Is BMI a Factor in Compliance to Adjuvant Chemotherapy for Locally Advanced Rectal Cancer?

Background: Compliance to adjuvant chemotherapy (AC) for patients undergoing rectal surgery ranges from 43% to 73.6%. Reasons reported for not initiating or completing AC include onset of postoperative complications, drug toxicity, disease progression and/or patient preferences. Little is known regarding the impact of obesity on the compliance to AC in this setting. Methods: This multicenter, retrospective study analyzed compliance to AC and treatment-related morbidity in 511 patients having undergone surgery with curative intent for rectal cancer in six Italian colorectal centers between January 2013 and December 2017. Results: 70 patients were obese (BMI 30 kg/m2). The proportion of open procedures (22.9% vs. 13.4%) and conversions (14.3% vs. 4.8%) was greater in obese compared to non-obese patients (p 0.001). Median hospital stay was one day longer for obese patients (9 days vs. 10 days, p=0.038) while there was no statistically significant difference in the complication rate, whether overall (58.6% in obese vs. 52.3% in non-obese) or with a Clavien-Dindo score 3 (17.1% vs 10.9%). AC was offered to 49/70 (70%) patients in the obese group and 306/441 (69.4%) in the non-obese group (p=0.43). There was no statistically significant difference in AC compliance: 18.4% and 22.9% did not start AC, while 36.7% and 34.6%, started AC but did not complete the scheduled treatment (p=0.79) in the obese and non-obese group, respectively. Overall, 55% of patients who started AC successfully completed their adjuvant treatment. Conclusions: Obesity did not impact compliance to AC for locally advanced rectal cancer: compliance was poor in obese and non-obese patients with no statistically significant difference between the two groups. Major complication rate was not statistically significantly affected by increased BMI.

Compliance to Adjuvant Chemotherapy of Patients Who Underwent Surgery for Rectal Cancer: Report from a Multi-institutional Research Network.

INTRODUCTION: Adjuvant chemotherapy for locally advanced rectal cancer is associated with improved overall survival. However, recent evidence from randomized trials showed a compliance rate of 43 to 73%, which may affect efficacy. The aim of this multicenter retrospective analysis was to investigate the compliance rate to adjuvant treatment for patients who underwent rectal surgery for cancer. METHODS: Patients who underwent surgery with curative intent for rectal cancer in six Italian colorectal centers between January 2013 and December 2017 were retrospectively reviewed. Exclusion criteria were age less than 18 years, palliative or emergency surgery, and stage IV disease. Parameters of interest were patients' characteristics, preoperative tumor stage, neo-adjuvant chemoradiation therapy, intra-operative and postoperative outcomes. Although the participating centers referred to the same treatment guidelines for treatment, the chemotherapy regiment was not standardized across the institutions. Reasons for not starting adjuvant chemotherapy when indicated, interruption, and modification of drug regimen were collected to investigate compliance. RESULTS: A total of 572 patients were included in the analysis. Two hundred and fifty-two (44.1%) patients received neo-adjuvant chemoradiation therapy. All patients underwent high anterior rectal resection, low anterior rectal resection, or Miles' procedure. Of 399 patients with an indication to adjuvant chemotherapy, 176 (44.1%) completed the treatment as planned. Compliance for patients who started chemotherapy was 56% (95% CI 50.4-61.6%). Sixty-six patients interrupted the treatment, 76 patients significantly reduced the drug dose, and 41 patients had to switch to other therapeutic regimens. CONCLUSIONS: The present multicenter investigation reports a low compliance rate to adjuvant chemotherapy after rectal resection for cancer. Multidisciplinary teams should focus on future effort to improve compliance for these patients.

Pain control in laparoscopic surgery: a case-control study between transversus abdominis plane-block and trocar-site anesthesia.

Local anesthesia in laparoscopic operations is gaining increasing consensus. To standardize analgesia, a prospective case-control study was created over a 1-year period, in collaboration with the anesthesiology service in our community hospital. Starting from February 2016, we prospectively enrolled adult patients (more than 16 years old) undergoing laparoscopic appendectomy or cholecystectomy, either in emergency or elective setting. Patients were preoperatively assigned (based on the chart-admission number) either to transversus abdominis plane (TAP) block treatment (Group 1-experimental arm) or trocar-site anesthesia (TSA) (Group 2-experimental arm), and then compared with group of patients not submitted to treatment (Group 3-control arm). Demographic and clinical characteristics of each patient were recorded. Post-operative pain level (primary outcome) was assessed with visual analog scale (VAS) score; analgesic use and length of stay in hospital were defined as secondary outcomes. Forty-two patients were assigned to TAP block treatment (Group 1), fifty-two to TSA (Group 2), and thirty-nine underwent no pre-incisional treatment (Group 3). In the comparison between patients undergoing TAP block or TSA with the control arm, a significance difference in reported pain was recorded in every scheduled time (p < 0.05 at 0, 6, 12, 18, 24, and 48 h from awakening). Both local anesthesia groups share a benefit in terms of primary outcome. The use of pre-incisional TSA for all the patients undergoing laparoscopic cholecystectomy and appendectomy could become a routine practice to reduce post-operative pain both in the elective and emergency setting.

Creation of a rectal cancer registry in Italy by the Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network.

Background: The management of rectal cancer is multimodal and involves a multidisciplinary team of cancer specialists with expertise in medical oncology, surgical oncology, radiation oncology and radiology. It is crucial for highly specialized centers to collaborate via networks that aim to maintain uniformity in every aspect of treatment and rigorously gather patients' data, from the first clinical evaluation to the last follow-up visit. The Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network aims to create a rectal cancer registry. This will prospectively collect the data of patients operated on for non-metastatic rectal cancer in high volume colorectal surgical units through a well design pre-fashioned database for non-metastatic rectal cancer, in order to take all multidisciplinary aspects into consideration. Methods/Design: The protocol describes a multicenter prospective observational cohort study, investigating demographics, frailty, cancer-related features, surgical and radiological parameters, and oncological outcomes among patients with non-metastatic rectal cancer who are candidates for surgery with curative intent. Patients enrolled in the present registry will be followed up for 5 years after surgery. Discussion: Standardization and centralization of data collection for neoplastic diseases is a virtuous process for patient care. The creation of a register will allow the control of the quality of treatments provided and permit prospective and retrospective studies to be carried out on complete and reliable high quality data. Establishing data collection in a prospective and systematic fashion is the only possibility to preserve the enormous resource that each patient represents.

Total Parathyroidectomy with Subcutaneous Parathyroid Forearm Autotransplantation in the Treatment of Secondary Hyperparathyroidism: A Single-Center Experience.

INTRODUCTION: Secondary hyperparathyroidism is common in chronic kidney disease. Parathyroidectomy is indicated in refractory hyperparathyroidism when medical treatments and so the parathyroid hormone levels cannot be lowered to acceptable values without causing significant hyperphosphatemia or hypercalcemia. The aim of this study is to compare the efficacy and safety of total parathyroidectomy with subcutaneous forearm autotransplantation with total parathyroidectomy with intramuscular forearm autotransplantation. MATERIALS AND METHODS: A single-center retrospective cohort study of total parathyroidectomy with forearm autotransplantation from January 2002 to February 2013 was performed. According to the surgical technique, patients were divided into an intramuscular group (Group 1) and a subcutaneous group (Group 2). 38 patients with secondary hyperparathyroidism were enrolled; 23 patients were subjected to total parathyroidectomy with parathyroid tissue replanting in the subcutaneous forearm of the upper nondominant limb, while 15 patients were subjected to replanting in the intramuscular seat. RESULTS: A total of 38 patients (56 ± 13 years) were enrolled. In both groups, the preoperative iPTH value was markedly high, 1750 ± 619 pg/ml in the intramuscular autotransplantation group and 1527 ± 451 pg/ml in the subcutaneous autotransplantation group (p = 0.079). Transient hypoparathyroidism was shown in 7 patients, and 1 patient showed persistent hypoparathyroidism (p = 0.387). 2 patients showed persistent hyperparathyroidism (p = 0.816), and in 2 others was found recurrent hyperparathyroidism (p = 0.816); 3 of them underwent autograftectomy. The anterior compartment of the forearm nondominant limb was sacrificed in 1 case of intramuscular autotransplantation with functional arm deficit. CONCLUSIONS: The efficacy and safety of parathyroid tissue autotransplantation in the subcutaneous forearm of the upper nondominant limb is confirmed with a good rate of tissue engraftment and with a comparable number of postsurgical transient and persistent hypoparathyroidism and hyperparathyroidism incidence in both techniques. Furthermore, this technique preserves arm functionality in the case of autograftectomy. Consequently, it is our opinion that total parathyroidectomy with subcutaneous forearm autotransplantation is currently the best choice.

Prognosis of elderly gastric cancer patients after surgery: a nomogram to predict survival.

This study aimed to identify clinicopathological factors associated with the outcome of elderly patients with gastric cancer (GC), and to construct a nomogram for individual risk prediction. Tumor characteristics of 143 patients aged ≥ 80 years underwent surgery for GC were collected and analyzed by uni- and multivariate analyses. A prognostic nomogram was constructed using the factors which resulted to be significantly associated with overall survival. Discrimination of nomogram was tested by Kaplan-Meier (KM) curves and boxplots. With a median follow up of 18.37 months, overall 1-year survival rate was 51% and it was 60 and 40% for older and younger than 83 years, respectively (P = 0.003). Univariate analysis indicated that age (P = 0.008), pre-operatory performance status (P < 0.001), depth of invasion (P = 0.007), lymph nodes involvement (P < 0.001), and residual tumor (P < 0.001) were significant prognostic factors. Based on these variables, a nomogram to predict 3, 6, 12, and 24 months survival probability after GC surgery was developed. KM and boxplots according to the range of nomogram total points highlighted the appropriateness of distinguish the patients' survival in all the subgroups. Moreover, this nomogram exhibited superior prognostic discrimination between intermediate stages (II-III) than AJCC-TNM classification. This study showed that after good surgical selection, the prognosis of elderly GC patients may be influenced by several clinicopathological factors. Therefore, a predictive nomogram to distinguish more accurately fit patients may allow physicians to individualize treatments and to detect those patients who may benefit from an intensive multidisciplinary approach.

CT colonography for the detection of nonpolypoid colorectal lesions A prospective series.

AIM: To determine the diagnostic accuracy of CT-colonography (CTC) for colorectal nonpolypoid lesions. MATERIALS AND METHODS: In the period 2010-2011, 51 out of 454 patients undergoing CTC received also optical colonoscopy (OC). Three human readers with high, intermediate and low expertise interpreted the images. Flat lesions were defined as 3 mm or less in height; laterally spreading type (LST) lesions were defined as nonpolypoid lesions with more than 10 mm lateral diameter. RESULTS: A total of 75 nonpolypoid colorectal lesions were identified in 21 patients: 43 type II-A low-grade adenomas, 2 type II-c Tis adenocarcinomas, 2 LST Tis adenocarcinomas, 24 nonadenomatous (hyperplastic) lesions and 4 LST infiltrating tumors (T1N0M0 in 2 cases and T2N0M0 in 2 cases). Per-lesion sensitivity and NPV were 44% and 80.5%, while per-patient sensitivity, specificity, PPV, NPV and accuracy were 80.9%, 93.7%, 89.5%, 88.2%, 88.7%. The readers with high and intermediate experience yielded significantly better diagnostic performances than reader with low experience (p =0.072 and p=0.030). All the infiltrating carcinomas and 75% of tis carcinomas were detected by all the readers. CONCLUSION: CTC showed a low per-lesion and an high per-patient diagnostic accuracy for all nonpolypoid colorectal lesions, but an high ability to detect nonpolypoid colorectal carcinomas. Diagnostic performances are strictly related to the reader experience. KEY WORDS: Adenoma, Colon cancer, Colonoscopy CT colonography, Non polypoid lesions, Screening.