Contrast-enhanced ultrasound (CEUS): one step forward in the identification of "high risk" solitary fibrotic tumors of the liver.

BACKGROUND: Solitary fibrous tumors of the liver (SFTL) are rare neoplasms, whose identification and definition of malignant potential are challenging. CASE PRESENTATION: A 62-year-old patient underwent conventional imaging and CEUS to characterize an indeterminate liver lesion after other imaging techniques were inconclusive. In fact, all diagnostic techniques concluded that it was a partially fibrotic lesion, while CEUS determined its extra-hepatocellular origin and malignant potential, initially hypothesized to be a cholangiocarcinoma. Due to the possible risk of seeding following a biopsy procedure, the patient was a candidate for surgery. Subsequently, histopathological examination revealed SFTL. CONCLUSION: CEUS confidently characterized the malignancy and hypothesized the origin of the liver lesion, thus aiding in treatment planning.

Neo-Adjuvant Treatment in Primary Resectable Pancreatic Cancer: A Systematic Review and PRISMA-Compliant Updated Metanalysis of Oncological Outcomes.

BACKGROUND: Despite advances in treatment, the prognosis of resectable pancreatic adenocarcinoma remains poor. Neoadjuvant therapy (NAT) has gained great interest in hopes of improving survival. However, the results of available studies based on different treatment approaches, such as chemotherapy and chemoradiotherapy, showed contrasting results. The aim of this systematic review and meta-analysis is to clarify the benefit of NAT compared to upfront surgery (US) in primarily resectable pancreatic adenocarcinoma. METHODS: A PRISMA literature review identified 139 studies, of which 15 were finally included in the systematic review and meta-analysis. All data from eligible articles was summarized in a systematic summary and then used for the meta-analysis. Specifically, we used HR for OS and DFS and risk estimates (odds ratios) for the R0 resection rate and the N+ rate. The risk of bias was correctly assessed according to the nature of the studies included. RESULTS: From the pooled HRs, OS for NAT patients was better, with an HR for death of 0.80 (95% CI: 0.72-0.90) at a significance level of less than 1%. In the sub-group analysis, no difference was found between patients treated with chemoradiotherapy or chemotherapy exclusively. The meta-analysis of seven studies that reported DFS for NAT resulted in a pooled HR for progression of 0.66 (95% CI: 0.56-0.79) with a significance level of less than 1%. A significantly lower risk of positive lymph nodes (OR: 0.45; 95% CI: 0.32-0.63) and an improved R0 resection rate (OR: 1.70; 95% CI: 1.23-2.36) were also found in patients treated with NAT, despite high heterogeneity. CONCLUSIONS: NAT is associated with improved survival for patients with resectable pancreatic adenocarcinoma; however, the optimal treatment strategy has yet to be defined, and further studies are required.

Neuraxial anesthesia for abdominal surgery, beyond the pandemic: a feasibility pilot study of 70 patients in a suburban hospital.

The aim of this study is to establish the feasibility of awake laparotomy under neuraxial anesthesia (NA) in a suburban hospital. A retrospective analysis of the results of a consecutive series of 70 patients undergoing awake abdominal surgery under NA at the Department of Surgery of our Hospital from February 11th, 2020 to October 20th, 2021 was conducted. The series includes 43 cases of urgent surgical care (2020) and 27 cases of elective abdominal surgery on frail patients (2021). Seventeen procedures (24.3%) required sedation to better control patient discomfort. Only in 4/70 (5.7%) cases, conversion to general anesthesia (GA) was necessary. Conversion to GA was not related to American Society of Anesthesiology (ASA) score or operative time. Only one of the four cases requiring conversion to GA was admitted to the Intensive Care Unit (ICU) postoperatively. Fifteen patients (21.4%) required postoperative ICU support. A statistically non-significant association was observed between conversion to GA and postoperative ICU admission. The mortality rate was 8.5% (6 patients). Five out of six deaths occurred while in the ICU. All six were frail patients. None of these deaths was related to a complication of NA. Awake laparotomy under NA has confirmed its feasibility and safety in times of scarcity of resources and therapeutic restrictions, even in the most frail patients. We believe that this approach should be considered as an useful asset, especially for suburban hospitals.

Gut microbiota composition in colorectal cancer patients is genetically regulated.

The risk of colorectal cancer (CRC) depends on environmental and genetic factors. Among environmental factors, an imbalance in the gut microbiota can increase CRC risk. Also, microbiota is influenced by host genetics. However, it is not known if germline variants influence CRC development by modulating microbiota composition. We investigated germline variants associated with the abundance of bacterial populations in the normal (non-involved) colorectal mucosa of 93 CRC patients and evaluated their possible role in disease. Using a multivariable linear regression, we assessed the association between germline variants identified by genome wide genotyping and bacteria abundances determined by 16S rRNA gene sequencing. We identified 37 germline variants associated with the abundance of the genera Bacteroides, Ruminococcus, Akkermansia, Faecalibacterium and Gemmiger and with alpha diversity. These variants are correlated with the expression of 58 genes involved in inflammatory responses, cell adhesion, apoptosis and barrier integrity. Genes and bacteria appear to be involved in the same processes. In fact, expression of the pro-inflammatory genes GAL, GSDMD and LY6H was correlated with the abundance of Bacteroides, which has pro-inflammatory properties; abundance of the anti-inflammatory genus Faecalibacterium correlated with expression of KAZN, with barrier-enhancing functions. Both the microbiota composition and local inflammation are regulated, at least partially, by the same germline variants. These variants may regulate the microenvironment in which bacteria grow and predispose to the development of cancer. Identification of these variants is the first step to identifying higher-risk individuals and proposing tailored preventive treatments that increase beneficial bacterial populations.

18F-FDG PET Radiomics as Predictor of Treatment Response in Oesophageal Cancer: A Systematic Review and Meta-Analysis.

The best treatment strategy for oesophageal cancer patients achieving a complete clinical response after neoadjuvant chemoradiation is a burning topic. The available diagnostic tools, such as 18F-FDG PET/CT performed routinely, cannot accurately evaluate the presence or absence of the residual tumour. The emerging field of radiomics may encounter the critical challenge of personalised treatment. Radiomics is based on medical image analysis, executed by extracting information from many image features; it has been shown to provide valuable information for predicting treatment responses in oesophageal cancer. This systematic review with a meta-analysis aims to provide current evidence of 18F-FDG PET-based radiomics in predicting response treatments following neoadjuvant chemoradiotherapy in oesophageal cancer. A comprehensive literature review identified 1160 studies, of which five were finally included in the study. Our findings provided that pooled Area Under the Curve (AUC) of the five selected studies was relatively high at 0.821 (95% CI: 0.737-0.904) and not influenced by the sample size of the studies. Radiomics models exhibited a good performance in predicting pathological complete responses (pCRs). This review further strengthens the great potential of 18F-FDG PET-based radiomics to predict pCRs in oesophageal cancer patients who underwent neoadjuvant chemoradiotherapy. Additionally, our review imparts additional support to prospective studies on 18F-FDG PET radiomics for a tailored treatment strategy of oesophageal cancer patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42021274636.

Colorectal medullary carcinoma: heterogeneous presentations of a rare clinico-pathological entity. Report of two cases.

Colorectal medullary carcinoma (CMC) is a rare subset of minimally differentiated carcinomas. CMC tend to be right-sided and present at an advanced stage. Despite this, distant metastases are rare at presentation. The liver and the regional lymph nodes represent the most common sites of metastases. Most of the time, CMCs exhibit mismatch repair deficiency and a strong association with high-level microsatellite instability. There is no conspicuous data regarding treatment strategies and short-term outcomes. CMC is supposed to be related to better prognosis compared to poorly-differentiated and undifferentiated colonic adenocarcinomas, but reports are controversial.This lesion, with heterogeneous presentations and unclear prognostic significance, may be unfamiliar to histopathologists and can lead to diagnostic uncertainty and overtreatments.Our aim is to renew the attention to this rare histological subtype through the report of two cases.

Pain Distraction During Awake Major Colorectal Surgery: Supporting Patients Beyond the COVID-19 Era. Preliminary Findings.

Introduction: During the coronavirus disease 2019 (COVID-19) pandemic, hospitals rapidly ran out of intensive care beds. Because minimally invasive surgery and general anaesthesia are both aerosol-generating procedures, their use has become controversial. We report a case series of awake undelayable colorectal surgeries which, innovatively, took advantage of intraoperative pain distraction. Moreover, we describe our frugal solution to social distancing in psychological support of inpatients. Methods: Between October 2020 and February 2021, five patients underwent acute-care colorectal surgery under locoregional anaesthesia in our department. A 3D mobile theatre (3DMT) was used during the operation to distract the patients from pain. Vital signs, pain intensity, ergonomic comfort/discomfort, sense of presence and distress were intraoperatively monitored. A postoperative "cuddle delivery" service was instituted: video messages from relatives and close friends were delivered daily to the patient through the 3DMT. Emotional effects were investigated through clinical interviews conducted by a psychologist at our hospital. Results: Both intraoperative and postoperative pain were always well controlled. Conversion to general anaesthesia and postoperative intensive support/monitoring were never necessary. The "cuddle delivery" initiative helped patients fill the emotional gap created by the strict containment measures implemented inside the hospital, distracting them from emotional anxiety and physical pain. Conclusions: During the next phase of the COVID-19 pandemic and even after the COVID-19 era, awake laparotomy under locoregional anaesthesia may be a crucial option for delivering acute-care surgery to selected patients when intensive care beds are unavailable and postponing surgery is unacceptable. We also introduce a new modality for the provision of emotional support during postoperative inpatient care as a countermeasure to the restrictions imposed by social distancing measures.

Trans-prosthetic recanalization of a collapsed iliac limb using the GoBack catheter: a case report.

BACKGROUND: Recanalization of graft limb occlusion can prove challenging and the use of the GoBack crossing and reentry device may be a suitable option, especially when there is no other way to restore flow with an usual endovascular approach. The GoBack catheter is a novel device designed to enhance pushability, and to enable direction-change inside hard plaques and crossing of tough lesions, even when they involve graft fabric. CASE PRESENTATION: It's reported a case of a 76-year-old male who presented with claudication, previous placement of an aorto-bi iliac graft by open surgery for a ruptured abdominal aneurysm 10 years ago that, over time, developed severe kinking on the left limb and a fabric occlusion on the right limb. After several unsuccessful attempts to cross the occlusion of the right common iliac artery, the GoBack™ was deployed to create a lumen through graft's folds. After angioplasty and stenting a satisfactory result was achieved, restoring flowCT-scan at 1 month and duplex ultrasound (DUS) at 3 months confirmed the patency of ilio-femoral axis. CONCLUSIONS: The advent of this new CTO crossing device has the potential to facilitate recanalization of some of the most challenging occlusions. Facilitating more consistent distal entry and allowing for a decrease in crossing time. Therefore, the GoBack catheter should be considered as a potential complementary tool to treat vascular occlusions via endovascular approaches, especially when classical endovascular techniques fail.

Awake Major Abdominal Surgeries in the COVID-19 Era.

Background: During the outbreak of coronavirus disease 2019 (COVID-19), allocating intensive care beds to patients needing acute care surgery became a very difficult task. Moreover, since general anesthesia is an aerosol-generating procedure, its use became controversial. This strongly restricted therapeutic strategies. Here, we report a series of undeferrable surgical cases treated with awake surgery under neuraxial anesthesia. Contextual benefits of this approach are deepened. Methods: During the first pandemic surge, thirteen patients (5 men and 8 women) with a mean age of 80 years, needing undelayable surgery due to abdominal emergencies, underwent awake open surgery at our Hospital. Prior to surgery, all patients underwent nasopharyngeal swab tests for COVID-19 diagnosis. In all cases, regional anesthesia (spinal, epidural, or combined spinal-epidural anesthesia) was performed. Intraoperative and postoperative pain intensities have been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. Postoperative course has been examined. Results: The mean operative time was 87 minutes (minimum 60 minutes; maximum 165 minutes). In one case, conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. No perioperative major complications (Clavien-Dindo ≥3) occurred. Early readmission after surgery never occurred. All nasopharyngeal swabs resulted negative. Conclusions: In our experience, awake laparotomy under regional anesthesia resulted feasible, safe, painless, and, in specific cases, was the only viable option. This approach allowed prevention of the need of postoperative intensive monitoring during the COVID-19 era. In such a peculiar time, we believe it could become part of an ICU-preserving strategy and could limit viral transmission inside theatres.

The management of "fragile" and suspected COVID-19 surgical patients during pandemic: an Italian single-center experience.

BACKGROUND: During Coronavirus disease (COVID-19) pandemic entire countries rapidly ran out of intensive care beds, occupied by critically ill infected patients. Elective surgery was initially halted and acute non-deferrable surgical care drastically limited. The presence of COVID-19 patients into intensive care units (ICU) is currently decreasing but their congestion have restricted our therapeutic strategies during the last months. METHODS: In the COVID-19 era eighteen patients (8 men, 10 women) with a mean age of 80 years, needing undelayable abdominal surgery underwent awake open surgery at our Department. Prior to surgery, all patients underwent COVID-19 investigation. In all cases locoregional anesthesia (LA) was performed. Intraoperative and postoperative pain has been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. RESULTS: Mean operative time was 104 minutes. In only one case conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. Only one perioperative complication occurred. Early readmissions after surgery were never observed. CONCLUSIONS: On the basis of our experience awake laparotomy under LA resulted feasible, safe, painless and, in specific cases, the only viable option. For patients presenting fragile cardiovascular and respiratory, reserves and in whom general anesthesia (GA) would presumably increase morbidity and mortality we encourage LA as an alternative to GA. In the COVID-19 era, it has become part of our ICU-preserving strategy allowing us to carry out undeferrable surgeries.

Comment on "Response of a comprehensive cancer center to the COVID-19 pandemic: the experience of the Fondazione IRCCS-Istituto Nazionale dei Tumori di Milano".

Although European governments have launched the so-called phase 2 in the coronavirus disease 2019 (COVID-19) pandemic (a transitional phase of beginning to downsize containment measures), intensive care units are not COVID-19-free and this restricts our therapeutic strategies. Moreover, minimally invasive surgery and general anesthesia are under debate as they are both aerosol-generating procedures and may contribute to contamination spread inside operating theatres. During this pandemic, 13 fragile patients needing abdominal surgery underwent awake open surgery under locoregional anesthesia at our department. This approach was feasible, safe, and, in specific cases, the only viable option. In the COVID-19 era, this approach could allow surgeons to carry out undeferrable surgeries, preventing viral transmission inside the operating room.

Three-dimensional laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomoses for morbid obesity. A single center experience.

PURPOSE: To assess the impact of three-dimensional (3D) vision use on operative time (OT) in laparoscopic Roux-en-Y gastric bypass (LRYGB) with hand-sewn anastomoses. METHODS: We analyzed a prospectively collected database of patients who underwent LRYGB. We included all patients operated on with either 2D or 3D vision. Demographics and clinical characteristics, operative time, hospital stay and 30-day postoperative complications were collected for all patients and analyzed. RESULTS: During the study time, out of 143 patients who underwent LRYGB for morbid obesity, 111 were considered eligible. Seventy-eight patients were operated with 2D vision and 33 patients with 3D vision. Demographics and clinical characteristics were not different among groups. Mean OT was 203±51 and 167±32 minutes in the 2D and 3D groups respectively (p<0.001). Multivariate analyses showed that increasing age and BMI were independently related to prolonged OT, while 3D vision (OR 6.675, 95% CI 2.380-24.752, p<0.001) was strongly associated with shorter OT. CONCLUSIONS: The use of 3D vision in LRYGB significantly reduced the OT, though intra- and postoperative complication rates and the length of hospital stay were not affected. Despite its limitations, our study supports the value of 3D vision laparoscopy in bariatric surgery.

Three-dimensional laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomoses for morbid obesity. A single center experience

Abstract Purpose To assess the impact of three-dimensional (3D) vision use on operative time (OT) in laparoscopic Roux-en-Y gastric bypass (LRYGB) with hand-sewn anastomoses. Methods We analyzed a prospectively collected database of patients who underwent LRYGB. We included all patients operated on with either 2D or 3D vision. Demographics and clinical characteristics, operative time, hospital stay and 30-day postoperative complications were collected for all patients and analyzed. Results During the study time, out of 143 patients who underwent LRYGB for morbid obesity, 111 were considered eligible. Seventy-eight patients were operated with 2D vision and 33 patients with 3D vision. Demographics and clinical characteristics were not different among groups. Mean OT was 203±51 and 167±32 minutes in the 2D and 3D groups respectively (p<0.001). Multivariate analyses showed that increasing age and BMI were independently related to prolonged OT, while 3D vision (OR 6.675, 95% CI 2.380-24.752, p<0.001) was strongly associated with shorter OT. Conclusions The use of 3D vision in LRYGB significantly reduced the OT, though intra- and postoperative complication rates and the length of hospital stay were not affected. Despite its limitations, our study supports the value of 3D vision laparoscopy in bariatric surgery.

Economic growth and health progress in Italy: 30 years of National Health Service.

On December 23 of 1978, during first Italian recession since the end of World War II, Parliament voted for Law 833 that gives birth to the Italian National Public Health Services (SSN) as the new and alternative model of health care system. It was the beginning of the match of Italian health care with the world class level of the public health care. Each crisis requires solidarity and actions. Maintaining levels of health and other social expenditures is critical to protect life and livelihood and to boost productivity. The purpose of the present study is to establish an alternative point of view to demonstrate that Gross Domestic Product, is a function of health care expenditure. The chronology of the events was created by using the laws published on "Gazzetta Ufficiale" (GU). In order to analyze the corporate effectiveness and efficiency, we have divided the SSN into its three main components, namely resources (input), services (output) and performances (outcome). Health services have certainly been pioneers and are still today standard-bearers of a challenge which has borne its fruits. According to the "Organization for Economic Co-operation and Development", SSN ranks second in the world classification of the return on the health care services in 2000. The World Health Organization has published in 2005 the same result: SSN ranks second in the world for ability and quality of the health care in relationship to the resources invested The continuous reforms of health care system introduced stability to the Italian system more than others countries. Success of SSN function rooted in the ability of system to adapt assuring mechanism of positive feed-back correction. In the future SSN, will required new set of reforms, such as redefinition of structures and mechanisms of governance, strategic plans, clinical administrations.

Metastasis of sigmoid colon cancer in cryptorchid testis: report of a case.

Isolated testicular metastasis from colorectal cancer is considered an unusual event. In this case report we describe for the first time a metastasis from an adenocarcinoma of the sigmoid colon to a cryptorchid testis. The patient developed a painless testicular nodule three years after the diagnosis of primary sigmoid colon cancer. Recent reports have suggested that the incidence of genitourinary abnormalities in human males has increased over the past 50 years; in particular, cryptorchid testes increase the clinical risk factors for primary or metastatic testicular cancer. In conclusion, there should be awareness of the risk of metastasis of colorectal cancer to the testis in the workup of patients with testicular symptoms. Furthermore, patients with colorectal cancer and cryptorchidism should be managed with a single surgical intervention: when the primary colorectal tumor is removed, the cryptorchid testicle should also be removed to reduce the risk of late metastases.

Wall defects after abdominoperineal resection: a modified tension-free technique.

BACKGROUND: The treatment of wall defects after abdominoperineal resection has yet to be defined. In this study we report the outcome of a modified prosthetic technique for the treatment of combined large incisional and parastomal hernia performed after abdominoperineal resection. MATERIAL AND METHODS: Between January 2005 and July 2008, 21 consecutive patients who underwent abdominoperineal resection for low rectal cancer received surgical repair for large incisional hernias with a modified mesh technique consisting of a tension-free attachment of the prosthetic material to the posterior sheath of the rectus abdominis muscle. The surgical outcome was assessed mainly as the recurrence rate of abdominal hernia and postoperative complications. RESULTS: Among the 21 patients we reported two minor complications: partial necrosis of the skin flap (4.8%) and a seroma (4.8%). One major complication occurred: extensive necrosis of the skin flap (4.8%). We reported one death due to stroke 20 days after surgery. The mean postoperative hospital stay was 6.1 days (SD, 2.3). CONCLUSIONS: This study encourages the use of a tension-free modified prosthetic technique for the repair of combined wall defects after abdominoperineal resection. The technique does not lead to an increase in the incidence of complications, offering a considerable advantage to the patient.

Primary ileus after total hip arthroplasty: rare complication or sentinel event?

The incidence of hip dislocation after primary total hip arthroplasty (THA) has been reported to range from 1 to 25% in THA revision. Here, we explore the hypothesis that there is a correlation between postoperative ileus (POI) and THA dislocation, with POI after THA possibly representing a sentinel event. We retrospectively identified a cohort of 529 consecutive patients who underwent hip arthroplasty from 2008 to 2010. Of them, 251 were male and 278 were female, and a mean average for age of 71.5 (range 65-76). In particular, 19 THA patients showed signs of gastrointestinal complications, and therapeutic consultation was performed with the onset of the first intestinal symptom. Of these 19 patients, 3 THA patients developed POI within 1 week after surgical treatment. A conservative treatment was practised and it seemed to improve the condition: canalization returned and all patients were discharged from the hospital. Unfortunately, two of these patients were readmitted after 2 weeks due to THA dislocation and they underwent THA revision and were discharged from the hospital 7 days later. Follow-up revealed no further problems at 6 months. Our clinical experience with these post-THA primary ileus patients raises the possibility that intra-abdominal symptoms represent a sentinel event in THA dislocation. THA dislocation using neuronal pathway of immunomodulation may modulate POI. Since the risk of THA dislocation is the greatest in the first 3 months after hip arthroplasty, the surgeon should be familiar with the relationship between THA and various pelvic and visceral complications to ensure that POI remains only a rare complication.

Multiple genetic loci modulate lung adenocarcinoma clinical staging.

PURPOSE: The main prognostic factor of lung cancer patient outcome is clinical stage, a parameter of tumor aggressiveness. Our study was conducted to test whether germ line variations modulate individual differences in clinical stage. EXPERIMENTAL DESIGN: We conducted a case-only genome-wide association study (GWAS) using a 620,901 single-nucleotide polymorphism (SNP) array in a first series of 600 lung adenocarcinoma (ADCA) patients and in a replication series of 317 lung ADCA patients. RESULTS: GWAS identified 54 putatively associated SNPs, 3 of which were confirmed in the replication series. Joint analysis of the two series pointed to 22 statistically associated (P < 0.01) genetic variants that together explained about 20% of the phenotypic variation in clinical staging (P < 2 × 10(-16)) and showed a statistically significant difference in overall survival (P = 8.0 × 10(-8)). The strongest statistical association was observed at rs10278557 (P = 1.1 × 10(-5)), located in the mesenchyme homeobox 2 (MEOX2) gene. CONCLUSION: These data point to the role of germ line variations involving multiple loci in modulating clinical stage and, therefore, prognosis in lung ADCA patients.

Giant condyloma acuminatum of the anorectum: successful radical surgery with anal reconstruction.

Buschke-Löwenstein tumor, or giant condyloma acuminatum, is a relatively uncommon lesion of the anus with aggressive local invasive behavior which may present as a large warty tumor of the genital region with expansive and destructive growth. Many sporadic reports have been published suggesting various therapeutic strategies. We report a case of Buschke-Löwenstein tumor treated with conservative surgery followed by reconstructive procedures without a loop colostomy

Hospital bodies: the genesis of Italian National Health Service.

Hospital public bodies were instituted in Italy in 1968. Their creation represents a fundamental step forward in the evolution of the national healthcare system and has allowed improvements in social equity in hospitals. The lack of independent funding beyond the insurance-type healthcare system existing at the time, hindered its success. The hospital body has however left a trace in the modern national healthcare system with the introduction of the hospital corporation.