Early non compliance to enhanced recovery pathway might be an alert for underlying complications following colon surgery

PURPOSE

Early non compliance to postoperative ERAS pathway has been reported in 20-30% of patients who underwent elective colon surgery. The aim of the present study is to investigate the possible relationship between early non compliance and postoperative complications.

METHODS

We reviewed a prospective database including 1391 consecutively collected patients undergoing elective colon surgery in 22 Italian hospitals between January 2017 and June 2020. Early compliance to ERAS protocol was assessed on postoperative day (POD) 2. Failure of oral feeding, urinary catheter removal, intravenous fluids stop, and adequate mobilization were indicators of non compliance. Postoperative follow-up was carried out for 30 days after hospital discharge. The association among early postoperative ERAS compliance and the occurrence of complications was assessed with uni- and multivariate analysis.

RESULTS

A total of 1089 (78.3%) patients had malignancy and minimally invasive surgery was successfully performed in 1174 (84.3%) patients. Postoperative morbidity occurred in 403 (29.0%) patients. At multivariate analysis, male gender, open surgery, and each of the four non compliance indicators on POD 2 were significantly associated to postoperative complications. Morbidity progressively increased from 16.8% in patients with full compliance to ERAS protocol to 47.2% in patients with two non compliance indicators and 69.2% in patients with all four indicators (p < 0.001).

CONCLUSIONS

Early non compliance to ERAS protocol was significantly associated with postoperative morbidity.

The pan - COVID - AGICT study. The impact of COVID-19 pandemic on surgically treated pancreatic cancer patients. A multicentric Italian study

BACKGROUND

In this article we aimed to perform a subgroup analysis using data from the COVID-AGICT study, to investigate the perioperative outcomes of patients undergoing surgery for pancreatic cancers (PC) during the COVID-19 pandemic.

METHODS

The primary endpoint of the study was to find out any difference in the tumoral stage of surgically treated PC patients between 2019 and 2020. Surgical and oncological outcomes of the entire cohort of patients were also appraised dividing the entire peri-pandemic period into six three-month timeframes to balance out the comparison between 2019 and 2020.

RESULTS

Overall, a total of 1815 patients were surgically treated during 2019 and 2020 in 14 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (p = 0.846). During the pandemic, neoadjuvant chemotherapy (NCT) has dropped significantly (6.2% vs 21.4%, p < 0.001) and, for patients who didn't undergo NCT, the latency between diagnosis and surgery was shortened (49.58 ± 37 days vs 77.40 ± 83 days, p < 0.001). During 2020 there was a significant increase in minimally invasive procedures (p < 0.001). The rate of postoperative complication was the same in the two years but during 2020 there was an increase of the medical ones (19% vs 16.1%, p = 0.001).

CONCLUSIONS

The post-pandemic dramatic modifications in healthcare provision, in Italy, did not significantly impair the clinical history of PC patients receiving surgical resection. The present study is one of the largest reports available on the argument and may provide the basis for long-term analyses.

The Role of Three-Dimensional Modeling to Improve Comprehension of Liver Anatomy and Tumor Characteristics for Medical Students and Surgical Residents

OBJECTIVE

Studying liver anatomy can be challenging for medical students and surgical residents due to its complexity. Three-dimensional visualization technology (3DVT) allows for a clearer and more precise view of liver anatomy. We sought to assess how 3DVT can assist students and surgical residents comprehend liver anatomy.

DESIGN

Data from 5 patients who underwent liver resection for malignancy at our institution between September 2020 and April 2022 were retrospectively reviewed and selected following consensus among the investigators. Participants were required to complete an online survey to investigate their understanding of tumor characteristics and vascular variations based on patients' computed tomography (CT) and 3DVT.

SETTING

The study was carried out at the General and Hepato-Biliary Surgery Department of the University of Verona.

PARTICIPANTS

Among 32 participants, 13 (40.6%) were medical students, and 19 (59.4%) were surgical residents.

RESULTS

Among 5 patients with intrahepatic lesions, 4 patients (80.0%) had at least 1 vascular variation. Participants identified number and location of lesions more correctly when evaluating the 3DVT (84.6% and 80.9%, respectively) compared with CT scans (61.1% and 64.8%, respectively) (both p ≤ 0.001). The identification of any vascular variations was more challenging using the CT scans, with only 50.6% of correct answers compared with 3DVT (72.2%) (p < 0.001). Compared with CT scans, 3DVT led to a 23.5%, 16.1%, and 21.6% increase in the correct definition of number and location of lesions, and vascular variations, respectively. 3DVT allowed for a decrease of 50.8 seconds (95% CI 23.6-78.0) in the time needed to answer the questions. All participants agreed on the usefulness of 3DVT in hepatobiliary surgery.

CONCLUSIONS

The 3DVT facilitated a more precise preoperative understanding of liver anatomy, tumor location and characteristics.

Evaluation of the ACS-NSQIP Surgical Risk Calculator in Patients with Hepatic Metastases from Colorectal Cancer Undergoing Liver Resection

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC) has been designed to predict morbidity and mortality and help stratify surgical patients. This study evaluates the performance of the SRC for patients undergoing surgery for colorectal liver metastases (CRLM).

METHODS

SRC was retrospectively computed for patients undergoing liver or simultaneous colon and liver surgery for colorectal cancer (CRC) in two high tertiary referral centres from 2011 to 2020. C-statistics and Brier score were calculated as a mean of discrimination and calibration respectively, for both group and for every level of surgeon adjustment score (SAS) for liver resections in case of simultaneous liver-colon surgery. An AUC ≥ 0.7 shows acceptable discrimination; a Brier score next to 0 means the prediction tool has good calibration.

RESULTS

Four hundred ten patients were included, 153 underwent simultaneous resection, and 257 underwent liver-only resections. For simultaneous surgery, the ACS-NSQIP SRC showed good calibration and discrimination only for cardiac complication (AUC = 0.720, 0.740, and 0.702 for liver resection unadjusted, SAS-2, and SAS-3 respectively; 0.714 for colon resection; and Brier score = 0.04 in every case). For liver-only surgery, it only showed good calibration for cardiac complications (Brier score = 0.03). The SRC underestimated the incidence of overall complications, pneumonia, cardiac complications, and the length of hospital stay.

CONCLUSIONS

ACS-NSQIP SRC showed good predicting capabilities only for 1 out of 5 evaluated outcomes; therefore, it is not a reliable tool for patients undergoing liver surgery for CRLM, both in the simultaneous and staged resections.

Transcriptome analysis of primary sporadic neuroendocrine tumours of the intestine identified three different molecular subgroups

BACKGROUND

Intestinal neuroendocrine tumours (I-NETs) represent a non-negligible entity among intestinal neoplasms, with metastatic spreading usually present at the time of diagnosis. In this context, effective molecular actionable targets are still lacking. Through transcriptome analysis, we aim at refining the molecular taxonomy of I-NETs, also providing insights towards the identification of new therapeutic vulnerabilities.

MATERIALS AND METHODS

A retrospective series of 38 primary sporadic, surgically-resected I-NETs were assessed for transcriptome profiling of 20,815 genes.

RESULTS

Transcriptome analysis detected 643 highly expressed genes. Unsupervised hierarchical clustering, differential expression analysis and gene set enriched analysis identified three different tumour clusters (CL): CL-A, CL-B, CL-C. CL-A showed the overexpression of ARGFX, BIRC8, NANOS2, and SSTR4 genes. Its most characterizing signatures were those related to cell-junctions, and activation of mTOR and WNT pathway. CL-A was also enriched in T CD8 + lymphocytes. CL-B showed the overexpression of PCSK1, QPCT, ST18, and TPH1 genes. Its most characterizing signatures were those related to adipogenesis, neuroendocrine metabolism, and splice site machinery-related processes. CL-B was also enriched in T CD4 + lymphocytes. CL-C showed the overexpression of ALB, ANG, ARG1, and HP genes. Its most characterizing signatures were complement/coagulation and xenobiotic metabolism. CL-C was also enriched in M1/2 macrophages. These CL-based differences may have therapeutic implications in refining the management of I-NET patients. At last, we described a specific gene-set for differentiating I-NET from pancreatic NET.

DISCUSSION

Our data represent an additional step for refining the molecular taxonomy of I-NET, identifying novel transcriptome subgroups with different biology and therapeutic opportunities.

Laparoscopic double mesh repair of a large Morgagni hernia: a video vignette

Morgagni hernia (MH) is a rare congenital diaphragmatic hernia (CDH) that accounts for less than 2% of surgically repaired CDH in adulthood. Even if this condition is often asymptomatic, surgery is advised due to the risk of life-threatening complications such as volvulus or bowel strangulation. Surgery for MH repair can be performed by transthoracic, transabdominal, laparoscopic, or thoracoscopic approaches. Though laparoscopy has recently improved surgical outcomes, the use of prosthetic meshes and the need for reduction of the hernia sac are still the most debated issues. We present the video of a laparoscopic repair of a large MH with the use of a double mesh technique and no resection of the hernia sac.

Pre-diagnostic prognostic value of leukocytes count and neutrophil-to-lymphocyte ratio in patients who develop colorectal cancer

Introduction

Emerging evidence is pointing towards a relevant role of immunity in cancer development. Alterations in leukocytes count and neutrophil-to-lymphocyte ratio (NLR) at diagnosis of colorectal cancer (CRC) seems to predict poor prognosis, but no data is available for the pre-diagnostic values.

Methods

Retrospective analysis of patients who underwent surgery for CRC at our center (2005 - 2020). 334 patients with a complete blood count dating at least 24 months prior to diagnosis were included. Changes in pre-diagnosis values of leukocytes (Pre-Leu), lymphocytes (Pre-Lymph), neutrophils (Pre-Neut), and NLR (Pre-NLR) and their correlation with overall- (OS) and cancer-related survival (CRS) were analyzed.

Results

Pre-Leu, Pre-Neut and Pre-NLR showed an increasing trend approaching the date of diagnosis, while Pre-Lymph tended to decrease. The parameters were tested for associations with survival after surgery through multivariable analysis. After adjusting for potential confounding factors, Pre-Leu, Pre-Neut, Pre-Lymph and Pre-NLR resulted independent prognostic factors for OS and CRS. On sub-group analysis considering the interval between blood sampling and surgery, higher Pre-Leu, Pre-Neut, and Pre-NLR and lower Pre-Lymph were associated with worse CRS, and the effect was more evident when blood samples were closer to surgery.

Conclusion

To our knowledge, this is the first study showing a significant correlation between pre-diagnosis immune profile and prognosis in CRC.

The MIS-COVID-AGICT Study: Trend of Minimally Invasive Surgery for Gastrointestinal Cancer Treatment During the First Waves of the COVID-19 Pandemic in Italy. Subgroup Analysis from the COVID-AGICT Study: COVID-19 and Advanced Gastrointestinal Cancer Surgical Treatment

Background: A preliminary analysis from the COVID-Advanced Gastrointestinal Cancer Surgical Treatment (AGICT) study showed that the rate of minimally invasive surgery (MIS) for elective and urgent procedures did not decrease during the pandemic year. In this article, we aimed to perform a subgroup analysis using data from the COVID-AGICT study to evaluate the trend of MIS during the COVID-19 pandemic period in Italy. Methods: This study was conducted collecting data of MIS patients from the COVID-AGICT database. The primary endpoint was to demonstrate whether the SARS-CoV-2 pandemic scenario reduced MIS for elective treatment of gastrointestinal cancer (GIC) in Italy in 2020. The secondary endpoint was to evaluate the impact of the pandemic period on perioperative outcomes in the MIS group. Results: In the pandemic year, 62% of patients underwent surgery with a minimally invasive approach, compared to 63% in 2019 (P = .23). In 2020, the proportion of patients undergoing elective MIS decreased compared to the previous year (80% versus 82%, P = .04), and the rate of urgent MIS did not differ between the 2 years (31% and 33% in 2019 and 2020 - P = .66). Colorectal cancer was less likely to be treated with MIS approach during 2020 (78% versus 75%, P < .001). Conversely, the rate of MIS pancreatic resection was higher in 2020 (28% versus 22%, P < .002). Conversion to an open approach was lower in 2020 (7.2% versus 9.2% - P = .01). Major postoperative complications were similar in both years (11% versus 11%, P = .9). Conclusion: In conclusion, although MIS for elective treatment of GIC in Italy was reduced during the COVID-19 pandemic period, our study revealed that the overall proportion of MIS (elective and urgent) and postoperative outcomes were comparable to the prepandemic period. ClinicalTrial.gov (NCT04686747).

5 year oncological outcomes of the HIGHLOW randomized clinical trial

INTRODUCTION

The oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA MATERIALS AND METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled.

RESULTS

Five-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years.

CONCLUSION

We confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.

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.

A national survey on the current status of minimally invasive gastric practice on behalf of GIRCG

Italian Research Group for Gastric Cancer (GIRCG), during the 2013 annual Consensus Conference to gastric cancer, stated that laparoscopic or robotic approach should be limited only to early gastric cancer (EGC) and no further guidelines were currently available. However, accumulated evidences, mainly from eastern experiences, have supported the application of minimally invasive surgery also for locally advanced gastric cancer (AGC). The aim of our study is to give a snapshot of current surgical propensity of expert Italian upper gastrointestinal surgeons in performing minimally invasive techniques for the treatment of gastric cancer in order to answer to the question if clinical practice overcome the recommendation. Experts in the field among the Italian Research Group for Gastric Cancer (GIRCG) were invited to join a web 30-item survey through a formal e-mail from January 1st, 2020, to June 31st, 2020. Responses were collected from 46 participants out of 100 upper gastrointestinal surgeons. Percentage of surgeons choosing a minimally invasive approach to treat early and advanced gastric cancer was similar. Additionally analyzing data from the centers involved, we obtained that the percentage of minimally invasive total and partial gastrectomies in advanced cases augmented with the increase of surgical procedures performed per year (p = 0.02 and p = 0.04 respectively). It is reasonable to assume that there is a widening of indications given by the current national guideline into clinical practice. Propensity of expert Italian upper gastrointestinal surgeons was to perform minimally invasive surgery not only for early but also for advanced gastric cancer. Of interest volume activity correlated with the propensity of surgeons to select a minimally invasive approach.

A machine learning analysis of difficulty scoring systems for laparoscopic liver surgery

INTRODUCTION

In the last decade, several difficulty scoring systems (DSS) have been proposed to predict technical difficulty in laparoscopic liver resections (LLR). The present study aimed to investigate the ability of four DSS for LLR to predict operative, short-term, and textbook outcomes.

METHODS

Patients who underwent LLR at a single tertiary referral center from January 2014 to June 2020 were included in the present study. Four DSS for LLR (Halls, Hasegawa, Kawaguchi, and Iwate) were investigated to test their ability to predict operative and postoperative complications. Machine learning algorithms were used to identify the most important DSS associated with operative and short-term outcomes.

RESULTS

A total of 346 patients were included in the analysis, 28 (8.1%) patients were converted to open surgery. A total of 13 patients (3.7%) had severe (Clavien-Dindo ≥ 3) complications; the incidence of prolonged length of stay (> 5 days) was 39.3% (n = 136). No patients died within 90 days after the surgery. According to Halls, Hasegawa, Kawaguchi, and Iwate scores, 65 (18.8%), 59 (17.1%), 57 (16.5%), and 112 (32.4%) patients underwent high difficulty LLR, respectively. In accordance with a random forest algorithm, the Kawaguchi DSS predicted prolonged length of stay, high blood loss, and conversions and was the best performing DSS in predicting postoperative outcomes. Iwate DSS was the most important variable associated with operative time, while Halls score was the most important DSS predicting textbook outcomes. No one of the DSS investigated was associated with the occurrence of complication.

CONCLUSIONS

According to our results DDS are significantly related to surgical complexity and short-term outcomes, Kawaguchi and Iwate DSS showed the best performance in predicting operative outcomes, while Halls score was the most important variable in predicting textbook outcome. Interestingly, none of the DSS showed any correlation with or importance in predicting overall and severe postoperative complications.

The LIver SEntinel LYmph-node (LISELY) study: A prospective intraoperative real time evaluation of liver lymphatic drainage and sentinel lymph-node using near-infrared (NIR) imaging with Indocyanine Green (ICG)

Near-infrared (NIR) imaging with Indocyanine green (ICG) has been recently proposed for the sentinel lymph node (SLN) and lymphatic out-flow detection in several tumors. Nowadays its application in primary and secondary liver (LCs) and biliary cancers (BTCs) remains uninvestigated. A proof-of-concept prospective observational study including 18 patients underwent surgery for LCs and BTCs from September 2021 to November 2021 was carried out. The intraoperative NIR imaging with ICG was detected at predefined temporary intervals in order to identify the main lymphatic out-flow and the SLN. In 14 patients (77.8%) the lymphatic outflow pathway was visualized with a median time of 3 min after ICG injection (IQR 3-10). The SLN was detected and confirmed at the histological examination in 12 patients (66.7%). Intraoperative NIR imaging with ICG is a safe and feasible method to identify the lymphatic out-flow and SLN in LCs and BTCs.

Immediate versus early (24-hours) urinary catheter removal after elective minimally invasive colonic resection: study protocol for a randomized, multicenter, non-inferiority trial

Background

Enhanced Recovery After Surgery (ERAS) represents the standard of care in colorectal surgery. Among ERAS items, early removal of urinary catheter (UC) is considered a key issue, though adherence to this specific item still varies among centers. UC placement allows for monitoring of post-operative urinary output but relates to an increased risk of urinary tract infection (UTI), reduced mobility, and patient’s discomfort. Several studies investigated the role of early UC removal specifically looking at the rate of acute urinary retention (AUR) but most of them were retrospective, single-center, underpowered, cohort studies. The main purpose of this study is to compare the rate of AUR after immediate (at the end of the surgery) versus early (within 24 h from the completion of surgery) removal of UC in patients undergoing minimally invasive colonic resection (MICR). The secondary outcomes focus on goals that could be positively impacted by the immediate removal of the UC at the end of the surgery. In particular, the rate of UTIs, perception of pain, time-to-return of bowel and physical functions, postoperative complications, and length of hospital stay will be measured.

Methods

This is a prospective, randomized, controlled, two-arm, multi-center, study comparing the rate of AUR after immediate versus early removal of UC in patients undergoing MICR. The investigators hypothesize that immediate UC removal is non-inferior to 24-h UC removal in terms of AUR rate. Randomization is at the patient level and participants are randomized 1:1 to remove their UC either immediately or within 24 h from the completion of surgery. Those eligible for inclusion were patients undergoing any MICR with an anastomosis above the peritoneal reflection. Those patients who need to continue urinary output monitoring after the surgery will be excluded. The number of patients calculated to be enrolled in each group is 108 based on an expected AUR rate of 3% for the 24-h UC removal group and considering acceptable an AUR of 9% for the immediate UC removal group.

Discussion

The demonstration of a non-inferiority of immediate versus 24-h removal of UC would call into question the usefulness of urinary drainage in the setting of MICR.

Trial registration

ClinicalTrials.gov NCT05249192. Prospectively registered on February 21, 2022.

Impact of age and comorbidities on short- and long-term outcomes of patients undergoing surgery for colorectal cancer

Background

As the world population is progressively ageing, more and more elderly patients will require cancer surgery. Although curative surgery is the treatment of choice for resectable colorectal cancer (CRC), it is still debated whether elderly frail patients should undergo major cancer surgery due to the increased risk of postoperative and long-term mortality. The aim of this retrospective study was to evaluate the impact of age and comorbidities on postoperative mortality/morbidity and long-term outcomes, looking for potential age-related survival differences.

Methods

A total of 1,482 patients operated for CRC at our institution between January 2005 and October 2020 were analysed. The independent effect of age and comorbidities on postoperative complications was assessed by a logistic model, while the effect on overall survival (OS) and cancer-related survival (CRS) was estimated by a Cox regression model.

Results

The median age in the cohort was 67.8 years. Postoperative mortality was very low in the whole cohort (0.8%) and contained even in older age groups (3.2% in patients aged 80–84 years, 4% in the 85–90-year age group). The cumulative incidence of postoperative complications was doubled in patients with comorbidities (32.8% vs. 15.1%, p = 0.002). With regard to OS, as expected, it exponentially decreased with advancing age. Conversely, differences in CRS were less pronounced between age groups and absent in patients with stage 0–I CRC. Analysis of all causes and cancer-related mortality revealed a peak within 2 years from surgery, suggesting a prolonged impact of surgery. In patients aged 75 years and above, all-cause mortality showed a steep increase 1 year after surgery, while cancer-related mortality plateaued at about 4 years after surgery. On multivariable analysis, OS, but not CRS, was significantly influenced by age.

Conclusions

Although acceptable results of surgery in elderly patients, OS is strongly dependent on age: older people die more from competing causes than cancer-related treatments compared to younger age classes. The preoperative identification of risk factors for low OS may help the selection of those elderly patients who would benefit from curative CRC surgery.

Sarcobesity Index Predicts Poor Disease-Specific Survival After Resection for Colorectal Cancer

INTRODUCTION

Sarcobesity (SO) is traditionally defined as the association between low muscle mass and obesity and has been reported to worsen prognosis after curative resection for colorectal cancer (CRC). This study aimed to propose a new definition of SO based on computed tomography measurements of the skeletal muscle area (SMA) and visceral adipose tissue (VAT) and to assess its implications on long-term survival after curative resection for stage I-III CRC.

METHODS

We retrospectively analyzed 506 patients with stage I-III CRC who underwent surgery between January 2010 and December 2019. Preoperative computed tomography images were analyzed and the sarcobesity index (SI) was calculated for each patient as the VAT/SMA ratio. The optimal cutoff value for predicting survival was determined using time-dependent receiver operating characteristic analysis. Overall survival and disease-specific survival (DSS) were compared between SO (SI > 1.25) and non-SO (SI ≤ 1.25) patients. The rates and modes of recurrence were also compared between the two groups.

RESULTS

Three hundred (59.3%) patients were identified to be sarcobese. No differences in short-term outcomes and administration of adjuvant chemotherapy were found, except for a longer length of stay in patients with SO. In a univariable analysis, SO was associated with a worse 5-y overall survival and DSS, considering the whole population and stages II and III separately. A multivariable analysis confirmed SO to be an independent risk factor for DSS (hazard ratio 2.29; 95% confidence interval 1.13-4.62, P = 0.02). Although the overall recurrence rate did not differ between the groups, a significantly higher rate of recurrence at multiple sites was observed in patients with SO (P = 0.01).

CONCLUSIONS

The SI, defined as per the VAT/SMA ratio, seems to be a reliable tool for identifying patients with worse DSS after potentially curative surgery for stage I-III CRC.

Prediction of Metachronous Peritoneal Metastases After Radical Surgery for Colon Cancer: A Scoring System Obtained from an International Multicenter Cohort

Background

Since novel strategies for prevention and treatment of metachronous peritoneal metastases (mPM) are under study, it appears crucial to identify their risk factors. Our aim is to establish the incidence of mPM after surgery for colon cancer (CC) and to build a statistical model to predict the risk of recurrence.

Patients and Methods

Retrospective analysis of consecutive pT3–4 CC operated at five referral centers (2014–2018). Patients who developed mPM were compared with patients who were PM-free at follow-up. A scoring system was built on the basis of a logistic regression model.

Results

Of the 1423 included patients, 74 (5.2%) developed mPM. Patients in the PM group presented higher preoperative carcinoembryonic antigen (CEA) [median (IQR): 4.5 (2.5–13.0) vs. 2.7 (1.5–5.9), P = 0.001] and CA 19-9 [median (IQR): 17.7 (12.0–37.0) vs. 10.8 (5.0–21.0), P = 0.001], advanced disease (pT4a 42.6% vs. 13.5%; pT4b 16.2% vs. 3.2%; P < 0.001), and negative pathological characteristics. Multivariate logistic regression identified CA 19-9, pT stage, pN stage, extent of lymphadenectomy, and lymphovascular invasion as significant predictors, and individual risk scores were calculated for each patient. The risk of recurrence increased remarkably with score values, and the model demonstrated a high negative predictive value (98.8%) and accuracy (83.9%) for scores below five.

Conclusions

Besides confirming incidence and risk factors for mPM, our study developed a useful clinical tool for prediction of mPM risk. After external validation, this scoring system may guide personalized decision-making for patients with locally advanced CC.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-12097-9.

Infectious complications after surgery for perihilar cholangiocarcinoma: A single Western center experience

BACKGROUND

The aim of this study was to analyze the risk factors for surgical infectious complications and the outcomes of patients undergoing surgery for perihilar cholangiocarcinoma according to the microbiological examinations.

METHODS

Patients who underwent surgery for perihilar cholangiocarcinoma in the last decade were enrolled, and all clinical and microbiological data were collected from a retrospective monocentric database. Univariate and multivariate analyses were performed distinguishing patients who developed at least 1 surgical infectious complication (surgical site infections, acute bacterial cholangitis, bacteremia).

RESULTS

A total of 98 patients were included. Among patients who developed surgical infectious complications (51%), many preoperative characteristics were significantly more frequent: American Society of Anesthesiologists score ≥3 (P = .026), neutrophil-to-lymphocyte ratio ≥3.4 (P = .001), endoscopic sphincterotomy (P = .032), ≥2 biliary drainage procedures (P = .013), acute cholangitis (P = .012), multidrug resistant (P = .009), and ≥3 microorganisms' detection (P = .042); whereas during the postoperative period, surgical infectious complications were associated to increased incidence of intensive care unit readmission (P = .031), major complications (P < .001), posthepatectomy liver failure (P = .005), ascites (P = .008), biliary leakage (P = .008), 90-day readmission (P = .003), and prolonged length of hospital stay (P < .001). At the multivariate analysis 3 independent preoperative risk factors for surgical infectious complications were identified: neutrophil-to-lymphocyte ratio ≥3.4 (P = .004), endoscopic sphincterotomy (P = .009), and acute cholangitis (P = .013). The presence of multidrug-resistance in the perioperative biliary cultures was related to postoperative multidrug-resistant species from all cultures (P < .001) and organ/space and incisional-surgical site infections (P ≤ .044).

CONCLUSION

Infective complications after surgery for perihilar cholangiocarcinoma worsen the short-term outcomes. A careful microbiological surveillance should be carried out in all cases to prevent and promptly treat surgical infectious complications.

Laparoscopic surgery does not reduce the need for red blood cell transfusion after resection for colorectal tumour: a propensity score match study on 728 patients

BACKGROUND

Patients with colorectal tumour often present with anaemia, and up to 60% will receive red blood cells (RBC) transfusion. Some evidence suggests a correlation between RBC transfusion and worse outcomes. Since laparoscopy minimizes intraoperative blood loss, we retrospectively investigated its role in reducing haemoglobin (Hb) drop and requirements for postoperative RBC transfusions.

METHODS

Patients were identified from consecutive cases undergone elective surgery for non-metastatic colorectal tumour between 2005 and 2019. Laparoscopic cases were matched 1:1 with open controls through propensity score matching (PSM). The main outcome measures were postoperative Hb drop and requirement for RBC. The secondary aim was evaluation of risk factors for postoperative RBC transfusions.

RESULTS

After application of PSM, 364 patients treated by laparoscopy were matched with 364 patients undergone open surgery. The two groups presented similar clinical and pathological characteristics, as well as comparable postoperative outcomes. 56 patients in the open group and 47 in the laparoscopic group required postoperative RBC (P = 0.395). No difference was observed in terms of mean number of RBC units (P = 0.608) or Hb drop (P = 0.129). Logistic regression analysis identified preoperative anaemia and occurrence of postoperative complications as relevant risk factors for postoperative RBC transfusion, while surgical approach did not prove statistically significant.

CONCLUSION

Laparoscopy did not influence postoperative requirements for RBC transfusions after elective colorectal surgery. Preoperative anaemia and occurrence of postoperative complications represent the major determinants for postoperative transfusions after open as well as laparoscopic surgery.

Risk factors for anastomotic leakage after anterior resection for rectal cancer (RALAR study): A nationwide retrospective study of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative Group

AIM

Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage.

METHODS

The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured.

RESULTS

A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection.

CONCLUSIONS

While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction.

Laparoscopic versus open surgery for left flexure colon cancer: A propensity score matched analysis from an international cohort

AIM

Surgical treatment of splenic flexure cancer (SFC) still presents some debated issues, including the role of laparoscopic surgery. The literature is based on small single-centre series, while randomized controlled studies comparing open and laparoscopic treatment for colon cancer exclude SFC. This study aimed to determine the role of laparoscopic surgery in the treatment of SFC, comparing short- and long-term outcomes with open surgery.

METHOD

This was an international multicentre retrospective cohort study that analysed patients from 10 tertiary referral centres. From a cohort of 641 cases, 484 patients with Stage I-III SFC submitted to elective surgery with curative intent were selected. After 1:1 propensity score matching, 130 patients in the laparoscopic group (LapGroup) were compared with 130 patients in the open surgery group (OpenGroup).

RESULTS

After propensity score matching, the two groups were comparable for demographic and clinical parameters. OpenGroup presented a higher incidence of overall (P = 0.02) and surgery-related complications (P = 0.05) but a similar rate of severe complications (P = 0.75). Length of stay was notably shorter in the LapGroup (P = 0.001). Overall (P = 0.793) as well as cancer-specific survival (P = 0.63) did not differ between the two groups.

CONCLUSIONS

Elective laparoscopic surgery for Stage I-III SFC is feasible and associated with improved short-term postoperative outcomes compared to open surgery. Moreover, laparoscopic surgery appears to provide excellent long-term cancer outcomes.

Ablation Difficulty Score: Proposal of a new tool to predict success rate of percutaneous ablation for hepatocarcinoma

PURPOSE

Identify the factors related to failure ablation after percutaneous ultrasound guided single electrode radiofrequency ablation (RFA) for hepatocarcinoma (HCC) and propose a score for improving patient selection and treatment allocation.

METHODS

From 2010 to 2020 585 HCC nodules treated with RFA were prospectively collected. Ablation Difficulty Score (ADS) was built-up according to clinical and radiological factors related to failure ablation identified by Cox-logistic regression analysis. The study population was stratified in low risk (ADS 0), intermediate risk (ADS 1), and high risk (ADS ≥ 2) of failure ablation.

RESULTS

Overall ablation success rate was 85.5%. Morbidity and mortality rates were 3.5% and 0.0%. According to per nodule analysis the following factors resulted related to failure ablation: size > 20 mm (p = 0.002), sub-capsular location (p = 0.008), perivascular location (p = 0.024), isoechoic appearance (p = 0.008), and non-cirrhotic liver (p = 0.009). The ablation success rate was 93.5% in ADS 0, 85.8% in ADS 1 and 71.3% in ADS ≥ 2 (p < 0.001). The 1-year local tumor progression (LTP) free survival was 90.2% in ADS 0, 80.6% in ADS 1, and 72.3% in ADS ≥ 2 (p = 0.009). Nodule's size > 20 mm (p = 0.014), isoechoic appearance (p = 0.012), perivascular location (p = 0.012) resulted related to lower LTP free survival.

CONCLUSION

Ablation Difficulty Score could be a simple and useful tool for guiding the treatment decision making of HCC. RFA in high risk nodules (ADS ≥ 2) should be carefully evaluated and reserved for patients not suitable for surgery or liver transplantation.

Visceral obesity enhances inflammatory response after laparoscopic colorectal resection

AIMS

C-reactive protein (CRP) is used for monitoring postoperative inflammation (POI) and detecting infectious complications. The aim of this study was to assess the effect of visceral obesity (VO) on acute POI measured through CRP after elective laparoscopic colorectal resection.

METHODS

Pre-operative Computed tomography images of 357 patients who underwent laparoscopic colorectal resection were analyzed. Visceral adipose tissue (VAT) area was measured for each patient. VO was defined as VAT area >163.8 cm² in men and >80.1 cm² in women according to accepted sex-specific cut-offs. Postoperative outcomes and CRP values were compared between VO and non-VO groups. The most appropriate CRP value for identifying infectious complications in the two groups was assessed with receiver operating characteristic (ROC) curves. Univariate and multivariate analyses were conducted for factors affecting POI including VO.

RESULTS

No differences in postoperative outcomes and infectious complications were found in VO patients (62.2% of the overall population). Both in the overall cohort and in patients without infectious complications, VO was associated with higher CRP values on postoperative day (POD) 1, POD2, POD3, and POD5. A positive correlation was found between VAT and CRP on all PODs. VO independently predicted higher CRP on POD1-3 in patients without infectious complications but not in those who developed complications. ROC curves analysis showed optimal accuracy for detection of infectious complications for CRP on POD3 in both groups, though the optimal cut-off value was higher in VO group (154 vs 136 mg/L).

CONCLUSIONS

VO is not associated to increased complications after laparoscopic colorectal resection. Nevertheless, it is independently associated to higher CRP in the overall population and in patients without infectious complications. Consequently, CRP values on POD3 higher than cut-offs commonly adopted in the clinical practice should be carefully evaluated in VO patients to assess the occurrence of infectious complications.

Colorectal cancer with microsatellite instability: Right-sided location and signet ring cell histology are associated with nodal metastases, and extranodal extension influences disease-free survival

Colorectal cancer (CRC) with microsatellite instability (MSI) accounts for 15-18 % of all CRCs and represents the category with the best prognosis. This study aimed at determining any possible clinical/pathological features associated with a higher risk of nodal metastasization in MSI-CRC, and at defining any possible prognostic moderators in this setting. All surgically resected CRCs of the last 20 years (mono-institutional series) with a PCR-based diagnosis of MSI, with and without nodal metastasis, have been retrieved for histological review, which was performed following WHO guidelines. Furthermore, the most important prognostic moderators have been investigated with a survival analysis. The study of 33 cases of MSI-CRCs with nodal metastasis highlighted a high fidelity of histology maintenance between primary tumors and matched nodal metastases. At survival analysis, the strongest prognostic variable in MSI-CRCs with nodal metastasis was the extranodal extension (multivariate analysis, HR: 14.4, 95 %CI: 1.46-140.9, p = 0.022). Furthermore, through a comparison between nodal positive (33 cases) and nodal negative (71 cases) MSI-CRCs, right-sided location (p < 0.0001), pT4 stage (p = 0.0004) and signet-ring histology (p = 0.0089) emerged as parameters more commonly associated with nodal metastasization. These findings shed new light on the biology of MSI-CRC and can be of help for the prognostic stratification of MSI-CRC patients.

Comparison of Short-term Results after Laparoscopic Complete Mesocolic Excision and Standard Colectomy for Right-Sided Colon Cancer: Analysis of a Western Center Cohort

Purpose

Laparoscopic complete mesocolic excision (CME) right colectomy is a technically demanding procedure infrequently employed in Western centers. This retrospective cohort study aims to analyze the safety of laparoscopic CME colectomy compared to standard colectomy for right-sided colon cancer in a Western series.

Methods

Prospectively collected data from 60 patients who underwent laparoscopic CME right colectomy were compared to the ones of 55 patients who underwent laparoscopic standard right colectomy.

Results

No differences in clinical characteristics were observed between the CME and standard right colectomy groups. No differences were demonstrated in terms of blood loss (P = 0.060), intraoperative complications (P = 1), conversion rate (P = 0.102), and operative time (P = 0.473). No deaths were observed in either group, while complication rate was 40.0% in the CME and 49.1% in the standard group (P = 0.353). Severe complications occurred in 10.0% vs. 9.1% (P = 0.842), redo surgery in 5.0% vs. 7.3% (P = 0.708), and unplanned readmission in 5.0% vs. 5.5% (P = 1) after CME and standard colectomy, respectively. A significant difference in favor of CME was observed in the total length of specimen (P < 0.001), proximal (P = 0.018), and distal margins (P = 0.037). The number of lymph nodes harvested was significantly higher in the CME group (27 vs. 22, P = 0.037).

Conclusion

In Western series, where patients have less favorable clinical characteristics, laparoscopic CME allows to obtain better quality surgical specimens and comparable short-term outcomes compared to standard right colectomy.

ICG fluorescence imaging in colorectal surgery: a snapshot from the ICRAL study group

Background

Fluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date.

Methods

This survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire.

Results

Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future.

Conclusion

The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

More Favorable Short and Long-Term Outcomes for Screen-Detected Colorectal Cancer Patients

Background

Screening significantly reduces mortality from colorectal cancer (CRC). Screen detected (SD) tumors associate with better prognosis, even at later stage, compared to non-screen detected (NSD) tumors. We aimed to evaluate the association between diagnostic modality (SD vs. NSD) and short- and long-term outcomes of patients undergoing surgery for CRC.

Materials and Methods

This retrospective cohort study involved patients aged 50–69 years, residing in Veneto, Italy, who underwent curative-intent surgery for CRC between 2006 and 2018. The clinical multi-institutional dataset was linked with the screening dataset in order to define diagnostic modality (SD vs. NSD). Short- and long-term outcomes were compared between the two groups.

Results

Of 1,360 patients included, 464 were SD (34.1%) and 896 NSD (65.9%). Patients with a SD CRC were more likely to have less comorbidities (p = 0.013), lower ASA score (p = 0.001), tumors located in the proximal colon (p = 0.0018) and earlier stage at diagnosis (p < 0.0001). NSD patients were found to have more aggressive disease at diagnosis, higher complication rate and higher readmission rate due to surgical complications (all p < 0.05). NSD patients had a significantly lower Disease Free Survival and Overall Survival (all p < 0.0001), even after adjusting by demographic, clinic-pathological, tumor, and treatment characteristics.

Conclusions

SD tumors were associated with better long-term outcomes, even after multiple adjustments. Our results confirm the advantages for the target population to participate in the screening programs and comply with their therapeutic pathways.

Laparoscopic intragastric resection of gastric synovial sarcoma: report of the first ever case with video demonstration

BACKGROUND

Synovial sarcoma (SS) is a rare soft tissue tumor. Among different anatomical locations where it can be found, gastric localization is a very uncommon one. Based on soft tissue sarcoma guidelines, complete tumor excision is considered the main treatment approach. Depending on size and localization of the tumor, both wedge and major gastric resections have been performed in the past for the treatment of this condition.

CASE PRESENTATION

We present the case of a 43-year-old woman who underwent a laparoscopic intragastric excision of a gastric 10-mm SS located nearby the esophagogastric junction. Pathology examination confirmed the presence of a SS. The resected specimen confirmed margin-free excision of a monophasic spindle cell neoplasm invading the submucosa and presenting the rearrangement of SS18 gene at fluorescence in situ hybridization (FISH). No adjuvant treatment was offered, and 18 months after surgery, the patient was alive and disease free.

CONCLUSIONS

This represents the first case reported in literature of a laparoscopic intragastric resection for a gastric SS. This approach allowed to obtain a full thickness radical tumor resection with the advantages of minimally invasive and organ preserving surgery.

Endoscopic Ultrasound Through-the-Needle Biopsy for the Diagnosis of an Abdominal Bronchogenic Cyst

A 57-year-old woman with epigastric pain was diagnosed with a 6-cm abdominal cystic lesion of unclear origin on cross-sectional imaging. Endoscopic ultrasound (EUS) demonstrated a unilocular cyst located between the pancreas, gastric wall, and left adrenal gland, with a regular wall filled with dense fluid with multiple hyperechoic floating spots. A 19-G needle was used to puncture the cyst, but no fluid could be aspirated. Therefore, EUS-guided through-the-needle biopsy (EUS-TTNB) was performed. Histological analysis of the retrieved fragments revealed a fibrous wall lined by "respiratory-type" epithelium with ciliated columnar cells, consistent with the diagnosis of a bronchogenic cyst. Laparoscopic excision was performed, and the diagnosis was confirmed based on the findings of the surgical specimen. Abdominal bronchogenic cysts are extremely uncommon, and a definitive diagnosis is commonly obtained after the examination of surgical specimens due to the lack of pathognomonic findings on cross-sectional imaging and poor cellularity on EUS-guided fine-needle aspiration cytology. EUS-TTNB is useful for establishing a preoperative histological diagnosis, thus supporting the decision-making process.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Clinical Significance of Preoperative Inflammatory Markers in Prediction of Prognosis in Node-Negative Colon Cancer: Correlation between Neutrophil-to-Lymphocyte Ratio and Poorly Differentiated Clusters

Although stage I and II colon cancers (CC) generally show a very good prognosis, a small proportion of these patients dies from recurrent disease. The identification of high-risk patients, who may benefit from adjuvant chemotherapy, becomes therefore essential. We retrospectively evaluated 107 cases of stage I (n = 28, 26.2%) and II (n = 79, 73.8%) CC for correlations among preoperative inflammatory markers, histopathological factors and long-term prognosis. A neutrophil-to-lymphocyte ratio greater than 3 (H-NLR) and a platelet-to-lymphocyte ratio greater than 150 (H-PLR) were significantly associated with the presence of poorly differentiated clusters (PDC) (p = 0.007 and p = 0.039, respectively). In addition, H-NLR and PDC proved to be significant and independent survival prognosticators for overall survival (OS; p = 0.007 and p < 0.001, respectively), while PDC was the only significant prognostic factor for cancer-specific survival (CSS; p < 0.001,). Finally, the combination of H-NLR and PDC allowed an optimal stratification of OS and CSS in our cohort, suggesting a potential role in clinical practice for the identification of high-risk patients with stage I and II CC.

Clinical-Pathologic Characteristics and Long-term Outcomes of Left Flexure Colonic Cancer: A Retrospective Analysis of an International Multicenter Cohort

BACKGROUND

Colorectal cancer seldom presents at the splenic flexure. Small series on left flexure tumors reported a high occurrence of negative prognostic factors called into question as causes of poor prognosis. However, because of the small number of cases, no definite conclusions can be drawn.

OBJECTIVE

The aim of this study was to compare clinical-pathologic characteristics and short- and long-term outcomes of left flexure tumors with other colonic locations.

DESIGN

This was a retrospective analysis of consecutive patients who underwent surgery for tumors at the splenic flexure. Each tumor was paired in a 1 to 1 fashion with a right-sided and sigmoid tumor.

SETTINGS

The study was conducted in 10 international centers.

PATIENTS

A total of 641 patients with left flexure tumors were included in the study.

MAIN OUTCOME MEASURES

Overall survival and cancer-specific survival were measured.

RESULTS

Left flexure tumors presented more frequently with stenosis (30.5%; p < 0.001), with lesions infiltrating beyond the serosa (21.9%; p = 0.001) and with a high rate of mucinous histology (8.8%; p = 0.001). Looking at long-term prognosis, no differences were observed among the 3 groups, both considering overall and cancer-specific survival. However, left flexure tumors recurred more frequently as peritoneal carcinomatosis (20.6%; p < 0.001).

LIMITATIONS

This study was limited because of its retrospective nature.

CONCLUSIONS

Although left flexure tumors display several negative prognostic factors, they are not characterized by a worse prognosis compared with other colon cancer locations. See Video Abstract at http://links.lww.com/DCR/B395. CARACTERÍSTICAS CLÍNICO-PATOLÓGICAS Y RESULTADOS A LARGO PLAZO DEL CÁNCER DE COLON DE ÁNGULO IZQUIERDO: UN ANÁLISIS RETROSPECTIVO DE UNA COHORTE MULTICÉNTRICA INTERNACIONAL: El cáncer colorrectal rara vez se presenta en el ángulo esplénico. Pequeñas series sobre tumores de ángulo izquierdo informaron una alta incidencia de factores pronósticos negativos cuestionados como causas de mal pronóstico. Sin embargo, debido al pequeño número de casos, no se pueden sacar conclusiones definitivas.El objetivo de este estudio fue comparar las características clínico-patológicas, los resultados a corto y largo plazo de los tumores de ángulo izquierdo con otras ubicaciones de colon.Análisis retrospectivo de pacientes consecutivos que se sometieron a cirugía por tumores en el ángulo esplénico. Cada tumor se emparejó de forma individual con un tumor del lado derecho y sigmoide.El estudio se realizó en 10 centros internacionales.Se incluyeron en el estudio un total de 641 pacientes con tumores del ángulo izquierdo.Supervivencia general y específica del cáncerLos tumores de ángulo izquierda se presentaron con mayor frecuencia con estenosis (30.5%, p <0.001), con lesiones infiltradas más allá de la serosa (21.9%, p = 0.001), y con una alta tasa de histología mucinosa (8.8%, p = 0.001). En cuanto al pronóstico a largo plazo, no se observaron diferencias entre los tres grupos, considerando la supervivencia general y específica del cáncer. Sin embargo, los tumores de ángulo izquierdo recurrieron con mayor frecuencia como carcinomatosis peritoneal (20,6%; p <0,001).Este estudio fue limitado debido a su naturaleza retrospectiva.Aunque los tumores de ángulo izquierdo muestran varios factores pronósticos negativos, no se caracterizan por un peor pronóstico en comparación con otras ubicaciones de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B395.

Outcomes of vascular resection associated with curative intent hepatectomy for intrahepatic cholangiocarcinoma

BACKGROUND AND AIMS

We aimed to investigate the impact of vascular resection (VR) on postoperative outcomes and survival of patients undergoing hepatectomy for intrahepatic cholangiocarcinoma (ICC).

METHODS

A retrospective analysis of a multi-institutional series of 270 patients with resected ICC was carried out. Patients were divided into three groups: portal vein VR (PVR), inferior vena cava VR (CVR) and no VR (NVR). Univariate and multivariate analysis were applied to define the impact of VR on postoperative outcomes and survival.

RESULTS

Thirty-one patients (11.5%) underwent VR: 15 (5.6%) to PVR and 16 (5.9%) to CVR. R0 resection rates were 73.6% in NVR, 73.3% of PVR and 68.8% in CVR. The postoperative mortality rate was increased in VR groups: 2.5% in NVR, 6.7% in PVR and 12.5% in CVR. The 5-years overall survival (OS) rates progressively decreased from 38.4% in NVR, to 30.1% in CVR and to 22.2% in PVR, p = 0.030. However, multivariable analysis did not confirm an association between VR and prognosis. The following prognostic factors were identified: size ≥50 mm, patterns of distribution of hepatic nodules (single, satellites or multifocal), lymph-node metastases (N1) and R1 resections. In the VR group the 5-years OS rate in patients without lymph-node metastases undergoing R0 resection (VRR0N0) was 44.4%, while in N1 patients undergoing R1 resection was 20% (p < 0.001).

CONCLUSION

Vascular resection (PVR and CVR) is associated with higher operative risk, but seems to be justified by the good survival results, especially in patients without other negative prognostic factors (R0N0 resections).

Analgesic efficacy of pre-emptive local wound infiltration plus laparoscopic-assisted transversus abdominis plane block versus wound infiltration in patients undergoing laparoscopic colorectal resection: results from a randomized, multicenter, single-blind, non-inferiority trial

BACKGROUND

Transversus abdominis plane (TAP) block is considered a reliable locoregional technique for pain control after laparoscopic colorectal surgery. However, no clear benefit of TAP block over wound infiltration has been demonstrated by the current literature. This multicenter randomized clinical trial tested the non-inferiority of wound infiltration (WI) compared to WI plus laparoscopic-assisted TAP block (L-TAP).

METHODS

All patients with colorectal cancer and diverticular disease scheduled for laparoscopic resection at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, Verona, Italy and at the Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University, Daegu, Korea, between April 2018 and March 2019 were considered for the trial. Patients were randomly allocated to either the WI group or the WI plus L-TAP group in a 1:1 allocation ratio. In total, 108 patients entered the study and 102 patients were analyzed; 50 patients received WI plus L-TAP and 52 patients received WI. The primary end point was the efficacy in pain control at 6 h measured according to Numeric Rating Scale (NRS). Secondary aims evaluated pain control at 12, 24, 48 and 72 h and other short-term results related to pain management.

RESULTS

Estimation of pain intensity at 6 h was comparable between the two groups (p = 0.16) with a mean (95% CI) difference in pain scores of 0.94 (- 0.13 to 2.02). No differences in pain scores were observed at other interval times or considering analgesic consumption, return of bowel function, postoperative complications and length of hospital stay.

CONCLUSION

This study suggests that adding TAP block to WI does not affect pain control, amount of analgesics and other short-term outcomes.

TRIAL REGISTRATION

NCT03376048 ( https://www.clinicaltrials.gov ).

Colorectal surgery in Italy during the Covid19 outbreak: a survey from the iCral study group

BACKGROUND

The COVID19 pandemic had a deep impact on healthcare facilities in Italy, with profound reorganization of surgical activities. The Italian ColoRectal Anastomotic Leakage (iCral) study group collecting 43 Italian surgical centers experienced in colorectal surgery from multiple regions performed a quick survey to make a snapshot of the current situation.

METHODS

A 25-items questionnaire was sent to the 43 principal investigators of the iCral study group, with questions regarding qualitative and quantitative aspects of the surgical activity before and after the COVID19 outbreak.

RESULTS

Two-thirds of the centers were involved in the treatment of COVID19 cases. Intensive care units (ICU) beds were partially or totally reallocated for the treatment of COVID19 cases in 72% of the hospitals. Elective colorectal surgery for malignancy was stopped or delayed in nearly 30% of the centers, with less than 20% of them still scheduling elective colorectal resections for frail and comorbid patients needing postoperative ICU care. A significant reduction of the number of colorectal resections during the time span from January to March 2020 was recorded, with significant delay in treatment in more than 50% of the centers.

DISCUSSION

Our survey confirms that COVID19 outbreak is severely affecting the activity of colorectal surgery centers participating to iCral study group. This could impact the activity of surgical centers for many months after the end of the emergency.

Impact of visceral obesity and sarcobesity on surgical outcomes and recovery after laparoscopic resection for colorectal cancer

BACKGROUND & AIMS

Studies analyzing the impact of visceral fat excess on surgical outcomes after resection for colorectal cancer (CRC) have yielded conflicting results. Visceral obesity (VO) and sarcobesity (SO) have been recently addressed as risk factors for poor short-term results while no data are available for recovery goals after surgery. No data are available on the protective effect of ERAS in VO and SO patients. The aim of this study was to assess clinical implications of computed tomography (CT) assessed VO and SO on surgical and recovery outcomes after minimally invasive resection for CRC before and after ERAS protocol implementation.

METHODS

Visceral adipose tissue (VAT) and skeletal muscle area (SMA) were retrospectively assessed using pre-operative CT studies of 261 patients who underwent laparoscopic resection for CRC between January 2012 and April 2019; ERAS protocol was adopted in 160 patients operated on after March 2014. Patients' surgical and recovery outcomes were compared according to BMI categories, VO and SO which was defined using the VAT/SMA ratio (Sarcobesity Index). Predictive factors for poor surgical and recovery outcomes were evaluated by univariate and multivariate analyses.

RESULTS

Of the 261 patients, 12.6% were BMI obese while 68.6% presented visceral obesity. BMI was not associated to any of the outcomes considered. No differences in intra-operative results were found except for a lower number of retrieved lymph nodes both in VO and SO patients. While VO showed no impact on post-operative course, SO resulted an independent risk factor for cardiac complications and prolonged post-operative ileus (PPOI) at logistic regression analysis. Furthermore, sarcobese patients showed delayed recovery after surgery. Patients enrolled in the ERAS protocol showed improved recovery outcomes for both VO and SO groups, although ERAS did not result to be a protective factor for cardiac complications and PPOI.

CONCLUSIONS

A high Sarcobesity Index is a risk factor for developing cardiac complications and PPOI after laparoscopic resection for CRC. A reduced number of lymph nodes retrieved is associated to VO and SO. These conditions should then be considered in clinical practice for the risk of down staging the N stage. Effect of VO and SO on recovery items after surgery should be further investigated. ERAS protocol application should be implemented to improve recovery outcomes in VO and SO patients undergoing laparoscopic colorectal resection.

Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study

INTRODUCTION

Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach.

MATERIALS AND METHODS

This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery.

RESULTS

The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001).

CONCLUSIONS

According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Multigene mutational profiling of biliary tract cancer is related to the pattern of recurrence in surgically resected patients

The aim of the present study was to investigate the relationship between the mutational gene profile and recurrence in biliary tract cancers (BTC). A total of 103 specimens of patients with BTC, who underwent curative surgery in a single tertiary HPB surgery referral center from 1990 to 2012, were assessed for mutational status in 52 cancer-related genes. Considering the different types of BTC, the 5-year recurrence-free survival (RFS) rate was 16.7% (median RFS 7 months) in gallbladder cancer, 42.9% (median RFS 26.4 months) in intrahepatic cholangiocarcinoma, and 19.7% (median RFS 16.5 months) in perihilar cholangiocarcinoma, p = 0.166. At the multivariate analysis including clinical, pathological, and molecular features, the factors independently related to RFS were radicality of surgery (OR 2.050, CI 1.104-3.807, p = 0.023), LN status (OR 1.835, CI 1.006-3.348, p = 0.048), mutational status of ARID1A (OR 2.566, CI 1.174-5.608, p = 0.018), and TP53 (OR 2.805, CI 4.432-5.496, p = 0.003). ARID1A mutation was associated with a local and systemic recurrence in the 43% and 29% of cases, respectively; and TP53 mutation was associated with a local and systemic recurrence in the 29% and 41% of cases. Moreover, TP53 was most commonly mutated in tumor of patients with early recurrence, p = 0.044. ARID1A and TP53 mutations seem to be related to poor outcome after surgery and may be considered molecular predictors of the biological aggressiveness in BTC.