Propensity Score-Matched Analysis of Minimal Invasive Surgery versus Open Surgery for Colorectal Cancer in Older Patients.

Introduction: Currently, surgeons deal with an older patient cohort, confronting new challenges brought by the raised life expectancy. This population is unrepresented in surgical trials; therefore, the optimal therapy is still a matter of debate. The efficacy of open versus minimal invasive management of colorectal cancer (CRC) in an elderly cohort is not clearly established. The current study assesses the minimal invasive approach in elderly patients undergoing colorectal surgery. Material and Methods: The General Surgery Department database was inquired between 2012 and 2015 using the following filters: age â?¥ 65 and rectal or colon adenocarcinoma. After applying the exclusion criteria, 975 cases were obtained: 842 underwent open surgery (OS) and 133 underwent minimal invasive surgery (MIS). A propensity score matching was performed to reduce patient selection bias. Results: After the propensity score matching, the MIS group had a shorter postoperative hospital stay than the OS group (p = 0.025). From the preoperative variables, the presence of chronic lung disease was significantly higher in the OS group (p = 0.039). The presence of chronic lung disease positively associates with the Clavien-Dindo classification (p 0.001) and with the number of days from surgery to discharge (p = 0.028). Conclusion: The chronological age alone should not be a limit to MIS granting that it showed no inferiority to the OS in terms of postoperative morbidity, correlating with lower postoperative stay in the elderly. Further prospective studies are needed to assess the outcome of MIS in elderly population.

TNF-alpha releasing capacity of the whole blood drops after open total splenectomy, but increases after partial/subtotal or minimally invasive splenectomy.

BACKGROUND: The mechanisms that induce immunodeficiency after splenectomy remain unknown. The aim of this study was to measure the cytokine releasing capacity of the whole blood as an expression of the innate immunity after total (TS) and subtotal/partial splenectomy (S/PS) in order to assess the impact of splenectomy on the individual cytokine reactivity. METHODS: We prospectively collected blood before (D0) and at multiple time points after splenectomy (7 days - D7, 30 days - D30, 90 days - D90, 180 days - D180, and 360 days - D360) and measured the cytokines releasing capacity of IL-6, TNF-alpha and IL-10 from whole blood under LPS stimulation which we normalized to the monocytes number. RESULTS: When analyzing all splenectomies at D0, D7 and D30, normalized ΔTNF-alpha significantly dropped after splenectomy (p = .0038) and normalized ΔIL-6 and ΔIL-10 did not significantly change. More specifically, normalized ΔTNF-alpha dropped after TS (p = .0568) and significantly increased after S/PS (p = .0388). Open surgery induced a decrease in normalized ΔTNF-alpha (p = .0970), whereas minimally invasive (MI) surgery significantly increased the normalized ΔTNF-alpha releasing capacity (p = .0178). The cytokine levels were heterogenous between pathologies at D0, and ΔIL-6 dropped mainly in cirrhotic patients after splenectomy (all underwent TS), ΔTNF-alpha dropped in immune thrombocytopenic purpura patients (all underwent TS), but increased in spherocytosis (91% underwent S/PS) after splenectomy. CONCLUSIONS: Splenectomy induces a decrease of the pro-inflammatory cytokine TNF-alpha and if splenic parenchyma is spared and the surgery is performed MI, this change is hindered.

Opportunistic Network Algorithms for Internet Traffic Offloading in Music Festival Scenarios.

Constant Internet connectivity has become a necessity in our lives. Hence, music festival organizers allocate part of their budget for temporary Wi-Fi equipment in order to sustain the high network traffic generated in such a small geographical area, but this naturally leads to high costs that need to be decreased. Thus, in this paper, we propose a solution that can help offload some of that traffic to an opportunistic network created with the attendees' smartphones, therefore minimizing the costs of the temporary network infrastructure. Using a music festival-based mobility model that we propose and analyze, we introduce two routing algorithms which can enable end-to-end message delivery between participants. The key factors for high performance are social metrics and limiting the number of message copies at any given time. We show that the proposed solutions are able to offer high delivery rates and low delivery delays for various scenarios at a music festival.

Is Long-Term Survival in Metastases from Neuroendocrine Neoplasms Improved by Liver Resection?

Background and Objectives: Although many of the neuroendocrine neoplasms (NEN) have a typically prolonged natural history compared with other gastrointestinal tract cancers, at least 40% of patients develop liver metastases. This study aims to identify whether liver resection improves the overall survival of patients with liver metastases from NEN. Materials and Methods: We conducted a retrospective study at "Fundeni" Clinical Institute over a time period of 15 years; we thereby identified a series of 93 patients treated for NEN with liver metastases, which we further divided into 2 groups as follows: A (45 patients) had been subjected to liver resection complemented by systemic therapies, and B (48 patients) underwent systemic therapy alone. To reduce the patient selection bias we performed at first a propensity score matching. This was followed by a bootstrapping selection with Jackknife error correction, with the purpose of getting a statistically illustrative sample. Results: The overall survival of the matched virtual cohort under study was 41 months (95% CI 37-45). Group A virtual matched patients showed a higher survival rate (52 mo., 95% CI: 45-59) than B (31 mo., 95% CI: 27-35), (p < 0.001, Log-Rank test). Upon multivariate analysis, seven independent factors were identified to have an influence on survival: location (midgut) and primary tumor grading (G3), absence of concomitant LM, number (2-4), location (unilobar), grading (G3) of LM, and 25-50% hepatic involvement at the time of the metastatic disease diagnosis. Conclusions: Hepatic resection is nowadays the main treatment providing potential cure and prolonged survival, for patients with NEN when integrated in a multimodal strategy based on systemic therapy.

Gait Recognition as an Authentication Method for Mobile Devices.

With the rate at which smartphones are currently evolving, more and more of human life will be contained in these devices. At a time when data privacy is extremely important, it is crucial to protect one's mobile device. In this paper, we propose a new non-intrusive gait recognition based mechanism that can enhance the security of smartphones by rapidly identifying users with a high degree of confidence and securing sensitive data in case of an attack, with a focus on a potential architecture for such an algorithm for the Android environment. The motion sensors on an Android device are used to create a statistical model of a user's gait, which is later used for identification. Through experimental testing, we prove the capability of our proposed solution by correctly classifying individuals with an accuracy upwards of 90% when tested on data recorded during multiple activities. The experiments, conducted on a low sampling rate and at short time intervals, show the benefits of our solution and highlight the feasibility of an efficient gait recognition mechanism on modern smartphones.

Long-Term Evaluation of the Outcomes of Subtotal Laparoscopic and Robotic Splenectomy in Hereditary Spherocytosis.

BACKGROUND: Hereditary spherocytosis (HS) is a common inherited disease affecting the erythrocyte membrane. Total splenectomy (TS) is effective in reducing hemolysis and decreasing the need of transfusions, but total removal of the spleen represents a potential risk factor for infectious and non-infectious complications. On the other hand, subtotal splenectomy (STS) could be an alternative therapy for HS. The aim of this study is to establish which surgical approach has the best outcome in HS. METHODS: All patients (n = 63) receiving splenectomy for HS between 2002 and 2016 from one institution were retrospectively reviewed. Hemoglobin and reticulocytes levels during preoperative and postoperative follow-up periods were compared. Additionally, a meta-analysis was performed analyzing data regarding hemoglobin and reticulocytes levels from several available studies. RESULT: At 1-year follow-up, our clinical data showed that mean hemoglobin levels increased after TS from (mean ± SD) 9.77 ± 1.82 to 11.88 ± 2.08 g/dl, while after STS from 8.98 ± 1.66 to 11.87 ± 1.38 g/dl. At 3-year and 5-year follow-up after TS, we observed an increase from 9.77 ± 1.82 to 13.59 ± 2.03 and 13.46 ± 1.64 g/dl, respectively. At 3-year and 5-year follow-up after STS in our cohort, we observed an increase from 8.98 ± 1.66 to 13.21 ± 1.95 and 13.68 ± 1.65 g/dl, respectively. The meta-analysis (for a follow-up period of 1 year) showed that the hemoglobin levels increased with 2.61 g/dl (95% CI 2.15-3.08 g/dl; p < 0.001) after TS, and with 1.67 g/dl (95% CI 1.25-2.10 g/dl; p < 0.001) after STS. CONCLUSION: We conclude that subtotal and minimally invasive splenectomy could be considered as the first line of treatment in severe HS cases, especially in children.

Quality of Life in Patients with Surgically Removed Skin Tumors.

Background and Objectives: Skin cancer is one of the most frequently diagnosed malignancies. The main goal of the therapeutic management is total excision with the prevention of recurrence and metastasis. The quality of life of the patients with skin cancer is affected by the morbidity risk, surgery, and cosmetic or functional aspects. The aim of this study was to evaluate the quality of life of patients with skin cancer prior to and post surgical intervention. Material and methods: We performed a prospective study on 247 patients with skin tumors. Quality of life was evaluated through an initial questionnaire that was given to all consenting patients. This was used to determine patients' mobility, selfcare, normal activities, pain, and despair, using a five-point Likert scale. The general autoperceived health state was also recorded using a 100-point scale. The study included the responses of all patients at hospital admission, after one month of surgery, and after one year of surgery. Results: In patients with squamous cell carcinoma (SCC), the general health state indicator statistically significantly decreased one month after surgery and increased at one-year follow-up. In malignant melanoma (MM) patients, mobility, selfcare, normal activities, and discomfort presented a decrease in values one year after surgery, compared to the values registered at hospital admission. In patients with basal cell carcinoma (BCC), all indicators of quality of life presented an impaired value one year after surgery, after a decreasing trend. The general health state indicator statistically significantly increased one month after surgery and after one year. Conclusions: Surgery is one of the main steps in treating skin cancer. It has a great impact on patients' quality of life because of pain andthe effect on mobility and normal activities. Skin cancers influence the quality of life of patients both psychologicallyand physically.

Circulating miRNAs in sepsis-A network under attack: An in-silico prediction of the potential existence of miRNA sponges in sepsis.

Biomarkers based on the molecular mechanism of sepsis are important for timely diagnosis and treatment. A large panel of small non-coding microRNAs was reported to modulate the immune response in sepsis but have not been tested in clinical practice. Large-scale identification of microRNA networks in sepsis might reveal a new biological mechanism that can be also targeted by gene therapy. Therefore, the main objective of this study is to perform a comparison of the miRNA network between septic patients and healthy controls. We used the previously measured levels of expression of 16 different circulating human and viral microRNAs in plasma from 99 septic patients and 53 healthy controls. We used three different computational methods to find correlations between the expressions of microRNAs and to build microRNA networks for the two categories, septic patients and healthy controls. We found that the microRNA network of the septic patients is significantly less connected when compared to miRNA network of the healthy controls (21 edges vs 52 edges, P < 0.0001). We hypothesize that several microRNAs (miR-16, miR-29a, miR-146, miR-155, and miR-182) are being sponged in sepsis explaining the loss of connection in the septic patient miRNA network. This was specific for sepsis, as it did not occur in other conditions characterized by an increased inflammatory response such as in post-surgery patients. Using several target prediction instruments, we predicted potential common sponges for the miRNA network in sepsis from several signaling pathways. Understanding the dynamics of miRNA network in sepsis is useful to explain the molecular pathophysiology of sepsis and for designing therapeutic strategies that target essential components of the immune response pathways.

Liver resection for ovarian cancer liver metastases as part of cytoreductive surgery is safe and may bring survival benefit.

BACKGROUND: The aim of this study was to evaluate whether hepatic resections of ovarian cancer liver metastases provide a benefit in terms of survival as part of primary, secondary, tertiary, and even quaternary cytoreductive surgery. METHODS: Data of patients submitted to surgery for ovarian cancer liver metastases at Fundeni Clinical Institute between January 2002 and April 2014 were retrospectively reviewed. Liver lesions were classified according to their origin in parenchymal and peritoneal lesions. RESULTS: A total of 31 patients were identified: 11 of them underwent liver resection as part of primary cytoreduction, 15 at secondary cytoreduction, 3 at tertiary cytoreduction, and 2 at the time of quaternary cytoreduction. The survival of patients with primary cytoreduction including liver resection was significantly higher compared with that of patients with secondary cytoreductive surgery including liver resection (15.63 versus 6.63 months, log-rank p=0.057, 90% CI). The median survival of patients with hepatectomy for liver metastases from peritoneal seeding was higher than that of patients with hepatectomy for liver metastases from hematogenous origin (16.08 versus 12.66 months, log-rank p=0.523). CONCLUSIONS: Hepatectomy in ovarian cancer liver metastases is a safe and effective procedure; however, a benefit in terms of survival in favor of peritoneal seeding has been systematically observed.

Robotic splenectomy: what is the real benefit?

BACKGROUND: The laparoscopic approach to a difficult splenectomy requires a longer total operative time and is frequently associated with an increased risk of bleeding and a high conversion rate. METHODS: A total of 418 elective splenectomies were registered in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute between January 1995 and June 2012, of which 299 splenectomies (212 laparoscopic and 77 robotic) were performed by a single surgical team and retrospectively documented. The effect of the learning curve and the relative complexity of each type of procedure were analyzed using the Minimally Invasive Splenectomy Score, which further allowed categorizing the splenectomies as simple or difficult. Statistical analyses using the CUSUM algorithm of the intra- and postoperative parameters of the laparoscopic and robotic approaches, for both the simple and the difficult splenectomies, were performed. RESULTS: The results of the statistical analyses clearly indicated that there was a learning curve effect for laparoscopic splenectomy but not for robotic splenectomy. When compared with the laparoscopic approach in difficult splenectomies, the robotic approach had a shorter total operative time (84.13 vs. 97.2 min), less blood loss (30.88 vs. 156.9 ml), and decreased risk of hemorrhagic complications during surgery. CONCLUSIONS: Laparoscopic splenectomy remains the approach of choice for simple splenectomies in the surgical treatment for common indications. The robotic system is particularly beneficial in difficult splenectomies (i.e., partial splenectomy, splenectomy in liver cirrhosis, splenic tumors, or malignant hemopathies).

An exploratory study of inflammatory cytokines as prognostic biomarkers in patients with ductal pancreatic adenocarcinoma.

OBJECTIVES: We measured the serum concentration of a panel of inflammatory cytokines and evaluated their association with circulating proangiogenic biomarkers and with outcome in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: We collected serum samples from 36 patients with PDAC, 9 patients with chronic pancreatitis, and 22 healthy volunteers as a control. Inflammatory cytokines and proangiogenic biomarkers were measured using the multianalyte xMAP array and carcinoembryonic antigen (CEA) and carbohydrate 19-9 by immunoassay. RESULTS: Patients with PDAC had higher circulating levels of interleukin 6 (IL-6) than those of patients with pancreatitis or healthy individuals and higher levels of IL-10 and tumor necrosis factor α (TNF-α) compared with those of healthy individuals. In patients with PDAC, circulating IL-6, TNF-α, IL-1ß, and IL-10 correlated with serum concentrations of vascular endothelial growth factor and basic fibroblast growth factor; circulating IL-6, IL-1ß, and TNF-α correlated with carbohydrate 19-9; and IL-8, IL-10, and TNF-α correlated with CEA levels. Circulating IL-8, TNF-α, and CEA; tumor stage; and lymph node metastases were associated with a poor outcome. CONCLUSIONS: The results of this exploratory study indicate that inflammatory cytokines should be pursued as potential prognostic biomarkers as well as targets for therapy in larger studies in PDAC.

Risk factors for surgical complications after central pancreatectomy.

BACKGROUND/AIMS: Central pancreatectomy is a pancreas-sparing alternative to standard pancreatic resections in selected cases. Although associated with high morbidity, the risk factors for surgical complications of this procedure are not yet defined. METHODOLOGY: The clinicopathological and perioperative data of 24 patients who underwent central pancreatectomies (2002-2010) were correlated with surgical complications. RESULTS: The overall morbidity rate was 54% (pancreatic fistula, 40%). In a univariate analysis, age over 40 years, body mass index ≥30kg/m2, smoking and American Society of Anesthesiologists III scores were significantly correlated with increased morbidity. In a multivariate analysis, a significant correlation with the development of complications was found for body mass index ≥30kg/m2 and age over 40 years. CONCLUSIONS: Certain patient-related factors (older age, obesity and smoking) appear to have a negative impact on early postoperative outcome after central pancreatectomy. For patients with these factors, an alternative distal pancreatectomy should be considered. Central pancreatectomy should be tailored not only to the pathology but also to the patient profile.