IMMUNOREACT 7: Regular aspirin use is associated with immune surveillance activation in colorectal cancer.

BACKGROUND: Long-term daily use of aspirin reduces incidence and mortality due to colorectal cancer (CRC). This study aimed to analyze the effect of aspirin on the tumor microenvironment, systemic immunity, and on the healthy mucosa surrounding cancer. METHODS: Patients with a diagnosis of CRC operated on from 2015 to 2019 were retrospectively analyzed (METACCRE cohort). Expression of mRNA of immune surveillance-related genes (PD-L1, CD80, CD86, HLA I, and HLA II) in CRC primary cells treated with aspirin were extracted from Gene Expression Omnibus-deposited public database (GSE76583). The experiment was replicated in cell lines. The mucosal immune microenvironment of a subgroup of patients participating in the IMMUNOREACT1 (ClinicalTrials.gov NCT04915326) project was analyzed with immunohistochemistry and flow cytometry. RESULTS: In the METACCRE Cohort, 12% of 238 patients analyzed were aspirin users. Nodal metastasis was significantly less frequent (p = .008) and tumor-infiltrating lymphocyte infiltration was higher (p = .02) among aspirin users. In the CRC primary cells and selected cell lines, CD80 mRNA expression was increased following aspirin treatment (p = .001). In the healthy mucosa surrounding rectal cancer, the ratio of CD8/CD3 and epithelial cells expressing CD80 was higher in aspirin users (p = .027 and p = .034, respectively). CONCLUSIONS: These data suggested that regular aspirin use may have an active role in enhancing immunosurveillance against CRC.

Complete mesocolic excision versus conventional hemicolectomy in patients with right colon cancer: a systematic review and meta-analysis.

PURPOSE: Complete mesocolic excision (CME) has introduced a promising surgical approach for treatment of right colon cancer. However, benefits of CME are still a matter of debate. We conducted a systematic review and meta-analysis to assess safety and long-term outcomes of CME versus conventional right hemicolectomy (CRH). METHODS: We systematically searched MEDLINE, the Cochrane Database of Systematic Reviews, Scopus, Web of Science, and Embase for retrieving studies comparing CME with CRH in right colon cancer. After data extraction from the included studies, meta-analysis was performed to compare postoperative complications, anastomotic leakage, 30-day mortality, number of lymph node yield, disease-free survival (DFS), and overall survival (OS). RESULTS: Eight studies met the inclusion criteria with a total of 1871 patients enrolled. No difference was observed in postoperative complications (OR 1.13, 95% CI 0.88-1.47, p = 0.34). CME was associated with significantly higher number of lymph nodes retrieved (MD 9.17, CI 4.67-13.68, p < 0.001). CME also improved 3-year OS (OR 1.57, 95% CI 1.17-2.11, p = 0.003), 5-year OS (OR 1.41, 95% CI 1.06-1.89, p = 0.02), and 5-year DFS (OR 1.99, 95% CI 1.29-3.07, p = 0.002). A sub-group analysis for patients with stage III colon cancer showed no significant impact of CME on 3-year and 5-year OS (OR 2.47, 95% CI 0.86-7.06, p = 0.09; OR 1.23, 95% CI 0.78-1.94, p = 0.38). CONCLUSION: Although with limited evidence, CME shows similar postoperative complication rates and an improved survival outcome compared with CRH.

A Potentially Misleading Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) typically presents in patients with a chronic liver disease and rarely develops in healthy liver, especially within an accessory liver lobe. We present a case of a healthy 64-years-old woman who showed a serum alpha-fetoprotein (AFP) value of 226.3 µg/mL during a screening blood test. Past medical history was negative for chronic liver disease or cirrhosis. Intraoperative finding was an ovaloid mass connected with the second hepatic segment by a thin pedicle of hepatic tissue. Lesion was safely resected by laparoscopic approach. Histopathology analysis showed a trabecular hepatocellular carcinoma. After a 6-month follow up, there was no evidence of recurrent disease. This case report showed how serum AFP remains a highly sensitive marker, although the presentation of HCC was unusual. To our knowledge, this is the second case reported in the literature.

Extra-gastrointestinal stromal tumor of the pancreas: case report and review of the literature.

Primary extra-gastrointestinal stromal tumor (EGISTs) arising in the pancreas is extremely rare: only 20 cases have previously been reported in the English literature from 2000 to 2013. We reported a case of EGIST of the pancreas in a 69-year-old woman who presented with abdominal pain and with a solid, heterogeneously enhancing neoplasm in the uncinate process of the pancreas, revealed preoperatively by an abdominal computed tomography scan. A diagnosis of neuroendocrine tumor was suggested. Positron emission tomography with 68Ga-DOTATOC did not show pathological accumulation of the tracer in the pancreas. The patient underwent enucleation, under ultrasonic guidance, of the pancreatic tumor that emerged to the surface of the pancreas. Histopathology and immunohistochemical examination confirmed the final diagnosis of EGIST of the pancreas (CD117+), with one mitosis per 50 high-power fields. Although rarely, GIST can involve the pancreas as a primary site, and this tumor should be considered in the differential diagnosis of pancreatic neoplasms.

Clinical benefits of symptom resolution after palliative surgery in advanced cancer: A single-center experience.

BACKGROUND: Palliative surgery (PS) is defined as any surgical procedure aimed at improving quality of life or relieving symptoms caused by an advanced or metastatic cancer. The involvement of patients, caregivers, and other professional figures is crucial for obtaining optimal symptom relief and avoiding complications. This study aims to evaluate the short-term outcome and related factors in patients undergoing PS. PATIENTS AND METHODS: A retrospective analysis was performed in consecutive patients who underwent palliative gastrointestinal surgery at our surgical unit during the period June 2018 to May 2023. Demographic, clinical, pathological and follow-up data were collected from a prospectively maintained department database. The main outcomes were complications, symptoms palliation, symptoms recurrence and return to systemic chemotherapy. Standard statistical analysis was performed. RESULTS: During the study period, 127 patients underwent palliative surgery. The Clavien-Dindo 3-5 complication rate and mortality rate were 19.7 % and 6 %, respectively. The resolution of symptoms was achieved in 109 patients (89 %). Successful symptom palliation was significantly related to the possibility of returning to systemic chemotherapy (SC) (OR 9.30 95 % CI 0.1.83-47.18, p 0.007). The only factor related to survival in multivariate analysis was the return to systemic chemotherapy (HR 0.25 95 % CI 0.15-0.42 0.001). CONCLUSION: PS in selected patients is effective for symptom resolution and improving overall survival, if the result is making anticancer therapy possible. Prospective data collection is in any case warranted in every institution performing PS for the purpose of monitoring appropriateness and quality of surgical care.

Role of Immune Microenvironment in Pancreatic Ductal Adenocarcinoma: Could It Be Considered a Predictor of Prognosis?

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is characterized by a highly immunosuppressive tumor microenvironment (TME). The aim of this study is to determine the potential significant TME immune markers of long-term survival. METHODS: We retrospectively included patients with a diagnosis of resectable PDAC having undergone upfront surgery. Immunohistochemical (IHC) staining using tissue microarray for PD-L1, CD3, CD4, CD8, FOXP3, CD20, iNOS and CD163 was performed in order to characterize the TME. The primary endpoint was long-term survival, defined as the Overall Survival > 24 months from surgery. RESULTS: A total of 38 consecutive patients were included, and 14 (36%) of them were long-term survivors. Long-term survivors showed a higher density of CD8+ lymphocytes intra- and peri-acinar (p = 0.08), and a higher CD8/FOXP3 intra- and peri-tumoral ratio (p = 0.05). A low density of intra- and peri-tumoral FOXP3 infiltration is a good predictor of long-term survival (p = 0.04). A significant association of the low density of intra- and peri-tumoral tumor-associated macrophages (TAMs) iNOS+ with long-term survival was detected (p = 0.04). CONCLUSIONS: Despite the retrospective nature and small sample size, our study showed that the high infiltration of CD8+ lymphocytes and low infiltration of FOXP3+ and TAMs iNOS+ are predictors of good prognosis. A preoperative assessment of these potential immune markers could be useful and determinant in the staging process and in PDAC management.

Exploring a novel composite method using non-contrast EUS enhanced microvascular imaging and cyst fluid analysis to differentiate pancreatic cystic lesions.

BACKGROUND AND AIMS: Differentiating pancreatic cystic lesions (PCLs) remains a diagnostic challenge. The use of high-definition imaging modalities which detect tumor microvasculature have been described in solid lesions. We aim to evaluate the usefulness of cystic microvasculature when used in combination with cyst fluid biochemistry to differentiate PCLs. METHODS: We retrospectively analyzed 110 consecutive patients with PCLs from 2 Italian Hospitals who underwent EUS with H-Flow and EUS fine needle aspiration to obtain cystic fluid. The accuracy of fluid biomarkers was evaluated against morphological features on radiology and EUS. Gold standard for diagnosis was surgical resection. A clinical and radiological follow up was applied in those patients who were not resected because not surgical indication and no signs of malignancy were shown. RESULTS: Of 110 patients, 65 were diagnosed with a mucinous cyst, 41 with a non-mucinous cyst, and 4 with an undetermined cyst. Fluid analysis alone yielded 76.7% sensitivity, 56.7% specificity, 77.8 positive predictive value (PPV), 55.3 negative predictive value (NPV) and 56% accuracy in diagnosing pancreatic cysts alone. Our composite method yielded 97.3% sensitivity, 77.1% specificity, 90.1% PPV, 93.1% NPV, 73.2% accuracy. CONCLUSIONS: This new composite could be applied to the holistic approach of combining cyst morphology, vascularity, and fluid analysis alongside endoscopist expertise.

The impact of gender on outcome after infrainguinal arterial reconstructions for peripheral occlusive disease.

OBJECTIVE: The role of gender on the outcome of infrainguinal arterial revascularization (IAR) for peripheral arterial occlusive disease remains uncertain. This study analyzed the outcome of IARs performed over 15 years, stratifying the results by sex. METHODS: Details of consecutive patients undergoing primary IAR for peripheral arterial occlusive disease from 1995 to 2009 at our institution were prospectively stored in a vascular registry. Demographics, risk factors, indications for surgery, inflow sources, outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination supplemented with duplex scans and ankle-brachial index measurements in all patients at discharge, 30 days, 6 months, and every 6 months thereafter. End points of the study, ie, patency, limb salvage, and survival rates, were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance. RESULTS: Our sample consisted of 1459 IARs performed in 1333 patients, comprising 496 women (37.2%; 531 IARs), who were a mean 3 years older than the men (74 vs 71 years; P < .001) and had a higher incidence of diabetes mellitus (52% vs 46%; P = .03) and surgery for limb salvage (91% vs 87%; P = .02). An autogenous vein conduit (great or small saphenous, or both, spliced, arm, or composite veins) was used in 87% of the IARs. No deaths occurred perioperatively (30 days). The major and minor complication rates were comparable between men and women. At 10 years, the primary patency rate was 47% in women vs 49% in men (P = .67), the assisted primary patency rate was, respectively, 53% vs 50% (P = .69), the secondary patency rate was 61% vs 61% (P = .66), limb salvage rate was 93% vs 91% (P = .54), and survival rate was 43% vs 49% (P = .65). Stratifying by type of conduit revealed no differences in patency or limb salvage rates. CONCLUSIONS: Despite an older age and more advanced stages of disease on presentation in women, IAR performed in women can achieve patency and limb salvage rates statistically no different from those recorded in their male counterparts, supporting the conviction that sex per se does not influence the outcome of lower extremity revascularization.

Could Total Neoadjuvant Therapy Followed by Surgical Resection Be the New Standard of Care in Pancreatic Cancer? A Systematic Review and Meta-Analysis.

BACKGROUND: Total neoadjuvant therapy (TNT), intended as induction chemotherapy (IC) followed by radio-chemotherapy (RCT), has been taking hold in the treatment of pancreatic ductal adenocarcinoma (PDAC). The aim of this review is to summarize the available evidence on the role of TNT followed by curative surgery. METHODS: Eligible studies were those reporting on patients with PDAC undergoing curative surgery after TNT. The primary endpoint was overall survival (OS). RESULTS: A total of 1080 patients with PDAC who had undergone TNT were analyzed. The most common IC regimen was Gemcitabine (N 620, 57%). Toxicity during IC varied from 14% to 51%. Disease progression during IC varied from 3% to 25%. 607 (62%) patients underwent curative surgery after IC + CRT. In meta-analysis, the available data on lymph node metastases radicality and 2 years OS had better results in favor of TNT groups (OR 1.77, 95% CI 1.20-2.60, p = 0.004 and OR 2.03, 95% CI 1.19-3.47, p = 0.01 and OR 1.64, CI 1.09-2.47, p = 0.02, respectively). CONCLUSIONS: Despite the heterogeneity of the studies, different selection criteria, and non-negligible drop-out rate, TNT demonstrated a potential superiority to NAT without CRT in oncological and pathological outcomes, even if the main differences seem to depend on the IC regimen.

Impact of Microscopic Confirmation on Therapeutic Management of Pancreatic Cancer Patients: Lessons from an Italian Regional Tumor Registry.

Background: Incidence of pancreatic cancer (PC) is increasing worldwide and is set to become the second leading cause of cancer-related death in 2040 with a poor 5-year overall survival (OS). The aim of this study was to analyze the impact of microscopic diagnosis of PC (MiDPC) on diagnostic−therapeutic management and outcome. Methods: The Veneto region (north-eastern Italy) has been covered by a cancer registry (CR) since 1987. Clinical and oncological data about all cases of PC in the Veneto region from 1987 were extracted from the Veneto CR database. Results: In 2018, 1340 incident cases of PC in the Veneto population were registered (4.1% of all malignant tumors), with an increasing trend in females and stable incidence in males. Five-year OS in patients with PC was 8%. The percentage of MiDPC increased from 44% in 2010 to 60% in 2018 (p = 0.001). MiDPC was higher among patients aged < 75 years old (84.4%) compared to those aged ≥75 years old (38.9%), p = 0.001. Between 2010 and 2018, a significant increase in biopsy on the primary neoplasm (24.9% vs. 13%, p < 0.001) was reported. Patients with MiDPC had higher 5-year survival than patients with no MiDPC (12.9% vs. 1.2%, p < 0.001). Conclusions: The implementation of MiDPC was essential to improve diagnostic−therapeutic pathways and consequently the survival of PC patients.

Predictors of neck bleeding after eversion carotid endarterectomy.

OBJECTIVE: The aim of this study was to identify predictors for neck bleeding after eversion carotid endarterectomy (eCEA). METHODS: A prospectively compiled computerized database of all primary eCEAs performed at a tertiary referral center between September 1998 and December 2009 was analyzed. The end point was any neck bleeding after eCEA. End point predictors were identified by univariate analysis. RESULTS: Of 1458 eCEAs performed by the same surgeon on 1294 patients under general anesthesia with continuous electroencephalographic monitoring and selective shunting, there were five major and three minor perioperative strokes (0.5%), and no deaths. Neck bleeding after eCEA occurred in 120 cases (8.2%), of which 69 (4.7%) needed re-exploration. Univariate analysis (odds ratio [95% confidence interval]) identified preoperative antiplatelet treatment with clopidogrel (1.77 [1.20-2.62], P = .004), particularly when continued to the day before CEA (3.84 [2.01-7.33], P < .001), and postoperative hypertension (9.44 [6.34-14.06], P < .001) as risk factors for neck bleeding in general and for neck bleeding requiring re-exploration (4.50 [1.85-10.89], P = .001; 15.27 [2.08-104.43], P = .006, and 2.44 [1.12-5.30], P = .02, respectively). An increased risk of neck bleeding in general was associated with clopidogrel plus acetylsalicylic acid (12.00 [2.59-56.78], P = .005), acetylsalicylic acid alone (4.37 [1.99-9.57], P < .001), and ticlopidine (2.49 [1.10-5.63], P = .02) only when they were continued to the day before CEA. No neck bleeding was associated with preoperative treatment with dipyridamole or warfarin, or no medication. No further complications occurred in the patients who underwent re-exploration. CONCLUSIONS: The results of this single-center university hospital study show that neck bleeding after CEA is relatively common but is not associated with an increased risk of stroke or death. Preoperative treatment with clopidogrel, particularly when it is continued to the day before surgery, and postoperative arterial hypertension seem to be associated with a higher risk of neck bleeding after CEA, requiring re-exploration in most cases. Other antiplatelet agents appear to be associated with an increased risk of postoperative neck bleeding only if they are continued to the day before CEA. Larger studies are warranted to confirm our findings and prevent this feared surgical complication.

Timing and pharmacological support in the surgical treatment of multiple perianal fistulas in Crohn's disease.

We present a case report on the management of a young woman affected by Crohn's Disease ever since childhood, complicated by complex, multiple perianal fistulas. In literature, there is increasing evidence to support the treatment of perianal fistulas using a combined association of medical and surgical strategies. In the case of our patient, the choice of surgery in association with pharmacological treatment was supported by the consideration of the fact that intervening during a quiescent phase of the disease, from the symptomatic, clinical-biohumoral and endoscopic standpoint, would have reduced the risk of complications and thus promoted healing. (www.actabiomedica.it).

Impact on Quality of Life of Seton Placing in Perianal Crohn's Disease.

INTRODUCTION: Often, in perineal Crohn's disease (CD), a seton is placed to guarantee a constant drainage and prevent septic complication while biologic therapy is ongoing. This study aimed to assess the long-term quality of life after surgery for perineal CD in relation to seton placing. PATIENTS AND METHODS: Data of 65 consecutive patients with CD and non-CD operated on from 2014 to 2019 for perianal fistula or abscess were retrieved. Forty-three had CD and 14 of them had a seton placed during surgery and they kept it on while they had anti-TNF-alpha therapy. Patients were interviewed with the Cleveland Global Quality of Life (CGQL) and SF-12 quality of life questionnaires. Disease activity was defined as Harvey-Bradshaw Index (HBI) and Perianal Disease Activity Index (PDAI). Comparisons between groups were carried out with the nonparametric tests, and multiple regression models were used to assess predictors of quality of life. RESULTS: The total CGQL score and SF-12 mental component score (MCS) were significantly higher (and thus better) in the seton group than in patients treated without seton. On the contrary, SF-12 physical component score (PCS) was not different between the two groups. HBI was significantly better in patients in the seton group. At multivariate analysis, seton placement and HBI were confirmed to be independent predictors of long-term SF-12 MCS whereas only HBI confirmed to be a predictor of total CGQL score. CONCLUSIONS: Seton placing during anti-TNF-alpha therapy is independently associated with a better MCS. Unexpectedly, this device, instead of to cause psychological distress, seems to assure patients during their biologic therapy providing psychological benefit beyond the mere medical effect.

Clinical and predictive value of blood lactate levels during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): a comparative analysis.

Postoperative outcome after cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is strongly related to surgical and anesthesiologic expertise. This study aims to evaluate the clinical significance and prognostic value of lactate levels (LL) measured during CRS-HIPEC on postoperative outcome compared to similar major surgical procedures. Patients who were treated between January and September 2019 at our Institute and met the inclusion criteria were selected. Patients were divided into three groups: group 1: patients who underwent major surgical procedures; group 2: patients who underwent CRS without HIPEC; group 3: patients who underwent CRS with HIPEC. Intraoperative LL were analyzed and correlated with surgical procedure and postoperative outcome. We observed a significant increase of LL during surgical/CRS phase (group 1: p = 0.0001; group 2: p = 0.001; group 3: p = 0.057), rather than during the HIPEC phase in group 3 (p = ns). In patients undergoing CRS and peritonectomies, the mean LL were significantly higher compared to group 1 (p = 0.05). Although not statistically significant, the complication rate was higher in patients with end-CRS lactate values > 2 mMol/l, especially in the group undergoing CRS plus HIPEC. Our pilot study shows that higher LL during peritoneal cancer surgery are expected compared to major surgical procedures. Cytoreductive phase, rather than HIPEC, is related to an increase of LL. The role of LL as an early marker of postoperative complications after CRS-HIPEC should be further verified in properly designed studies.

Predictors of electroencephalographic changes needing shunting during carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, hence various cerebral protection strategies, including pharmacological management and routine or selective shunting, are commonly available. This study aimed to analyze the results of CEA with intraoperative electroencephalographic (EEG) monitoring to identify factors associated with EEG changes consistent with cerebral ischemia which needed shunting. METHODS: A prospectively compiled, computerized database of all primary CEAs performed at our institution with EEG monitoring for symptomatic or asymptomatic severe carotid lesions between January 1990 and June 2009 was analyzed. RESULTS: In all, 1,914 CEA procedures were performed on 1,696 patients, of which 218 had staged bilateral CEAs. EEG changes were recorded in 392 patients (20.5%), but a shunt was inserted during 312 CEA procedures (16.3%). Multivariate analysis showed that a symptomatic presentation (odds ratio [OR], 1.37; 95% confidence intervals [CI], 1.07-1.76; p = 0.012), prior stroke (OR, 2.28; 95% CI, 1.66-3.13; p < 0.001), contralateral carotid occlusion (OR, 2.14; 95% CI, 1.18-3.91; p = 0.019), and moderate (<80%) ipsilateral carotid disease (OR, 1.95; 95% CI, 1.08-3.52; p = 0.033) predicted the need for shunting. CONCLUSIONS: EEG was an excellent detector of cerebral ischemia and a valuable tool in guiding the need for shunting. Patients who were symptomatic or had a history of stroke, a contralateral carotid occlusion, or an ipsilateral moderate carotid stenosis were more prone to EEG changes consistent with cerebral ischemia. Surgeons should consider EEG changes during clamping as an effective criterion for selective shunting.

Laparoscopic Ventral Rectopexy for Obstructed Defecation: Functional Results and Quality of Life.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal and external rectal prolapse with obstructed defecation syndrome (ODS) and/or fecal incontinence. The aim of our study was to analyze functional outcome and quality of life (Health-Related Quality of Life) after LVR for symptomatic internal prolapse and/or rectocele with ODS. METHODS: Prospectively collected data on LVR for internal rectal prolapse were analyzed in 50 consecutive female patients operated between January 2011 and December 2018. In all cases, we performed a LVR according to the D'Hoore technique. Patients had ODS and internal rectal prolapse (grade 3 or 4) confirmed at the defecogram study. We registered only 1 major complication that required surgical treatment (Clavien-Dindo IIIb). The median hospital stay was 4 days [interquartile range (IQR): 2 to 5 d]. Functional results were measured with the Wexner Constipation Score and the 36-Item Short-Form Health Survey, and were analyzed before surgery and after 3, 6, or 12 months. RESULTS: After a median follow-up of 16.5 months (IQR: 10 to 44.25 mo), the Wexner Total Score was significantly improved in almost all items passing from 14 (IQR: 11 to 18) to 11 (IQR: 6.25 to 14.75) after surgery (P<0.0001). Incontinence was cured in 8 of 11 patients (P=0.036). Compared with the preoperative score, the 36-Item Short-Form Health Survey score improved, especially for physical activity, varying from 75 to 87.5 (P=0.0156). No worsening of continence status, constipation, or sexual function was observed. CONCLUSION: LVR appears to provide a sustained improvement in Health-Related Quality of Life, constipation, and incontinence in patients with ODS without worsening constipation with low morbidity and recurrence.

Oligometastatic Pancreatic Cancer to the Liver in the Era of Neoadjuvant Chemotherapy: Which Role for Conversion Surgery? A Systematic Review and Meta-Analysis.

Background: the improved survival rates achieved using new polychemotherapy regimens in patients with metastatic pancreatic cancer (mPDAC) have suggested a potential role for surgery following a favorable response to initial chemotherapy (IC). The purpose of this systematic review is to summarize the available evidence on the role of surgery following IC in mPDAC, focusing on oligometastatic disease to the liver (lmPDAC). Methods: studies reporting on patients with lmPDAC undergoing surgery after IC were included. The main outcome was overall survival (OS). Results: six observational retrospective studies were included in the qualitative analysis. Data were retrieved on 2087 patients. The most common IC regimen in patients undergoing surgery was FOLFIRINOX (N 84, 73%). Only three studies reported survival comparison among patients treated with IC+surgery vs. IC alone. Median OS varied from 23 to 56 months after conversion surgery vs. 11 to 16.4 months after IC alone. Conclusions: despite wide heterogeneity of chemotherapy regimens, different downstaging criteria and potential selection biases, patients with oligometastatic lmPDAC undergoing surgery after IC have significantly higher survival rates compared to patients treated with IC alone. Future trials are needed for definition of univocal criteria of downstaging, oligometastatic definition and indications for surgery.

Impact of Age on Short- and Long-Term Outcomes after Pancreatoduodenectomy for Periampullary Neoplasms.

BACKGROUND: Although mortality and morbidity of pancreatoduodenectomy (PD) have improved significantly over the past years, the impact of age for patients undergoing PD is still debated. This study is aimed at analyzing short- and long-term outcomes of PD in elderly patients. METHODS: 124 consecutive patients who have undergone PD for pancreas neoplasms in our center between 2012 and 2017 were analyzed. Patients were divided into two groups: group I (<75 years) and group II (≥75 years). Demographic features and intraoperative and clinical-pathological data were collected. Primary endpoints were perioperative morbidity and mortality; complications were classified according to the Clavien-Dindo Score. Secondary endpoints included feasibility of adjuvant treatment and overall survival rates. RESULTS: A total of 106 patients were included in this study. There were 73 (68.9%) patients in group I and 33 (31.1%) in group II. Perioperative deceases were 4 (3.6%), and postoperative pancreatic fistulas were 34 (32.1%). Significant difference between two groups was demonstrated for the ASA Score (p = 0.004), Karnofsky Score (p = 0.025), preoperative jaundice (p = 0.004), and pulmonary complications (p = 0.034). No significance was shown for diabetes, radicality of resection, stage of disease, operative time, length of stay, postoperative complications according to the Clavien-Dindo Score, postoperative mortality, pancreatic fistula, and reoperation rates. 69.9% of the patients in group I underwent adjuvant treatment vs. 39.4% of the older ones (p = 0.012). Mean overall survival was 28.5 months in group I vs. 22 months in group II (p = 0.909). CONCLUSION: PD can be performed safely in elderly patients. Advanced age should not be an absolute contraindication for PD, even if greater frailty should be considered. The outcome of elderly patients who have undergone PD is similar to that of younger patients, even though adjuvant treatment administration is significantly lower, demonstrating that surgery remains the main therapeutic option.

Perioperative albumin ratio is associated with post-operative pancreatic fistula.

BACKGROUND: Despite improvements in surgical techniques and perioperative management, post-operative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). The aim of this study was to evaluate the role of perioperative clinical variables of patients, including albumin level, in predicting pancreatic fistula. METHODS: A total of 86 patients underwent PD for pancreas cancer between 2011 and 2017 at our institution. We prospectively investigated the relation between patient's characteristics and the incidence of clinically relevant (CR)-POPF. Perioperative albumin ratio was defined as post-operative day 1 (POD1) albumin level/preoperative albumin level. RESULTS: A total of 23 patients (26.7%) developed CR-POPF. At univariate analysis POPF correlated with soft pancreas (P = 0.045), low POD1 albumin (P = 0.02), POD1 and POD3 amylase levels in drainage fluid (P = 0.003 and P = 0.014, respectively) and perioperative albumin ratio (0.58 ± 0.10 versus 0.69 ± 0.12 in patients without POPF; P = 0.003). No significant correlations with POPF were demonstrated for surgical time, serum amylase levels and preoperative albumin levels. At multivariate analysis POD3 amylase level in drainage fluid and perioperative albumin ratio were the only significant independent parameters (P = 0.027 and P = 0.047, respectively). CONCLUSIONS: Perioperative albumin ratio can predict POPF after PD.

Natural history of symptomatic and asymptomatic carotid artery occlusion contralateral to carotid endarterectomy: a prospective study.

The natural history of carotid occlusion (CO) has generally been analyzed in the presence of a contralateral patent but diseased internal carotid artery (ICA). Few previous studies have focused on the fate of CO contralateral to the side of a prior carotid endarterectomy (CEA). The aim of this study was to analyze the mortality rate and the incidence of cerebrovascular events in the hemisphere ipsilateral to CO (HICO) in patients who had undergone contralateral CEA. The 30-day and long-term outcomes of 153 consecutive patients who had CEA for severe symptomatic and asymptomatic ICA lesions contralateral to a symptomatic or asymptomatic CO over a 15-year period were considered. The endpoints of the study were mortality and neurological events in the HICO. Overall, the 30-day mortality and stroke rates were 0.6% (1/153) and 1.9% (3/153), respectively; the only death was stroke-related and the stroke was ipsilateral to the operated side. The other 2 strokes were ipsilateral to a symptomatic CO. The follow-up was completed for all patients (mean, 7.7 years; range, 1-172 months). Overall, there were 4 late strokes (2.6%), one of them lacunar in a patient with a symptomatic CO, whereas the other 3 were atheroembolic and ipsilateral to the operated ICA. The risk of late stroke in the HICO at 5 and 12 years was 2%. Overall, there were 19 late deaths, none of them stroke-related. CO, with or without symptoms, contralateral to CEA could be considered a locally benign condition in the long term.