In Situ Transglutaminase Cross-Linking Improves Mechanical Properties of Self-Assembling Peptides for Biomedical Applications

The development of three-dimensional (3D) biomaterials that mimic natural tissues is required for efficiently restoring physiological functions of injured tissues and organs. In the field of soft hydrogels, self-assembled peptides (SAPs) stand out as distinctive biomimetic scaffolds, offering tunable properties. They have garnered significant attention in nanomedicine due to their innate ability to self-assemble, resulting in the creation of fibrous nanostructures that closely mimic the microenvironment of the extracellular matrix (ECM). This unique feature ensures their biocompatibility and bioactivity, making them a compelling area of study over the past few decades. As they are soft hydrogels, approaches are necessary to enhance the stiffness and resilience of the SAP materials. This work shows an enzymatic strategy to selectively increase the stiffness and resiliency of functionalized SAPs using transglutaminase (TGase) type 2, an enzyme capable of triggering the formation of isopeptide bonds. To this aim, we synthesized a set of SAP sequences and characterized their cross-linking via rheological experiments, atomic force microscopy (AFM), thioflavin-T binding assay, and infrared spectroscopy (ATR-FTIR) tests. The results showed an improvement of the storage modulus of cross-linked SAPs at no cost of the maximum stress-at-failure. Further, in in vitro tests, we examined and validated the TGase capability to cross-link SAPs without hampering seeded neural stem cells (hNSCs) viability and differentiation, potentially leaving the door open for safe in situ cross-linking reactions in vivo.

Structural and Biomechanical Properties of Supramolecular Nanofiber-Based Hydrogels in Biomedicine

The field of supramolecular nanofiber-based hydrogels in biomedicine has witnessed remarkable growth over the past two decades [...].

Dynamic surgical anatomy using 3D reconstruction technology in complex hepato-biliary surgery with vascular involvement. Results from an international multicentric survey

INTRODUCTION

Three-dimensional liver modeling can lead to substantial changes in choosing the type and extension of liver resection. This study aimed to explore whether 3D reconstruction helps to better understand the relationship between liver tumors and neighboring vascular structures compared to standard 2D CT scan images.

METHODS

Contrast-enhanced CT scan images of 11 patients suffering from primary and secondary hepatic tumors were selected. Twenty-three experienced HBP surgeons participated to the survey. A standardized questionnaire outlining 16 different vascular structures (items) having a potential relationship with the tumor was provided. Intraoperative and histopathological findings were used as the reference standard. The proper hypothesis was that 3D accuracy is greater than 2D. As a secondary endpoint, inter-raters' agreement was explored.

RESULTS

The mean difference between 3D and 2D, was 2.6 points (SE: 0.40; 95 % CI: 1.7-3.5; p < 0.0001). After sensitivity analysis, the results favored 3D visualization as well (mean difference 1.7 points; SE: 0.32; 95 % CI: 1.0-2.5; p = 0.0004). The inter-raters' agreement was moderate for both methods (2D: W = 0.45; 3D: W = 0.44).

CONCLUSION

3D reconstruction may give a significant contribution to better understanding liver vascular anatomy and the precise relationship between the tumor and the neighboring structures.

Unleashing the Power of Artificial Intelligence in Materials Design

The integration of artificial intelligence (AI) algorithms in materials design is revolutionizing the field of materials engineering thanks to their power to predict material properties, design de novo materials with enhanced features, and discover new mechanisms beyond intuition. In addition, they can be used to infer complex design principles and identify high-quality candidates more rapidly than trial-and-error experimentation. From this perspective, herein we describe how these tools can enable the acceleration and enrichment of each stage of the discovery cycle of novel materials with optimized properties. We begin by outlining the state-of-the-art AI models in materials design, including machine learning (ML), deep learning, and materials informatics tools. These methodologies enable the extraction of meaningful information from vast amounts of data, enabling researchers to uncover complex correlations and patterns within material properties, structures, and compositions. Next, a comprehensive overview of AI-driven materials design is provided and its potential future prospects are highlighted. By leveraging such AI algorithms, researchers can efficiently search and analyze databases containing a wide range of material properties, enabling the identification of promising candidates for specific applications. This capability has profound implications across various industries, from drug development to energy storage, where materials performance is crucial. Ultimately, AI-based approaches are poised to revolutionize our understanding and design of materials, ushering in a new era of accelerated innovation and advancement.

Computational Mechanics of Form-Fitting 3D-Printed Lattice-Based Wrist-Hand Orthosis for Motor Neuron Disease

Motor neuron disease (MND) patients often experience hand-wrist muscle atrophy resulting in severe social consequences and hampering their daily activities. Although hand-wrist orthosis is commonly used to assist weakened muscles, its effectiveness is limited due to the rapid progression of the disease and the need for customization to suit individual patient requirements. To address these challenges, this study investigates the application of three-dimensional (3D) printing technology to design and fabricate two lattice structures inspired by silkworm cocoons, using poly-ε-caprolactone as feedstock material. Finite element method (FEM) analysis is employed to study the mechanical behavior, enabling control over the geometric configuration incorporated into the hand-wrist orthosis. Through tensile displacement and three-point bending simulations, the stress distribution is examined for both lattice geometries. Geometry-1 demonstrates anisotropic behavior, while geometry-2 exhibits no strict directional dependence due to its symmetry and uniform node positioning. Moreover, the biocompatibility of lattices with human skin fibroblasts is investigated, confirming excellent biocompatibility. Lastly, the study involves semi-structured interviews with MND patients to gather feedback and develop prototypes of form-fitting 3D-printed lattice-based hand-wrist orthosis. By utilizing 3D printing technology, this study aims to provide customized orthosis that can effectively support weakened muscles and reposition the hand for individuals with MND.

Biomimetic scaffolds using triply periodic minimal surface-based porous structures for biomedical applications

The design of biomimetic porous scaffolds has been gaining attention in the biomedical sector lately. Shells, marine sponges, shark teeth, cancellous bone, sea urchin spine, and the armadillo armor structure are examples of biological systems that have already been studied to drive the design of innovative, porous, and multifunctional structures. Among these, triply periodic minimal surfaces (TPMSs) have attracted the attention of scientists for the fabrication of biomimetic porous scaffolds. The interest stems from their outstanding properties, which include mathematical controllable geometry features, highly interconnected porous architectures, high surface area to volume ratio, less stress concentration, tunable mechanical properties, and increased permeability. All these distinguishing features enable better cell adhesion, optimal integration to the surrounding tissue avoiding stress shieldings, a good permeability of fluid media and oxygen, and the possibility of vascularization. However, the sophisticated geometry of these TPMS-based structures has proven challenging to fabricate by conventional methods. The emergence of additive manufacturing (AM) and the enhanced manufacturing freedoms and flexibility it guarantees could solve some of the bottlenecks, thus leading to a surge of interest in designing and fabricating such structures in this field. Also, the feasibility of using AM technologies allows for obtaining size programmable TPMS printable in various materials, from polymers to metal alloys. Here, a comprehensive overview of 3D-printed TPMS porous structures is provided from a design for additive manufacturing (DfAM) and application perspective. First, design strategies, geometry design algorithms, and related topological optimization are introduced according to diverse requirements. Based on that, the performance control of TPMS and the pros and cons of the different AM processes for fabricating TPMS scaffolds are summarized. Lastly, practical applications of 3D-printed biomimetic TPMS porous structures for the biomedical field are presented to clarify the advantages and potential of such structures.

In vitro fertilization: an unexpected finding in a cohort of patients with biliary atresia

In biliary atresia (BA), efforts to prevent premature liver transplantation (LT) are aimed at early diagnosis, timing of Kasai-portoenterostomy (KPE), and centralization of care. This report presents the clinical picture, treatment strategies, and outcomes of BA patients with no previous treatment. A retrospective cohort study (Jan/2001 to Jan/2021) was conducted to evaluate the outcome of patients with BA referred to a single team. Study groups were: 1) Kasai-only group (K-only) n=9), 2) LT-only group (n=7), and 3) Kasai+LT group (K+LT) (n=23). Survival with native liver and overall survival were 22.9 and 94.8%, respectively, at 120 months of follow-up. There was no difference in age at KPE in the K-only group (46.8±21.8 days) vs K+LT (52.1±22 days), P=0.4. Ten (25.6%) patients were babies conceived through in vitro fertilization (IVF). Four IVF patients (40%) presented associated congenital heart disease vs 5 patients (17%) in the remaining group (P=0.14). Two of the IVF patients were premature (<37 weeks). Median maternal age at birth was 35 years (33 to 41 years). Excellent patient survival is expected for patients with BA with the available treatment strategies. IVF+BA was an unexpected prevalent association in this cohort, and further studies are required to better understand these findings.

Human Neural Stem Cell-Based Drug Product: Clinical and Nonclinical Characterization

Translation of cell therapies into clinical practice requires the adoption of robust production protocols in order to optimize and standardize the manufacture and cryopreservation of cells, in compliance with good manufacturing practice regulations. Between 2012 and 2020, we conducted two phase I clinical trials (EudraCT 2009-014484-39, EudraCT 2015-004855-37) on amyotrophic lateral sclerosis secondary progressive multiple sclerosis patients, respectively, treating them with human neural stem cells. Our production process of a hNSC-based medicinal product is the first to use brain tissue samples extracted from fetuses that died in spontaneous abortion or miscarriage. It consists of selection, isolation and expansion of hNSCs and ends with the final pharmaceutical formulation tailored to a specific patient, in compliance with the approved clinical protocol. The cells used in these clinical trials were analyzed in order to confirm their microbiological safety; each batch was also tested to assess identity, potency and safety through morphological and functional assays. Preclinical, clinical and in vitro nonclinical data have proved that our cells are safe and stable, and that the production process can provide a high level of reproducibility of the cultures. Here, we describe the quality control strategy for the characterization of the hNSCs used in the above-mentioned clinical trials.

Exploitation of Olive (Olea europaea L.) Seed Proteins as Upgraded Source of Bioactive Peptides with Multifunctional Properties: Focus on Antioxidant and Dipeptidyl-Dipeptidase—IV Inhibitory Activities, and Glucagon-like Peptide 1 Improved Modulation

Agri-food industry wastes and by-products include highly valuable components that can upgraded, providing low-cost bioactives or used as an alternative protein source. In this context, by-products from olive production and olive oil extraction process, i.e., seeds, can be fostered. In particular, this work was aimed at extracting and characterizing proteins for Olea europaea L. seeds and at producing two protein hydrolysates using alcalase and papain, respectively. Peptidomic analysis were performed, allowing to determine both medium- and short-sized peptides and to identify their potential biological activities. Moreover, an extensive characterization of the antioxidant properties of Olea europaea L. seed hydrolysates was carried out both in vitro by 2,2-diphenyl-1-picrylhydrazyl (DPPH), by ferric reducing antioxidant power (FRAP), and by 2,2′-Azino-bis(3-ethylbenzothiazoline-6-sulfonic acid) diammonium salt (ABTS) assays, respectively, and at cellular level by measuring the ability of these hydrolysates to significant reduce the H₂O₂-induced reactive oxygen species (ROS) and lipid peroxidation levels in human intestinal Caco-2 cells. The results of the both hydrolysates showed significant antioxidant properties by reducing the free radical scavenging activities up to 65.0 ± 0.1% for the sample hydrolyzed with alcalase and up to 75.7 ± 0.4% for the papain hydrolysates tested at 5 mg/mL, respectively. Moreover, similar values were obtained by the ABTS assays, whereas the FRAP increased up to 13,025.0 ± 241.5% for the alcalase hydrolysates and up to 12,462.5 ± 311.9% for the papain hydrolysates, both tested at 1 mg/mL. According to the in vitro results, both papain and alcalase hydrolysates restore the cellular ROS levels up 130.4 ± 4.24% and 128.5 ± 3.60%, respectively, at 0.1 mg/mL and reduce the lipid peroxidation levels up to 109.2 ± 7.95% and 73.0 ± 7.64%, respectively, at 1.0 mg/mL. In addition, results underlined that the same hydrolysates reduced the activity of dipeptidyl peptidase-IV (DPP-IV) in vitro and at cellular levels up to 42.9 ± 6.5% and 38.7 ± 7.2% at 5.0 mg/mL for alcalase and papain hydrolysates, respectively. Interestingly, they stimulate the release and stability of glucagon-like peptide 1 (GLP-1) hormone through an increase of its levels up to 660.7 ± 21.9 pM and 613.4 ± 39.1 pM for alcalase and papain hydrolysates, respectively. Based on these results, olive seed hydrolysates may represent new ingredients with antioxidant and anti-diabetic properties for the development of nutraceuticals and functional foods for the prevention of metabolic syndrome onset.

Gel-Forming of Self-Assembling Peptides Functionalized with Food Bioactive Motifs Modulate DPP-IV and ACE Inhibitory Activity in Human Intestinal Caco-2 Cells

Food bioactive peptides are increasingly used for formulating food products, nutraceuticals, and functional food, since they are generally considered safe for human consumption and metabolic syndrome prevention. They are also becoming popular as sustainable sources of novel functional biomaterials such as hydrogels, edible nanonutraceuticals, delivery systems, and packing materials. However, such food peptides are mostly unstable, and degrade during food processing, or in a gastrointestinal environment, thus resulting in low bioavailability precluding their practical applications. Here, we decided to functionalize the well-known and characterized self-assembling peptide RADA16 with two synthetic analogues of food bioactive peptides deriving from the hydrolysis of soybean glycinin and lupin β-conglutin (namely IAVPTGVA and LTFPGSAED) for control of and improvement in their gel-forming nanostructures, biomechanics, and biological features. Extensive characterization was performed via Circular Dichroism (CD) spectroscopy, Fourier Transform Infrared spectroscopy (FT-IR), Thioflavin T (ThT) binding assay, rheological measurements, and Atomic Force Microscopy (AFM) analysis. Lastly, since self-assembling peptides (SAPs) can be co-assembled with diluent SAPs (without a bioactive epitope) as an approach to control the density of biological signals and therefore attain enhanced bioactivity, we investigated the effect of the co-assembly of RADA16 and functionalized food bioactive SAPs (dubbed cAP-Soy1 and cAP-Lup1) for the growth of Caco-2 human intestinal cells and contextually we characterized their biological activities as DPP-IV and ACE inhibitors, in order to demonstrate their potential use for the prevention of metabolic syndrome.

Emerging technologies for management of patients with amyotrophic lateral sclerosis: from telehealth to assistive robotics and neural interfaces

Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease, is characterized by the degeneration of both upper and lower motor neurons, which leads to muscle weakness and subsequently paralysis. It begins subtly with focal weakness but spreads relentlessly to involve most muscles, thus proving to be effectively incurable. Typically, death due to respiratory paralysis occurs in 3–5 years. To date, it has been shown that the management of ALS patients is best achieved with a multidisciplinary approach, and with the help of emerging technologies ranging from multidisciplinary teleconsults (for monitoring the dysphagia, respiratory function, and nutritional status) to brain-computer interfaces and eye tracking for alternative augmentative communication, until robotics, it may increase effectiveness. The COVID-19 pandemic created a spasmodic need to accelerate the development and implementation of such technologies in clinical practice, to improve the daily lives of both ALS patients and caregivers. However, despite the remarkable strides that have been made in the field, there are still issues to be addressed. This review will be discussed on the eureka moment of emerging technologies for ALS, used as a blueprint not only for neurodegenerative diseases, examining the current technologies already in place or being evaluated, highlighting the pros and cons for future clinical applications.

Bioinspired photo-crosslinkable self-assembling peptides with pH-switchable "on-off" luminescence

Significant progress has been made in peptide self-assembly over the past two decades; however, the in situ cross-linking of self-assembling peptides yielding better performing nanomaterials is still in its infancy. Indeed, self-assembling peptides (SAPs), relying only on non-covalent interactions, are mechanically unstable and susceptible to solvent erosion, greatly hindering their practical application. Herein, drawing inspiration from the biological functions of tyrosine, we present a photo-cross-linking approach for the in situ cross-linking of a tyrosine-containing LDLK12 SAP. This method is based on the ruthenium-complex-catalyzed conversion of tyrosine to dityrosine upon light irradiation. We observed a stable formation of dityrosine cross-linking starting from 5 minutes, with a maximum peak after 1 hour of UV irradiation. Furthermore, the presence of a ruthenium complex among the assembled peptide bundles bestows unusual fluorescence intensity stability up to as high as 42 °C, compared to the bare ruthenium complex. Also, due to a direct deprotonation-protonation process between the ruthenium complex and SAP molecules, the fluorescence of the photo-cross-linked SAP is capable of exhibiting "off-on-off-on" luminescence switchable from acid to basic pH. Lastly, we showed that the photo-cross-linked hydrogel exhibited enhanced mechanical stability with a storage modulus of ∼26 kPa, due to the formation of a densely entangled fibrous network of SAP molecules through dityrosine linkages. As such, this ruthenium-mediated photo-cross-linked SAP hydrogel could be useful in the design of novel tyrosine containing SAP materials with intriguing potential for biomedical imaging, pH sensing, photonics, soft electronics, and bioprinting.

Nanostructure, Self-Assembly, Mechanical Properties, and Antioxidant Activity of a Lupin-Derived Peptide Hydrogel

Naturally occurring food peptides are frequently used in the life sciences due to their beneficial effects through their impact on specific biochemical pathways. Furthermore, they are often leveraged for applications in areas as diverse as bioengineering, medicine, agriculture, and even fashion. However, progress toward understanding their self-assembling properties as functional materials are often hindered by their long aromatic and charged residue-enriched sequences encrypted in the parent protein sequence. In this study, we elucidate the nanostructure and the hierarchical self-assembly propensity of a lupin-derived peptide which belongs to the α-conglutin (11S globulin, legumin-like protein), with a straightforward N-terminal biotinylated oligoglycine tag-based methodology for controlling the nanostructures, biomechanics, and biological features. Extensive characterization was performed via Circular Dichroism (CD) spectroscopy, Fourier Transform Infrared spectroscopy (FT-IR), rheological measurements, and Atomic Force Microscopy (AFM) analyses. By using the biotin tag, we obtained a thixotropic lupin-derived peptide hydrogel (named BT13) with tunable mechanical properties (from 2 to 11 kPa), without impairing its spontaneous formation of β-sheet secondary structures. Lastly, we demonstrated that this hydrogel has antioxidant activity. Altogether, our findings address multiple challenges associated with the development of naturally occurring food peptide-based hydrogels, offering a new tool to both fine tune the mechanical properties and tailor the antioxidant activities, providing new research directions across food chemistry, biochemistry, and bioengineering.

Assessment of the Physicochemical and Conformational Changes of Ultrasound-Driven Proteins Extracted from Soybean Okara Byproduct

This study was aimed at the valorization of the okara byproduct deriving form soy food manufacturing, by using ultrasound at different temperatures for extracting the residual proteins. The physicochemical and conformational changes of the extracted proteins were investigated in order to optimize the procedure. Increasing the temperature from 20 up to 80 °C greatly enhanced the yields and the protein solubility without affecting the viscosity. The protein secondary and tertiary structures were also gradually modified in a significant way. After the ultrasonication at the highest temperature, a significant morphological transition from well-defined single round structures to highly aggregated ones was observed, which was confirmed by measuring the water contact angles and wettability. After the ultrasound process, the improvement of peptides generation and the different amino acid exposition within the protein led to an increase of the antioxidant properties. The integrated strategy applied in this study allows to foster the okara protein obtained after ultrasound extraction as valuable materials for new applications.

High Versus Low Ligation of the Inferior Mesenteric Artery During Rectal Resection for Cancer: Oncological Outcomes After Three Years of Follow-Up From the HIGHLOW Trial

Objectives

To determine the disease-free survival (DFS), disease-specific survival (DSS), and recurrence in patients who underwent laparoscopic low anterior rectal resection with total mesorectal excision (TME) with either high or low ligation of the inferior mesenteric artery (IMA).

Background

The level of IMA ligation during anterior rectal resection with TME is still a matter of debate, especially in terms of oncological adequacy.

Methods

Between June 2014 and December 2016, patients scheduled to undergo elective laparoscopic low anterior resection (LAR) and TME in 6 Italian nonacademic hospitals were randomized into 2 groups in the HIGHLOW Trial (ClinicalTrials.gov Identifier: NCT02153801) according to the level of IMA ligation: high ligation (HL) versus low ligation (LL). DFS, DSS, and recurrence were inquired. Recurrence was determined at 3, 6, 9, and 12 months and every 6 months thereafter. Patients and tumor characteristics as well as surgical outcomes were analyzed to identify risk factors for recurrence.

Results

One hundred ninety-six patients from the HIGHLOW trial were analyzed. Median follow-up for DFS was 40.6 (interquartile range [IQR], 6-64.7) and 40 (IQR, 7.6-67.8), while median follow-up for DSS was 41.2 (IQR, 10.7-64.7) and 42.7 (IQR, 6-67.6) in the HL and LL groups, respectively. The 3-year DFS rate of HL and LL patients was 82.2% and 82.1% (P = 0.874), respectively. The 3-year DSS for HL and LL patients was 92.1% and 93.4% (P = 0.897), respectively. There was no statistically significant difference in the local recurrence rate (2% HL vs 2.1% LL), in the regional recurrence rate (3% HL vs 2.1% LL), and in the distant recurrence rate (12.9% HL vs 13.7% LL). Multivariate analysis found conversion to open surgery (hazard ratio [HR], 3.68; P = 0.001) and higher stage of disease (HR, 7.73; P < 0.001) to be significant determinant for DFS.

Conclusions

The level of inferior mesenteric artery ligation during LAR and TME for rectal cancer does not affect DFS, DSS, and recurrence.

"Bottom-Up" Strategy for the Identification of Novel Soybean Peptides with Angiotensin-Converting Enzyme Inhibitory Activity

IAVPTGVA (Soy1) and LPYP are two soybean peptides, which display a multifunctional behavior, showing in vitro hypocholesterolemic and hypoglycemic activities. A preliminary screening of their structures using BIOPEP suggested that they might be potential angiotensin-converting enzyme (ACE) inhibitors. Therefore, a bottom-up-aided approach was developed in order to clarify the in vitro hypotensive activity. Soy1 and LPYP dropped the intestinal and renal ACE enzyme activity with IC50 values equal to 14.7 ± 0.28 and 5.0 ± 0.28 μM (Caco-2 cells), and 6.0 ± 0.35 and 6.8 ± 0.20 μM (HK-2 cells), respectively. In parallel, a molecular modeling study suggested their capability to act as competitive inhibitors of this enzyme. Finally, in order to increase both their stability and hypotensive properties, a suitable strategy for the harmless control of their release from a nanomaterial was developed through their encapsulation into the RADA16-assembling peptide.

Design Parameters of Tissue-Engineering Scaffolds at the Atomic Scale

Stem-cell behavior is regulated by the material properties of the surrounding extracellular matrix, which has important implications for the design of tissue-engineering scaffolds. However, our understanding of the material properties of stem-cell scaffolds is limited to nanoscopic-to-macroscopic length scales. Herein, a solid-state NMR approach is presented that provides atomic-scale information on complex stem-cell substrates at near physiological conditions and at natural isotope abundance. Using self-assembled peptidic scaffolds designed for nervous-tissue regeneration, we show at atomic scale how scaffold-assembly degree, mechanics, and homogeneity correlate with favorable stem cell behavior. Integration of solid-state NMR data with molecular dynamics simulations reveals a highly ordered fibrillar structure as the most favorable stem-cell scaffold. This could improve the design of tissue-engineering scaffolds and other self-assembled biomaterials.

Creation of a rectal cancer registry in Italy by the Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network

Background: The management of rectal cancer is multimodal and involves a multidisciplinary team of cancer specialists with expertise in medical oncology, surgical oncology, radiation oncology and radiology. It is crucial for highly specialized centers to collaborate via networks that aim to maintain uniformity in every aspect of treatment and rigorously gather patients’ data, from the first clinical evaluation to the last follow-up visit.

The Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network aims to create a rectal cancer registry. This will prospectively collect the data of patients operated on for non-metastatic rectal cancer in high volume colorectal surgical units through a well design pre-fashioned database for non-metastatic rectal cancer, in order to take all multidisciplinary aspects into consideration.

Methods/Design: The protocol describes a multicenter prospective observational cohort study, investigating demographics, frailty, cancer-related features, surgical and radiological parameters, and oncological outcomes among patients with non-metastatic rectal cancer who are candidates for surgery with curative intent. Patients enrolled in the present registry will be followed up for 5 years after surgery.

Discussion: Standardization and centralization of data collection for neoplastic diseases is a virtuous process for patient care. The creation of a register will allow the control of the quality of treatments provided and permit prospective and retrospective studies to be carried out on complete and reliable high quality data. Establishing data collection in a prospective and systematic fashion is the only possibility to preserve the enormous resource that each patient represents.

Compliance to Adjuvant Chemotherapy of Patients Who Underwent Surgery for Rectal Cancer: Report from a Multi-institutional Research Network

INTRODUCTION

Adjuvant chemotherapy for locally advanced rectal cancer is associated with improved overall survival. However, recent evidence from randomized trials showed a compliance rate of 43 to 73%, which may affect efficacy. The aim of this multicenter retrospective analysis was to investigate the compliance rate to adjuvant treatment for patients who underwent rectal surgery for cancer.

METHODS

Patients who underwent surgery with curative intent for rectal cancer in six Italian colorectal centers between January 2013 and December 2017 were retrospectively reviewed. Exclusion criteria were age less than 18 years, palliative or emergency surgery, and stage IV disease. Parameters of interest were patients' characteristics, preoperative tumor stage, neo-adjuvant chemoradiation therapy, intra-operative and postoperative outcomes. Although the participating centers referred to the same treatment guidelines for treatment, the chemotherapy regiment was not standardized across the institutions. Reasons for not starting adjuvant chemotherapy when indicated, interruption, and modification of drug regimen were collected to investigate compliance.

RESULTS

A total of 572 patients were included in the analysis. Two hundred and fifty-two (44.1%) patients received neo-adjuvant chemoradiation therapy. All patients underwent high anterior rectal resection, low anterior rectal resection, or Miles' procedure. Of 399 patients with an indication to adjuvant chemotherapy, 176 (44.1%) completed the treatment as planned. Compliance for patients who started chemotherapy was 56% (95% CI 50.4-61.6%). Sixty-six patients interrupted the treatment, 76 patients significantly reduced the drug dose, and 41 patients had to switch to other therapeutic regimens.

CONCLUSIONS

The present multicenter investigation reports a low compliance rate to adjuvant chemotherapy after rectal resection for cancer. Multidisciplinary teams should focus on future effort to improve compliance for these patients.

Symptomatic Uncomplicated Diverticular Disease and Incidence of Unexpected Abscess during Sigmoidectomy: A Multicenter Prospective Observational Study

BACKGROUND

Symptomatic uncomplicated diverticular disease can affect patients' everyday routine. Considerable efforts have been made to identify clinical features that correlate to the severity of the disease. Unexpected intraoperative abscesses are reported in large retrospective series, showing how uncomplicated symptoms and presentations can underlie a complicated disease. The aim of this study was to investigate the incidence of pericolic or intramural abscess in patients undergoing elective sigmoidectomy for symptomatic uncomplicated diverticular disease and see if chronic symptoms correlate to the presence of an abscess.

METHODS

Between January 2016 and June 2018, we prospectively collected data of patients who were given indication to elective sigmoidectomy for symptomatic uncomplicated diverticular disease. Patients were divided into 3 groups: acute resolving, smoldering, and atypical according to a previously described classification of uncomplicated diverticular disease.

RESULTS

One hundred fifty-eight consecutive patients were enrolled in the study. The median age was 63 years (22- 88), and the mean body mass index was 26 (±7) kg/m2. There were 114 patients in the acute resolving group, 36 in the smoldering group, and 8 in the atypical group. An unexpected abscess was reported in 75 patients (47.5%) during surgery or pathological examination. The incidence of -abscess was greater for patient in the smoldering group (p = 0.0243).

CONCLUSION

Our series of patients affected by symptomatic uncomplicated diverticular disease showed an incidence of unexpected pericolic or intramural abscess of 47.5%. Patients affected by smoldering diverticular disease presented a greater abscess rate.

A Supramolecular Approach to Develop New Soybean and Lupin Peptide Nanogels with Enhanced Dipeptidyl Peptidase IV (DPP-IV) Inhibitory Activity

Soy1 (IAVPTGVA) and Lup1 (LTFPGSAED), two peptides from soybean and lupin protein hydrolysis, have been singled out as dipeptidyl peptidase IV (DPP-IV) activity inhibitors in different model systems. However, their activity is affected by their instability toward intestinal proteases. Here, an innovative strategy based on nanogels was developed in order to increase both their stability and antidiabetic properties through encapsulation into the RADA16 peptide. The nanogel formation was stimulated by a solvent-triggered approach, allowing us to produce stable nanogels ( G' = 1826 Pa, stress-failure ≥50 Pa) with shear-thinning propensity. ThT binding assay, and ATR-FTIR spectroscopy experiments showed that nanogels self-aggregated into stable cross-β structures providing higher resistance against proteases (ex vivo experiments) and increased bioavailability of Soy1 and Lup1 peptides (in situ experiments on Caco-2 cells). Hence, this simple and harmless nanotechnological approach could be a key-step in making innovative nanomaterials for nutraceuticals delivering.

Self-assembling peptides cross-linked with genipin: resilient hydrogels and self-standing electrospun scaffolds for tissue engineering applications

Self-assembling peptides (SAPs) are synthetic bioinspired biomaterials that can be feasibly multi-functionalized for applications in surgery, drug delivery, optics and tissue engineering (TE). Despite their promising biocompatibility and biomimetic properties, they have never been considered real competitors of polymers and/or cross-linked extracellular matrix (ECM) natural proteins. Indeed, synthetic SAP-made hydrogels usually feature modest mechanical properties, limiting their potential applications, due to the transient non-covalent interactions involved in the self-assembling phenomenon. Cross-linked SAP-hydrogels have been recently introduced to bridge this gap, but several questions remain open. New strategies leading to stiffer gels of SAPs may allow for a full exploitation of the SAP technology in TE and beyond. We have developed and characterized a genipin cross-linking strategy significantly increasing the stiffness and resiliency of FAQ(LDLK)3, a functionalized SAP already used for nervous cell cultures. We characterized different protocols of cross-linking, analyzing their dose and time-dependent efficiency, influencing stiffness, bioabsorption time and molecular arrangements. We choose the best developed protocol to electrospin into nanofibers, for the first time, self-standing, water-stable and flexible fibrous mats and micro-channels entirely made of SAPs. This work may open the door to the development and tailoring of bioprostheses entirely made of SAPs for different TE applications.

Enhancement of the Stability and Anti-DPPIV Activity of Hempseed Hydrolysates Through Self-Assembling Peptide-Based Hydrogels

Although there is an increasing interest for bioactive food protein hydrolysates as valuable ingredients for functional food and dietary supplement formulations, their potential applications are hampered by their insufficient stability in physiological conditions. In this study, an innovative strategy based on nanomaterials was developed in order to increase the hempseed hydrolysate stability and the anti-diabetic properties, through their encapsulation into ionic self-complementary RADA16 peptide based-hydrogels. Atomic force microscope (AFM) morphological analysis indicated that the new nanomaterials were composed of a nanofibril network, whose increased diameter in respect to native RADA16 suggests the presence of transient non-covalent interactions among the RADA16 supramolecular assemblies and the embedded hempseed peptides. Structural analysis by FT-IR spectroscopy indicated typical β-sheet signatures. The RADA16-hempseed protein hydrolysate hydrogel was shown to act as a novel dipeptidyl peptidase IV (DPPIV) inhibitor in different biological assays. Finally, this nanoformulation was used as a drug delivery system of the anti-diabetic drug sitagliptin, helping to reduce its dosage and eventually associated side-effects.

Branched peptides integrate into self-assembled nanostructures and enhance biomechanics of peptidic hydrogels

Self-assembling peptides (SAP) have drawn an increasing interest in the tissue engineering community. They display unquestionable biomimetic properties, tailorability and promising biocompatibility. However their use has been hampered by poor mechanical properties making them fragile soft scaffolds. To increase SAP hydrogel stiffness we introduced a novel strategy based on multiple ramifications of (LDLK)₃, a well-known linear SAP, connected with one or multiple "lysine knots". Differently branched SAPs were tested by increasing the number of (LDLK)₃-like branches and by adding the neuro-regenerative functional motif BMHP1 as a single branch. While pure branched peptides did not have appealing self-assembling propensity, when mixed with the corresponding linear SAP they increased the stiffness of the overall hydrogel of multiple times. Notably, optimal results (or peak) were obtained 1) at similar molar ratio (between linear and branched peptides) for all tested sequences and 2) for the branched SAPs featuring the highest number of branches made of (LDLK)₃. The functional motif BMHP1, as expected, seemed not to contribute to the increase of the storage modulus as efficiently as (LDLK)₃. Interestingly, branched SAPs improved the β-sheet self-arrangement of (LDLK)₃ and allowed for the formation of assembled nanofibers. Indeed in coarse-grained molecular dynamics we showed they readily integrate in the assembled aggregates providing "molecular connections" among otherwise weakly paired β-structures. Lastly, branched SAPs did not affect the usual response of human neural stem cells cultured on (LDLK)₃-like scaffolds in vitro. Hence, branched SAPs may be a valuable new tool to enhance mechanical properties of self-assembling peptide biomaterials harmlessly; as neither chemical nor enzymatic cross-linking reactions are involved. As a consequence, branched SAPs may enlarge the field of application of SAPs in tissue engineering and beyond.

STATEMENT OF SIGNIFICANCE

Self-assembling peptides stand at the forefront of regenerative medicine because they feature biomimetic nano-architectures that mimic the complexity of natural peptide-based extracellular matrices of living tissues. Their superior biocompatibility and ease of scale-up production are hampered by weak mechanical properties due to transient non-covalent interactions among and within the self-assembled peptide chains, thus limiting their potential applications. We introduced new branched self-assembling peptides to be used as "molecular connectors" among self-assembled nanostructures made of linear SAPs. Branched SAPs could be mixed with linear SAPs before self-assembling in order to have them intermingled with different β-sheets of linear SAPs after gelation. This strategy caused a manifold increase of the stiffness of the assembled hydrogels (proportional to the number of self-assembling branches), did not affect SAP propensity to form β-sheet but, instead, further stimulated their secondary structure rearrangements. It is now possible to modularly improve SAP scaffold mechanical properties without using harmful chemical reactions. Therefore, branched SAPs represent an additional tool to be adopted for efficient and harmless SAP scaffold customization in tissue engineering.

Tumor response evaluation after neoadjuvant chemotherapy in locally advanced gastric adenocarcinoma: a prospective, multi-center cohort study

BACKGROUND

To verify the prognostic value of the pathologic and radiological tumor response after neoadjuvant chemotherapy in the treatment of locally advanced gastric adenocarcinoma.

METHODS

A total of 67 patients with locally advanced gastric cancer (clinical ≥ T2 or nodal disease and without evidence of distant metastases) underwent perioperative chemotherapy (ECF or ECX regimen) from December 2009 through June 2015 in two surgical units. Histopathological and radiological response to chemotherapy were evaluated by using tumor regression grade (TRG) (Becker's criteria) and volume change assessed by CT.

RESULTS

Fifty-one (86%) patients completed all chemotherapy scheduled cycles successfully and surgery was curative (R0) in 64 (97%) subjects. The histopathological analysis showed 19 (29%) specimens with TRG1 (less than 10% of vital tumor left) and 25 (37%) patients had partial or complete response (CR) assessed by CT scan. Median disease free survival (DFS) and overall survival (OS) were 25.70 months (range, 14.52-36.80 months) and 36.60 months (range, 24.3-52.9 months), respectively. The median follow up was 27 months (range, 5.00-68.00 months). Radiological response and TRG were found to be a prognostic factor for OS and DFS, while tumor histology was not significantly related to survival.

CONCLUSIONS

Both radiological response and TRG have been shown as promising survival markers in patients treated with perioperative chemotherapy for locally advanced gastric cancer. Other predictive markers of response to chemotherapy are strongly required.

Routine clinical application of virtual reality in abdominal surgery

BACKGROUND

The advantages of 3D reconstruction, immersive virtual reality (VR) and 3D printing in abdominal surgery have been enunciated for many years, but still today their application in routine clinical practice is almost nil. We investigate their feasibility, user appreciation and clinical impact.

MATERIAL AND METHODS

Fifteen patients undergoing pancreatic, hepatic or renal surgery were studied realizing a 3D reconstruction of target anatomy. Then, an immersive VR environment was developed to import 3D models, and some details of the 3D scene were printed. All the phases of our workflow employed open-source software and low-cost hardware, easily implementable by other surgical services. A qualitative evaluation of the three approaches was performed by 20 surgeons, who filled in a specific questionnaire regarding a clinical case for each organ considered.

RESULTS

Preoperative surgical planning and intraoperative guidance was feasible for all patients included in the study. The vast majority of surgeons interviewed scored their quality and usefulness as very good.

CONCLUSIONS

Despite extra time, costs and efforts necessary to implement these systems, the benefits shown by the analysis of questionnaires recommend to invest more resources to train physicians to adopt these technologies routinely, even if further and larger studies are still mandatory.

Peptidic Biomaterials: From Self-Assembling to Regenerative Medicine

Peptidic biomaterials represent a particularly exciting topic in regenerative medicine. Peptidic scaffolds can be specifically designed for biomimetic customization for targeted therapy. The field is at a pivotal point where preclinical research is being translated into clinics, so it is crucial to understand the theory and describe the status of this rapidly developing technology. In this review, we highlight major advantages and current limitations of self-assembling peptide-based biomaterials, and we discuss the most widely used classes of assembling peptides, describing recent and promising approaches in tissue engineering, drug delivery, and clinics. We also suggest design strategies and hurdles that still need to be overcome to fully exploit their therapeutic potential.

A biocompatibility study of new nanofibrous scaffolds for nervous system regeneration

The development of therapeutic approaches for spinal cord injury (SCI) is still a challenging goal to achieve. The pathophysiological features of chronic SCI are glial scar and cavity formation: an effective therapy will require contribution of different disciplines such as materials science, cell biology, drug delivery and nanotechnology. One of the biggest challenges in SCI regeneration is to create an artificial scaffold that could mimic the extracellular matrix (ECM) and support nervous system regeneration. Electrospun constructs and hydrogels based on self-assembling peptides (SAPs) have been recently preferred. In this work SAPs and polymers were assembled by using a coaxial electrospinning setup. We tested the biocompatibility of two types of coaxially electrospun microchannels: the first one made by a core of poly(ε-caprolactone) and poly(d,l-lactide-co-glycolide) (PCL-PLGA) and a shell of an emulsion of PCL-PLGA and a functionalized self-assembling peptide Ac-FAQ and the second one made by a core of Ac-FAQ and a shell of PCL-PLGA. Moreover, we tested an annealed scaffold by PCL-PLGA microchannel heat-treatment. The properties of coaxial scaffolds were analyzed using scanning electron microscopy (SEM), Fourier transform spectroscopy (FTIR), contact angle measurements and differential scanning calorimetry (DSC). In vitro cytotoxicity was assessed via viability and differentiation assays with neural stem cells (NSCs); whereas in vivo inflammatory response was evaluated following scaffold implantation in rodent spinal cords. Emulsification of the outer shell turned out to be the best choice in terms of cell viability and tissue response: thus suggesting the potential of using functionalized SAPs in coaxial electrospinning for applications in regenerative medicine.

Autotransplantation of pancreatic islets. A single-center first experience

INTRODUCTION

Islets auto-transplantation (IAT) is a well-known procedure that may improve glycemic control after total or completion pancreatectomy compared to insulin therapy alone.

CASE REPORT

We herein report our experience in IAT with the case of a sixty years old woman underwent completion pancreatectomy for recurrent pancreatitis. She received IAT by percutaneous trans-hepatic intra-portal injection. The patient recovered well, except for a surgical wound infection that was treated with vacuum therapy. She was discharged on p.o.d. 27th in good general conditions and tolerating a diet.

DISCUSSION

Data in literature demonstrate that IAT is cost-effective on the long-run compared to insulin therapy in patients with diabetes. 30-days mortality rate for islets auto-transplantation (IAT) following total pancreatectomy is 5%, which is comparable with previous reports on total pancreatectomy without IAT. Our report may expand the literature on this procedure in order to further develop and improve both technique and outcomes, and clarify the correct indication to surgery.

KEY WORDS

Auto-transplantation, Chronic pancreatitis, IAT, Pancreatic islets, Total pancreatectomy.

"High or low Inferior Mesenteric Artery ligation in Laparoscopic low Anterior Resection: study protocol for a randomized controlled trial" (HIGHLOW trial)

Background

The position of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision can affect genito-urinary function, bowel function, oncological outcomes, and the incidence of anastomotic leakage. Ligation to the inferior mesenteric artery at the origin or preservation of the left colic artery are both widely performed in rectal surgery. The aim of this study is to compare the incidence of genito-urinary dysfunction, anastomotic leak and oncological outcomes in laparoscopic anterior rectal resection with total mesorectal excision with high or low ligation of the inferior mesenteric artery in a controlled randomized trial.

Methods/design

The HIGHLOW study is a multicenter randomized controlled trial in which patients are randomly assigned to high or low inferior mesenteric artery ligation during laparoscopic anterior rectal resection with total mesorectal excision for rectal cancer. Inclusion criteria are middle or low rectal cancer (0 to 12 cm from the anal verge), an American Society of Anesthesiologists score of I, II, or III, and a body mass index lower than 30. The primary end-point measure is the incidence of post-operative genito-urinary dysfunction. The secondary end-point measure is the incidence of anastomotic leakage in the two groups. A total of 200 patients (100 per arm) will reliably have 84.45 power in estimating a 20% difference in the incidence of genito-urinary dysfunctions. With a group size of 100 patients per arm it is possible to find a significant difference (α = 0.05, β = 0.1555). Allowing for an estimated dropout rate of 5%, the required sample size is 212 patients.

Discussion

The HIGHLOW trial is a randomized multicenter controlled trial that will provide evidence on the merits of the level of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision in terms of better preserved post-operative genito-urinary function.

Trial registration

ClinicalTrials.gov Identifier: NCT02153801

Protocol Registration Receipt 29/5/2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-014-0537-5) contains supplementary material, which is available to authorized users.

Safe introduction of laparoscopic colorectal surgery even in remote areas of the world: the value of a comprehensive telementoring training program

BACKGROUND

Advanced laparoscopic surgery training courses equipped with state-of-the-art lab facilities allow the acquisition of surgical skills in a harmless environment for the patients. In addition, active participation in intensive clinical mini-fellowship programs helps in acquiring clinical competence for the novice surgeons to properly manage patients affected by colorectal diseases. Despite this, inexperienced surgeons still need supervision during their first cases, especially to perform more complex laparoscopic procedures; however, availability of experts is particularly critical in remote areas of the globe. The aim of this study was to demonstrate the feasibility and effectiveness of a comprehensive theoretical and hands-on training program that included long-distance telementoring to assist inexperienced surgeons in performing laparoscopic colonic resections.

MATERIALS AND METHODS

One surgeon with no previous experience in laparoscopic colonic resection participated in an intensive training program that incorporated a theoretical master class and practical modules in the lab, including telementored sessions in experimental settings. A 4-week intensive clinical mini-fellowship was also part of the training program.

RESULTS

After completion of the extended training program, two laparoscopic colorectal resections for colon cancer were successfully performed in a remote area of Russia with telementoring assistance from Italy. A highly integrated operative room and standard secured network system were used to connect the expert and the novice surgeon. After this preliminary experience, the remote learner successfully operated on 25 more patients without any further need for remote expert assistance.

CONCLUSIONS

A comprehensive theoretical and practical mini-fellowship training program associated with initial telementoring assistance can help to safely start to perform advanced laparoscopic procedures, even in remote areas of the globe.

Successful domino liver transplantation in maple syrup urine disease using a related living donor

Maple syrup urine disease (MSUD) is an autosomal recessive disease associated with high levels of branched-chain amino acids. Children with MSUD can present severe neurological damage, but liver transplantation (LT) allows the patient to resume a normal diet and avoid further neurological damage. The use of living related donors has been controversial because parents are obligatory heterozygotes. We report a case of a 2-year-old child with MSUD who underwent a living donor LT. The donor was the patient's mother, and his liver was then used as a domino graft. The postoperative course was uneventful in all three subjects. DNA analysis performed after the transplantation (sequencing of the coding regions of BCKDHA, BCKDHB, and DBT genes) showed that the MSUD patient was heterozygous for a pathogenic mutation in the BCKDHB gene. This mutation was not found in his mother, who is an obligatory carrier for MSUD according to the family history and, as expected, presented both normal clinical phenotype and levels of branched-chain amino acids. In conclusion, our data suggest that the use of a related donor in LT for MSUD was effective, and the liver of the MSUD patient was successfully used in domino transplantation. Routine donor genotyping may not be feasible, because the test is not widely available, and, most importantly, the disease is associated with both the presence of allelic and locus heterogeneity. Further studies with this population of patients are required to expand the use of related donors in MSUD.

Panitumumab in combination with infusional oxaliplatin and oral capecitabine for conversion therapy in patients with colon cancer and advanced liver metastases. The MetaPan study

BACKGROUND

Preoperative chemotherapy improves the outcome in patients with colorectal cancer with liver metastases. In the current study, the authors evaluated the activity of a conversion treatment with the combination of capecitabine plus oxaliplatin (XELOX) used in association with panitumumab in patients with unresectable, liver-only, metastatic colon cancer.

METHODS

Chemotherapy-naive patients with unresectable liver metastases from colon cancer with no other metastatic disease sites were enrolled. All patients received upfront therapy with XELOX plus panitumumab (P-XELOX) and were reevaluated for resectability every 4 cycles. The primary endpoint was the objective response rate (ORR). Secondary endpoints were overall survival (OS), progression-free survival, the percentage of patients whose disease became radically resectable, and the safety of the P-XELOX combination.

RESULTS

A total of 49 patients were recruited, 35 of whom had wild-type KRAS (wtKRAS) and 14 of whom (who were enrolled before study amendment) had unknown (9 patients) or mutated (5 patients) KRAS mutational status. Forty-six patients were evaluable for response. After conversion P-XELOX therapy, the ORR in the general population was 54%, with 2 complete responses, 23 partial responses, and 14 cases of stable disease. In patients with wtKRAS, the ORR of the patients reached 65% (2 CRs and 19 PRs), which allowed 15 patients with initial unresectable liver metastasis to be reclassified as having resectable disease. Survival analysis demonstrated a median progression-free survival of 8.5 months and a median OS of 21.9 months. Patients who underwent surgery were found to have a significantly better OS when compared with those who did not undergo surgery (P < .001). Overall, toxicities were found to be predictable and manageable, with the most common being cutaneous, gastrointestinal, and neurologic toxicities.

CONCLUSIONS

Conversion P-XELOX therapy yields high response and resectability rates for patients with metastatic colon cancer with extensive liver involvement.

Laparoscopic repair for recurrent incisional hernias: a single institute experience of 10 years

PURPOSE

The treatment of recurrent incisional hernias (RIH) has been associated with unsatisfactory postoperative (PO) morbidity and high failure rates. The aim of this study is to retrospectively investigate our single-center experience of laparoscopic repair (LR) for RIH.

METHODS

The case records of 69 patients with RIH who underwent LR in our institution between January 2002 and November 2011 were reviewed. The operative technique has been standardized and provides onlay placement of an ePTFE mesh fixed with titanium tacks. Patients' demographic data and comorbidities, intraoperative course, PO complications and recurrences at follow-up were systematically collected and analyzed. The influence of defect's size and obesity variables on clinical outcomes was also investigated.

RESULTS

The mean operative time was 147.6 ± 71.2 min and mean hospital stay was 5.8 ± 1.8 days. No conversion occurred while five intraoperative complications (7.2 %) were recorded: three bowel injuries treated by laparoscopic sutures, one omentum bleeding and one epigastric vessel lesion. PO mortality was null, while overall morbidity was 13 % (9 patients) with a prevalence of seroma lasting over 8 weeks in six patients (8.7 %). Along a mean follow-up of 41 months (range 6-119), recurrence rate was 5.7 % (4 patients). Univariate analysis for width of defects and BMI showed no significant influence on patients' outcomes.

CONCLUSIONS

Surgical treatment for RIH remains controversial because of lack in literature of specific studies on this topic. Morbid obesity and large defects have been often associated with technical difficulties and worse results. Our 10 years' experience with LR provided satisfactory results in terms of PO morbidity and recurrence rate, despite any kind of patient selection.

Totally laparoscopic versus laparoscopic-assisted right colectomy for colon cancer: is there any advantage in short-term outcomes? A prospective comparative assessment in our center

BACKGROUND

Several techniques are described in the literature about laparoscopic treatment of the right colon. Among them, laparoscopic-assisted colectomy (LAC) with creation of an extracorporeal ileocolonic anastomosis remains the favourite approach in most centers. So far, total laparoscopic colectomy (TLC) with intracorporeal anastomosis is not widely performed, because it requires adequate skills and competence in the use of mechanical linear staplers and laparoscopic manual sutures. The purpose of this study was to determine prospectively if TLC offers some advantages in short-term outcomes over LAC.

METHODS

A prospective comparative study was designed for 80 consecutive patients who were alternatively treated with TLC and LAC for right colon neoplasms. The following data were collected: operative time, intra- and postoperative complication rate, time to bowel movement, hospitalization time, length of minilaparotomy, number of harvested lymph nodes, and specimen length.

RESULTS

Operative time in TLC resulted significantly longer than in LAC (230 vs. 203 min), complication rate was similar in both groups, with no case of anastomotic dehiscence, two anastomotic bleedings in TLC vs. three in LAC and one case of postoperative ileus for each group. One case of death occurred in LAC patient developing a postoperative severe cardiopulmonary syndrome. Time to first flatus was in favour of TLC (2.2 vs. 2.6 days), whereas hospitalization was comparable. As regards to the oncological parameters of radicality, the specimen length was superior in TLC group, but the number of lymph nodes excised was equivalent. The length of the minilaparotomy was clearly shorter in TLC group (5.5 vs. 7.2 cm).

CONCLUSIONS

No evidence of relevant differences in terms of functional and safety outcomes between the two laparoscopic procedures. TLC determines less abdominal manipulation and shorter incision length, but clear advantages must be still demonstrated. Larger series are necessary to test the superiority of totally laparoscopic procedures for right colectomy.

Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical extraperitoneal colorectal anastomosis: a retrospective study

AIM

Loop ileostomy is a suitable procedure for transitory faecal diversion after low colorectal anastomosis, but it causes relevant morbidities (discomfort, peristomal infections, dehydration) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI) that can be removed without surgery.

METHOD

The data of 143 consecutive patients, undergoing elective laparoscopic anterior resection of the rectum for adenocarcinoma and low mechanical colorectal anastomosis, 68 with conventional loop ileostomy (CLI) and 75 with TPI, were analyzed.

RESULTS

Neither intra-operative complications nor deaths occurred during the follow-up period. Clinical anastomotic leakage occurred in 4 patients with CLI and in 1 with TPI (p = 0.191). The median time required for the emission of gases and faeces through the stoma was respectively 1 and 2.5 days in the CLI group, and 1 and 2 days in the TPI group (p = 0.259 and p = 0.126). The median post-operative stay was 8 days in the CLI group and 11 days in the TPI group (p < 0.001). PTIs were removed on the median of 9 days after surgery without major complications, whereas the CLIs were re-canalized in 79.4% of patients on an average of 106 days, with 2 major complications.

CONCLUSION

The temporary percutaneous ileostomy seems to be a valid alternative to conventional ileostomy, ensuring optimal faecal diversion and less patient discomfort. It can be easily removed without surgery, allowing patients a better outcome.

Laparoscopic gastrectomies for cancer: The ACOI-IHTSC national guidelines

Guidelines for laparoscopy and cancer of stomach have been outlined by several scientific societies: The main recommendation being that laparoscopy should be used only by surgeons already highly skilled in gastric surgery. The laparoscopic approach to gastric cancer surgery has become more and more frequent in most Italian centers. On behalf of the Guideline Committee of the Italian Society of Hospital Surgeons and the Italian Hi-Tech Surgical Club, a panel of experts analyzed the highest evidence of all scientific papers focusing on laparoscopic gastrectomies for cancer and published from 2003 to 2011, and drew these national guidelines. Laparoscopic gastrectomy may be considered as a safe procedure with better short-term and comparable long-term results. compared to open gastrectomy (Grade A). There is a general agreement that a laparoscopic approach to the treatment of gastric cancer should be chosen only by surgeons already highly skilled in gastric surgery and other advanced laparoscopic interventions. Furthermore, the first procedures should be carried out during a tutoring program. Diagnostic laparoscopy is strongly recommended as the first step of laparoscopic as well as laparotomic gastrectomies (Grade B). Additional randomized controlled trials (RCT) that compare and investigate the long-term oncological outcomes of laparoscopic assisted gastrectomy are required.

Laparoscopic and mini-invasive surgery

BACKGROUND

JGCA Gastric Cancer Treatment Guidelines (2004) include Laparoscopic Assisted Distal Gastrectomy (LADG) within the chapter of modified surgery. A metanalysis published in 2010 shows that LADG is significantly superior to Open Distal Gastrectomy (ODG) if comparing short term outcomes. Oncologic results prove to be comparable to ODG by one RCT and 2 retrospective studies. Little evidence is available on Laparoscopic Total Gastrectomy and concerns are raised about long-term oncologic outcomes.

MATERIALS AND METHODS

Laparoscopic Subtotal Gastrectomy is carried out with 4 to 5 ports in the periumbilical region (Hasson trocar for laparoscope) and upper quadrants. After exploration of the abdominal cavity surgical steps include coloepiploic detachment, omentectomy, dissection of the gastrocolic ligament, division of the left gastroepiploic vessels, division of right gastroepiploic vessels, division of pyloric vessels. The duodenum is transected with a linear stapler. Incision of the lesser omentum and dissection of the hepatoduodenal ligament allows completion of D2 lymphadenectomy. The 4/5ths of the stomach are transected starting from the greater curve at the junction of left and right gastroepiploic arcades by linear stapler. Roux-en-Y loop reconstruction is performed through a stapled side-to-side gastro-jejunal anastomosis and a side-to-side jejuno-jejunal anastomosis. Reconstruction after Laparoscopic Total Gastrectomy is performed preferably by a side-to-side esophago-jejunal anastomosis according to Orringer.

DISCUSSION AND CONCLUSION

A robotic assisted approach adds precision on lymphadenectomy and reconstructive techniques.

Subtotal gastrectomy with D2 dissection by minimally invasive surgery for distal adenocarcinoma of the stomach: results and 5-year survival

BACKGROUND

The purpose of this study is to assess outcomes and 5-year survival after subtotal gastrectomy (SG) for early and advanced distal adenocarcinoma with D2 dissection performed by minimally invasive surgery (MIS).

METHODS

From June 2000 to October 2009 a total of 70 patients with adenocarcinoma of the lower third of the stomach underwent SG with D2 nodal clearance by MIS. This series enrolled 37 patients with early gastric cancer (EGC) and 33 with advanced gastric cancer (AGC). SG was attempted by conventional laparoscopy (CL) in 52 cases and by robot-assisted (RA) technique in 18. Clinical and histopathologic results with 5-year survival were analyzed.

RESULTS

No intraoperative complication was registered. Conversion to laparotomy was required in five patients. Overall, the mean operating time for SG was 254 min (range = 145-460) and estimated mean blood loss was 146 ml (range = 45-250). Postoperative complications occurred in seven patients, including two duodenal leakages none of which required laparotomy. There were two postoperative deaths, one caused by hepatic failure and one by hemorrhagic stroke. Preoperative understaging occurred in ten cases (three were AGC). On average, 30 ± 8 lymph nodes were collected. The distance of proximal resection margin was 6.6 cm (range = 4-8.5 cm). Short-term results were equal with those of laparoscopic and RA gastrectomy. The mean hospital stay of all patients was 10 days (range = 7-24). The mean follow-up span was 53 months (range = 3-112). Relapse of disease occurred in 12 patients, 10 of whom died from the disease and their mean survival was 25 months (range = 12-38). The overall 3-year survival was 85% for CL gastrectomy and 78% for RA gastrectomy, but this difference was not significant with the log rank test (p > 0.05). The overall 5-year survival was 81% (97% for EGC and 67% for AGC).

CONCLUSION

D2 subtotal gastrectomy performed by MIS is reproducible and safe. The long-term outcomes and 5-year survival are acceptable. Extended lymphadenectomy was carried out for both EGC and AGC so as to ensure adequate nodal clearance and compensate preoperative underestimation.

International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients

OBJECTIVES

Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases.

METHODS

Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented.

RESULTS

Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients.

CONCLUSIONS

Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.

Hybrid NOTES transvaginal cholecystectomy: operative and long-term results after 18 cases

PURPOSE

Natural orifice transluminal endoscopic surgery (NOTES) is a novel technique that aims at reducing or abolishing skin incisions and potentially also postoperative pain. The purpose of this study was to analyse operative and long-term results of a series of hybrid transvaginal cholecystectomy.

MATERIALS AND METHODS

Between July 2007 and May 2009, transvaginal NOTES cholecystectomy for symptomatic cholelithiasis was performed by a hybrid technique in 18 women (mean age 54 years), including four women with a body mass index >30 kg/m(2). Dissection was conducted in the first four cases by a round-tip unipolar electrode (UE) introduced through the operative channel of the endoscope coming from the vagina and in the last 14 cases by a ultrasonic scalpel (US) introduced through a 5-mm abdominal port. The short-term outcomes and the long-term results of the two methods were compared.

RESULTS

The transvaginal approach entailed no intraoperative complication and no conversion. The overall mean duration of procedures was 75 min (range 40-190). In the first four cases (UE), the operating time was 148 min (range 140-190), whilst in the last 14 (US), it was considerably shorter, 53 min (range 40-60, p < 0.01). We experienced one biliary leak in the UE group, whilst morbidity with US was nil (p < 0.005). The biliary leak healed in 7 days with nasobiliary drainage. No other complications were encountered in either group. The mean follow-up was 12 months (range 1-22), and none of the patients has complained of dyspareunia or other colpotomy-related complications so far.

CONCLUSIONS

Until specifically designed endoscopic tools are available for NOTES, the hybrid technique with US dissection conducted through a 5-mm port should be preferred in transvaginal cholecystectomy in order to shorten the duration of surgery and make this approach effective, safe and reproducible. After a mean follow-up of 1 year, none of our patients has complained of any problem related to transvaginal approach.

Laparoscopic bilateral simultaneous adrenalectomy: results of 11 operations

BACKGROUND

This study was undertaken to evaluate the outcomes of the simultaneous bilateral laparoscopic adrenalectomy.

MATERIALS AND METHODS

This was a retrospective study, including 11 patients with bilateral adrenal lesions, affected by Cushing's syndrome (n=2), Cushing's disease (n=6), pheochromocytoma (n=2), and 1 adrenocorticotrophin-hormone-dependent hypercortisolism of unknown origin.

RESULTS

Elevan bilateral adrenalectomies were carried out by the laparoscopic approach with no conversions. The operations were performed in 7 cases by the lateral transperitoneal adrenalectomy (LTLA), in 3 by the posterior approach (PRA), and in 1 by the combined approach. The mean size of the masses was 5 cm. (range, 4-13). The average operating time was 245 minutes for LTLA and 218 minutes for PRA (P<0.05). The estimated mean blood loss was 87+/-36 mL (range, 20-150). No patients required transfusions. The mean hospital stay was 5+/-1.8 days (range, 4-7). The mean follow-up was 34 months (range, 2-96).

CONCLUSIONS

Our study confirms that the bilateral adrenalectomy by the minimally invasive technique is safe and effective, affording acceptable blood loss and morbidity with a short hospital stay.

Laparoscopic resection for rectal adenocarcinoma

AIMS

Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival.

PATIENTS AND METHODS

Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up.

RESULTS

Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not (p=0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48+/-33 months (range 0.1-120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%.

CONCLUSION

Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.