metastatic IGLNs are not uncommon and should be highly considered. IGLN metastases could be potentially associated with an aggressive disease. IGLN dissection is not associated with higher morbidity and mortality than standard CME. Preoperative risk factors of IGLN involvement could guide surgical indication for extended lymphadenectomy.

Research Square (Research Square), Mar 22, 2023

Background Surgeons can minimize the risk of bile duct injury (BDI) during challenging mini-invas... more Background Surgeons can minimize the risk of bile duct injury (BDI) during challenging mini-invasive cholecystectomy through technical standardization by means of a precise anatomical landmark identi cation (Critical View of Safety) and advanced technology for biliary visualization. Among these systems, the adoption of magni ed stereoscopic 3-dimensional view provided by robotic platforms and near infrared uorescent cholangiography (NIRF-C) are the most promising. Methods In this prospective cohort study we evaluated all consecutive minimally invasive cholecystectomies (laparoscopic and robotic) performed with NIRF-C between May 2022 and January

Updates in Surgery, Oct 5, 2022

Colorectal Disease, Aug 10, 2023

AimIntersphincteric resection (ISR) is an oncologically complex operation for very low‐lying rect... more AimIntersphincteric resection (ISR) is an oncologically complex operation for very low‐lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future.MethodA modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra‐low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol.ResultsThree rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements.ConclusionThis study provides an international expert consensus‐based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined.

Journal of Robotic Surgery, Mar 21, 2023

Background: The aim of this study was to compare perioperative and long-term oncological outcomes... more Background: The aim of this study was to compare perioperative and long-term oncological outcomes between laparoscopic sphincter-preserving total mesorectal excision in female patients (F-Lap-TME) and robotic sphincter-preserving total mesorectal excision in male patients (M-Rob-TME) with mid-low rectal cancer (RC). Methods: A retrospective analysis of a prospectively maintained database was performed. 170 cases (F-Lap-TME: 60 patients; M-Rob-TME: 110 patients) were performed by a single surgeon (January 2011-January 2020). Results: Clinical characteristics did not differ signi cantly between the two groups. Operating time was longer in M-Rob-TME than in FLap -TME group (185.3±28.4 vs 124.5±35.8 minutes, p<0.001). There was no conversion to open surgery in both groups. Quality of mesorectum was complete/near-complete in 58 (96.7%) and 107 (97.3%) patients of FLap -TME and M-Rob-TME (p=0.508), respectively. Circumferential radial margin involvement was observed in 2 (3.3%) and 3 (2.9%) in FLap -TME and M-Rob-TME patients (p=0.210), respectively. Median length of follow-up was 62 (24-108) months in the FLap -TME and 64 (24-108) months in the M-Rob-TME group. Five-year overall survival rates were 90.5% in the FLap -TME and 89.6% in the M-Rob-TME groups (p=0.120). Disease-free survival rates in FLap -TME and M-Rob-TME groups were 87.5% and 86.5% (p=0.145), respectively. Local recurrence rates were 5% (n=3) and 5.5% (n=6) (p=0.210), in the FLap -TME and M-Rob-TME groups, respectively. Conclusion: The robotic technique can potentially overcome some technical challenges related to the pelvic anatomical difference between sex compared to laparoscopy. Laparoscopic and robotic approach, respectively in female and male patients provide similar surgical specimen quality, perioperative outcomes, and long-term oncological results.

Ejso, Aug 1, 2021

INTRODUCTION Intersphincteric resection (ISR) is the ultimate anal-sparing technique as an altern... more INTRODUCTION Intersphincteric resection (ISR) is the ultimate anal-sparing technique as an alternative to abdominoperineal resection in selected patients. Oncological safety is still debated. This study analyses long-term oncological results and evaluates risk factors for local recurrence (LR) and overall survival (OS) after minimally-invasive ISR. MATERIALS AND METHODS Retrospective single-center data were collected from a prospectively maintained colorectal database. A total of 161 patients underwent ISR between 2008 and 2018. OS and local recurrence-free survival (LRFS) were assessed using Kaplan-Meier analysis (log-rank test). Risk factors for OS and LRFS were assessed with Cox-regression analysis. RESULTS Median follow-up was 55 months. LR occurred in 18 patients. OS and LRFS rates at 1, 3, and 5 years were 96%, 91%, and 80% and 96%, 89%, and 87%, respectively. Tumor size (p = 0.035) and clinical T-stage (p = 0.029) were risk factors for LRFS on univariate analysis. On multivariate analysis, tumor size (HR 2.546 (95% CI: 0.976-6.637); p = 0.056) and clinical T-stage (HR 3.296 (95% CI: 0.941-11.549); p = 0.062) were not significant. Preoperative CEA (p < 0.001), pathological T-stage (p = 0.033), pathological N-stage (p = 0.016) and adjuvant treatment (p = 0.008) were prognostic factors for OS on univariate analysis. Preoperative CEA (HR 4.453 (95% CI: 2.015-9.838); p < 0.001) was a prognostic factor on multivariate analysis. CONCLUSIONS This study confirms the oncological safety of minimally-invasive ISR for locally advanced low-lying rectal tumors when performed in experienced centers. Despite not a risk factor for LR, tumor size and, locally advanced T-stage with anterior involvement should be carefully evaluated for optimal surgical strategy. Preoperative CEA is a prognostic factor for OS.

Turkish journal of colorectal disease, Jun 10, 2020

Intersphincteric resection (ISR) for low rectal cancer is a relatively novel anal-sparing techniq... more Intersphincteric resection (ISR) for low rectal cancer is a relatively novel anal-sparing technique that requires a thorough knowledge of the anatomy of the deep pelvic space and advanced surgical skills. The development of laparoscopic intersphincteric resection, through magnification of the surgical field, has renewed the interest in the anatomical description of the anal canal and deep pelvis, which has been historically fraught with inconsistencies. Introduction of the robotic platform has made the deep pelvis technically accessible to a greater number of colorectal surgeons. The literature describes ISR as an oncologically safe technique with good functional outcomes; however, there is often confusion regarding its definition, indications and technical aspects of this challenging procedure. This review aims to evaluate the current state of robotic ISR through the discussion of novel detailed anatomical descriptions, surgical techniques and indications, together with oncological and functional results.

Annals of coloproctology, Feb 8, 2023

Intersphincteric resection (ISR) with coloanal anastomosis is an oncologically safe anus-preservi... more Intersphincteric resection (ISR) with coloanal anastomosis is an oncologically safe anus-preserving technique for very low-lying rectal cancers. Most studies focused on oncological and functional outcomes of ISR with very few evaluating long-term postoperative anorectal complications. Full-thickness prolapse of the neorectum is a relatively rare complication. This report presents the case of a 70-year-old woman presenting with full-thickness prolapse of the side limb of the side-to-end coloanal anastomosis occurring 2 weeks after the stoma closure and 2 months after a robotic partial ISR performed with the Da Vinci single-port platform (Intuitive Surgical System Inc.). The anastomosis was revised through resection of the side limb and conversion of the side-to-end anastomosis into an end-to-end handsewn anastomosis with interrupted stitches. This study describes the first case of full-thickness prolapse of the side limb of the side-to-end handsewn coloanal anastomosis following ISR. Moreover, a revision of all reported cases of post-ISR full-thickness and mucosal prolapse was performed.

Diseases of The Colon & Rectum, Jan 9, 2023

PubMed, Nov 1, 2022

Background: Patients undergoing colorectal cancer surgery may require a blood transfusion. Howeve... more Background: Patients undergoing colorectal cancer surgery may require a blood transfusion. However, blood transfusions are associated with postoperative complications and long-term oncologic outcomes. Patient blood management (PBM) is an evidence-based multimodal approach for blood transfusion optimisation. We sought to investigate the effects of PBM implementation in blood transfusion practice and on short-term postoperative outcomes. Materials and methods: This study retrospectively reviewed data from 2,080 patients who had undergone colorectal cancer surgery at a single centre from 2015 to 2020. PBM was implemented in 2018, and outcomes were compared between the pre-PBM (2015-2017) and the post-PBM (2018-2020) periods. Results: A total of 951 patients in the pre-PBM group and 1,129 in the post-PBM group were included. The transfusion rate of the total number of packed red blood cells (PRBCs) used decreased after PBM implementation (16.3 vs 8.3%; p<0.001). The rate of appropriately transfused PRBCs increased from the pre-PBM period to the post-PBM period (42 vs 67%; p<0.001). There was no significant difference in rates of complications between the two groups (23.0 vs 21.5%; p=0.412); however, a reduction in both anastomosis leakage (5.8 vs 3.7%; p=0.026) and the length of stay after surgery (LOS) (10.3±11.2 vs 8.2±5.7 days; p<0.001) was reported after PBM implementation. Discussion: The PBM programme optimised the transfusion rate in patients undergoing colorectal cancer surgery. Implementation of the PBM programme had a positive effect on postoperative length of stay and anastomosis leakage while no increase in the risk of other complications was reported.

Techniques in Coloproctology, Mar 4, 2022

Transverse colon cancer accounts for 10% of all colon cancers [1]. Surgical treatment can be exte... more Transverse colon cancer accounts for 10% of all colon cancers [1]. Surgical treatment can be extended right/left colectomy or transverse colectomy (TC) according to the surgeon’s preference as there is no difference in 5-year overall and disease-free survival between the two procedures with open or laparoscopic approach [2]. However, TC has often been considered suboptimal both for oncological (lymph-node harvesting) and technical purpose (adequate mobilization of the flexures, optimal anastomosis creation, possible tissue ischemia, and following risk of anastomotic leak). Aiming for a TC could theoretically provide functional benefits following the preservation of the ileocecal valve and ileocecal vessels. Minimally invasive TC is poorly described in the literature [3] with few reports showing the technique in detail [1]. Robotic colectomy has been reported to be safe and feasible; however, its application to TC is scarcely reported in the literature with only few small series [3]. A robotic approach was reported to theoretically benefit the technically challenging steps of TC such as middle colic vessel lymphadenectomy, flexure mobilization, and intracorporeal anastomosis. Moreover, the robotic approach demonstrated better recovery outcomes (time to first flatus, tolerance to solid diet, and patients’ mobilization) over laparoscopy [3]. Da Vinci® SP (SP) was recently developed to combine the benefits of articulated robotic instruments with a single access approach. The SP is characterized by three fully wristed, elbowed instruments and a fully wristed endoscope through a single 25 mm trocar. This conformation allows triangulation, prevents external/internal collision, and allows a 360° rotation within and around the port’s remote center for multiquadrant surgery with no need of re-docking with the relocate function. We recently reported our SP technique for right hemicolectomy [4] and intersphincteric resection [5]. This video is the first to show step-by-step the technique for SP-TC through a suprapubic approach for a mid-transverse colon cancer. A 62-year-old woman was diagnosed with a small midtransverse colon cancer during screening. The patient underwent endoscopic mucosal resection in another center, reporting adenocarcinoma with positive margins. Transverse colectomy was indicated over an extended right hemicolectomy following the mid-location, transverse colon redundancy, and early disease at staging. During consultation, the patient preferred a single port robotic approach over a standard laparoscopic TC. Under general anesthesia, the patient was positioned supine, left-tilted, and in anti-Trendelenburg position. A 30 mm Pfannenstiel incision was performed. A 12 mm laparoscopic port was placed in the left lower quadrant. A Uni-port systemTM (Daelim Medical, Seoul, Republic of Korea) was placed in the suprapubic incision and the SP trocar was inserted. The patient cart was positioned and docked on the patient’s left side. A 0° camera was inserted with an inferior setting (“camera down”) inside the SP trocar. The instrument setting was: SP bipolar Maryland forceps into #2; SP Cadiere forceps into #3; SP monopolar scissors into #4. The assistant stayed on patient’s left side. After exploring the abdominal cavity, the endoscopic tattoo was visualized in the mid-transverse colon. The transverse mesentery was lifted upwards with the Cadiere forceps and was opened above the duodenum. The anterior pancreaticoduodenal space was dissected. The right branch of the middle colic artery was identified, dissected, and divided between clips according to the principles of D2 lymphadenectomy. The common pedicle of the middle colic vein was identified, dissected, and divided between clips. Finally, the left branch of the middle colic artery was identified, dissected, and divided. The polymeric clips were positioned with an SP clip applier (placed into #4). The greater omentum * S. H. Kim drkimsh@korea.ac.kr

Techniques in Coloproctology, Feb 7, 2022

The transverse colon arises from the midgut (proximal twothirds) and hindgut (distal one-third) w... more The transverse colon arises from the midgut (proximal twothirds) and hindgut (distal one-third) which are supplied by the middle and left colic artery, respectively. Transverse colon cancer accounts for approximately 10% of all colon cancers [1]. There are no guidelines on the treatment of such cancers, therefore the surgical approach is frequently based on the surgeon’s preference of an extended right/left colectomy or a segmental transverse colectomy (TC). TC is considered challenging due to anatomical and technical factors such as potential vascular insufficiency, extent of lymphadenectomy at the middle colic vessels, the mobilization of both flexures, and the proximity to the stomach, liver, and spleen. Therefore, TC is often considered not as safe as extended colonic resections with a consequent lack of studies and exclusion from larger trials [2]. The rapid adoption of minimally invasive approaches to colon cancer was associated with a decreased number of TC probably due to technical difficulty with surgeons preferring an extended right colectomy to a TC [2, 3]. Literature on the surgical technique of TC is sparse with few reports describing CME and D3 lymphadenectomy with anatomical and technical details. Moreover, extended CME with infrapyloric dissection is rarely described. This video reports step-by-step the technique for laparoscopic transverse colectomy with extended CME for locally advanced mid-transverse colon cancer. An 80-year-old patient was diagnosed with mid-transverse cT3N + colon cancer. After staging a TC was indicated. The laparoscopic five trocar approach is the standard in our center for elective colon resections. A 12 mm trocar was placed in the umbilicus, while four 5 mm trocars were placed at the lower left/right quadrant and upper left/right quadrant. After exploring the abdominal cavity, the lesion was visualized in the mid-transverse colon and marked with a polymeric clip. The transverse mesentery was opened above the duodenum and the anterior pancreaticoduodenal space was dissected to identify the middle colic vessels. The common pedicle of the middle colic artery was identified and dissected at the origin of the superior mesenteric artery (SMA) according to the principles of D3 lymphadenectomy. The right colic vein is the landmark for complete mesocolic excision. Once identified it was divided from the branching of the anterosuperior pancreaticoduodenal vein. The middle colic vein originated from the gastrocolic trunk in this patient as described in 12% of cases [4], and was divided at the origin. The dissection proceeded with the division of the right gastroepiploic vein from the gastrocolic trunk. The mesocolic dissection proceeded to the infrapyloric lymphatic station, which is located around the right gastroepiploic artery that was divided along with the superior margin of the pancreas and dissected together with the infrapyloric nodes. The mesocolic mobilization proceeded cranially. The lesser sac was opened just cranially to the arcade of the gastroepiploic vessels along the gastric greater curvature. A suspicious infrapyloric node was recognized and dissected. The hepatic flexure of the colon, the caudal segment of the ascending colon, and the caudal transverse colon were mobilized along the plane between the visceral and parietal fascia * S. H. Kim drkimsh@korea.ac.kr

British Journal of Surgery

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The a... more Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains...

Diseases of the Colon & Rectum

World Journal of Surgical Oncology

Aim To report long-term oncological outcomes and organ preservation rate with a chemoradiotherapy... more Aim To report long-term oncological outcomes and organ preservation rate with a chemoradiotherapy-consolidation chemotherapy (CRT-CNCT) treatment for locally advanced rectal cancer (LARC). Method Retrospective analysis of prospectively maintained database was performed. Oncological outcomes of mid-low LARC patients (n=60) were analyzed after a follow-up of 63 (50–83) months. Patients with clinical complete response (cCR) were treated with the watch-and-wait (WW) protocol. Patients who could not achieve cCR were treated with total mesorectal excision (TME) or local excision (LE). Results Thirty-nine (65%) patients who achieved cCR were treated with the WW protocol. TME was performed in 15 (25%) patients and LE was performed in 6 (10%) patients. During the follow-up period, 10 (25.6%) patients in the WW group had regrowth (RG) and 3 (7.7%) had distant metastasis (DM). Five-year overall survival (OS) and disease-free survival (DFS) were 90.1% and 71.6%, respectively, in the WW group. F...

Techniques in Coloproctology, 2022

Da Vinci® Single Port (dvSP) was recently developed. Its application in colorectal surgery is und... more Da Vinci® Single Port (dvSP) was recently developed. Its application in colorectal surgery is under investigation. The aim of this study was to explore the safety and feasibility of dvSP for intersphincteric (dvSP-ISR), right colectomy (dvSP-RC), and transverse colectomy (dvSP-TC). Surgical indication and short-term results were analyzed. All consecutive patients from a prospective database of patients who underwent dvSP-ISR, dvSP-RC, and dvSP-TC at Korea University Anam Hospital from November 2020 to December 2021, were analyzed. Perioperative, pathological, and oncological short-term outcomes were analyzed. A total of 7 dvSP-ISR, 5 dvSP-RC, and 1 dvSP-TC were performed. Median age was 56.0 (55.0–61.0) years for the dvSP-ISR and 54.0 (44.7–63.5) years for the dvSP-RC/TC. Median body mass index was 22.8 (17.1–24.8) kg/m2 for the dvSP-ISR and 23.6 (20.8–26.9) kg/m2 for the dvSP-RC/TC. All dvSP-ISR patients received neoadjuvant long-course chemoradiotherapy, including one patient with squamocellular carcinoma who was treated with 5-fluorouracil (5-FU)/mitomycin. All other patients, excluding one dvSP-RC patient with Crohn’s disease, had an adenocarcinoma. Median operation time was 280 (240–370) minutes for the dvSP-ISR and 220 (201–270) minutes for the dvSP-RC/TC. Estimated blood loss was insignificant. No intraoperative complications or conversions to multiport/open surgery was reported. Median post-operative stay was 7.0 (6.0–10.0) days for the dvSP-ISR and 5.0 (4.0–6.7) days for the dvSP-RC/TC. Quality of mesorectum was complete for six patients, and nearly complete for one. Median number of retrieved lymph nodes were 21 (17–25) for the dvSP-ISR and 28 (24–49) for the dvSP-RC/TC. Proximal and distal resection margins were tumor free. Four patients experienced post-operative complications not related to the platform which were: ileus, voiding dysfunction, infected pelvic hematoma, and wound infection. Median follow-up was 9 (6–11) months and 11 (7–17) months for the dvSP-ISR and dvSP-RC/TC, respectively. Two patients had systemic recurrence; all others were tumor free. The dvSP platform is safe and feasible for intersphincteric resection with right lower quadrant access, and right/transverse colectomy with suprapubic access. Further studies are needed to evaluate benefit differences compared to multiport robotic platform.