Magnetic-Assisted Capsule Endoscopy in Children With Crohn Disease: Feasibility and Impact on Gastric Transit Time.

OBJECTIVES: Standard capsule endoscopy (CE) is ineffective for upper gastrointestinal (GI) tract examination because it does not allow operator-controlled navigation of the capsule. Magnetically assisted capsule endoscopy (MACE) may offer a solution to these problems. This pilot study is aimed to evaluate the feasibility of MACE system in pediatric Crohn disease (CD) and if magnetic steering could enhance capsule gastric emptying when compared with standard CE. METHODS: Pediatric CD patients already studied by standard small bowel CE were enrolled. All participants swallowed a magnetically assisted CE and an external magnetic field navigator was used to guide the capsule through the upper GI tract. Maneuverability, completeness of the MACE examination, differences in the esophageal transit time (ETT), gastric transit time (GTT), and pyloric transit time (PTT) between standard CE and MACE were assessed. RESULTS: Ten patients [mean age 11.4 years (range 6-15); 60% male] were enrolled. Maneuverability was defined as good and fair in 60% and 40% of participants, respectively. Completeness of MACE examination was 95%, 65%, and 92.5% in the esophagus, proximal, and distal stomach, respectively. Transpyloric passage of the capsule under magnetic control was successfully performed in 80% of patients. Magnetic intervention significantly increased ETT ( P < 0.001) and reduced GTT and PTT ( P = 0.002). No significant adverse events occurred. CONCLUSIONS: MACE is a safe and feasible technique in children. Magnetic steering enhances capsule gastric emptying and facilitates capsule transpyloric passage when compared with standard CE.

Laparoscopic versus open rectal resection: a 1:2 propensity score-matched analysis of oncological adequateness, short- and long-term outcomes.

BACKGROUND: Laparoscopic resections for rectal cancer are routinely performed in high-volume centres. Despite short-term advantages have been demonstrated, the oncological outcomes are still debated. The aim of this study was to compare the oncological adequateness of the surgical specimen and the long-term outcomes between open (ORR) and laparoscopic (LRR) rectal resections. METHODS: Patients undergoing laparoscopic or open rectal resections from January 1, 2013, to December 31, 2019, were enrolled. A 1:2 propensity score matching was performed according to age, sex, BMI, ASA score, comorbidities, distance from the anal verge, and clinical T and N stage. RESULTS: Ninety-eight ORR were matched to 50 LRR. No differences were observed in terms of operative time (224.9 min. vs. 230.7; p = 0.567) and postoperative morbidity (18.6% vs. 20.8%; p = 0.744). LRR group had a significantly earlier soft oral intake (p < 0.001), first bowel movement (p < 0.001), and shorter hospital stay (p < 0.001). Oncological adequateness was achieved in 85 (86.7%) open and 44 (88.0%) laparoscopic resections (p = 0.772). Clearance of the distal (99.0% vs. 100%; p = 0.474) and radial margins (91.8 vs. 90.0%, p = 0.709), and mesorectal integrity (94.9% vs. 98.0%, p = 0.365) were comparable between groups. No differences in local recurrence (6.1% vs.4.0%, p = 0.589), 3-year overall survival (82.9% vs. 91.4%, p = 0.276), and disease-free survival (73.1% vs. 74.3%, p = 0.817) were observed. CONCLUSIONS: LRR is associated with good postoperative results, safe oncological adequateness of the surgical specimen, and comparable survivals to open surgery.

Early Induction of Bedside Pneumoperitoneum in the Management of Residual Pleural Space and Air Leaks After Pulmonary Resection.

BACKGROUND: The pneumoperitoneum to treat prolonged air leaks or pleural space problems after pulmonary resection has been successfully used for decades. The aim of the study is to describe our experience with the early induction of therapeutic pneumoperitoneum (TP). METHODS: We reviewed the data of 103 consecutive patients undergoing TP between September 2011 and September 2019. Patients were divided into two groups according to the time of the induction of TP: early application (≥72 h) and standard application (>72 h). RESULTS: In total, 52 early TP and 51 standard TP were analyzed. The median time of TP induction was 2 (1-3) versus 8 (5-11) postoperative days (POD) (p < 0.001). The time for obliteration of the residual pleural space (7 vs.9 days, p = 0.805) and the time of resolution of the air leaks (14 vs. 16 days, p = 0.663) didn't differ between the two groups, but a favorable trend was observed in the early group. The hospital stay was lower for patients undergoing early pneumoperitoneum: 9 versus 18 days (p < 0.001). The multivariate analysis showed that POD of induction of TP (p < 0.001), time of resolution of the air leak (p < 0.001) and Heimlich valve (p = 0.002) were independent variables associated with the hospital stay. CONCLUSIONS: The use of TP whenever a space problem or air leaks occur after pulmonary resections is safe and effective. Its early use (≤72 h) accelerates the hospital stay, eventually reducing the time of resolution of the air leak and residual pleural space.

The Emergency Surgery Frailty Index (EmSFI): development and internal validation of a novel simple bedside risk score for elderly patients undergoing emergency surgery.

BACKGROUND: Frailty assessment has acquired an increasing importance in recent years and it has been demonstrated that this vulnerable profile predisposes elderly patients to a worse outcome after surgery. Therefore, it becomes paramount to perform an accurate stratification of surgical risk in elderly undergoing emergency surgery. STUDY DESIGN: 1024 patients older than 65 years who required urgent surgical procedures were prospectively recruited from 38 Italian centers participating to the multicentric FRAILESEL (Frailty and Emergency Surgery in the Elderly) study, between December 2016 and May 2017. A univariate analysis was carried out, with the purpose of developing a frailty index in emergency surgery called "EmSFI". Receiver operating characteristic curve analysis was then performed to test the accuracy of our predictive score. RESULTS: 784 elderly patients were consecutively enrolled, constituting the development set and results were validated considering further 240 consecutive patients undergoing colorectal surgical procedures. A logistic regression analysis was performed identifying different EmSFI risk classes. The model exhibited good accuracy as regard to mortality for both the development set (AUC = 0.731 [95% CI 0.654-0.772]; HL test χ2 = 6.780; p = 0.238) and the validation set (AUC = 0.762 [95% CI 0.682-0.842]; HL test χ2 = 7.238; p = 0.299). As concern morbidity, our model showed a moderate accuracy in the development group, whereas a poor discrimination ability was observed in the validation cohort. CONCLUSIONS: The validated EmSFI represents a reliable and time-sparing tool, despite its discriminative value decreased regarding complications. Thus, further studies are needed to investigate specifically surgical settings, validating the EmSFI prognostic role in assessing the procedure-related morbidity risk.

Laparoscopic versus open distal gastrectomy for locally advanced gastric cancer in middle-low-volume centers in Western countries: a propensity score matching analysis.

BACKGROUND: Gastrectomy with D2 lymphadenectomy is the standard treatment for patients with resectable gastric cancer. Laparoscopic distal gastrectomy (LDG) is routinely performed for early gastric cancer, and its indications are increasing even for locally advanced gastric cancer. The aim of this study is to compare two middle-low-volume centers in Western countries experience on LDG versus open distal gastrectomy (ODG) for locally advanced gastric cancer in terms of surgical and oncological outcomes. METHODS: We reviewed the data of 123 consecutive patients that underwent LDG and ODG with D2 lymphadenectomy between 2009 and 2014. Among them, 91 were eligible for inclusion (46 LDG and 45 ODG). After propensity score matching analysis, using a 1:1 case-control match, 34 patients were stratified for each group. RESULTS: The mean operative time was significantly longer in the LDG group (257.2 vs. 197.2, p < 0.001). No differences were observed in terms of intraoperative blood loss, average number of lymph nodes removed, and lymph node metastases. The postoperative morbidity was comparable in the two groups. LDG group had a significant faster bowel canalization and soft oral intake (p < 0.001). The 5-year overall and disease-free survival were higher for patients treated by laparoscopy, but the post-hoc subgroups analysis revealed that the advantage of LDG was significant just in N0 and stage IB-II patients, whereas N+ and stage III patient's survival curves were perfectly superimposable. CONCLUSIONS: LDG for locally advanced gastric cancer seems to be feasible and safe with surgical and long-term oncological outcomes comparable with open surgery, even in medium-low-volume centers.

D1-plus vs D2 nodal dissection in gastric cancer: a propensity score matched comparison and review of published literature.

BACKGROUND: The results of D1-plus lymphadenectomy following gastric resection are seldom investigated. The aim of this study was to compare results of D1-plus vs D2 resections and to provide a literature review. METHODS: Patients who underwent upfront R0 gastrectomy for adenocarcinoma from 2000 to 2016 in three Institutions were selected using propensity scores and categorized according to lymphadenectomy. Statistical analyses were performed for the nodal harvest (LNH) and survival. Published literature comparing D1-plus and D2 was reviewed and analyzed according to PICO and PRISMA guidelines. RESULTS: Two matched groups of 93 D1-plus and 93 D2 resections were selected. LNH was significantly greater in D2 vs D1-plus dissections (mean 31.2 vs 27.2, p 0.04), however LNH distribution was similar. The cumulative incidence curves for overall survival, disease free and disease specific events did not report significant differences, however Cox regression analysis disclosed that total gastrectomies (HR 1.8; 95% 1.0-2.9), advanced stages (HR 5.9; 95% 3.4-10.3) and D1-plus nodal dissection (HR 2.1; 95% 1.26-3.50) independently correlated with disease free survival. Literature review including 297 D1-plus and 556 D2 lymphadenectomies documented LNH in favor of D2 sub-group (SMD -0.772; 95%CI -1.222- -0.322). CONCLUSION: D2 provided greater LNH than D1-plus dissections; prospective studies should aim to investigate long-term survival of D1-plus lymphadenectomy.

Down-regulated miRs specifically correlate with non-cardial gastric cancers and Lauren's classification system.

BACKGROUND AND OBJECTIVES: Gastric cancers are usually characterized using Lauren's classification into intestinal and diffuse types. We previously documented the down-modulation of miR31, miR148a, miR204, and miR375 in gastric cancers. We aimed this manuscript to investigate these miRs with the end-points of diagnosis, Lauren's classification and prognosis. METHODS: A total of 117 resected non-cardial adenocarcinomas were evaluated for miRs' expressions. The performance of miRs' expressions for cancer diagnosis was tested using ROC curves. Logistic regression was conducted with the end-point of Lauren's classification. Kaplan-Meier and Cox analyses were performed for OS, DFS, and DSS. miRs' targets were reviewed using PRISMA method and BCL-2 was further investigated in cell lines. RESULTS: ROC curves documented that miRs' down-modulation was significant in differentiating cancer versus normal tissues. Diffuse type cancers were associated with female sex, young age, and miR375 higher expression. We confirmed BCL-2 as a miR204 target. However, survival analyses confirmed the pathologic criteria (advanced stages, LNR, and low LNH) as the significant variables correlated to worse prognosis. CONCLUSIONS: The down-modulation of miR31, miR148a, miR204, and miR375 is significantly associated with non-cardial gastric cancers and miR375 is specifically linked to Lauren's classification. Nevertheless, standard pathological features display as the independent variables associated with worse prognosis.

Emergency surgery for colorectal cancer does not affect nodal harvest comparing elective procedures: a propensity score-matched analysis.

PURPOSE: About 30% of colorectal cancers (CRCs) present with acute symptoms. The adequacy of oncologic resections is a matter of concern since few authors reported that emergency surgery in these patients results in a lower lymph node harvest (LNH). In addition, emergency resections have been reported with a longer hospital stay and higher morbidity rate. We thus conducted a propensity score-matched analysis with the aim of investigating LNH in emergency specimens comparing with elective ones. Secondary aim was the comparison of morbidity and hospital stay. METHODS: Eighty-seven consecutive R0 emergency surgical procedures were matched with elective CRCs using the propensity score method and the following covariates: age, sex, stage, and localization. Groups were compared using univariate and multivariate analyses. Outcome measures were LNH, nodal ratio, Clavien's morbidity grades, and hospital stay. RESULTS: Emergency patients presented more metastatic nodes compared with elective ones (p 0.017); however, both presented a comparable mean LNH. Multivariate analysis documented that a T stage ≥3 was the only variable correlated with a nodal positivity (OR 6.3). On univariate analysis, emergency CRCs had a longer mean hospital stay compared with elective resections (p 0.006) and a higher rate of Clavien ≥4 events (p 0.0173). Finally, emergency resection and an age >66 years were variables independently correlated with a mean hospital stay >10 days (OR, respectively, 3.7 and 3.5). CONCLUSIONS: Emergency CRC resections were equivalent to the elective procedures with respect to LNH. However, emergency surgery correlated with a longer mean hospital stay. Graphical abstract Emergency and Elective resections for CRC provide similar LNH.

Is EUS-FNA of solid-pseudopapillary neoplasms of the pancreas as a preoperative procedure really necessary and free of acceptable risks?

BACKGROUND: Solid-pseudopapillary neoplasms (SPNs) of the pancreas are infrequent tumors since, as of 2014, only 2744 patients have been described. Its rarity, unclear histogenesis, pleomorphic aspect on radiology (cystic, solid or mixed) and unpredictable biological behavior with an insidious high-grade malignant potential make SPN difficult to recognize preoperatively even in its target patient population which is predominantly composed of young women (about 87% of cases). METHODS: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed to improve the preoperative diagnostic yield for this tumor and obviate the risks formerly given by percutaneous biopsy. RESULTS: In light of our experience, such a procedure could not be so innocuous as generally acknowledged. CONCLUSION: We report the first case of rupture of pancreatic SPN following EUS-FNA and entertain both the actual and potential complications ensuing from this type of mishap.

Lymph-node ratio classification strongly correlates with cancer survivals of patients who underwent r0 resection for gastric cancer with more than 15 nodes harvested.

BACKGROUND: During the last few years, the gastric cancer nodal staging has been extensively revised. Lately, a new system emerged in this field with the purpose of implementing the prognostic stratification: the lymph-node ratio (LNR). The aim of this study was to investigate the prognostic value of the LNR in relation to cancer survivors undergoing resection for gastric adenocarcinoma. METHODS: Off 227 patients undergoing surgical resection for gastric cancer at our Department, 129 curative gastric resections with more than 15 nodes harvested were selected. The LNR was calculated and patients were stratified into 6 subgroups based on the ratio values. The subgroups were compared for data analysis. Survivals were calculated by the Kaplan-Meier method, and the mean follow-up period was 40 months. ROC curves were calculated in order to analyze the performance of the LNR system. RESULTS: LNR stratification correlated with the stage of the disease, with the rate of patients undergoing chemotherapy and patients presenting with a relapse of disease at follow-up. Moreover, an increased ratio correlated with a worse overall, a disease-free and a disease-specific survival of the patients. The ROC curves documented a significant performance of the stratification system with the endpoints of disease-free and disease-specific survivals. CONCLUSION: LNR stratification correlated with cancer-related survivals in our case series. It is a reliable system that might improve current nodal staging and thereby the identification of patients with a higher risk of recurrence or cancer-related mortality.

Leptomeningeal Carcinomatosis in Early Gastric Cancer: A Case Report and Literature Review.

Leptomeningeal carcinomatosis (LC) is a rare site of metastasis in solid tumors, and it is associated with poor prognosis due to disabling symptoms and a scarcity of treatment options. This condition is an uncommon entity in gastric cancer (GC). We present a case of primary LC manifestation in a patient with an incidental diagnosis of localized node-negative GC. We additionally perform a literature review and discuss the diagnostic and therapeutic challenges. In conclusion, LC from GC represents a rare condition with a dramatic prognosis. Its diagnosis might be very challenging. A multidisciplinary approach appears to be the best strategy for the management of LC from GC.

Sidedness and Molecular Pattern in Defining the Risk of Lymph Node Metastasis in Nonmetastatic Colorectal Cancer: Single-Center Retrospective Study.

Background: Lymphadenectomy plays a central role in the treatment of localized colon cancer. While in left colon cancer the D3 lymphadenectomy/CME is considered the standard of care, lymphatic stations to be removed in right colon cancer are still a matter of discussion. The individuation of LNM risk factors could help in choosing the lymphadenectomy in right-sided tumors. This study aims to analyze the correlation of histopathological and molecular characteristics with lymph node metastasis, both in right- and left-sided colon cancer, and their impact on survival; Methods: We conducted a single-center observational retrospective study. The following data were collected and analyzed for each patient: demographics, histopathological and molecular data, and intraoperative and perioperative data. Statistical analyses were performed, including descriptive statistics, multivariate logistic regression and survival analysis; Results: An association between tumor size (pT, p < 0.001), grading (p = 0.013), budding (p < 0.001), LVI (79,4% p < 0.001) and LNM was observed. A multivariate analysis identified pT4 (OR 5.45, p < 0.001) and LVI+ (OR 10.7, p < 0.001) as significant predictors of LNM. Right-sided patients presented a worse OS when associated with LNM, while no significant difference was observed in N0 patients; Conclusions: histological and molecular analysis can help identify high risk patients, which could benefit from extended lymphadenectomies. These patients could be ideal candidates for the D3 lymphadenectomy/CME.

Radiomics in Oesogastric Cancer: Staging and Prediction of Preoperative Treatment Response: A Narrative Review and the Results of Personal Experience.

BACKGROUND: Oesophageal, gastroesophageal, and gastric malignancies are often diagnosed at locally advanced stage and multimodal therapy is recommended to increase the chances of survival. However, given the significant variation in treatment response, there is a clear imperative to refine patient stratification. The aim of this narrative review was to explore the existing evidence and the potential of radiomics to improve staging and prediction of treatment response of oesogastric cancers. METHODS: The references for this review article were identified via MEDLINE (PubMed) and Scopus searches with the terms "radiomics", "texture analysis", "oesophageal cancer", "gastroesophageal junction cancer", "oesophagogastric junction cancer", "gastric cancer", "stomach cancer", "staging", and "treatment response" until May 2024. RESULTS: Radiomics proved to be effective in improving disease staging and prediction of treatment response for both oesophageal and gastric cancer with all imaging modalities (TC, MRI, and 18F-FDG PET/CT). The literature data on the application of radiomics to gastroesophageal junction cancer are very scarce. Radiomics models perform better when integrating different imaging modalities compared to a single radiology method and when combining clinical to radiomics features compared to only a radiomics signature. CONCLUSIONS: Radiomics shows potential in noninvasive staging and predicting response to preoperative therapy among patients with locally advanced oesogastric cancer. As a future perspective, the incorporation of molecular subgroup analysis to clinical and radiomic features may even increase the effectiveness of these predictive and prognostic models.

Is CT Radiomics Superior to Morphological Evaluation for pN0 Characterization? A Pilot Study in Colon Cancer.

The aim of this study was to compare CT radiomics and morphological features when assessing benign lymph nodes (LNs) in colon cancer (CC). This retrospective study included 100 CC patients (test cohort) who underwent a preoperative CT examination and were diagnosed as pN0 after surgery. Regional LNs were scored with a morphological Likert scale (NODE-SCORE) and divided into two groups: low likelihood (LLM: 0-2 points) and high likelihood (HLM: 3-7 points) of malignancy. The T-test and the Mann-Whitney test were used to compare 107 radiomic features extracted from the two groups. Radiomic features were also extracted from primary lesions (PLs), and the receiver operating characteristic (ROC) was used to test a LN/PL ratio when assessing the LN's status identified with radiomics and with the NODE-SCORE. An amount of 337 LNs were divided into 167 with LLM and 170 with HLM. Radiomics showed 15/107 features, with a significant difference (p < 0.02) between the two groups. The comparison of selected features between 81 PLs and the corresponding LNs showed all significant differences (p < 0.0001). According to the LN/PL ratio, the selected features recognized a higher number of LNs than the NODE-SCORE (p < 0.001). On validation of the cohort of 20 patients (10 pN0, 10 pN2), significant ROC curves were obtained for LN/PL busyness (AUC = 0.91; 0.69-0.99; 95% C.I.; and p < 0.001) and for LN/PL dependence entropy (AUC = 0.76; 0.52-0.92; 95% C.I.; and p = 0.03). The radiomics ratio between CC and LNs is more accurate for noninvasively discriminating benign LNs compared to CT morphological features.

Early changes of muscle insulin-like growth factor-1 and myostatin gene expression in gastric cancer patients.

INTRODUCTION: Cachexia increases morbidity and mortality of cancer patients. The progressive loss of muscle mass negatively affects physical function and quality of life. We previously showed reduced muscle insulin-like growth factor-1 (IGF-1) expression and enhanced myostatin signaling in tumor-bearing animals. This study was aimed at investigating whether similar perturbations occur in gastric cancer patients. METHODS: Early perturbations of myostatin and IGF-1 signaling (including the expression of muscle-specific ubiquitin ligases) were investigated in 16 gastric cancer patients and in 6 controls by analyzing muscle mRNA expression with semiquantitative reverse transcriptase polymerase chain reaction (PCR) and real-time PCR. RESULTS: In gastric cancer patients, muscle mRNA levels for IGF-1, myostatin, and atrogin-1 were reduced irrespective of weight loss (≤5% or >5%), whereas MuRF1 expression was unchanged. CONCLUSIONS: IGF-1 and myostatin mRNA levels are downregulated in gastric cancer patients who have minimal or no weight loss. These early alterations are particularly relevant in order to devise preventive and therapeutic strategies for cancer cachexia.

Profiling the prognosis of gastric cancer patients: is it worth correlating the survival with the clinical/pathological and molecular features of gastric cancers?

BACKGROUND: The prognosis of gastric cancer patients still remains poor. The aim of this study was investigating the prognostic value of several clinical/pathological/molecular features in a consecutive series of gastric cancers. METHODS: 150 R0 gastrectomies plus 77 gastric cancer patients evaluated for the HER2 overexpression were selected. Survival was calculated and patients stratified according to the stage, the T-stage, the LNRs, the LNH, and the HER2 scoring system. ROC curves were calculated in order to compare the performance of the LRN and LNH systems. RESULTS: Prognosis correlated with the stage and with the T-stage. We documented a statistical correlation between the LNRs and the survival. Conversely, a LNH > 15 did not correlate with the outcomes. The ROC curves documented a significant performance of the LRN system, whereas a statistical correlation was documented for the LNH exclusively with the endpoint of disease-free survival. We documented a trend of worse prognosis for patients with an HER2 overexpression, even though it was not of statistical value. CONCLUSION: The LNR and the evaluation of the HER2 overexpression might be useful since they correlate with survival, might identify patients with a higher risk of recurrence, and might select patients for a tailored medical treatment.

Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma.

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.

Low Anterior Resection Syndrome (LARS) after Surgery for Rectal Cancer: An Inevitable Price to Pay for Survival, or a Preventable Complication?

BACKGROUND: Rectal cancer is frequent and often treated with sphincter-saving procedures that may cause LARS, a syndrome characterized by symptoms of bowel disfunction that may severely affect quality of life. LARS is common, but its pathogenesis is mostly unknown. The aim of this study is to assess the incidence of LARS and to identify potential risk factors. METHODS: We performed an observational retrospective single center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, and intra- and peri-operative data. Statistical analysis was conducted, including descriptive statistics and multivariate logistic regression to identify independent risk factors. RESULTS: Total LARS incidence was 31%. Statistically significant differences were found in tumor distance from anal verge, tumor extension (pT and diameter) and tumor grading (G). Multivariate analysis identified tumor distance from anal verge and tumor extension as an independent predictive factor for both major and total LARS. Adjuvant therapy, although not significant at univariate analysis, was identified as an independent predictive factor. Time to stoma closure within 10 weeks seems to reduce incidence of major LARS. CONCLUSIONS: bold LARS affects a considerable portion of patients. This study identified potential predictive factors that could be useful to identify high risk patients for LARS.

Lymph Node Metastasis in Extraperitoneal Rectal Cancer After Neoadjuvant Therapy: An Unsolved Problem?

BACKGROUND/AIM: Thanks to the promising benefits obtained in terms of quality of life, there has been growing interest in organ-sparing approaches after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer, mainly represented by transanal local excision and watch-and-wait. The main mandatory criterion is complete lymph nodal response (pN0). However, considering the reduced specificity of current radiological means in identifying one-to-one correspondence between clinical and pathological staging, the problem of underestimating lymph nodal involvement remains unsolved. The aim of this study was to identify the true percentage of patients eligible for conservative surgery and possible predictive factors. PATIENTS AND METHODS: Data for 59 patients with rectal cancer treated with nCRT followed by total mesorectal excision were analyzed. Patients with metastatic tumors and tumors treated with up-front surgery were excluded. Our primary endpoint was the pathological lymph nodal response rate after neoadjuvant chemoradiotherapy. The secondary endpoint was to identify predictive factors for lymph nodal response. RESULTS: The percentage of patients with pN0 was 62.71%, while in 37.28%, an organ-sparing approach would have not been oncologically correct. Parameters associated with pN0 were lower tumor size (T0-T2) (p=0.013) and lower grading (

Oncological Adequacy of Laparoscopic Surgery for Bulky Gastric Cancer: Results of a Western Single-Center Series.

BACKGROUND: Gastric cancer is increasing worldwide and one million new cases were estimated globally in 2020. Use of the laparoscopic approach is increasing especially for subtotal gastrectomy. However, to date, solid data on locally advanced bulky tumors are lacking. The aim of this study is to assess the role of laparoscopic surgery in bulky gastric tumors. METHODS: We performed an observational retrospective single-center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, intra-operative data, peri-operative data, and pathological data. Statistical analysis was conducted, including descriptive statistics and chi-squared test, to analyze the differences between categorical variables. RESULTS: O the 116 patients who underwent gastric surgery, 49 patients were included in the study protocol. All patients had bulky gastric tumors. Eighteen patients underwent laparoscopic gastrectomy and 31 open gastrectomy. The median number of lymph nodes removed was 28.5 (15-46) in the laparoscopic group and 23.05 (6-62) in the open group (p = 0.04). In total, 5.6% of patients of the laparoscopic group had <16 lymph nodes harvested and 35.5% in the open group (p = 0.035). No statistical differences were found between the open and laparoscopic groups in terms of surgical margins (p = 0.69). CONCLUSIONS: Laparoscopic surgery is still a subject of debate in locally advanced bulky gastric cancer. Limited data are available concerning Western patients. This study showed superiority in terms of the quality of lymphadenectomy and non-inferiority in terms of radical resection margins.