The COVID - AGICT study: COVID-19 and advanced gastro-intestinal cancer surgical treatment. A multicentric Italian study on the SARS-CoV-2 pandemic impact on gastro-intestinal cancers surgical treatment during the 2020. Analysis of perioperative and short-term oncological outcomes

BACKGROUND

This Italian multicentric retrospective study aimed to investigate the possible changes in outcomes of patients undergoing surgery for gastrointestinal cancers during the COVID-19 pandemic.

METHOD

Our primary endpoint was to determine whether the pandemic scenario increased the rate of patients with colorectal, gastroesophageal, and pancreatic cancers resected at an advanced stage in 2020 compared to 2019. Considering different cancer staging systems, we divided tumors into early stages and advanced stages, using pathological outcomes. Furthermore, to assess the impact of the COVID-19 pandemic on surgical outcomes, perioperative data of both 2020 and 2019 were also examined.

RESULTS

Overall, a total of 8250 patients, 4370 (53%) and 3880 (47%) were surgically treated during 2019 and 2020 respectively, in 62 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (P = 0.25). Nevertheless, the analysis of quarters revealed that in the second half of 2020 the rate of advanced cancer resected, tented to be higher compared with the same months of 2019 (P = 0.05). During the pandemic year 'Charlson Comorbidity Index score of cancer patients (5.38 ± 2.08 vs 5.28 ± 2.22, P = 0.036), neoadjuvant treatments (23.9% vs. 19.5%, P < 0.001), rate of urgent diagnosis (24.2% vs 20.3%, P < 0.001), colorectal cancer urgent resection (9.4% vs. 7.37, P < 0.001), and the rate of positive nodes on the total nodes resected per surgery increased significantly (7 vs 9% - 2.02 ± 4.21 vs 2.39 ± 5.23, P < 0.001).

CONCLUSIONS

Although the SARS-CoV-2 pandemic did not influence the pathological stage of colorectal, gastroesophageal, and pancreatic cancers at the time of surgery, our study revealed that the pandemic scenario negatively impacted on several perioperative and post-operative outcomes.

Prospective, randomised, multicentre, open-label trial, designed to evaluate the best timing of closure of the temporary ileostomy (early versus late) in patients who underwent rectal cancer resection and with indication for adjuvant chemotherapy: the STOMAD (STOMa closure before or after ADjuvant therapy) randomised controlled trial

INTRODUCTION

Temporary ileostomy is a valuable aid in reducing the severity of complications related to rectal cancer surgery. However, it is still unclear what is the best timing of its closure in relation to the feasibility of an adjuvant treatment, especially considering patient-reported outcomes and health system costs. The aim of the study is to compare the results of an early versus late closure strategy in patients with indication to adjuvant chemotherapy after resection for rectal cancer.

METHODS AND ANALYSIS

This is a prospective multicentre randomised trial, sponsored by Rete Oncologica Piemonte e Valle d'Aosta (Oncology Network of Piedmont and Aosta Valley-Italy). Patients undergone to rectal cancer surgery with temporary ileostomy, aged >18 years, without evidence of anastomotic leak and with indication to adjuvant chemotherapy will be enrolled in 28 Network centres. An early closure strategy (between 30 and 40 days from rectal surgery) will be compared with a late one (after the end of adjuvant therapy). Primary endpoint will be the compliance to adjuvant chemotherapy with and without ileostomy. Complications associated with stoma closure as well as quality of life, costs and oncological outcomes will be assessed as secondary endpoints.

ETHICS AND DISSEMINATION

The trial will engage the Network professional teams in a common effort to improve the treatment of rectal cancer by ensuring the best results in relation to the most correct use of resources. It will take into consideration both the patients' point of view (patient-reported outcome) and the health system perspective (costs analysis). The study has been approved by the Ethical Review Board of Città della Salute e della Scienza Hospital in Turin (Italy). The results of the study will be disseminated by the Network website, medical conferences and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04372992.

P776 Stress ecocardiography and speckle tracking analysis in patients with heart failure and preserved ejection fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is characterized by heart failure symptoms despite preserved LV systolic function together with at least one among left ventricle hypertrophy/left atrial enlargement plus diastolic dysfunction (DD) and increased brain natriuretic peptide levels. Rest echocardiography could still be normal despite patients experience HF symptoms. Speckle tracking analysis (STE) analyzes myocardial deformation and is able to identify subtle left ventricular dysfunction.

PURPOSE

to analyze the added value of stress echocardiography to improve diagnostic accuracy in patients with normal ejection fraction and unexplained dyspnoea by evaluating DD, lung B lines and STE.

METHODS

Main inclusion criteria were: suspected heart failure, EF &gt; 40%, DD up to moderate at rest (E/e"&lt;14), age &lt; 85 and &gt;18 years, satisfactory acoustic window. Exclusion criteria were: comorbidities limiting the prognosis, valvulopathy more than moderate, coronary artery disease, moderate to severe DD at rest (E/e"≥14; E/A≥2), pregnancy or lactation. Each patient underwent physical stress echo and STE by GE Vivid 7, (AFI).

RESULTS

After measuring diastolic function parameters variation with stress, HFpEF was diagnosed in 8 patients, who had baseline non-diagnostic echocardiogram (Table 1). In the remaining 20 patients a non-cardiac etiology of dyspnoea was diagnosed (NCD). EF did not significantly change from rest to stress either in HFpEF group (58 ± 6 vs 61 ± 8.7 p:0.62) or in DNC group (59 ± 8 vs 62.2 ± 7.4; p:0.26). GLS values tended to decrease in patients with HFpEF (-18.5 ± 2.2 at baseline vs -15.96 ± 6.67 at peak stress; p:0.33), and it was stable in DNC (-17.69 ± 1.15 at baseline vs - 18.04 ± 2.02 at peak stress; p:0.64).

CONCLUSIONS

Study of diastolic function during stress echocardiography is a useful diagnostic tool to reveal HFpEF in patients with dyspnea and unremarkable baseline echocardiogram. STE could offer useful adjunctive diagnostic information but further studies are needed to confirm its value.

Table 1 HFpEF NCD p HFpEF NCD p GLS -18,5 ± 2,2 -17,6 ± 1,15 0,23 -15,96 ± 6,67 18,04 ± 2,02 0,26 E/A 0,8 ± 0,1 1 ± 0,7 0,55 1,67 ± 0,7 1,26 ± 0,6 0,07 E/e’ 10,1 ± 2,2 9,9 ± 3,7 0,4 16,4 ± 0,9 13,8 ± 5 0,16 PAP 25,6 ± 4,1 22,33 ± 0,55 0,57 49,8 ± 9,65 28,27 ± 4,35 0,001 LA 35,5 ± 8,5 23,44 ± 4,9 0,001 34,45 ± 4,88 27,32 ± 7,33 0,018 EF 58 ± 6 59 ± 8 0,6 61 ± 8,7 62,2 ± 7,4 0,7 Echocardiographic parameters at baseline and at peak stress in patients with HFpEF and with NCD

P1462 Additive value of global longitudinal strain measurement in patients with known or suspected ischaemic heart disease undergoing stress echo

BACKGROUND

Speckle-tracking echocardiography (STE) can be applied in a large variety of clinical conditions.

Global longitudinal strain (GLS) shows high diagnostic accuracy for the detection of myocardial

ischemia as it reflects changes in subendocardial fibers deformation that are more exposed to

ischemic damage, even before alterations in segmental kinetics are revealed.

PURPOSE

Aim of our study was to assess whether the measurement of global longitudinal strain during

stress-echo can provide additional information compared to the assessment of conventional

parameters such as left ventricular ejection fraction (LVEF) and wall motion abnormalities. We

also evaluated the added value of strain in patients with complete (CRP) and incomplete

revascularization (IRP).

METHODS

We enrolled 69 patients, 39 with known (IHD) and 30 with suspected ischaemic heart disease

(SIHD) with indication to perform a stress echocardiogram. Inclusion criteria were: known or

suspected CAD, age &lt;85 and &gt;18, adeguate acoustic window. Cardiological evaluation and stress

echo were performed in all patients. Primary end point was evaluating whether in patients with

negative stress test the presence of reduced GLS identifies patients with an adverse prognosis at

follow up and to assess if in IRP and negative stress test there is evidence of left subclinical ventricular

dysfunction identifiable by GLS analysis compared to CRP.

RESULTS

LVEF was significantly reduced in IHD patients compared to SIHD patients (54 ± 7vs 60 ± 4 at rest;

55 ± 8vs62 ± 3 at peak; p &lt; 0.0001). We also observed a significant reduction of GLS in IHD patients

compared to SIHD patients (-16.7 ± 4,3vs-19 ± 2.2 - p = 0.07 at rest, -18 ± 4.6vs22 ± 3.4-p = 0.004 at

peak). In CRP patients GLS did not change significantly with a tendency to improve (-17.6 ± 4 at rest

vs -19 ± 4.5 at peak - p = 0.4). Instead in IRP patients, significant reduction of GLS was observed at

peak (17.5 ± 0.7 at rest vs 14.2 ± 0.3 at peak, p value 0,03). LVEF did not significantly differ in CRP

(54 ± 5 at baseline vs 55 ± 7 at peak, p = 0.5) and IRP (52 ± 9 at baseline vs. 52 ± 9 at peak, p =

0.9) .

CONCLUSIONS

Our study shows that strain analysis during stress echocardiography can provide additional information in identifying a subclinical reduction of myocardial function at baseline and

a reduction in contractile reserve under stress, secondary to coronary flow reduction. Being GLS a

powerful prognostic marker probably patients with negative stress test and incomplete

revascularization, reduced baseline GLS and reduction of GLS at peak exercise represent a population at higher risk of coronary artery disease progression and development of left ventricular dysfunction who need a closer follow up. To verify our hypothesis we plan to increase our sample size and to

prospectively follow up our patients.

Neoadjuvant chemotherapy for gastric cancer. Is it a must or a fake?

AIM

To investigate the neoadjuvant chemotherapy (NAC) effect on the survival of patients with proper stomach cancer submitted to D2 gastrectomy.

METHODS

We proceeded to a review of the literature with PubMed, Embase, ASCO and ESMO meeting abstracts as well as computerized use of the Cochrane Library for randomized controlled trials (RCTs) comparing NAC followed by surgery (NAC + S) with surgery alone (SA) for gastric cancer (GC). The primary outcome was the overall survival rate. Secondary outcomes were the site of the primary tumor, extension of node dissection according to Japanese Gastric Cancer Association (JGCA) performed in both arms, disease-specific (DSS) and disease-free survival (DFS) rates, clinical and pathological response rates and resectability rates after perioperative treatment.

RESULTS

We identified a total of 16 randomized controlled trials comparing NAC + S (n = 1089) with SA (n = 973) published in the period from January 1993 - March 2017. Only 6 of these studies were well-designed, structured trials in which the type of lymph node (LN) dissection performed or at least suggested in the trial protocol was reported. Two out of three of the RCTs with D2 lymphadenectomy performed in almost all cases failed to show survival benefit in the NAC arm. In the third RCT, the survival rate was not even reported, and the primary end points were the clinical outcomes of surgery with and without NAC. In the remaining three RCTs, D2 lymph node dissection was performed in less than 50% of cases or only recommended in the “Study Treatment” protocol without any description in the results of the procedure really perfomed. In one of the two studies, the benefit of NAC was evident only for esophagogastric junction (EGJ) cancers. In the second study, there was no overall survival benefit of NAC. In the last trial, which documented a survival benefit for the NAC arm, the chemotherapy effect was mostly evident for EGJ cancer, and more than one-fourth of patients did not have a proper stomach cancer. Additionally, several patients did not receive resectional surgery. Furthermore, the survival rates of international reference centers that provide adequate surgery for homogeneous stomach cancer patients’ populations are even higher than the survival rates reported after NAC followed by incomplete surgery.

CONCLUSION

NAC for GC has been rapidly introduced in international western guidelines without an evidence-based medicine-related demonstration of its efficacy for a homogeneous population of patients with only stomach tumors submitted to adequate surgery following JGCA guidelines with extended (D2) LN dissection. Additional larger sample-size multicentre RCTs comparing the newer NAC regimens including molecular therapies followed by adequate extended surgery with surgery alone are needed.

Gastric Cancer After Restrictive Bariatric Surgery: A Clinical Pitfall

Although vertical banded gastroplasty is rarely performed at present, most bariatric surgery departments continue to follow up patients who underwent this procedure in the past few decades. In view of this, it is advisable for bariatric and general surgeons to know how to diagnose the very rare event of the development of a gastric cancer after this restrictive procedure. In this report, 2 cases of gastric cancer occurring years after vertical banded gastroplasty are presented, and clinical presentation and diagnostic difficulties are discussed.

Esophagogastric cancer after bariatric surgery: systematic review of the literature

BACKGROUND

Because the number of patients with a previous bariatric procedure continues to rise, it is advisable for bariatric surgeons to know how to manage the rare event of the development of an esophagogastric cancer. The aim of the study was to perform a systematic review of all reported cases of esophagogastric cancers after bariatric surgery.

METHODS

Systematic review of English and French written literature in MEDLINE and EMBASE database.

RESULTS

Globally, 28 articles describing 33 patients were retrieved. Neoplasms were diagnosed at a mean of 8.5 years after bariatric surgery (range 2 months-29 years). There were 11 esophageal and 22 gastric cancers; although adenocarcinoma represented most cases (90.6%), a tubulovillous adenoma with high-grade atypia, an intramural gastrointestinal stromal tumor, and a diffuse large B-cell lymphoma of the gastric fundus were also reported. Node involvement was reported in 14 cases, and distal metastases in 5. The most frequently reported symptoms were dysphagia and food intolerance, vomiting, epigastric pain, and weight loss. Surgery was performed in 28 patients, although 4 underwent only chemotherapy and/or radiotherapy and 1 received palliative care. Reported mortality rate was 48.1%.

CONCLUSIONS

To date, it is not possible to quantify the incidence of esophagogastric cancer after bariatric surgery because of the paucity of reported data. Nevertheless, because the main concern is the delay in diagnosis, it is of critical importance to carefully evaluate any new or modified upper digestive tract symptom occurring during bariatric surgery follow-up.

Motion Index: a new parameter to evaluate the diastole by M-Mode imaging

AIM

Heart failure with normal left ventricle (LV) ejection fraction is commonly understood as diastolic heart failure because this expression implies the presence of LV diastolic dysfunction diagnosed by specific echocardiographic findings, such as slow LV relaxation and increased LV stiffness. In this work the authors propose a new parameter named Motion Index, which is measurable by M-Mode technique and it is likely linked to diastolic dysfunction.

METHODS

A patient population composed by 134 subjects was enrolled. They all were in New York Heart Association (NYHA) functional class II. Echocardiogram carried out in all patients allowed the authors to distinguish 2 patient arms depending on the presence or absence of diastolic dysfunction, evaluated by flow Doppler and tissue Doppler.

RESULTS

After carrying out every echocardiographic examination, the authors also measured the new parameter that called Motion Index, and found that it had an average value of 46 in patients with normal diastolic function and 33.5 in patients with diastolic dysfunction. This parameter did not depend on systolic dysfunction.

CONCLUSIONS

Data obtained showed a statistically significant correlation between Motion Index and means of diastolic function assessed by both flow and tissue Doppler.

Extracoronary atherosclerosis in patients with chronic ischemic heart disease: relationship with risk factors and the severity of coronary artery disease

AIM

The aim of the present study was to investigate the prevalence of carotid and/or peripheral atherosclerotic lesions in patients with chronic ischemic heart disease (previous acute myocardial infarction [AMI] or stable angina).

METHODS

We studied 248 patients (168 male and 80 female), mean age 63+/-10 years, which were investigated for traditional risk factors. Systolic blood pressure, body mass index, lipid profile, fasting glucose and plasma fibrinogen were also measured. We assessed the prevalence of atherosclerotic lesions in carotid and lower limb arteries, by ultrasound duplex scanning (UDS).

RESULTS

Angina was present in 33% of the patients, a previous AMI in 67%, a previous transient ischemic attack in 4% and a previous ischemic stroke in 6% of patients. A total of 195 patients underwent coronary angiography: 1 vessel was involved in 48% of patients, 2 vessels in 33%, and 3 vessels in 19%. Detecting peripheral atherosclerotic lesions by UDS, increased intima-media thickness (IMT) or plaques in carotid arteries were found in 232 patients (94%) and carotid stenosis >70% in 13 patients (5%). In lower limb arteries, IMT or plaques were present in 202 patients (82%) and a stenosis >70% in 18 patients (7%). Severity of coronary artery disease (CAD) was correlated to extracoronary atherosclerosis: carotid and lower limb arterial atherosclerosis was detected in 73% of patients with 1 vessel, in 83% of patients with 2 vessel, in 87% of those with 3 vessel CAD.

CONCLUSION

Our study suggests that in patients with CAD, it is useful to screen the peripheral circulation by non-invasive tests, such as UDS. Patients with the diagnosis of ischemic heart disease and combined extracoronary atherosclerosis need a careful follow-up and a more aggressive therapy for secondary prevention.

Prognostic significance of the evolution of left ventricular ejection fraction in patients with acute myocardial infarction not treated with thrombolytic therapy

Several controlled trials on the thrombolytic treatment of acute myocardial infarction (AMI) have failed to demonstrate that thrombolysis has a simultaneous positive effect on left ventricular function and survival. One explanation may be that spontaneous changes in left ventricular function occurred during the progression of AMI in control patients. The aim of this study was to evaluate the spontaneous evolution of left ventricular ejection fraction (LVEF) and its prognostic influence on early (1 month) and late (1 year) mortality in patients with AMI. We studied 216 patients admitted to our CCU within 24 h of the onset of symptoms. LVEF was determined by radionuclide ventriculography on admission (RNV1) and at the end of the necrotic phase (RNV2). Fourteen patients died before RNV2. On the basis of LVEF values at RNV1, the remaining 202 patients were divided into two groups: those with a normal LVEF (> or = 55%), and those with an abnormal LVEF (< 55%). Among patients with a normal LVEF at RNV1 (64 patients), a significant increase (> 12%) in LVEF at RNV2 was observed in 12.5%, a significant decrease (> 12%) in 12.5% and no change at all in 75%. All of these patients survived, regardless of the evolution of LVEF. In patients with an abnormal LVEF at RNV1 (138) a significant increase (> 5%) in LVEF at RNV2 was observed in 72.5%, a significant decrease (> 5%) in 6.5% and no change at all in 21%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Electrocardiographic indices of reperfusion and limitation of the necrotic area in acute myocardial infarct]

The aim of this study was to assess the evolution of ST segment displacement and the formation of new Q waves in relation to the late angiographic demonstration of recanalization of the infarct-related vessel in 36 patients with acute myocardial infarction admitted in our Institution within 8 hours from the onset of symptoms. Eighteen patients were treated with intravenous urokinase (200,000 + 1,200,000 UI) followed by sodium-heparin 1,000 U/ev/hour for 48 hours and calcium-heparin 3,000 UI/10 Kg/12 hours from the third day to discharge. Eighteen patients were treated from admission only with calcium-heparin as seen before. All the patients have been followed with serial electrocardiograms; we evaluated the sum of ST displacements (ST12) and Q waves score (Q12) in the 12 standard leads on admission, and on the twelfth, twenty-fourth, forty-eighth hour, and on discharge. On the basis of the late angiographic findings and apart from the treatment, we divided the patients into 2 groups: patients with recanalization of infarct-related vessel (20 patients, 55.5%) and patients with occlusion of the infarct-related vessel (16 patients, 44.6%). We did not observe statistically significant differences between the 2 groups for decrease of ST segment displacement of formation of new Q waves, even if reperfused patients showed a more rapid and complete decrease of ST segment displacement and a more rapid formation of new Q waves with respect to occluded patients. Our data indicate that from a clinical point of view electrocardiographic indices are not a sensitive marker of recanalization of infarct-related vessel.(ABSTRACT TRUNCATED AT 250 WORDS)

[Short- and long-term effects of enalapril on the left ventricular function in patients with congestive heart insufficiency]

Several studies have demonstrated that enalapril causes a clinical and hemodynamic improvement in patients with congestive heart failure. Nevertheless, the drug capability of influencing left ventricular systolic and diastolic indexes has not been evaluated. In 12 patients with severe congestive heart failure (NYHA class III-IV), treated with digitalis and diuretics, we performed a baseline evaluation through a right heart catheterization, echocardiography and radionuclide ventriculography. The effects on left ventricular systolic and diastolic function indexes after the administration of enalapril 5 mg by oral route have been evaluated. After 3 months of chronic therapy with enalapril 5 mg twice daily, we performed a further evaluation through echocardiography and radionuclide ventriculography. At the acute test we observed a significant improvement of left ventricular ejection fraction (EF), left ventricular stroke index (LVSI), and peak of filling rate (PFR), with a significant reduction of pulmonary wedge pressure (PWP) and peripheral vascular resistance (PVR). After 3 months of chronic therapy EF was significantly increased with respect to baseline values (37 +/- 6.9% vs 28.7 +/- 7.9%, p less than 0.05) and showed a further increase after the drug administration (from 37 +/- 6.9% to 48 +/- 5.4%, p less than 0.001). PFR showed a similar behaviour and reached at the follow-up evaluation normal values (from 1.97 +/- 0.7 edv/s to 2.57 +/- 0.6 efv/s, p less than 0.001). Furthermore, the echocardiographic dimensions of the left ventricle decreased significantly with a significant increase of shortening fraction. In conclusion, our study demonstrates that in patients with severe congestive heart failure enalapril improves the left ventricular systolic and diastolic function indexes and this improvement is persistent.