A pragmatic approach improves the clinical management of stage IV gastric cancer: Comparison between the Meta-Gastro results and the GIRCG's retrospective series.

INTRODUCTION: The Italian Research Group for Gastric Cancer developed a prospective database about stage IV gastric cancer, to evaluate how a pragmatic attitude impacts the management of these patients. MATERIALS AND METHODS: We prospectively collected data about metastatic gastric cancer patients thanks to cooperation between radiologists, oncologists and surgeons and we analyzed survival and prognostic factors, comparing the results to those obtained in our retrospective study. RESULTS: Three-hundred and eighty-three patients were enrolled from 2018 to September 2022. We observed a higher percentage of laparoscopic exploration with peritoneal lavage in the prospective cohort. In the registry only 3.6 % of patients was submitted to surgery without associated chemotherapy, while in the retrospective population 44.3 % of patients were operated on without any chemotherapy. At univariate and multivariate analyses, the different metastatic sites did not show any survival differences among each other (OS 20.0 vs 16.10 vs 16.7 months for lymphnodal, peritoneal and hepatic metastases, respectively), while the number of metastatic sites and the type of treatment showed a statistical significance (OS 16,7 vs 13,0 vs 4,5 months for 1, 2 and 3 different metastatic sites respectively, p < 0.001; 24,2 vs 12,0 vs 2,5 months for surgery with/without chemotherapy, chemotherapy alone and best supportive treatment respectively, p < 0.001). CONCLUSIONS: Our data highlight that the different metastatic sites did not show different survivals, but survival is worse in case of multiple localization. In patients where a curative resection can be achieved, acceptable survival rates are possible. A better diagnostic workup and a more accurate staging impact favorably upon survival.

Clinical outcomes of patients with complicated post-operative course after gastrectomy for cancer: a GIRCG study using the GASTRODATA registry.

Gastrectomy for gastric cancer is still performed in Western countries with high morbidity and mortality. Post-operative complications are frequent, and effective diagnosis and treatment of complications is crucial to lower the mortality rates. In 2015, a project was launched by the EGCA with the aim of building an agreement on list and definitions of post-operative complications specific for gastrectomy. In 2018, the platform www.gastrodata.org was launched for collecting cases by utilizing this new complication list. In the present paper, the Italian Research Group for Gastric Cancer endorsed a collection of complicated cases in the period 2015-2019, with the aim of investigating the clinical pictures, diagnostic modalities, and treatment approaches, as well as outcome measures of patients experiencing almost one post-operative complication. Fifteen centers across Italy provided 386 cases with a total of 538 complications (mean 1.4 complication/patient). The most frequent complications were non-surgical infections (gastrointestinal, pulmonary, and urinary) and anastomotic leaks, accounting for 29.2% and 17.3% of complicated patients, with a median Clavien-Dindo score of II and IIIB, respectively. Overall mortality of this series was 12.4%, while mortality of patients with anastomotic leak was 25.4%. The clinical presentation with systemic septic signs, the timing of diagnosis, and the hospital volume were the most relevant factors influencing outcome.

Oligometastatic Gastric Cancer: Clinical Data from the Meta-Gastro Prospective Register of the Italian Research Group on Gastric Cancer.

BACKGROUND: Interest in the field of metastatic gastric cancer has grown in recent years, and the identification of oligometastatic patients plays a critical role as it consents to their inclusion in multimodal treatment strategies, which include systemic therapy but also surgery with curative intent. To collect sound clinical data on this subject, The Italian Research Group on Gastric Cancer developed a prospective multicentric observational register of metastatic gastric cancer patients called META-GASTRO. METHODS: Data on 383 patients in Meta-Gastro were mined to help our understanding of oligometastatic, according to its double definition: quantitative/anatomical and dynamic. RESULTS: the quantitative/anatomical definition applies to single-site metastases independently from the metastatic site (p < 0.001) to peritoneal metastases with PCI ≤ 12 (p = 0.009), to 1 or 2 hepatic metastases (p = 0.024) and nodal metastases in station 16 (p = 0.002). The dynamic definition applies to a percentage of cases variable according to the metastatic site: 8%, 13.5 and 23.8% for hepatic, lymphatic and peritoneal sites, respectively. In all cases, the OS of patients benefitting from conversion therapy was similar to those of cases deemed operable at diagnosis and operated after neoadjuvant chemotherapy. CONCLUSIONS: META-GASTRO supports the two-fold definition of oligometastatic gastric cancer: the quantitative/anatomical one, which accounts for 30% of our population, and the dynamic one, observed in 16% of our cases.

MRI-Pathology Agreement in Rectal Cancer: Real-World Data from a Prospective Rectal Cancer Registry.

Introduction: Magnetic Resonance Imaging (MRI) is routinely used in preoperative rectal cancer staging. The concordance of MRI staging with final pathologic exam, albeit improved, has not yet reached perfection. The aim of this study is to analyze the agreement between MRI and pathologic exam in patients operated on for mid-low rectal cancer. Material and Method: Patients undergoing neoadjuvant chemoradiation therapy (nCRT) or upfront surgery were analyzed. Between January 2019 to December 2019, 140 patients enrolled in the AIMS Academy rectal cancer registry were analyzed. Sixty-two patients received nCRT and 78 underwent upfront surgery. Results: Overall, the agreement between MRI and pathologic exam on T stage and N stage were 64.7% and 69.2%, respectively. The agreement between MRI and pathologic exam on T stage was 62.7% for patients who did not receive nCRT and 67.4% for patients who received nCRT (p = 0.62). The agreement on N stage was 76.3% for patients who did not receive nCRT and 60.0% for patients who received nCRT (p = 0.075). Conclusions: Real-world data shows MRI is still far from being able to correlate with the pathology findings which raises questions about the accuracy of the real-life decision-making process during cancer boards.

Evaluation of global and intragenic hypomethylation in colorectal adenomas improves patient stratification and colorectal cancer risk prediction.

BACKGROUND: Aberrant DNA hypomethylation of the long interspersed nuclear elements (LINE-1 or L1) has been recognized as an early event of colorectal transformation. Simultaneous genetic and epigenetic analysis of colorectal adenomas may be an effective and rapid strategy to identify key biological features leading to accelerated colorectal tumorigenesis. In particular, global and/or intragenic LINE-1 hypomethylation of adenomas may represent a helpful tool for improving colorectal cancer (CRC) risk stratification of patients after surgical removal of polyps. To verify this hypothesis, we analyzed a cohort of 102 adenomas derived from 40 high-risk patients (who developed CRC in a post-polypectomy of at least one year) and 43 low-risk patients (who did not develop CRC in a post-polypectomy of at least 5 years) for their main pathological features, the presence of hotspot variants in driver oncogenes (KRAS, NRAS, BRAF and PIK3CA), global (LINE-1) and intragenic (L1-MET) methylation status. RESULTS: In addition to a significantly higher adenoma size and an older patients' age, adenomas from high-risk patients were more hypomethylated than those from low-risk patients for both global and intragenic LINE-1 assays. DNA hypomethylation, measured by pyrosequencing, was independent from other parameters, including the presence of oncogenic hotspot variants detected by mass spectrometry. Combining LINE-1 and L1-MET analyses and profiling the samples according to the presence of at least one hypomethylated assay improved the discrimination between high and low risk lesions (p = 0.005). Remarkably, adenomas with at least one hypomethylated assay identified the patients with a significantly (p < 0.001) higher risk of developing CRC. Multivariable analysis and logistic regression evaluated by the ROC curves proved that methylation status was an independent variable improving cancer risk prediction (p = 0.02). CONCLUSIONS: LINE-1 and L1-MET hypomethylation in colorectal adenomas are associated with a higher risk of developing CRC. DNA global and intragenic hypomethylation are independent markers that could be used in combination to successfully improve the stratification of patients who enter a colonoscopy surveillance program.

Quality of Life After Elective Laparoscopic Sigmoidectomy for Symptomatic Uncomplicated Diverticular Disease.

INTRODUCTION: Symptomatic uncomplicated diverticular disease (SUDD) is characterized by abdominal pain and altered bowel function and may affect quality of life. When symptoms are severe and conservative therapy is ineffective, surgical intervention becomes an option. OBJECTIVE: This study aims to investigate quality of life after elective sigmoidectomy for patients affected by SUDD. MATERIALS AND METHODS: Retrospective multicenter review of consecutive patients affected by SUDD that underwent elective laparoscopic sigmoidectomy from January 2015 to March 2018. SUDD was defined as the presence of diverticula with persistent localized pain and diarrhea or constipation without macroscopic inflammation. Quality of life was investigated using the Gastrointestinal Quality of Life Index questionnaire at baseline, and at 6 and 12 months after surgery. Readmissions, unplanned clinical examination, mesalazine resumption, and emergency department visit for abdominal symptoms were recorded. RESULTS: Fifty-two patients were included in the analysis. Gastrointestinal Quality of Life Index score at 6 months from surgery did not statistically differ from baseline (96±10.2 vs. 89±11.2; P>0.05), while patients reported a better quality of life at 12 months after surgery (109±8.6; P<0.05). Within the first year of follow-up, 3 patients (5.8%) were readmitted for acute enteritis, 8 patients (15.4%) had emergency room access for abdominal pain, and 8 patients had unplanned outpatients' medical examinations for referred lower abdominal pain and bowel changes. Mesalazine was resumed in 17.3% of patients. CONCLUSION: Elective laparoscopic sigmoidectomy for SUDD is safe and effective in improving quality of life, although in some cases symptoms may persist.

Low Ligation of Inferior Mesenteric Artery in Laparoscopic Anterior Resection for Rectal Cancer Reduces Genitourinary Dysfunction: Results From a Randomized Controlled Trial (HIGHLOW Trial).

OBJECTIVES: The aim of the present study was to compare the incidence of genitourinary (GU) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (LAR + TME) with high or low ligation (LL) of the inferior mesenteric artery (IMA). Secondary aims included the incidence of anastomotic leakage and oncological outcomes. BACKGROUND: The criterion standard surgical approach for rectal cancer is LAR + TME. The level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. Retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on GU function is poorly understood. METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian nonacademic hospitals were randomized to high ligation (HL) or LL of IMA after meeting the inclusion criteria. GU function was evaluated using a standardized survey and uroflowmetric examination. The trial was registered under the ClinicalTrials.gov Identifier NCT02153801. RESULTS: A total of 214 patients were randomized to HL (n = 111) or LL (n = 103). GU function was impaired in both groups after surgery. LL group reported better continence and less obstructive urinary symptoms and improved quality of life at 9 months postoperative. Sexual function was better in the LL group compared to HL group at 9 months. Urinated volume, maximum urinary flow, and flow time were significantly (P < 0.05) in favor of the LL group at 1 and 9 months from surgery. The ultrasound measured post void residual volume and average urinary flow were significantly (P < 0.05) better in the LL group at 9 months postoperatively. Time of flow worsened in both groups at 9 months compared to baseline. There was no difference in anastomotic leak rate (8.1% HL vs 6.7% LL). There were no differences in terms of blood loss, surgical times, postoperative complications, and initial oncological outcomes between groups. CONCLUSIONS: LL of the IMA in LAR + TME results in better GU function preservation without affecting initial oncological outcomes. HL does not seem to increase the anastomotic leak rate.

Laparoscopic Approach to Large Bowel Neoplastic Obstruction After Self-Expandable-Metal-Stent (SEMS) Placement.

Endoscopic self-expandable metal stent (SEMS) placement as a bridge to surgery in large bowel neoplastic obstruction is an alternative to emergency surgery for the obstructive colorectal neoplasms. This study aims to analyze postoperative and long-term outcomes in a series of patients who underwent laparoscopic colorectal resection after SEMS placement. The analysis, after the stratification based on the time elapsed between the onset of the occlusive symptoms and the SEMS positioning, revealed an interesting result, with lower mortality for patients who underwent the procedure within 24 hours of hospitalization (P=0.0159). This trend may indicate the need to reduce the endoscopic time schedules as much as possible, even if an emergency procedure is needed. The laparoscopic approach, after stent placement as bridge therapy, can be a safe alternative to emergency surgery, if the procedure is precociously applied.

Complications after gastrectomy for cancer: Italian perspective.

Surgery for gastric cancer is associated with significant major morbidity and an estimated mortality rate of about 5%. A reliable comparison of post-operative outcomes is hampered by the lack of a clear, universally recognized, definition of the most frequent complications. This paper reports the final results of a project launched by the Italian Research Group for Gastric Cancer in September 2015, whose goal was to propose a comprehensive list of surgical-related, gastric cancer-specific complications, with their definitions. The project was carried out through a multicentric, mainly web-based, consensus of experts. The proposed list, following assessment and validation by a group of experts of the European Chapter of the International Gastric Cancer Association, will form the basis for implementing a "Complications Recording Sheet" that can be disseminated worldwide for proper and reliable post-operative assessment.

The Italian Research Group for Gastric Cancer (GIRCG) guidelines for gastric cancer staging and treatment: 2015.

This article reports the guidelines for gastric cancer staging and treatment developed by the GIRCG, and contains comprehensive indications for clinical management, including radiological, endoscopic, surgical, pathological, and oncological paths.

Uncommon Case of a Post-Traumatic Portal Vein Pseudoaneurysm Treated with Percutaneous Transhepatic Stent Grafting.

We describe a man who presented with a traumatic portal vein pseudoaneurysm, which was subsequently managed with a percutaneous transhepatic stent graft. This case demonstrates a rarely seen condition in the traumatic population and a novel management strategy, which should be considered in the management of this challenging injury.

Laparoscopic repair of voluminous symptomatic hiatal hernia using absorbable synthetic mesh.

INTRODUCTION: Hiatal hernia is a common disorder and a controversial topic. In symptomatic voluminous hernias laparoscopic surgery and use of mesh can be considered. An initial experience in voluminous hiatal hernia laparoscopic repair using absorbable glycolic acid/trimethylene carbonate synthetic mesh is reported. MATERIAL AND METHODS: Retrospective study from an institutional database was performed to analyze laparoscopic hiatal hernia repair using absorbable synthetic mesh from January 2010 to December 2013. All preoperative symptoms and exams were collected and a standardized procedure was performed. Clinical and radiological follow-up was performed. RESULTS: Eight patients underwent laparoscopic repair of hiatal hernia performed by two highly skilled laparoscopic surgeons. One Toupet and seven Nissen fundoplications were tailored. No conversions into laparotomy, neither intraoperative complications nor mortality occurred. After a median follow-up of 23.5 months (range 14 - 44) no mesh complications occurred and all patients are asymptomatic. Two radiological recurrences (25%) were detected. CONCLUSIONS: Voluminous symptomatic hiatal hernias can be successfully treated in a high-volume and long-term experienced laparoscopic surgical center by the use of an absorbable synthetic mesh. Further studies and a longer-term follow-up are necessary to confirm this preliminary report.

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

BACKGROUND: The position of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision can affect genito-urinary function, bowel function, oncological outcomes, and the incidence of anastomotic leakage. Ligation to the inferior mesenteric artery at the origin or preservation of the left colic artery are both widely performed in rectal surgery. The aim of this study is to compare the incidence of genito-urinary dysfunction, anastomotic leak and oncological outcomes in laparoscopic anterior rectal resection with total mesorectal excision with high or low ligation of the inferior mesenteric artery in a controlled randomized trial. METHODS/DESIGN: The HIGHLOW study is a multicenter randomized controlled trial in which patients are randomly assigned to high or low inferior mesenteric artery ligation during laparoscopic anterior rectal resection with total mesorectal excision for rectal cancer. Inclusion criteria are middle or low rectal cancer (0 to 12 cm from the anal verge), an American Society of Anesthesiologists score of I, II, or III, and a body mass index lower than 30. The primary end-point measure is the incidence of post-operative genito-urinary dysfunction. The secondary end-point measure is the incidence of anastomotic leakage in the two groups. A total of 200 patients (100 per arm) will reliably have 84.45 power in estimating a 20% difference in the incidence of genito-urinary dysfunctions. With a group size of 100 patients per arm it is possible to find a significant difference (α = 0.05, ß = 0.1555). Allowing for an estimated dropout rate of 5%, the required sample size is 212 patients. DISCUSSION: The HIGHLOW trial is a randomized multicenter controlled trial that will provide evidence on the merits of the level of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision in terms of better preserved post-operative genito-urinary function. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02153801 Protocol Registration Receipt 29/5/2014.

Laparoscopic repair of ventral hernia in a laparoscopic experienced surgical center: low recurrence rate, morbidity, and chronic pain are achievable.

PURPOSE: Recurrence rate and the perioperative outcome evaluation through laparoscopic approach for ventral (primary and incisional) hernia repair. MATERIALS AND METHODS: A retrospective evaluation of a series of patients treated through a minimally invasive approach for ventral hernia was performed. A standardized surgical technique was adopted. All the patients were evaluated through a clinical follow-up. RESULTS: From July 2004 to June 2011, 150 videolaparoscopic ventral hernia repairs were performed. The median follow-up was 40 months. One hernia recurrence (0.7%) was detected after 55 months. The intraoperative and postoperative complication rate was 2.6% (1 conversion to open surgery) and 5.3%, respectively. Chronic pain nonresponsive to drug was registered in 2 patients (1.3%). CONCLUSIONS: The videolaparoscopic approach to ventral hernia repair is a safe technique that can guarantee a low recurrence rate; moreover, if it is performed in an experienced laparoscopic surgical center, it can be a valid alternative to the traditional open approach.

Glove technique in single-port access laparoscopic surgery: results of an initial experience.

Introduction. Single-incision laparoscopic surgery (SILS) is a virtually "scarless" technique. A retrospective analysis is performed to evaluate an initial experience of this surgical approach. Materials and Methods. From January 2010 to October 2011, SILS was considered as a minimally invasive approach to abdominal disease. The access was made by a standard wound protector and a size 6 glove. A series of little accesses were made on the tips of the glove-fingers to induce pneumoperitoneum and to create a working channel for the laparoscopic instruments. An analysis of costs of this technique was made too. Results. SILS was successfully completed with low cost in 34 patients: 20 appendectomy, 12 cholecystectomy, and 2 right colectomy were performed with a median operative time of 35, 45, and 67.5 minutes, respectively. In no patient any conversion to standard laparoscopy or to open surgery was needed. The postoperative course was uneventful in all patients. In right hemicolectomy, the oncological parameters were respected. Conclusions. In this paper the glove-port technique showed multiple advantages. The SILS is a feasible approach for some pathologies in selected patients. The glove-port is a simple, low-cost, reproducible, and sure method to perform SILS in a high-experienced laparoscopic surgical centre.

Surgical technique, morbidity, and outcome of primary retroperitoneal sarcoma involving inferior vena cava.

BACKGROUND: Retroperitoneal sarcomas (RSTS) involving inferior vena cava (IVC) are rare entities. Vascular resection and reconstruction represent a technical challenge. The aim of the study was to review a monoinstitutional series of IVC resections for RSTS (mainly IVC leiomyosarcoma), focusing on the type of vascular replacement, morbidity, and oncologic outcome. METHODS: From January 2004 to January 2011, 15 patients (7 male, 8 female) surgically treated for RSTS involving primarily or secondarily IVC were included. RESULTS: A total of ten patients had IVC replacement and one had partial IVC resection (anterior wall). En bloc organ resection was performed in 14 patients (93%). Major venous reconstructions were performed using PTFE prosthesis (2) or banked venous homografts (8). In four patients IVC reconstruction was not necessary because of the presence of efficient collaterals. Early clinically relevant complications (grade ≥3) were detected in one patient (7%) (symptomatic graft thrombosis). No reoperations were needed. No late relevant complications (grade ≥3) were observed. Overall graft patency was 60%. At a median follow up of 31.6 months, local recurrence, distant metastases, and survival rate were 20, 26, and 80%, respectively. Complete tumor resection was achieved in all patients. CONCLUSIONS: IVC resection is safe and well tolerated in RSTS patients. The need for vascular reconstruction has to be assessed according to preoperative imaging, intraoperative findings, and extent of resection. The specific role of banked venous homografts needs to be investigated in larger studies.

Morbidity of left pancreatectomy when associated with multivisceral resection for abdominal mesenchymal neoplasms.

CONTEXT: Resection of adjacent visceral organs is often required in surgery for abdominal mesenchymal tumors. OBJECTIVES: To analyze the specific perioperative morbidity and mortality of a left pancreatectomy in multivisceral resections for mesenchymal tumors. PATIENTS: This paper considered all patients treated at National Cancer Institute, Milan, Italy, from January 1997 to May 2009 for the resection of abdominal mesenchymal neoplasms requiring a concomitant left pancreatectomy. The extension of surgery, pathology of both the tumor and the pancreatic tissue, completeness of resection, administration of pre or postoperative treatments and postoperative outcome were analyzed. The overall survival of the entire population was also assessed. RESULTS: Fifty-seven patients affected by localized left retroperitoneal mesenchymal neoplasms or intra-abdominal gastrointestinal stromal tumors were identified. A macroscopically complete resection was achieved in all but 3 patients (5.3%) and the neoplastic involvement of pancreatic tissue was documented at pathology in 26 (45.6%) patients. Surgical postoperative complications occurred in 20 patients (35.1%); 7 patients (12.3%) developed a postoperative pancreatic fistula. With a median follow-up of the surviving patients of 32 months (interquartile range: 20-57 months), the overall survival at 5 years was 67.0%. CONCLUSION: Left pancreatic resection seemed to be a safe procedure, even when it is part of a multivisceral resection for abdominal mesenchymal neoplasms. When margins are crucial for cure, the left pancreas should then always be resected, independently of its direct infiltration.

Pancreaticoduodenectomy with unusual artery reconstruction in a patient with celiac axis occlusion: report of a case.

Celiac axis stenosis is a relatively common finding that may require major revascularization during pancreaticoduodenectomy. We present a patient that underwent pancreaticoduodenectomy for intraductal papillary mucinous neoplasm of the pancreatic head associated with celiac axis obstruction. To secure arterial blood flow to the upper abdominal organs, the superior posterior pancreaticoduodenal artery and the posterior-inferior pancreatic-duodenal artery were carefully preserved, and anastomosed. The postoperative course was complicated by a pseudoaneurysm of the splenic artery that was successfully treated with angiographic embolization through the vascular bypass. This may be a valid alternative procedure for revascularization of the common hepatic artery during pancreaticoduodenectomy in a patient with celiac axis stenosis.

Distal pancreatectomy for body-tail pancreatic cancer: is there a role for celiac axis resection?

BACKGROUND/AIMS: Body-tail pancreatic cancer is an aggressive disease with a low resectability rate and a poor prognosis. Celiac axis invasion usually contraindicates resection. The aim of this study was to analyze the feasibility of distal pancreatectomy (DP) with celiac axis resection (DP-CAR) for locally advanced body-tail pancreatic cancer. METHODS: All DPs performed between January 1989 and December 2007 were considered. DP and DP-CAR were reviewed for pre-, intra- and postoperative data. An extensive, detailed literature review on DP and DP-CAR was also performed. RESULTS: DP was performed in 49 of our patients, and 745 cases were retrieved from the literature. The overall morbidity and mortality rates were 32.0 and 3.0%, respectively. We performed DP-CAR in 5 patients with no mortality but 80% morbidity. A further 90 patients were retrieved from the literature. Arterial reconstruction was needed in 1/5 of our patients and in 13/90 of patients in the literature. Collaterals from superior mesenteric artery maintained adequate hepatic artery blood flow in the remaining 81 patients. The overall morbidity and mortality rates were 40.6 and 2.1%, respectively. The median survival ranged between 4.5 and 25 months after DP and was 13 months after DP-CAR. CONCLUSIONS: DP-CAR improves resectability without increasing the mortality rate. The complication rate after DP-CAR was higher than after DP, but still within the range of extended DP. DP-CAR should be considered for the inclusion among the 'extended' procedures for the treatment of body-tail pancreatic cancers invading the celiac axis. and IAP.