A fast-track surgery programme leads to timelier treatment and higher resection rates in pancreatic cancer.

BACKGROUND: The aim was to perform a propensity-matched comparison of patients with pancreatic cancer undergoing surgery, with and without biliary stenting and an intention to treat analysis of long-term survival between the two groups. METHODS: This was an observational study of a cohort of consecutive patients presenting with obstructive jaundice and undergoing pancreatoduodenectomy for pancreatic and periampullary malignancies between November 2015 and May 2019. RESULTS: In this study of 216 consecutive operable patients, 70 followed the fast-track pathway and 146 had pre-operative biliary drainage. All 70 patients in the FT group and 122 out of 146 in the PBD group proceeded to surgery (100% and 83.6% respectively, p = 0.001). Interval time from diagnostic CT scan to surgery and from MDT decision to treat to surgery was shorter in the FT group, (median 8 vs 43 days p < 0.001 and 3 vs 36 days p < 0.001 respectively) as was the overall time from diagnostic CT to adjuvant treatment (88 vs 121 days p < 0.001). Postoperative outcomes including complications, readmission and mortality rates were comparable in the two groups. There was no difference in survival. CONCLUSION: For a person with pancreatic cancer who is proceeding to surgery, the best approach is to avoid pre-operative biliary drainage.

Robotic Versus Laparoscopic Partial Mesorectal Excision for Cancer of the High Rectum: A Single-Center Study with Propensity Score Matching Analysis.

BACKGROUND: The role of robotic surgery for partial mesorectal excision (PME) in patients with high rectal cancer (RC) remains unexplored. This study aimed to compare the operative and postoperative outcomes of robotic (R-PME) versus laparoscopic (L-PME) PME for high RC. METHODS: This was a single-center propensity score cohort study of consecutive patients diagnosed with RC in the high rectum (>10 to 15 cm from the anal verge) who underwent surgery between September 2012 and May 2019. RESULTS: Of 131 selected patients (50 R-PME and 81 L-PME), 88 were matched using propensity score (44 per group). Operative and postoperative variables were similar between R-PME and L-PME patients, except for operative time (220 min and 190 min, respectively; p < 0.0001). No conversion was needed. Overall morbidity was 15.9%; 4 patients (4.5%) developed anastomotic leakage. The mean hospital stay was 7.25 days for R-PME vs. 7.64 days for L-PME (p = 0.597). R0 resection was achieved in 100% of R-PME and 90.9% of L-PME (p = 0.116). Only 3 patients (1 R-PME, 2 L-PME) received a permanent stoma (p = 1). No group differences were observed for overall or disease-free survival rates at 5 years. The costs of R-PME were significantly higher than those of L-PME. CONCLUSION: Minimally invasive surgery can be performed safely for PME in high RC. No difference can be detected between R-PME and L-PME for both short- and long-term outcomes, leaving the choice of the surgical approach to the surgeon's experience. Specific health economic studies are needed to evaluate the cost-effectiveness of robotic surgery for RC.

Standard Versus Advanced Protective Measures in a COVID-Free Surgical Pathway.

Introduction The importance of coronavirus disease (COVID)-free surgical pathways during the coronavirus disease 2019 (COVID-19) pandemic has been demonstrated. However, the extent of protective measures to be applied against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), particularly before vaccines became available, remained unclear. Methods This retrospective study included all SARS-CoV-2-negative patients admitted to the COVID-free pathway of a regional abdominal surgery hub center in Northern Italy over 12 months, before the vaccination campaign. During the first seven months, basic protective measures against SARS-CoV-2 were adopted (surgical masks, swabs for symptomatic patients, and intra- or interhospital transfers), since patients were treated as effectively negative (standard management). During the last five months, advanced measures were implemented (enhanced personal protections and systematic control swabs), as patients were considered potentially positive (advanced management). The aim of this article was to compare SARS-CoV-2 incidence and surgical outcomes in these periods. Results A total of 283 and 194 patients were admitted under standard and advanced management, respectively; pre-admission data differed only in the rate of previous SARS-CoV-2 infection (2.5% versus 6.7%, p= 0.034). The SARS-CoV-2 incidence was 3.9% and 3.1% for standard and advanced periods, respectively (p = 0.835). Two internal outbreaks developed during the standard phase. The advanced protocol significantly increased the rate of patients re-tested for SARS-CoV-2 (83% versus 41.7%, p < 0.001) and allowed early detection of all infections, which remained sporadic. Surgical outcomes were similar. Conclusions Advanced management was instrumental in detecting positive patients early and preventing outbreaks, without affecting surgical results; accordingly, it stands as a reproducible model for future pandemic scenarios.

Emergency surgery for bowel obstruction in extremely aged patients.

BACKGROUND: As a result of the increasing of life expectancy, the incidence of pathologies that can lead to operation for bowel obstruction is also increasing. Comorbidities and reduced physiological reserve can decrease elderly patients' ability to tolerate operations especially in an emergency context. We retrospectively evaluated the treatment and outcomes of a cohort of patients aged more than 85 years who underwent emergency surgery for intestinal occlusion. METHODS: Two hundred seventy-eight patients who were admitted to our Institution and operated for acute bowel obstruction have been included in our study. We divided the study population in 2 groups (group A: patients aged>85 years old; group B patients aged ≤85 years). We evaluated the differences between the two groups in terms of intestinal occlusion aetiology, surgical procedures, morbidity and mortality rates. RESULTS: Group A consisted of 57 patients, group B of 221; elderly patients trend in ASA score classification was significantly towards high risk for elderly group; statistical analysis did not show differences in terms of bowel obstruction etiology (except colon volvulus, more frequent in advanced age), type of procedure, duration of hospital stay, procedure-related complication rate. Perioperative mortality was significantly higher in elderly group, due to the mayor incidence of cardiovascular and respiratory fatal events directly related to pre-existing comorbidities. CONCLUSIONS: Despite the high surgical risk, early diagnosis and treatment of the obstructive disease can lead to achieve encouraging outcomes also in extremely advanced age; an aggressive evaluation of comorbidities and the cardiorespiratory risks reduction, when possible, could be useful in improve postoperative outcomes in terms of mortality.

Early surgical management of acute cholecystitis in ultra-octogenarian patients: our 5-year experience.

BACKGROUND: Acute calculous cholecystitis is a leading cause for hospital admission especially in developed countries. As older age population increases, medical research should consider the efficacy of all therapeutic options, including early surgical procedure in an emergency context, for the treatment of acute cholecystitis in elderly high-risk patients. METHODS: From 01/01/2012 to 31/12/2016, 245 patients were admitted to our Institution with diagnosis of acute cholecystitis and managed with cholecystectomy within the same hospitalization. The study population was divided into 2 subgroups: group A (patients aged more than 80 years) and group B (patients within the limit of 80 years of age); the objective of the study was to evaluate and compare the surgical outcomes of the 2 groups in terms of conversion rate, mortality rate, overall morbidity and procedure-related complication rates. RESULTS: Statistical analysis did not show significant differences between ultra octogenarian and younger patients in terms of conversion to open procedure, iatrogenic bile duct lesions, postoperative peritoneal bleeding, bile leakage and peritoneal collection; no differences in terms of hospital stay have been demonstrated. Mortality and overall morbidity rates, even if similar to what observed in Literature and within acceptable values, were significantly higher in elderly patients, due to the presence of severe comorbidities leading to potentially fatal postoperative events. CONCLUSIONS: Minimally invasive approach in an emergency setting for acute cholecystitis seems to be a feasible and adequate therapeutic approach for extremely aged high-risk patients.

Peri-hepatic gauze packing for the control of haemorrhage during liver transplantation: A retrospective study.

BACKGROUND: Albeit accepted in the trauma setting, use of peri-hepatic gauze packing has been rarely reported during liver transplantation. AIMS: To assess the results of packing in liver transplantation. METHODS: We reviewed clinical characteristics, intraoperative events and postoperative outcome of consecutive adult liver transplantation recipients between 2003 and 2013. Patients treated with packing were compared to no-packing patients and to matched controls selected using a propensity score. RESULTS: Of 1396 recipients, 107 were treated with packing for peri-hepatic bleeding (76.6%), allograft damage (12.1%) or partial outflow obstruction (11.2%). Urgent reoperation for ongoing haemorrhage was required in 6 (5.6%). Correction of haemodynamic and coagulation parameters was constantly achieved. Overall, patient (90% vs. 98%, p<0.001) and graft (83.2% vs. 94.7%, p<0.001) 3-month survival was significantly reduced in packing patients. However, after matching, no significant difference was observed in patient (89.3% vs. 95.2%, p=0.12) and graft (83.5% vs. 92.2%, p=0.06) 3-month survival. Patient survival was associated with recipient age (HR 2.59; p=0.04) and donor age × recipient MELD (HR 2.04; p=0.02), but not with packing (HR 1.81; p=0.29). CONCLUSIONS: In our experience, packing was a valuable adjunct to conventional means of haemostasis during liver transplantation and, after accounting for confounding covariates, was not associated with inferior outcomes.