Posterior and Para-Aortic (D2plus) Lymphadenectomy after Neoadjuvant/Conversion Therapy for Locally Advanced/Oligometastatic Gastric Cancer.

Super-extended (D2plus) lymphadenectomy after chemotherapy has been reported in only a few studies. This retrospective study evaluates survival outcomes in a Western cohort of locally advanced or oligometastatic gastric cancer patients who underwent D2plus lymphadenectomy after neoadjuvant chemotherapy. A total of 97 patients treated between 2010 and 2022 were included. Of these, 62 had clinical stage II/III disease, and 35 had stage IV disease. Most patients (65%) received preoperative DOC/FLOT chemotherapy. The mean number of lymph nodes harvested was 39. Pathological positive nodes in the posterior/para-aortic stations occurred in 17 (17.5%) patients. Lymphovascular invasion, ypN stage, clinical stage, and perineural invasion were predictive factors for positive posterior/para-aortic nodes. Postoperative complications occurred in 21 patients, whereas severe complications (grade III or more) occurred in 9 cases (9.3%). Mortality rate was 1%. Median overall survival (OS) was 59 months (95% CI: 13-106), with a five-year survival rate of 49 ± 6%; the five-year OS after R0 surgery was 60 ± 7%. In patients with positive posterior/para-aortic nodes, the median OS was 15 months (95% CI: 13-18). D2plus lymphadenectomy after chemotherapy for locally advanced or oligometastatic gastric cancer is feasible and associated with low morbidity/mortality rates. The incidence of pathological metastases in posterior/para-aortic nodes is not negligible even after systemic chemotherapy, with poor long-term survival.

Survival Outcomes of Patients with Mantle Cell Lymphoma: A Retrospective, 15-Year, Real-Life Study.

Mantle cell lymphoma (MCL) prognosis has significantly improved in recent years; however, the possible survival benefit of new treatment options should be evaluated outside of clinical trials. We investigated 73 consecutive MCL patients managed from 2006 to 2020. For younger patients <65 years old, the median PFS was 72 months and we reported a 2-year, 5-year, and 10-year PFS of 73%, 62%, and 41%; median OS was not reached and we reported a 2-year, 5-year, and 10-year OS of 88%, 82%, and 66%. For patients aged 75 years or older, the median PFS was 36 months and we reported a 2-year, 5-year, and 10-year PFS of 52%, 37%, and 37%; median OS was not reached and we reported a 2-year, 5-year, and 10-year OS of 72%, 55%, and 55%. The median PFS was significantly reduced for patients treated between 2006 and 2010 compared to patients treated between 2011 and 2015 (p = 0.04). Interestingly, there was a trend towards improved OS for patients treated between 2016 and 2020 compared to between 2006 and 2010 and between 2011 and 2015 (5-year OS was 91%, 44%, and 33%). These findings could be due to the introduction of BR as a first-line regimen for elderly patients and to the introduction of ibrutinib as a second-line regimen.

Are small lymphocytic lymphoma and chronic lymphocytic leukemia the same disease? The unsolved dilemma.

The management of small lymphocytic lymphoma (SLL) as chronic lymphocytic leukemia (CLL) or an indolent non-Hodgkin lymphoma is highly debated. In this single-center, real-life study, 38 SLL patients managed between 2008 and 2022 were evaluated. Overall, 26/38 cases (68.4%) needed treatment and all but one received CLL concordant therapy, including BR (9/38 cases), fludarabine, cyclophosphamide, rituximab (5/38 cases), rituximab and chlorambucil (4/38 cases), BTK inhibitors (7/38 cases) and steroid (1 case with immune thrombocytopenia). Patients treated between 2008 and 2018 were more likely to receive chemoimmunotherapy compared to patients treated in 2019-2022, that were more likely to receive BTK inhibitors. The median PFS was 54 months and 3-y PFS was 58%, while the median OS was not reached, with a 3-y OS of 84%. We confirm a wide heterogeneity in SLL management and we suggest prospective studies are needed to improve the knowledge of its biology and harmonize its treatment.

Neuroendocrine tumors' patients treated with somatostatin analogue could complicate with emergency cholecystectomy.

BACKGROUND: Gastro-entero-pancreatic neuroendocrine tumors are gradually seeing their incidence increase, probably due to their low-rate mortality. Surgery and subsequent medical therapy through octeotride and somatostatin analogues is the recommended approach for hypersecretive hormonal forms, showing an effective control of symptoms and improved survival outcomes. AIM: The present study aims to evaluate the occurrence of gallbladder lithiasis, and its complications, in patients underwent upfront surgery for neuroendocrine tumors and subsequent long-term administration of somatostatin analogues. MATERIAL OF STUDY: We included four adults affected by neuroendocrine (gastric, appendiceal and ileal) tumors and without previous evidence of gallbladder stones, who needed an emergency cholecystectomy after long-term somatostatin treatment. RESULTS: The patients showed complicated conditions sustained by cholelithiasis, such as acute cholecystitis, gangrenous cholecystitis, or intestinal occlusion, which required emergency surgery. DISCUSSIONS: Somatostatin analogues may influence the cascade of enzymes that guarantee the gallbladder motility, and consequently cause the precipitation of cholesterol and calcium bilirubinate crystals. Therefore, higher and sustained levels of somatostatin may result in higher rates of gallstone development. CONCLUSIONS: The prophylactic cholecystectomy, during upfront surgery for neuroendocrine tumors, might prevent an emergency cholecystectomy for gallstones complications. KEY WORDS: Gallbladder stones, Neuroendocrine tumors, Somatostatine analogues.

Current Trends in Volume and Surgical Outcomes in Gastric Cancer.

Gastric cancer is ranked as the fifth most frequently diagnosed type of cancer. Complete resection with adequate lymphadenectomy represents the goal of treatment with curative intent. Quality assurance is a crucial factor in the evaluation of oncological surgical care, and centralization of healthcare in referral hospitals has been proposed in several countries. However, an international agreement about the setting of "high-volume hospitals" as well as "minimum volume standards" has not yet been clearly established. Despite the clear postoperative mortality benefits that have been described for gastric cancer surgery conducted by high-volume surgeons in high-volume hospitals, many authors have highlighted the limitations of a non-composite variable to define the ideal postoperative period. The textbook outcome represents a multidimensional measure assessing the quality of care for cancer patients. Transparent and easily available hospital data will increase patients' awareness, providing suitable elements for a more informed hospital choice.

The Emergency Surgery Frailty Index (EmSFI) in Elderly Patients with Acute Appendicitis: An External Validation of Prognostic Score.

BACKGROUND: Identification of reliable risk-stratification tools is critical for surgical decision making, particularly in frail and elderly. The aim of the study is to validate the Emergency Surgery Frailty Index (EmSFI), in over 65 years old patients operated on for acute appendicitis. METHODS: An observational study was conducted enrolling elderly patients with diagnosis of acute appendicitis who underwent emergency appendicectomy or right colectomy, between 2016 and 2021. All patients were treated according to the last SIFIPAC/WSES/SICG/SIMEU guidelines. RESULTS: Overall, 61 patients were analyzed. Complication rate was higher for patients in the second EmSFI risk Class. Moreover, ROC analyses identified 3 as the best cutoff value in predicting risk of adverse postoperative events. Complication rate was higher in oldest elderly patients-over 80 years-(42.9 vs 22.5%; p 0.05) and was mainly related to medical complications (42.9 vs 12.5%, p 0.007). However, intestinal obstruction, peri-appendicular abscess on preoperative CT, peritonitis and a longer duration of surgery are related with increased risk of complications in the group of patients under 80 years. CONCLUSION: The EmSFI score results a valid prognostic marker for frailty status, and it may support the surgeon in emergency setting for acute appendicitis. Patients aged 80 years or older have a higher risk of complications, independent from those factors which relate to increased morbidity in younger elderly patients. Age alone is not a reliable indicator of the real surgical risk, but it must encourage the adoption of multidisciplinary collaborative models of care for this group of patients.

Two secondary localisation of non-Hodgkin's lymphomas in the upper gastrointestinal tract.

Extranodal non-Hodgkin's lymphomas of the gastrointestinal tract represent 30%-40% of all extranodal lymphomas. Gastric lymphomas are increasingly described in the literature due to the development of diagnostic techniques and the increased incidence, together with the reduced incidence of gastric solid neoplasms. Significant diagnostic difficulties are determined by the non-specificity of the symptoms, which are mostly chronic, characterised by a slow progression. Localisation in the small intestine often appears as surgical urgency, due to the development of an intestinal obstruction or enterorrhagia. We present two cases of extranodal diffuse large B-cell lymphoma localisation, presented as a secondary lesion localised in the first one in the stomach, and in the second one in the first duodenal portion.

The Regenerative Effects of Botulinum Toxin A: New Perspectives.

Background: Botulinum Toxin A (BTX-A) has been found to improve blood flow perfusion. This study aimed to find in literature the use of BTX-A in Plastic Surgery and in particular its use to improve blood flow perfusion.Methods: We read the article "Effects of Botulinum Toxin A on the blood flow in expanded rat skin" and starting from this article we searched in the literature all the articles talking about the use of BTX-A to improve blood flow perfusion.Results: BTX-A increase the expression of VEGF, CD-31 and INOS. Moreover BTX-A selective suppress sympathetic neurons of the cutaneous microcirculation. We found 13 studies that confirm the effects of Botulinum Toxin A in improving blood flow perfusion of cutaneous and myocutaneous flaps.Conclusion: We think that in the future we could start to use BTX-A in these fields of plastic surgery, but we really need to understand good dosages and standardize them, see which are the effects on long-term outcomes, and put on randomized trials providing high-level evidence about the range of dosages in which we are safe to use BTX-A and asses the risk-benefit ratio in humans and the cost-benefit ratio.

Antimicrobial Prophylaxis Reduces the Rate of Surgical Site Infection in Upper Gastrointestinal Surgery: A Systematic Review.

Surgical site infection occurs with high frequency in gastrointestinal surgery, contributing to the high incidence of morbidity and mortality. The accepted practice worldwide for the prevention of surgical site infection is providing single- or multiple-dose antimicrobial prophylaxis. However, most suitable antibiotic and optimal duration of prophylaxis are still debated. The aim of the systematic review is to assess the efficacy of antimicrobial prophylaxis in controlling surgical site infection rate following esophagogastric surgery. PubMed and Cochrane databases were systematically searched until 31 October 2021, for randomized controlled trials comparing different antimicrobial regimens in prevention surgical site infections. Risk of bias of studies was assessed with standard methods. Overall, eight studies concerning gastric surgery and one study about esophageal surgery met inclusion criteria. No significant differences were detected between single- and multiple-dose antibiotic prophylaxis. Most trials assessed the performance of cephalosporins or inhibitor of bacterial beta-lactamase. Antimicrobial prophylaxis (AMP) is effective in reducing the incidence of surgical site infection. Multiple-dose antimicrobial prophylaxis is not recommended for patients undergoing gastric surgery. Further randomized controlled trials are needed to determine the efficacy and safety of antimicrobial prophylaxis in esophageal cancer patients.

Non-occlusive mesenteric ischemia (NOMI) and prognostic signs at CT: reperfusion or not reperfusion that is the question!

PURPOSE: Non-occlusive mesenteric ischemia (NOMI) is a misdiagnosed and dangerous condition. To our knowledge, a comprehensive evaluation of CT parameters that can predict the outcome of patients suffering from NOMI is still missing. MATERIALS AND METHODS: Contrast-enhanced CT examination of 84 patients with a confirmed diagnosis of NOMI (37 with clinical and laboratory confirmation and 47 biopsy or surgery proven) was retrospectively reviewed by assessing vessels, mesentery, bowel, and peritoneal cavity CT quantitative and dichotomous parameters, and data were analyzed with Fisher's test. Diameter of superior mesenteric artery (SMA), celiac trunk (CT), inferior vena cava (IVC), superior mesenteric vein (SMV), and differences in CT HU (Delta HU) of the bowel wall before and after intravenous contrast media (ICM) administration were correlated to the patients' outcome using ANOVA test. Receiver operating characteristic (ROC) curves were elaborated after a binary logistic regression was performed. RESULTS: Increased number and diameter of vessels, bowel wall thickening, and hypervascularity were more frequent in patients with good prognosis. Conversely, pale mesentery, paper thin, hypovascularity, and aeroportia were more frequent in patients with bad prognosis. A significant correlation between diameters of SMA, CT, IVC, IMA, and SMV and outcome was found at univariate analysis. Also Delta HU resulted to be correlated with the outcome. At multivariate analysis only IVC and Delta HU were significant (p = 0.038 and 0.01) and the combined AUC resulted in 0.806 (CI 0.708-0.903). CONCLUSION: Dichotomous signs of reperfusion and quantitative CT parameters can predict the outcome of patients with NOMI. In particular the combination of IVC diameter and Delta HU of bowel wall allows to predict the prognosis with the highest accuracy.

Pathological response and outcome after neoadjuvant chemotherapy with DOC (docetaxel, oxaliplatin, capecitabine) or EOF (epirubicin, oxaliplatin, 5-fluorouracil) for clinical T3-T4 non-metastatic gastric cancer.

PURPOSE: In this prospective observational study, we sought to compare the efficacy and safety of docetaxel + oxaliplatin + capecitabine (DOC) with epirubicin + oxaliplatin + 5-fluouracil (EOF) as neoadjuvant chemotherapy (NAC) for clinical T3 or T4 non-metastatic gastric cancer (GC) patients. METHODS: The DOC NAC consisted of docetaxel 35 mg/m2 (days 1-8), oxaliplatin 85 mg/m2 (day 1), and capecitabine 750 mg/m2 twice daily (days 1-14), every 3 weeks. The EOF NAC consisted of intravenous (IV) epirubicin 50 mg/m2 combined with IV oxaliplatin 130 mg/m2 on day 1 and continuous infusion 5-fluouracil 750 mg/m2 on days 1-5, every 3 weeks. After 4 cycles of NAC or upon progression during chemotherapy, patients underwent gastrectomy with standard D2 or D3 lymphadenectomy. Pathological complete response rate per Becker tumor regression grading system was the primary endpoint and the secondary endpoints included progression-free survival (2-yr PFS) and 2-year overall survival (2-yr OS) and tolerability. RESULTS: Overall, we identified 63 patients with T3-4 non-metastatic GC starting either NAC regimen between January 2010 and December 2017 at our Institution: 34 in the DOC group and 29 in EOF group. Thirty patients (88%) in the DOC group and 22 (76%) in the EOF group completed the 4 planned cycles of NAC. Fifty-seven patients received surgery. Results indicated no statistical significant differences between the two groups, and only a trend for some better data in favour of the DOC group. The R0 resection rate was 90.6% and 88.0% for the DOC and EOF cohorts, respectively. The pathological complete response rate was 6.2% in the DOC group and 4.0% in the EOF group. Becker 1-2 pathological response was found in 46.8% of the DOC cohort and 28.0% of the EOF cohort (p = .14). The 2-yr PFS rate was 54.1% for DOC vs. 41.4% for EOF (p = .14) and the 2-yr OS rate was 80.8% for DOC vs. 58.6% for EOF (p = .05). Neutropenia was the most common grade ≥3 toxicity and occurred in 8 (23.5%) patients of the DOC group and 10 (34.4%) patients of the EOF group (p = .33). CONCLUSIONS: These findings seem to confirm the feasibility of NAC for clinically T3 and T4 non-metastatic GC and, despite no statistical significant difference was documented, suggest a trend for better activity and tolerability for the docetaxel-based regimen (DOC) compared to the epirubicin-based combination (EOF).

Feasibility of modified docetaxel, oxaliplatin, capecitabine followed by capecitabine as maintenance chemotherapy as first-line therapy for patients with metastatic gastric or gastroesophageal cancer.

The aim of this study was to evaluate the efficacy and safety of modified docetaxel, oxaliplatin, capecitabine (DOC) combination chemotherapy, followed by maintenance capecitabine as first-line therapy for patients with metastatic gastric or gastroesophageal junction (GEJ) cancer. Treatment consisted of docetaxel 35 mg/m (days 1-8), l-OHP 85 mg/m (day 1), and capecitabine 750 mg/m twice daily (days 1-14), every 3 weeks. After six cycles of DOC, patients who did not progress received maintenance treatment with three-weekly capecitabine 1000 mg/m twice daily (days 1-14), until disease progression or unacceptable toxicity. Six-month disease control rate (DCR) was the primary endpoint and overall survival (OS), progression-free survival (PFS) and safety were the secondary endpoints. The Kaplan-Meier method was applied to estimate OS and PFS. Between July 2014 and September 2017, 37 patients with metastatic gastric or GEJ cancer were enrolled at our institution. Upon completion of the DOC regimen, 35 patients (94.5%) received capecitabine as maintenance chemotherapy for a median of 7 cycles (range, 3-14 cycles). The six-month DCR was 83.7% [95% confidence interval (CI), 71.8-95.6%], median PFS was 8.2 months (95% CI, 6.3-9.8 months), and median OS was 14.4 months (95% CI, 11.7-18.6 months). During DOC chemotherapy, the most common grade 3-4 adverse events were neutropenia (29.7%), anemia (10.8%), and diarrhea (10.8%). During maintenance treatment, toxicity was sporadic and mainly of grade 1-2. Modified DOC followed by capecitabine as maintenance chemotherapy seems to be an active and well tolerated first-line treatment strategy for patients with metastatic gastric and GEJ cancer.

Care with regard to details improves the outcome of Longo mucoprolapsectomy: long term follow up.

In this study we evaluated the results of stapled hemorrhoidopexy considering the histological features of the resected tissue obtained after the intervention, the staple line height and the improvement of the quality of life after the treatment. From January 2003 to December 2006, 72 patients with symptomatic grade 3 and 4 hemorrhoid that underwent stapled hemorrhoidopexy in our clinic were enroled in the study. Preoperative, intraoperative and postoperative characteristics of the patients were evaluated, including demographics, staple line height, specimen histology, complications, recurrence, day to return to work, quality of life (QoL) score and use of analgesics. Staple line height was always above 2.5 cm from the dentate line. Smooth muscle fibers were observed in 97.2%. The complication rate was 18%. Bleeding was observed in 5.5%. Fecal urgency was referred in 6.9%. Recurrence rate was 6.9%. Mean follow-up was 68 months. Hemorrhoidopexy is safe and effective but extreme attention must be paid to some critical details. We consider the placement of the purse string suture as a critical factor in the outcome of the patients. We find that some amount of the muscle fibers would invariably be involved in the resected specimen, without any significant impact in the clinical outcome or in the quality of life improvement.