3-D reconstruction in liver surgery: a systematic review.

BACKGROUND: Three-dimensional reconstruction of the liver offers several advantages to the surgeon before and during liver resection. This review discusses the factors behind the use of liver 3-D reconstruction. METHODS: Systematic electronic search, according to PRISMA criteria, was performed. A literature search of scientific papers was performed until October 2023. Articles were chosen based on reference to 3-D liver reconstruction and their use in liver surgery. GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies. RESULTS: The research included 47 articles and 7724 patients were analyzed. Preoperative planning was performed with 3-D liver reconstruction in the 87.2% of the studies. Most of preoperative 3-D liver reconstructions were performed in the planning of complex or major hepatectomies. Complex hepatectomies were performed in 64.3% patients. The 55.3% of the studies reported an improved navigation and accuracy during liver resection. Four studies (8.6%) on living donor liver transplant (LDLT) concluded that 3-D liver reconstruction is useful for graft selection and vascular preservation. Nine papers (19.1%) reported an accurate measurement of future liver remnant. CONCLUSION: Liver 3-D reconstruction helps surgeons in the planning of liver surgery, especially in liver graft and complex liver resections, increasing the accuracy of the surgical resection.

Local excision of T1 colorectal cancer: good differentiation, absence of lymphovascular invasion, and limited tumor radial infiltration (≤4.25 mm) may allow avoiding radical surgery.

BACKGROUND: Early colorectal cancer (ECC) is defined as T1NXM0 colorectal cancer (CRC). Although a non-negligible number of T1-CRCs presents metastatic lymph-nodes, local excision is increasingly proposed as alternative to radical resection. Several criteria have been suggested to identify low-risk T1-CRC, but recommendations on this topic are still heterogeneous. This study aims to identify criteria associated with N+ T1-CRC, to select patients to undergo (or not) local excision. METHODS: A retrospective analysis of demographic, clinical, and histology criteria of 122 consecutive T1-CRC patients undergoing radical resection at Parma University Hospital between 2000 and 2018 has been performed. RESULTS: Lymph-node metastasis (LNM) was observed in 15/122 patients (12.3%). No LNM was observed among well-differentiated (G1) tumors (0/37), while 10/65 (15.4%) G2 cases as well as 5/20 (25%) G3 patients presented LNM. G1 was associated with absence of LNM (p = 0.013). After excluding G1 patients, the rate of N + T1-CRC was 17.6% (15/85). LNM was observed in 4/8 (50%) patients with lymphovascular invasion (LVI) and in 11/77 (14.2%) without LVI. LVI resulted being associated with LNM (p < 0.042). LNM was reported in 28.3% of cases with a tumor infiltration >4.25 mm (13/46), compared to 5.1% in cases with an infiltration ≤4.25 mm (2/39) (p = 0.012). In Cox regression analysis, the higher hazard ratio (HR) was reported for the LVI + and infiltration >4.25 mm (HR 24.849). CONCLUSIONS: In patients with ECC (pT1NXM0), good differentiation (G1), absence of lymphovascular invasion (LVI-), and tumor radial infiltration ≤4.25 mm may allow performing local resection and avoiding radical surgery.

Unraveling the Interplay of KRAS, NRAS, BRAF, and Micro-Satellite Instability in Non-Metastatic Colon Cancer: A Systematic Review.

Microsatellite Instability (MSI-H) occurs in approximately 15% of non-metastatic colon cancers, influencing patient outcomes positively compared to microsatellite stable (MSS) cancers. This systematic review focuses on the prognostic significance of KRAS, NRAS, and BRAF mutations within MSI-H colon cancer. Through comprehensive searches in databases like MEDLINE, EMBASE, and others until 1 January 2024, we selected 8 pertinent studies from an initial pool of 1918. These studies, encompassing nine trials and five observational studies involving 13,273 patients, provided insights into disease-free survival (DFS), survival after recurrence, and overall survival. The pooled data suggest that while KRAS and BRAF mutations typically predict poorer outcomes in MSS colorectal cancer, their impact is less pronounced in MSI contexts, with implications varying across different stages of cancer and treatment responses. In particular, adverse effects of these mutations manifest significantly upon recurrence rather than affecting immediate DFS. Our findings confirm the complex interplay between genetic mutations and MSI status, emphasizing the nuanced role of MSI in modifying the prognostic implications of KRAS, NRAS, and BRAF mutations in colon cancer. This review underscores the importance of considering MSI alongside mutational status in the clinical decision-making process, aiming to tailor therapeutic strategies more effectively for colon cancer patients.

Prognostic Impact of Ras Mutation on Surgical Strategy in Rectal Cancer Patients Undergoing Neoadjuvant Treatment.

BACKGROUND/AIM: Complete clinical response in rectal cancer after neoadjuvant chemo-radiotherapy is challenging. Indeed, indication to surgery vs. "watch and wait" is a debate due the poor predictive value of restaging exams in order to identify a pathological complete response (pCR). Improving the knowledge on mutational pathways such as MAPK/ERK could be helpful in assessing the real impact of disease on prognosis and in choosing the best therapeutic target. This study aimed to evaluate the significance of biomolecular parameters as prognostic factors in patients undergoing radical surgery after chemo-radiotherapy. PATIENTS AND METHODS: A retrospective analysis was performed including 39 patients who had undergone radical surgery after neoadjuvant chemo-radiotherapy for rectal adenocarcinoma stage II-III through additional evaluation of the following biomolecular markers on surgical specimens: exons 2, 3 and 4 of the KRAS and NRAS genes and exon 15 of BRAF by pyrosequencing. Kaplan-Meier survival curves were plotted to evaluate the association of pathologic response and RAS status with progression-free survival (PFS) and overall survival (OS). The log-rank test was used to assess statistical differences among the survival curves. RESULTS: Data analysis showed RAS mutation in 15 patients (38.46%). pCR was achieved in seven patients (18%), including only two RAS mutation cases. The distribution of evaluated variables was homogeneous in the two groups based on pathological response. The Kaplan-Meier curve showed poor outcomes in OS and PFS in patients with RAS mutation (p=0.0022 and p=0.000392, respectively), but no significant differences based on pathological response for both OS and PFS. CONCLUSION: RAS mutation seems to be related to poor prognosis and increased risk of recurrence in rectal cancer patients undergoing radical surgery after chemo-radiotherapy.

Laparoscopic Resection of Synchronous Liver Metastasis Involving the Left Hepatic Vein and the Common Trunk Bifurcation: A Strategy of Parenchyma-Sparing Resection with Left Sectionectomy and 4a Subsegmentectomy by Arantius Approach.

When colorectal cancer presents with liver metastasis, hepatic resection remains the most important factor in prolonging survival, and new paradigms have been proposed to augment resectability. An adequate liver remnant and vascularisation are the only limits in complex liver resection, and parenchyma-sparing surgery is a strategy for minimising the complications, preserving liver function, and allowing patients to undergo further liver resection. The laparoscopic approach represents a new challenge, especially when lesions are located in the superior or posterior part of the liver. We discuss the case of an 81-year-old patient with a single synchronous liver metastasis involving the left hepatic vein and leaning into the middle hepatic vein at the common trunk, where we performed a simultaneous laparoscopic colonic resection with a left sectionectomy extended to segment 4a. The strategic approach to the Arantius ligament by joining the left and middle hepatic vein allowed us to avoid a major liver hepatectomy, preserve the liver parenchyma, reduce complications, enhance patient recovery, and perform the entire procedure by laparoscopy. Our example suggests that the Arantius approach to the left hepatic vein and the common trunk could be a feasible approach to consider in laparoscopic surgery for lesions located in their proximity.

Laparoscopic Partial Splenectomy: A Critical Appraisal of an Emerging Technique. A Review of the First 457 Published Cases.

Background: Laparoscopic partial splenectomy (LPS) may allow avoiding total splenectomy (TS) complications and maximizing the advantages of mini-invasive approach. The objective of this review is to assess feasibility and safety of LPS, to compare this approach with alternative options. Materials and Methods: A literature review of articles reporting LPS is performed. Several parameters, including age, indication, surgical technique, devices used for splenic section/hemostasis, adverse outcomes, including morbidity/mortality, conversions to open surgery, conversions to TS, operative time (OT), and hospital stay (HS), are analyzed. Articles comparing LPS' results with those of open partial splenectomy and laparoscopic TS are also analyzed. Results: Fifty-nine articles reporting 457 LPS were included. Patients' characteristics varied widely, concerning age and indications, including hematological disease (hereditary spherocytosis, drepanocytosis), splenic focal masses, and trauma. Several technical options are reported. Mean OT and HS are 128 ± 43.7 minutes and 4.9 ± 3.8 days, respectively. No mortality and 5.7% morbidity are reported. Conversion rates to open surgery and to TS are 3.9% and 3.7%, respectively. Conclusions: In conclusion LPS is feasible and safe, with no mortality, low morbidity, and low conversion rates to laparotomy and to TS. LPS may be accomplished by various techniques and tools. Major complications are sporadically reported, thus potential risks should not be underestimated.

Inguinal GIST: A Systematic Literature Review of Primary and Metastatic Cases.

BACKGROUND/AIM: Gastrointestinal stromal tumor (GIST) has a wide spectrum of clinical manifestations. Involvement of the groin region can cause interesting presentations but, as of 2020, has rarely been investigated. Our aim was to assess the clinicopathological and prognostic features of GIST appearing in this specific part of the body. MATERIALS AND METHODS: We investigated the world literature dealing with primary or metastatic GIST appearing in the inguinal region (IGIST). A case of metastatic IGIST from our clinical records was also included. RESULTS: We found only six cases of primary and nine of metastatic IGIST. All were of male gender, and most aged 60 years or more (10 cases). Inguinal hernia (11 cases) was the patient type most frequently affected. The association between metastatic IGIST and inguinal lymphadenopathy was statistically significant (p=0.049). CONCLUSION: IGIST is a rare entity with particular clinical manifestations. Inguinal hernia and inguinal lymphadenopathy should be carefully investigated in patients with a history of GIST.

Retrospective survival analysis of stage II-III rectal cancer: tumour regression grade, grading and lymphovascular invasion are the only predictors.

BACKGROUND: Tumour regression grade is gaining interest as a prognostic factor of patients undergoing neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer. METHODS: A series of 68 consecutive patients with locally advanced rectal cancer treated by neoadjuvant chemoradiotherapy and surgery between 2010 and 2016 was retrospectively studied. The impact on disease-free survival (DFS) and overall survival (OS) of several criteria was analysed. Univariate analysis was performed through Kaplan-Meier statistics. Multivariate analysis was performed through Cox regression model. Using criteria found to be related to long-term outcomes, a predictive model of patient's OS was calculated. RESULTS: Poor tumour regression grade - TRG3 (P = 0.010), poor grading - G3 (P = 0.001) and lymphovascular invasion (LVI; P = 0.030) were associated with short OS at univariate analysis. OS was associated with TRG3 and G3 at multivariate analysis (P = 0.016 and P = 0.027, respectively). DFS was associated with LVI (P = 0.001), G3 tumours (P = 0.046) and TRG3 (P = 0.045) at univariate analysis. At multivariate analysis, only LVI was associated with DFS (P = 0.041). A score, pondering the impact of three parameters (2 points for TRG3, 2 for G3 and 1 for LVI), was created and resulted to predict patient OS (P = 0.008), ranging from 94.5 months (score = 0-1) to 32 months (score = 3-5). CONCLUSION: TRG3 and G3 were associated with poor OS, and LVI was the most significant predictor of DFS. An easy-to-use score may allow for a more accurate prediction of OS.

The Holocaust Is a Significant and Independent Risk Factor of Late-Onset Cancers: A Systematic Review of the Literature and Original Data on Jewish Israeli, Jewish Non-Israeli and Non-Jewish Non-Israeli Survivors.

BACKGROUND/AIM: Seventy-six years after Auschwitz Liberation, the Holocaust keeps on persecuting its surviving victims. As witnessed by the psychiatric and medical literature in the last decades, in fact, the Holocaust survivors (HS) appear to suffer from several Shoah-related late-onset diseases impacting their survival, such as internal illnesses and post-traumatic stress disorder (PTSD). Cancer represents a further severe pathology which seems to be connected with the Holocaust experience. Our aim was to review the existing knowledge of Holocaust-related cancer in HS in order to assess its real incidence and clinicoprognostic significance. MATERIALS AND METHODS: We systematically reviewed the literature dealing with Israeli Jewish and non-Jewish non-Israeli HS developing cancer. We also reviewed and analyzed the cancer data of noted Jewish HS not resident or having resided in Israel available as public information. RESULTS: We found 16 and 15 studies on Israeli Jews and non-Jewish non-Israeli survivors, respectively. A statistically significant association between the Holocaust and development of late-onset cancer in HS was seen in most studies with cancer adversely impacting the survival. We also selected 330 noted Jewish non-Israeli HS: genocide-related late-onset cancer resulted to be a significant and independent risk factor of poor prognosis (p<0.0001) imparting shorter survival in affected versus non-cancer subjects (57 versus 64 years, respectively, p=0.0001). CONCLUSION: Although 76 years have passed, our review shows how the Holocaust keeps on burdening its survivors. Moreover, we offered the first analysis of Jewish HS not resident or having resided in Israel in terms of genocide-related late-onset diseases focusing on cancer. Further studies on Jewish non-Israeli HS are needed in order to corroborate our findings on late-onset cancer occurring in this targeted population.

Fully Robotic ALPPS and Simultaneous Left Colectomy for Synchronous Colorectal Liver Metastases.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a recent surgical advancement for increasing the rate of successful liver resection. This technique is particularly important for patients with advanced tumor burden in whom future liver remnant volume is estimated to be too small to meet hepatic metabolic demands. With increasing acceptance of laparoscopic liver surgery and the related experience, even complex liver resection techniques such as ALPPS have been performed laparoscopically to improve patient outcomes. However, conventional laparoscopy has certain technical limitations that can result in a lack of dexterity. By overcoming these limitations, robot-assisted laparoscopy could become the preferred procedure for complex liver resection. In this study, we describe the technique of fully robotic ALPPS with simultaneous left colectomy in a patient with stage IV colorectal cancer. We emphasize on the performance of the robotic platform during certain difficult steps of the procedure.

Acute diverticulitis: old challenge, current trends, open questions.

Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.

Stage III and Metastatic Lymph Node Ratio Are the only Independent Prognostic Factors in Colorectal Signet-ring Cell Carcinoma Patients.

BACKGROUND/AIM: Signet-ring cell carcinoma (SRCC) is an uncommon histological variant of colorectal cancer (CRC). Knowledge is scarce due to its rarity. Our aim was to better evaluate the clinicopathologic and prognostic features of this little-known malignancy. PATIENTS AND METHODS: Thirty-nine consecutive patients with non-metastatic colorectal SRCC undergoing curative resection at University Hospital of Parma between 2000 and 2018 were examined in this retrospective analysis. RESULTS: Mean overall (OS) and disease-free survival (DFS) were 33.6 and 31.5 months, respectively. At univariate analysis, the lymph-related parameters (nodal status, Stage III, metastatic lymph node ratio and lymphovascular invasion) were significantly associated with shorter OS and poorer DFS. At multivariate analysis, Stage III and a metastatic lymph node ratio ≥25% were found to be the only independent prognostic factors significantly correlated with worse OS and DFS. CONCLUSION: Nodal and lymphatic status should be carefully pondered when planning the most appropriate management of patients with colorectal SRCC.

Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases.

BACKGROUND/PURPOSE: In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset. METHODS: A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy. RESULTS: Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients. CONCLUSIONS: Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions. TYPE OF STUDY: Systematic review. LEVEL OF EVIDENCE: IV.

Peripheral neuropathies after bariatric surgery. Preliminary results from a single-centre prospective study in Northern Italy.

INTRODUCTION: Bariatric surgery (BS) has gained popularity in order to treat morbid obesity. However, post-operative (PO) neurologic complications have become increasingly recognized. Our aim was to examine incidence, clinical presentation, and outcomes of neurologic disorders secondary to BS. METHODS: Patients who underwent BS between the years 2012 and 2015 at Parma University were included in this survey, and assessed before (T0) and 1 year after surgery (T1). Baseline characteristics and medical comorbidities, type of surgery, and PO complications were retrieved. Patients with a previous history of peripheral neuropathic disease were excluded from the analysis. If a patient presented with a new onset neurologic symptom including extremity numbness, paresthesia, muscle weakness, the status was considered "positive" for PO-neuropathy. RESULTS: Overall, we retrieved data from 61 patients (n=30 Roux-en-Y Gastric bypasses, n=31 Gastric banding; 81.0% females). Of them, 7 (11.4%) developed some signs of PO-neuropathy, that eventually disappeared at T+24 months. The most common manifestations were paresthesia (n=6) and muscle weakness (n=4), similarly distributed in Gastric Bypass (n=4) and Gastric Banding (n=3) groups. Although patients affected by PO-neuropathy exhibited higher SF-36 score at T0 (p=0.018), no significant differences were found regarding BMI (T0, T1), percentual weight loss, serological data (i.e. vitamin B1, B2, B6, B12: in all cases p>0.05). CONCLUSION: PO-BS neuropathy is usually associated with lower levels of vitamin B1, B2, B12. However, no differences in PO-BMI, excess weight loss, and metabolic data levels were found. Larger data and more extended follow-up are required to validate our results.

Laparoscopic gastric bypass with remnant gastrectomy in a super-super obese patient with gastric metaplasia: a surgical hazard?

The endoscopic inaccessibility of the gastric remnant after Roux-en-Y gastric bypass (RYGBP) for morbid obesity represents an important issue for patients with familiar history of gastric cancer (GC) or affected by premalignant lesions, such as intestinal metaplasia. If a different bariatric procedure is contraindicated, RYGBP with remnant gastrectomy represents a reasonable alternative, significantly reducing the risk of GC but potentially increasing postoperative morbidity. For this reason, only few cases have been reported in the recent Literature and none regarding a super-super obese patient. We present the case of a 55-year-old super-super obese man with a family history of GC and antral gastritis with extensive intestinal metaplasia at preoperative upper endoscopy, who underwent laparoscopic RYGBP with remnant gastrectomy.

Laparoscopic subtotal gastrectomy for the treatment of advanced gastric cancer: a comparison with open procedure at the beginning of the learning curve.

BACKGROUND: In the last decades, after some initial concern, laparoscopic subtotal gastrectomy (LSG) is gaining popularity also for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare a single surgeon initial experience on LSG and open subtotal gastrectomy in terms of surgical safety and radicality, postoperative recovery and midterm oncological outcomes. METHODS: a case control study was conducted matching the first 13 LSG for AGC with 13 open procedures performed by the same surgeon. Operative and pathological data, postoperative parameters and midterm oncological outcomes were analyzed. RESULTS: There was no significant difference in mortality (0%) and morbidity, while the laparoscopic approach allowed lower analgesic consumption and faster bowel movement recovery. Operation time was significantly higher in LSG patients (301.5 vs 232 min, p: 0.023), with an evident learning curve effect. Both groups had a high rate of adequate lymph node harvest, but the number was significantly higher in LSG group (p: 0.033). No significant difference in survival was registered. Multivariate analysis identified age at diagnosis, diffuse-type tumor, pN and LODDS as independent predictors of worse prognosis. CONCLUSIONS: LSG can be safely performed for the treatment of AGC, allowing faster postoperative recovery.