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Santoro R, Goglia M, Brighi M, Curci FP, Amodio PM, Giannotti D, Goglia A, Mazzetti J, Antolino L, Bovino A, Zampaletta C, Levi Sandri GB, Ruggeri EM. Exploring 6 years of colorectal cancer surgery in rural Italy: insights from 648 consecutive patients unveiling successes and challenges. Updates Surg 2024; 76:963-974. [PMID: 38627306 PMCID: PMC11129985 DOI: 10.1007/s13304-024-01829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/12/2024] [Indexed: 05/28/2024]
Abstract
The multidisciplinary management of patients suffering from colorectal cancer (CRC) has significantly increased survival over the decades and surgery remains the only potentially curative option for it. However, despite the implementation of minimally invasive surgery and ERAS pathway, the overall morbidity and mortality remain quite high, especially in rural populations because of urban - rural disparities. The aim of the study is to analyze the characteristics and the surgical outcomes of a series of unselected CRC patients residing in two similar rural areas in Italy. A total of 648 consecutive patients of a median age of 73 years (IQR 64-81) was enrolled between 2017 and 2022 in a prospective database. Emergency admission (EA) was recorded in 221 patients (34.1%), and emergency surgery (ES) was required in 11.4% of the patients. Tumor resection and laparoscopic resection rates were 95.0% and 63.2%, respectively. The median length of stay was 8 days. The overall morbidity and mortality rates were 23.5% and 3.2%, respectively. EA was associated with increased median age (77.5 vs. 71 ys, p < 0.001), increased mean ASA Score (2.84 vs. 2.59; p = 0.002) and increased IV stage disease rate (25.3% vs. 11.5%, p < 0.001). EA was also associated with lower tumor resection rate (87.3% vs. 99.1%, p < 0.001), restorative resection rate (71.5 vs. 89.7%, p < 0.001), and laparoscopic resection rate (36.2 vs. 72.6%, p < 0.001). Increased mortality rates were associated with EA (7.2% vs. 1.2%, p < 0.001), ES (11.1% vs. 2.0%, p < 0.001) and age more than 80 years (5.8% vs. 1.9%, p < 0.001). In rural areas, high quality oncologic care can be delivered in CRC patients. However, the surgical outcomes are adversely affected by a still too high proportion of emergency presentation of elderly and frail patients that need additional intensive care supports beyond the surgical skill and alternative strategies for earlier detection of the disease.
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Affiliation(s)
- Roberto Santoro
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
| | - Marta Goglia
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy.
- PhD in Training in Translational Medicine and Oncology, Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy.
| | - Manuela Brighi
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
| | - Fabio Pio Curci
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
| | - Pietro Maria Amodio
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
| | - Domenico Giannotti
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
| | - Angelo Goglia
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
| | - Jacopo Mazzetti
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
| | - Laura Antolino
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
| | - Antonio Bovino
- Unit of Oncologic and General Surgery, Belcolle District Hospital, Viterbo, Italy
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Perivoliotis K, Tzovaras G, Tepetes K, Baloyiannis I. Comparison of intracorporeal and extracorporeal anastomosis in laparoscopic right colectomy: an updated meta-analysis and trial sequential analysis. Updates Surg 2024; 76:375-396. [PMID: 38216794 DOI: 10.1007/s13304-023-01737-8] [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] [Received: 04/18/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024]
Abstract
This meta-analysis was conducted to provide updated evidence regarding perioperative safety and efficacy, of IC and EC anastomosis in laparoscopic right colectomies. In this study, the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines were applied. The study protocol received a PROSPERO registration (CRD42020214596). A systematic literature search of the electronic scholar databases (Medline, Web of Science and Scopus) was performed. To reduce type I error, a trial sequential analysis (TSA) algorithm was introduced. The quality of evidence was evaluated based on the GRADE methodology. In total, 46 studies were included in this meta-analysis, Pooled comparisons and TSA confirmed that IC is superior in terms of incisional hernia (0.29; 95%CI: 0.19, 0.44), open conversion (0.45; 95%CI: 0.30, 0.67), reoperation (0.62; 95%CI: 0.46, 0.84]), LOS (- 0.76; 95%CI: - 1.03, - 0.49), blood loss (- 11.50; 95%CI: - 18.42, - 4.58), and cosmesis (- 1.71; 95%CI: - 2.01, - 1.42). Postoperative pain and return of bowel function were, also, shortened when the anastomosis was fashioned intracorporeally. The grading of most evidence ranged from 'low' to 'high'. Due to the discrepancy in the results of RCTs and non-RCTs, and the proportionally smaller sample size of the former, further randomized trials are required to increase the evidence of this comparison.
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Affiliation(s)
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Konstantinos Tepetes
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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Marcellinaro R, Spoletini D, Grieco M, Avella P, Cappuccio M, Troiano R, Lisi G, Garbarino GM, Carlini M. Colorectal Cancer: Current Updates and Future Perspectives. J Clin Med 2023; 13:40. [PMID: 38202047 PMCID: PMC10780254 DOI: 10.3390/jcm13010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Colorectal cancer is a frequent neoplasm in western countries, mainly due to dietary and behavioral factors. Its incidence is growing in developing countries for the westernization of foods and lifestyles. An increased incidence rate is observed in patients under 45 years of age. In recent years, the mortality for CRC is decreased, but this trend is slowing. The mortality rate is reducing in those countries where prevention and treatments have been implemented. The survival is increased to over 65%. This trend reflects earlier detection of CRC through routine clinical examinations and screening, more accurate staging through advances in imaging, improvements in surgical techniques, and advances in chemotherapy and radiation. The most important predictor of survival is the stage at diagnosis. The screening programs are able to reduce incidence and mortality rates of CRC. The aim of this paper is to provide a comprehensive overview of incidence, mortality, and survival rate for CRC.
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Affiliation(s)
- Rosa Marcellinaro
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy; (D.S.); (M.G.); (R.T.); (G.L.); (M.C.)
| | - Domenico Spoletini
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy; (D.S.); (M.G.); (R.T.); (G.L.); (M.C.)
| | - Michele Grieco
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy; (D.S.); (M.G.); (R.T.); (G.L.); (M.C.)
| | - Pasquale Avella
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80138 Naples, Italy; (P.A.); (M.C.)
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, Castel Volturno, 81030 Caserta, Italy
| | - Micaela Cappuccio
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80138 Naples, Italy; (P.A.); (M.C.)
| | - Raffaele Troiano
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy; (D.S.); (M.G.); (R.T.); (G.L.); (M.C.)
| | - Giorgio Lisi
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy; (D.S.); (M.G.); (R.T.); (G.L.); (M.C.)
| | - Giovanni M. Garbarino
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy; (D.S.); (M.G.); (R.T.); (G.L.); (M.C.)
| | - Massimo Carlini
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy; (D.S.); (M.G.); (R.T.); (G.L.); (M.C.)
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Avella P, Cappuccio M, Cappuccio T, Rotondo M, Fumarulo D, Guerra G, Sciaudone G, Santone A, Cammilleri F, Bianco P, Brunese MC. Artificial Intelligence to Early Predict Liver Metastases in Patients with Colorectal Cancer: Current Status and Future Prospectives. Life (Basel) 2023; 13:2027. [PMID: 37895409 PMCID: PMC10608483 DOI: 10.3390/life13102027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Artificial Intelligence (AI)-based analysis represents an evolving medical field. In the last few decades, several studies have reported the diagnostic efficiency of AI applied to Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) to early detect liver metastases (LM), mainly from colorectal cancer. Despite the increase in information and the development of different procedures in several radiological fields, an accurate method of predicting LM has not yet been found. This review aims to compare the diagnostic efficiency of different AI methods in the literature according to accuracy, sensibility, precision, and recall to identify early LM. METHODS A narrative review of the literature was conducted on PubMed. A total of 336 studies were screened. RESULTS We selected 17 studies from 2012 to 2022. In total, 14,475 patients were included, and more than 95% were affected by colorectal cancer. The most frequently used imaging tool to early detect LM was found to be CT (58%), while MRI was used in three cases. Four different AI analyses were used: deep learning, radiomics, machine learning, and fuzzy systems in seven (41.18%), five (29.41%), four (23.53%), and one (5.88%) cases, respectively. Four studies achieved an accuracy of more than 90% after MRI and CT scan acquisition, while just two reported a recall rate ≥90% (one method using MRI and CT and one CT). CONCLUSIONS Routinely acquired radiological images could be used for AI-based analysis to early detect LM. Simultaneous use of radiomics and machine learning analysis applied to MRI or CT images should be an effective method considering the better results achieved in the clinical scenario.
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Affiliation(s)
- Pasquale Avella
- HPB Surgery Unit, Pineta Grande Hospital, Castel Volturno, 81030 Caserta, Italy;
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Micaela Cappuccio
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Teresa Cappuccio
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (T.C.); (M.R.); (D.F.); (G.G.); (G.S.); (A.S.); (M.C.B.)
| | - Marco Rotondo
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (T.C.); (M.R.); (D.F.); (G.G.); (G.S.); (A.S.); (M.C.B.)
| | - Daniela Fumarulo
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (T.C.); (M.R.); (D.F.); (G.G.); (G.S.); (A.S.); (M.C.B.)
| | - Germano Guerra
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (T.C.); (M.R.); (D.F.); (G.G.); (G.S.); (A.S.); (M.C.B.)
| | - Guido Sciaudone
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (T.C.); (M.R.); (D.F.); (G.G.); (G.S.); (A.S.); (M.C.B.)
| | - Antonella Santone
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (T.C.); (M.R.); (D.F.); (G.G.); (G.S.); (A.S.); (M.C.B.)
| | | | - Paolo Bianco
- HPB Surgery Unit, Pineta Grande Hospital, Castel Volturno, 81030 Caserta, Italy;
| | - Maria Chiara Brunese
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (T.C.); (M.R.); (D.F.); (G.G.); (G.S.); (A.S.); (M.C.B.)
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Marcellinaro R, Grieco M, Spoletini D, Troiano R, Avella P, Brachini G, Mingoli A, Carlini M. How to reduce the colorectal anastomotic leakage? The MIRACLe protocol experience in a cohort in a single high-volume centre. Updates Surg 2023; 75:1559-1567. [PMID: 37452926 DOI: 10.1007/s13304-023-01588-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
This article reports the results of a novel perioperative treatment implementing the gut microbiota to prevent anastomotic fistula and leakage (AL) in patients undergoing laparoscopic colorectal resections for cancer and represents the continuation of our pilot study on 60 cases. A series of 131 patients underwent elective colorectal surgery at the S. Eugenio Hospital (Rome-Italy) between December 1, 2020, and November 30, 2022, and received a perioperative preparation following the Microbiota Implementation to Reduce Anastomotic Colorectal Leaks (MIRACLe) protocol comprising oral antibiotics, mechanical bowel preparation and perioperative probiotics. The results obtained in the MIRACLe group (MG) were compared to those registered in a Control group (CG) of 500 patients operated on between March 2015 and November 30, 2020, who received a standard ERAS protocol. Propensity score-matching (PSM) analysis was performed to overcome patients' selection bias. Patients were categorised according to perioperative preparation (MIRACLe protocol vs standard ERAS protocol) into two groups: 118 patients were in post-matched MIRACLe group (pmMG) and 356 were in post-matched Control group (pmCG). In the pmMG, only 2 anastomotic leaks were registered, and the incidence of AL was just 1.7% vs. 6.5% in the pmCG (p = 0.044). The incidence of surgical site infections (1.7% vs. 3.1%; p = 0.536), reoperations (0.8% vs. 4.2%; p = 0.136) and postoperative mortality (0% vs. 2.0%; p = 0.200) was lower in pmMG. Additionally, the postoperative outcomes were better: the times to first flatus, to first stool and to oral feeding were shorter (1 vs. 2, 2 vs. 3 and 2 vs. 3 days, respectively; p < 0.001). The postoperative recovery was faster, with a shorter time to discharge (5 vs. 6 days; p < 0.001). The MIRACLe protocol was confirmed to be safe and significantly able to reduce anastomotic leaks in patients receiving elective laparoscopic colorectal surgery for cancer.
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Affiliation(s)
- Rosa Marcellinaro
- Department of General Surgery, S. Eugenio Hospital, Piazzale Dell'Umanesimo 10, 00144, Rome, Italy.
| | - Michele Grieco
- Department of General Surgery, S. Eugenio Hospital, Piazzale Dell'Umanesimo 10, 00144, Rome, Italy
| | - Domenico Spoletini
- Department of General Surgery, S. Eugenio Hospital, Piazzale Dell'Umanesimo 10, 00144, Rome, Italy
| | - Raffaele Troiano
- Department of General Surgery, S. Eugenio Hospital, Piazzale Dell'Umanesimo 10, 00144, Rome, Italy
| | - Pasquale Avella
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Gioia Brachini
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Massimo Carlini
- Department of General Surgery, S. Eugenio Hospital, Piazzale Dell'Umanesimo 10, 00144, Rome, Italy
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Zhang T, Sun Y, Mao W. Meta‑analysis of randomized controlled trials comparing intracorporeal versus extracorporeal anastomosis in minimally invasive right hemicolectomy: upgrading the level of evidence. Int J Colorectal Dis 2023; 38:147. [PMID: 37248431 DOI: 10.1007/s00384-023-04445-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Minimally invasive right hemicolectomy has been increasingly used for the treatment of right hemicolectomy disease, and both intracorporeal anastomosis (ICA) and extracorporeal anastomosis (ECA) are available to restore intestinal continuity. However, the advantages and disadvantages of these two anastomoses are highly controversial. The present meta-analysis evaluated the effectiveness of ICA versus ECA in minimally invasive right colectomy to improve the grade of evidence. METHODS We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) comparing intracorporeal versus extracorporeal anastomosis in laparoscopic or robotic right hemicolectomy published from database inception to February 2023. Two researchers performed the literature review, data extraction, bias assessment, and meta-analysis of the data using Review Manager 5.4 software. RESULTS Seven RCTs with a total of 750 patients were included in the meta-analysis. The results showed a lower incidence of postoperative paralytic ileus (RR 0.62, 95% CI 0.39 ~ 0.99, p = 0.04) and shorter incision length (MD - 1.38; 95% CI: - 1.98 ~ - 0.78, p < 0.00001), but longer operative time (MD 10.69; 95% CI: 2.76 ~ 18.63, p = 0.008). The remaining events including bleeding (RR 0.49, 95% CI: 0.12 ~ 2.04, p = 0.33), anastomotic leak (RR 0.62, 95% CI: 0.39 ~ 0.99, p = 0.85), surgical site infection (RR 0.15, 95% CI: 0.22 ~ 1.25, p = 0.15), overall perioperative morbidity (RR 0.86, 95% CI: 0.58 ~ 1.26, p = 0.44), number of harvested lymph nodes (MD 0.75; 95% CI: - 0.15 ~ 1.65, p = 0.10), and length of hospital stay (MD - 0.27; 95% CI: - 0.91 ~ 0.38, p = 0.42) were not statistically significant. CONCLUSIONS Compared to ECA, ICA in minimally invasive right hemicolectomy reduced the risk of postoperative paralytic ileus and shortened the length of the incision but prolonged the operative time.
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Affiliation(s)
- Tuo Zhang
- Department of General Surgery, Qingdao Municipal Hospital, Qingdao Clinical Medical College, Nanjing Medical University, Qingdao, 266071, Shandong, China
| | - Yigong Sun
- Department of General Surgery, Qingdao Municipal Hospital of Qingdao University, Qingdao, 266071, Shandong, China
| | - Weizheng Mao
- Department of General Surgery, Qingdao Municipal Hospital, Qingdao Clinical Medical College, Nanjing Medical University, Qingdao, 266071, Shandong, China.
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Carlini M, Grieco M, Spoletini D, Menditto R, Napoleone V, Brachini G, Mingoli A, Marcellinaro R. Implementation of the gut microbiota prevents anastomotic leaks in laparoscopic colorectal surgery for cancer:the results of the MIRACLe study. Updates Surg 2022; 74:1253-1262. [PMID: 35739383 DOI: 10.1007/s13304-022-01305-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/17/2022] [Indexed: 10/17/2022]
Abstract
The aim of this pilot study was to evaluate the effects of a novel perioperative treatment for the implementation of the gut microbiota, to prevent anastomotic fistula and leakage (AL) in patients undergoing laparoscopic colorectal resections for cancer. A series of 60 patients who underwent elective colorectal surgery at S. Eugenio Hospital (Rome-Italy) between December 1, 2020 and November 30, 2021 and received a novel perioperative preparation following the MIRACLe (Microbiota Implementation to Reduce Anastomotic Colorectal Leaks) protocol (oral antibiotics, mechanical bowel preparation and perioperative probiotics), was compared to a group of 500 patients (control group) operated on between March 2015 and November 30, 2020, who received a standard ERAS protocol. In the MIRACLe Group only 1 anastomotic leak was registered. In this group the incidence of AL was just 1.7% vs. 6.4% in the control group (p = 0.238) and the incidence of surgical site infections (1.7% vs. 3.6%; p = 0.686), reoperations (1.7% vs. 4.2%; p = 0.547) and postoperative mortality (0% vs. 2.2%; p = 0.504) were lower. The postoperative outcomes were also better: the times to first flatus, to first stool and to oral feeding were shorter (1 vs. 2, 2 vs. 3 and 2 vs. 3 days, respectively; p < 0.001). Additionally, the postoperative recovery was faster, with a shorter time to discharge (4 vs. 6 days; p < 0.001). In this pilot study, the MIRACLe protocol appeared to be safe and considerably reduced anastomotic leaks in elective laparoscopic colorectal surgery for cancer, even if not statistically significant, due to the small number of cases.
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Affiliation(s)
- Massimo Carlini
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy
| | - Michele Grieco
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy
| | - Domenico Spoletini
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy
| | - Rosa Menditto
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy
| | | | - Gioia Brachini
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Rosa Marcellinaro
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy.
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