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1
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Lopuch AJ, Broderick J, Murphy S. Retrorectal tailgut cyst. BMJ Case Rep 2025; 18:e262758. [PMID: 40107749 DOI: 10.1136/bcr-2024-262758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2025] Open
Abstract
Retrorectal tailgut cysts are rare congenital cystic lesions that are found in the presacral space. A case of a woman in her 50s who had an incidental finding of a 7 cm presacral mass after an initial chief concern of flank pain is presented in this report. Further work-up with MRI and colonoscopy demonstrated an extraluminal cystic mass within the retrorectal space with hyperintense foci on T1-weighted imaging. A posterior approach was used to access the retrorectal space and remove the cystic mass. Pathology demonstrated findings consistent with a tailgut cyst, and the patient made a full recovery following the procedure.
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Affiliation(s)
- Andrew John Lopuch
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Joseph Broderick
- General Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
| | - Serena Murphy
- General Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
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2
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Tsarkov P, Barkhatov S, Shlyk D, Safyanov L, Balaban V, He M. Risk factors for rectal perforation during presacral cyst removal: a comparison between transabdominal, perineal, and combined surgical approaches. Tech Coloproctol 2024; 29:23. [PMID: 39699618 DOI: 10.1007/s10151-024-03071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 11/21/2024] [Indexed: 12/20/2024]
Abstract
BACKGROUND This study aimed to evaluate the risk factors associated with rectal perforation during various surgical interventions for presacral cysts. METHODS This retrospective study included 73 participants from 2013 to 2023 who met the inclusion criteria. Participants underwent surgical treatments through transabdominal, perineal, or combined approaches. Preoperative assessments of presacral cysts were performed using computed tomography (CT) and magnetic resonance imaging (MRI). Biannual postoperative follow-ups involved ultrasound, CT, or MRI scans. Data analysis was conducted using RStudio software. RESULTS The incidence of rectal perforation did not differ significantly across surgical approaches [combined 2 (18%) vs. perineal 3 (8.8%) vs. transabdominal 4 (14%), P = 0.7]. Cyst capsule rupture was more frequent in the transabdominal and combined approaches [17 (61%) and 5 (45%), respectively] versus perineal approach [8 (24%), P = 0.011]. The laparoscopic subgroup experienced a higher rate of cyst rupture compared to the robotic subgroup, with rectum perforation cases only correlating with ruptures in the robotic subgroup. Intraoperative complications prompted conversions to open surgery in the laparoscopic group, unlike in the robotic group. Postoperative follow-up revealed no mortalities, with malignant transformation observed in two cases and local recurrences in three. While univariate analysis did not identify significant predictors of rectal wall perforation, multivariate analysis suggested that the risk of perforation increased with cyst rupture and decreased when the cyst was located further from the anal verge. CONCLUSIONS The study identifies two primary risk factors for rectal wall perforation: the cyst capsule integrity and the cyst-rectum shortest distance, with the latter being accurately determined by MRI. These findings may inform further surgical planning and risk assessment.
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Affiliation(s)
- P Tsarkov
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov University, Moscow, Russia
| | - S Barkhatov
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov University, Moscow, Russia
| | - D Shlyk
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov University, Moscow, Russia
| | - L Safyanov
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov University, Moscow, Russia
| | - V Balaban
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov University, Moscow, Russia
| | - M He
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.
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3
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Jian L, Wang Y, Hao Y, Zhao D, Songlin W, Qun Q, Daojiang L. Development of Pseudosacral Cyst Following Surgery for Primary Presacral Neuroendocrine Tumors With Liver Metastasis: A Case Report. Clin Case Rep 2024; 12:e9672. [PMID: 39629039 PMCID: PMC11612513 DOI: 10.1002/ccr3.9672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Revised: 10/19/2024] [Accepted: 11/04/2024] [Indexed: 12/06/2024] Open
Abstract
Presacral neuroendocrine tumor (PSNET) is a rare disease that currently lacks a standardized treatment approach. In this report, we present a unique case of PSNET with liver metastasis that progressed into a pseudosacral cyst following complete surgical resection and sulfatinib treatment with radiofrequency ablation. Before undergoing surgical treatment for presacral neuroendocrinology, it is important to consider the potential risks of poor healing of the presacral incision and formation of pseudocysts. These complications may be caused by various factors, including the procedure itself and the use of targeted drugs.
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Affiliation(s)
- Li Jian
- Department of Colorectal and Anal SurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Clinical Center of Intestinal and Colorectal Diseases of Hubei ProvinceHubeiChina
- Hubei Key Laboratory of Intestinal and Colorectal DiseasesZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei ProvinceHubeiChina
| | - Youheng Wang
- Department of Colorectal and Anal SurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Clinical Center of Intestinal and Colorectal Diseases of Hubei ProvinceHubeiChina
- Hubei Key Laboratory of Intestinal and Colorectal DiseasesZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei ProvinceHubeiChina
| | - Yu Hao
- Department of RadiologyZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
| | - Ding Zhao
- Department of Colorectal and Anal SurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Clinical Center of Intestinal and Colorectal Diseases of Hubei ProvinceHubeiChina
- Hubei Key Laboratory of Intestinal and Colorectal DiseasesZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei ProvinceHubeiChina
| | - Wan Songlin
- Department of Colorectal and Anal SurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Clinical Center of Intestinal and Colorectal Diseases of Hubei ProvinceHubeiChina
- Hubei Key Laboratory of Intestinal and Colorectal DiseasesZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei ProvinceHubeiChina
| | - Qian Qun
- Department of Colorectal and Anal SurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Clinical Center of Intestinal and Colorectal Diseases of Hubei ProvinceHubeiChina
- Hubei Key Laboratory of Intestinal and Colorectal DiseasesZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei ProvinceHubeiChina
| | - Li Daojiang
- Department of Colorectal and Anal SurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Clinical Center of Intestinal and Colorectal Diseases of Hubei ProvinceHubeiChina
- Hubei Key Laboratory of Intestinal and Colorectal DiseasesZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei ProvinceHubeiChina
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4
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Kiosov O, Tkachov V, Gulevskyi S. Endoscopic Resection of Tailgut Cyst. Case Rep Gastrointest Med 2024; 2024:5538439. [PMID: 38939693 PMCID: PMC11208811 DOI: 10.1155/2024/5538439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/13/2024] [Accepted: 05/09/2024] [Indexed: 06/29/2024] Open
Abstract
Tailgut cyst or retrorectal cystic hamartoma is a rare congenital lesion, thought to arise from a portion of the embryological hindgut, usually benign, with no or unspecific symptoms, mainly diagnosed in middle-aged women. Complete surgical resection of the cyst is recommended to avoid complications and confirm the diagnosis. In this report, we present our experience in the successful endoscopic management of a tailgut cyst, outlining the endoscopic resection technique and discussing under what conditions this approach may be applicable.
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Affiliation(s)
- Oleksandr Kiosov
- Department of Faculty Surgery, Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
- Multidisciplinary Surgical Department, University Clinic of Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
| | - Vladyslav Tkachov
- Department of Faculty Surgery, Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
- Multidisciplinary Surgical Department, University Clinic of Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
| | - Sergii Gulevskyi
- Multidisciplinary Surgical Department, University Clinic of Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
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5
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Kobayashi T, Ishida M, Miki H, Yagyu T, Hatta M, Hamada M, Hirose Y, Sekimoto M. Analysis of the clinicopathological features of tailgut cyst with emphasis on the development of neoplastic lesions. Oncol Lett 2024; 27:286. [PMID: 38736740 PMCID: PMC11083925 DOI: 10.3892/ol.2024.14419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 04/11/2024] [Indexed: 05/14/2024] Open
Abstract
Tailgut cyst is a rare congenital cyst occurring in the retrorectal space and development of neoplastic lesions in tailgut cyst has been reported. Due to the rarity of the tumor, the histogenesis of neoplastic lesions in tailgut cyst has remained elusive. In the present study, the clinicopathological features of tailgut cyst were analyzed with a particular focus on the development of neoplastic lesions. The clinicopathological features of four patients with tailgut cyst (one female and three males) were retrospectively reviewed. No symptoms were present in two patients. Perineal discomfort, and constipation and urinary retention, were described in the other two patients, respectively. Magnetic resonance imaging showed that the cystic lesions were hypointense on T1- and hyperintense on T2-weigted images in all patients. Histopathological analysis revealed that all lesions were multilocular, and cystic walls were covered by squamous and ciliated epithelia without nuclear atypia. The development of neoplastic lesions was noted in two patients. Dysplastic change composed of piling-up proliferation of glandular cells with mild to moderate nuclear atypia was present in one patient, and invasive adenocarcinoma with a dysplasia component was observed in another patient. Dysplasia of the glandular cells, as seen in two patients in the present series, may be a precursor lesion of invasive adenocarcinoma; therefore, adenocarcinoma arsing in tailgut cyst may show a dysplasia-carcinoma sequence. While the reported incidence of neoplastic lesions in tailgut cysts is ~9% or less, their frequency remains to be accurately determined. Therefore, complete surgical resection is important for the management of patients with tailgut cyst. Additional clinicopathological and molecular studies with large cohorts may be required to clarify the histogenesis of neoplastic lesion in tailgut cyst.
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Affiliation(s)
- Toshinori Kobayashi
- Department of Surgery, Kansai Medical University, Hirakata, Osaka 573-1010, Japan
| | - Mitsuaki Ishida
- Department of Pathology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka 569-8686, Japan
| | - Hisanori Miki
- Department of Surgery, Kansai Medical University, Hirakata, Osaka 573-1010, Japan
| | - Takuki Yagyu
- Department of Surgery, Kansai Medical University, Hirakata, Osaka 573-1010, Japan
| | - Masahiko Hatta
- Department of Surgery, Kansai Medical University, Hirakata, Osaka 573-1010, Japan
| | - Madoka Hamada
- Department of Surgery, Kansai Medical University, Hirakata, Osaka 573-1010, Japan
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Osaka 573-1010, Japan
| | - Yoshinobu Hirose
- Department of Pathology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka 569-8686, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, Hirakata, Osaka 573-1010, Japan
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6
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Bulisani BM, Gomes LGL, Leite MADO, Moreno R, Rodrigues MR, Rossi FMB, Silva RBFD, Carmo LCBD, Waisberg J. Robotic approach to remove four tailgut cyst cases in Brazil: a case series. EINSTEIN-SAO PAULO 2023; 21:eRC0544. [PMID: 37970955 DOI: 10.31744/einstein_journal/2023rc0544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/14/2023] [Indexed: 11/19/2023] Open
Abstract
Tailgut cysts are rare congenital lesions that are remnants of the embryonic hindgut. This abnormality presents with non-specific symptoms or no symptoms; therefore, misdiagnosis is common. Here, we present four cases of tailgut cysts that were successfully removed using a robotic surgical approach. A 42-year-old woman with tenesmus, pain in the right gluteal region, and discomfort in the rectal region during evacuation was referred to our medical center. Another patient was a 28-year-old woman who presented with the same symptoms to our general practitioner. Both patients underwent upper abdominal and pelvic magnetic resonance imaging that revealed a tailgut cyst. Further, a 36-year-old woman was referred with coccyx and hypogastric pain. Magnetic resonance imaging revealed two pararectal cystic formations. She underwent robot-assisted surgery, and after analysis by a pathologist, the conclusion was that the tailgut cyst was associated with scarring fibrosis. A 55-year-old woman with posterior epigastric pelvic pain associated with heartburn underwent robot-assisted surgery to resect a retroperitoneal tumor. These cases highlighted the importance of tailgut cysts in the differential diagnosis of rectal lesions. Surgical treatment is preferred because malignant transformations can occur. The difference between laparoscopic and robotic approaches is the better visualization and stability of the latter, inducing less tissue damage. Robotic resection is a safe procedure, especially in patients with a narrow pelvis, because it reduces tissue damage.
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Affiliation(s)
| | | | | | - Ricardo Moreno
- RR Médicos Cirurgiões , São Bernardo do Campo , SP , Brazil
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Tao X, Ding M, Dong Q, Wang C. The definition of "complete resection" for tailgut cysts deserves much greater elaboration. Asian J Surg 2023; 46:5192-5193. [PMID: 37541868 DOI: 10.1016/j.asjsur.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/07/2023] [Indexed: 08/06/2023] Open
Affiliation(s)
- Xiaochun Tao
- Department of Anorectal, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Min Ding
- Department of Anorectal, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Qingjun Dong
- Department of Anorectal, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China.
| | - Chen Wang
- Department of Anorectal, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
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8
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Malliou P, Syrnioti A, Koletsa T, Karlafti E, Karakatsanis A, Raptou G, Apostolidis S, Michalopoulos A, Paramythiotis D. Mucinous adenocarcinoma arising from a tailgut cyst: A case report. World J Clin Oncol 2022; 13:853-860. [PMID: 36337315 PMCID: PMC9630997 DOI: 10.5306/wjco.v13.i10.853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/12/2022] [Accepted: 10/11/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Retrorectal hamartomas or tailgut cysts (TCs) are rare. In most cases, they are asymptomatic and benign; however, rarely, they undergo malignant transformation, mainly in the form of adenocarcinoma. CASE SUMMARY A 55-year-old woman presented to our hospital with lower back pain. On magnetic resonance imaging, a large pelvic mass was found, which was located on the right of the ischiorectal fossa, extending to the minor pelvis. The patient underwent extensive surgical resection of the lesion through the right buttock. Histological examination confirmed the diagnosis of a retrorectal mucinous adenocarcinoma originating from a TC. Surgical resection of the tumour was complete, and the patient recovered without complications. The pilonidal sinus was then excised. One year later, semi-annual positron emission tomography-computed tomography and magnetic resonance imaging scans did not reveal any evidence of local recurrence or metastatic disease. CONCLUSION Preoperative recognition, histological diagnosis, and treatment of TCs pose significant challenges. In addition, the possibility of developing invasive mucinous adenocarcinoma, although rare, should be considered.
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Affiliation(s)
- Petra Malliou
- The First Propaedeutic Surgery Department, AHEPA University General Hospital of Thessaloniki, Thessaloniki 54636, Greece
| | - Antonia Syrnioti
- Department of Pathology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Triantafyllia Koletsa
- Department of Pathology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Eleni Karlafti
- Department of Emergency, AHEPA University Hospital, Thessaloniki 54636, Greece
| | - Anestis Karakatsanis
- The First Propaedeutic Surgery Department, AHEPA University General Hospital of Thessaloniki, Thessaloniki 54636, Greece
| | - Georgia Raptou
- Department of Pathology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Stylianos Apostolidis
- The First Propaedeutic Surgery Department, AHEPA University General Hospital of Thessaloniki, Thessaloniki 54636, Greece
| | - Antonios Michalopoulos
- The First Propaedeutic Surgery Department, AHEPA University General Hospital of Thessaloniki, Thessaloniki 54636, Greece
| | - Daniel Paramythiotis
- The First Propaedeutic Surgery Department, AHEPA University General Hospital of Thessaloniki, Thessaloniki 54636, Greece
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Arshad R, Khalid N, Rafique M, Mushtaq R, Sial FM. Perianal Tailgut Cyst: An Unusual Presentation. Cureus 2022; 14:e27512. [PMID: 36060408 PMCID: PMC9424791 DOI: 10.7759/cureus.27512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/24/2022] Open
Abstract
A tailgut cyst (TGC) is a rare congenital lesion that occurs due to failure of involution of the distal hindgut, leading to the development of a mucus-secreting cyst. The clinical presentation is nonspecific, and often the diagnosis can be missed. We present the case of a 20-year-old female with a TGC in the perianal region. Surgical excision of the cyst was performed, followed by an uneventful recovery. The young age of our patient and the anatomical location of the TGC make our case a rare entity, highlighting the need for practicing surgeons to keep TGC as a differential in mind while examining masses in the perianal region.
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Di Nuzzo MM, De Werra C, Pace M, Franca RA, D’Armiento M, Bracale U, Lionetti R, D’Ambra M, Calogero A. Promoting Laparoscopic Anterior Approach for a Very Low Presacral Primary Neuroendocrine Tumor Arising in a Tailgut Cyst. Healthcare (Basel) 2022; 10:healthcare10050805. [PMID: 35627942 PMCID: PMC9141776 DOI: 10.3390/healthcare10050805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 02/07/2023] Open
Abstract
Background: Tailgut cysts are rare congenital lesions that develop in the presacral space. As they can potentially conceal primary neuroendocrine tumors, surgical excision is suggested as the treatment of choice. However, specific management guidelines have yet to be developed. A posterior approach is usually preferred for cysts extending to the third sacral vertebral body. Conversely, a transabdominal approach is preferred for lesions extending upward to achieve an optimal view of the surgical field and avoid injuries. Case report: Here, we report a case of a 48-year-old man suffering from perianal pain and constipation. Digital rectal examination and magnetic resonance imaging revealed a presacral mass below the third sacral vertebral body. A laparoscopic transabdominal presacral tumor excision was performed. The final histological diagnosis was a rare primary neuroendocrine tumor arising from a tailgut cyst. The postoperative course was uneventful, and no signs of recurrence were observed at the six-month follow-up. Conclusions: This study may help establish more well-grounded recommendations for the surgical management of rectal tumors, demonstrating that the laparoscopic transabdominal technique is safe and feasible, even for lesions below the third sacral vertebral body. This approach provided an adequate view of the presacral space, facilitating the preservation of cyst integrity, which is essential in cases of malignant pathologies.
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Affiliation(s)
- Maria Michela Di Nuzzo
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
- Correspondence: ; Tel.: +39-33-8936-9828
| | - Carlo De Werra
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Mirella Pace
- Department of Biomorfological and Functional Sciences, University of Naples Federico II, 80138 Naples, Italy; (M.P.); (R.A.F.)
| | - Raduan Ahmed Franca
- Department of Biomorfological and Functional Sciences, University of Naples Federico II, 80138 Naples, Italy; (M.P.); (R.A.F.)
| | - Maria D’Armiento
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Umberto Bracale
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Michele D’Ambra
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Armando Calogero
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
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