Preoperative predictors of liver decompensation after mini-invasive liver resection.

BACKGROUND: Post-hepatectomy liver failure (PHLF) represents the most frequent complication after liver surgery, and the most common cause of morbidity and mortality. Aim of the study is to identify the predictors of PHLF after mini-invasive liver surgery in cirrhosis and chronic liver disease, and to develop a model for risk prediction. METHODS: The present study is a multicentric prospective cohort study on 490 consecutive patients who underwent mini-invasive liver resection from the Italian Registry of Mini-invasive Liver Surgery (I go MILS). Retrospective additional biochemical and clinical data were collected. RESULTS: On 490 patients (26.5% females), PHLF occurred in 89 patients (18.2%). The only independent predictors of PHLF were Albumin-Bilirubin (ALBI) score (OR 3.213; 95% CI 1.661-6.215; p < .0.0001) and presence of ascites (OR 3.320; 95% CI 1.468-7.508; p = 0.004). Classification and regression tree (CART) modeling led to the identification of three risk groups: PHLF occurred in 23/217 patients with ALBI grade 1 (10.6%, low risk group), in 54/254 patients with ALBI score 2 or 3 and absence of ascites (21.3%, intermediate risk group) and in 12/19 patients with ALBI score 2 or 3 and evidence of ascites (63.2%, high risk group), p < 0.0001. The three groups showed a corresponding increase in postoperative complications (20.0%, 27.5% and 66.7%), Comprehensive Complication Index (5.1 ± 11.1, 6.0 ± 10.9 and 18.8 ± 18.9) and hospital stay (6.0 ± 4.0, 6.0 ± 6.0 and 8.0 ± 5.0 days). CONCLUSION: The risk of PHLF can be stratified by determining two easily available preoperative factors: ALBI and ascites. This model of risk prediction offers an objective instrument for a correct clinical decision-making.

Late Bowel Iischemia and Colovaginal Fistula after Low Anterior Resection in a COVID-19 Patient.

The spread of SARS-CoV-2 in Italy has been rapid, with over 230.000 infections and 33.000 deaths (May 31st, 2020). The full impact of COVID19 on surgery is still unknown, as its effects on healthcare strategy, hospital infrastructure, staff, regional economy and colorectal disease progression, may not be evident before several months. No systematic reports are available about a higher incidence of COVID19 infections in patients with cancer. However, available data indicate that older people are more vulnerable, particularly when there are underlying health conditions such as chemotherapy or active cancer. Herein, we present the case of a patient with rectal cancer treated with pull-through technique low anterior rectal resection and coloanal anastomosis with protective loop ileostomy, complicated with Sars-CoV-2 infection and late (31st post-operative day) colic ischemia with colo-vaginal fistula. Late intestinal ischemia is a rare complication and can be secondary to several traditional factors, but certainly small vessel thrombosis related to Coronavirus disease must be taken into consideration.

Endo-therapies for biliary duct-to-duct anastomotic stricture after liver transplantation: Outcomes of a nationwide survey.

BACKGROUND: The most appropriate endo-therapeutic approach to biliary anastomotic strictures is yet to be defined. AIM: To retrospectively report on the endo-therapy of duct-to-duct anastomotic strictures during 2013 in Italy. METHODS: Data were collected from 16 Endoscopy Units at the Italian Liver Transplantation Centers (BASALT study group). RESULTS: Complete endo-therapy and follow-up data are available for 181 patients: 101 treated with plastic multistenting, 26 with fully covered self-expandable metal stenting and 54 with single stenting. Radiological success was achieved for 145 patients (80%), that is, 88% of plastic multistenting, 88% of self-expandable metal stenting and 61% of single stenting (P < 0.001 vs plastic multistenting; P < 0.05 vs self-expandable metal stenting). After first-line endo-therapy failure, the patients underwent a second-line endo-therapy with plastic multistenting for 25%, fully covered self-expandable metal stenting for 53% and single stenting for 22% of cases, and radiological success was achieved for 84%, that is, 100%, 85% and 63% with plastic multistenting, self-expandable metal stenting and single stenting (P < 0.05 vs plastic multistenting or self-expandable metal stenting) respectively. Procedure-related complications occurred in 7.8% of endoscopic retrograde cholangiopancreatographies. Overall, clinical success was achieved in 87% of patients after a median follow-up of 25 months. CONCLUSION: Plastic multistenting is confirmed as the preferred first-line treatment, while fully covered self-expandable metal stenting as rescue option for biliary anastomotic strictures. Single stenting has sub-optimal results and should be abandoned.

The learning curve for using intestinal ultrasonography.

BACKGROUND AND AIMS: Intestinal ultrasonography (IUS) is challenging to learn. This prospective study examined how the accuracy of IUS increases with operator experience ("learning curve") and if prior abdominal ultrasound experience facilitates the learning process. METHODS: The study included two trainees with limited abdominal ultrasound experience (< 50 exams) and two with extensive experience (> 500 exams). Each trainee performed 99 examinations and reported four IUS findings. An expert sonographer repeated the exam, and concordance (k) between the expert and trainees was assessed in three consecutive testing periods of 33 exams each. RESULTS: A progressive improvement in concordance was observed for all IUS findings from Period 1 to Period 3, overall and for both groups of trainees, although those with experience in abdominal ultrasound had faster learning curves. The minimum number of examinations required to achieve concordance with the expert operator for detecting increased bowel wall thickness was 84 and detecting bowel dilatation was 79. However, a minimum of 97 examinations was necessary to achieve concordance for detecting intra-abdominal complications, considered an advanced IUS competence. CONCLUSION: Basic competence in IUS can be acquired with relatively few examinations, while advanced competence requires more extensive training, particularly for gastroenterologists without abdominal ultrasound experience.

A rare challenge in general surgery: double surgical procedure for large and small bowel obstruction in a patient with Gerstmann- Sträussler-Scheinker syndrome.

Gerstmann-Sträussler-Scheinker syndrome (GSS) is a rare, infectious syndrome related to a mutation in the prion protein gene. Described here are the challenges posed by surgery for a patient with GSS. A 61-yr-old woman with GSS was admitted to this department and underwent surgery twice for large and small bowel obstruction. This is the first report of two major surgical procedures in a patient with GSS. Experiences with this case and precautions when using a disposable device during endotracheal intubation and a surgical procedure to manage a patient with GSS are described.

Postrecurrence Survival After Liver Transplantation for Liver Metastases From Neuroendocrine Tumors.

BACKGROUND: Liver metastases from neuroendocrine tumors (NETs) are an accepted indication for liver transplantation (LT). Despite strict patient selection, post-LT recurrence is observed in 30%-50% of cases. Postrecurrence survival is poorly investigated as well as factors influencing postrecurrence outcomes. METHODS: Consecutive patients treated at a single institution for post-LT recurrence of NET between January 1, 2004, and December 31, 2018, were included. Baseline patients' characteristics, data on the primary tumor, pretransplant therapies, posttransplant recurrence and treatments, and long-term outcomes were prospectively collected and retrospectively analyzed. RESULTS: Thirty-two patients presented with post-LT NET recurrence occurring 82.9 mo (interquartile range, 29.4-119.1 mo) from LT, and the most common sites were abdominal lymph nodes (59.4%), peritoneum (6.3%), and lungs (6.3%). Fourteen patients (43.8%) underwent surgery with radical intent. Five- and 10-y survival after recurrence were 76.3% and 45.5%, respectively. Only time from LT to recurrence had a significant impact on postrecurrence survival, being 5-y overall survival 89.5% versus 0% for patients recurring >24 mo after LT versus ≤24 mo, respectively (P = 0.001). Moreover, for patients with Ki-67 monoclonal antibody staining >2% at recurrence, 5 y overall survival was 87.5% versus 0% for those undergoing surgery versus locoregional or systemic treatments (P = 0.011). CONCLUSIONS: The presented results, although based on a retrospective and relatively small series, show that excellent long-term survival is observed after post-LT NET recurrence, particularly in those patients recurring long after LT (>24 mo). An aggressive surgical treatment might result in a new chance of cure for a selected subgroup of patients.

The Diverticular Disease Registry (DDR Trial) by the Advanced International Mini-Invasive Surgery Academy Clinical Research Network: Protocol for a Multicenter, Prospective Observational Study.

Diverticular disease is an increasingly common issue, with a variety of clinical presentations and treatment options. However, very few prospective cohort studies explore outcomes between the different presentations and treatments. The Diverticular Disease Registry (DDR Trial) is a multicenter, prospective, observational cohort study on behalf of the Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network. The DDR Trial aims to investigate the short-term postoperative and long-term quality of life outcomes in patients undergoing surgery or medical treatments for diverticular disease. DDR Trial is open to participation by all tertiary-care hospitals. DDR Trial has been registered at ClinicalTrials.gov (NCT04907383). Data collection will be recorded on Research Electronic Data Capture (REDCap) starting on June 1st, 2021 and will end after 5 years of recruitment. All adult patients with imaging-proven colonic diverticular disease (i.e., symptomatic colonic diverticulosis including diverticular bleeding, diverticulitis, and Symptomatic Uncomplicated Diverticular Disease) will be included. The primary outcome of DDR Trial is quality of life assessment at 12-month according to the Gastrointestinal Quality of Life Index (GIQLI). The secondary outcome is 30-day postoperative outcomes according to the Clavien-Dindo classification. DDR Trial will significantly advance in identifying the optimal care for patients with diverticular disease by exploring outcomes of different presentations and treatments. HIGHLIGHTS: Diverticular disease (i.e., diverticulitis, bleeding) has different treatments.This is a clinical protocol for the Diverticular Disease Registry (DDR Trial).DDR Trial is a multicenter, prospective, observational cohort study open to participation.DDR Trial will study short-term postoperative and long-term quality of life outcomes.Medical treatments, interventional radiology and surgery will be explored.

The potential role of metformin in the treatment of patients with pancreatic neuroendocrine tumors: a review of preclinical to clinical evidence.

The incidence of pancreatic neuroendocrine tumors (panNETs) has increased worldwide in the last two decades. Given the indolent nature of these tumors, several patients are diagnosed with metastatic disease, which partially impairs the long-term efficacy of currently available treatments and reduces survival rates. The search for new therapeutic strategies for cancer patients has pushed towards the retrospective analysis of studies involving patients who concomitantly received other drugs together with standard anticancer agents. In this light, several retrospective analyses have shown that metformin use is associated with improved prognosis in patients with different tumor types treated with standard antitumor agents. Metformin, the cornerstone oral agent for the treatment of type 2 diabetes, plays a role in modulating glucose cell metabolism. Its potential ability to interfere with tumors may derive from the tight relationship between metabolic reprogramming in cancer cells and tumor progression. Indications for metformin use as an anticancer drug result from pre-clinical and clinical observations. In particular, metformin use in diabetic patients with advanced panNETs has been associated with better progression-free survival in patients treated with somatostatin analogues with or without metformin.

Gut and mesenteric lymph node involvement in pediatric patients infected with human immunodeficiency virus.

BACKGROUND: The gastrointestinal tract is a primary target for human immunodeficiency virus (HIV). HIV infection causes a depletion of CD4+ T-lymphocytes in gut-associated lymphoid tissue and affects gastrointestinal mucosal integrity and permeability. The gastrointestinal tract has also been suggested as the main reservoir of HIV despite highly active antiretroviral therapy (HAART). We performed a prospective case-control study to assess gut involvement in HIV-infected patients, either naïve or on HAART, using noninvasive methods such as bowel ultrasound and fecal calprotectin. METHODS: Thirty HIV-infected children and youth underwent the following tests: CD4+ T-cell count and HIV viral load, fecal calprotectin, and bowel ultrasound, with the latter evaluating bowel wall thickness and mesenteric lymph nodes. Fecal calprotectin and bowel ultrasound were also assessed in 30 healthy controls matched for age and sex. Fecal calprotectin was measured using a quantitative immunochromatographic point-of-care test, and concentrations ranging from 0 to 200 µg/g were considered to be normal reference values in children. RESULTS: Fecal calprotectin was normal in 29 HIV-infected patients and was not significantly different from controls (mean values 63.8±42.5 µg/g and 68.3±40.5 µg/g, respectively; P=0.419), and did not correlate with HIV viral load, CD4+ T-cell absolute count and percentage, or HAART treatment. No significant changes were found on bowel ultrasound except for enlarged mesenteric lymph nodes, which were observed in seven HIV-infected patients (23.3%) and two controls (6.6%). This finding was significantly correlated with high HIV viral load (P=0.001) and low CD4+ T-cell percentage (P=0.004). CONCLUSION: HIV-infected children did not have significant biochemical or ultrasonographic signs of bowel inflammation. A few patients showed enlarged mesenteric lymph nodes, which correlated with uncontrolled HIV infection.

Transperineal perineal ultrasound versus magnetic resonance imaging in the assessment of perianal Crohn's disease.

BACKGROUND: To assess the accuracy of transperineal ultrasound (TPUS), in comparison with magnetic resonance imaging (MRI), in classifying perianal Crohn's disease (CD) according to Parks' classification and the American Gastroenterological Association criteria. METHODS: Fifty-nine consecutive patients with confirmed or suspected perianal CD underwent TPUS and MRI within 10 days. An independent expert surgical evaluation, which took into account proctological and MRI findings, was used as the gold standard. Fistulae and perianal disease were classified according to Parks' classification and American Gastroenterological Association criteria, respectively. RESULTS: Forty-six patients showed 64 fistulae (9 intersphincteric, 34 transsphincteric, 2 suprasphincteric, 9 extrasphincteric, and 10 anovaginal) and 23 abscesses were also found. Fifty-one of 54 perianal fistulae (per-lesion sensitivity: 94.4%) and 9 of 10 anovaginal fistulae (sensitivity: 90.0%) were detected and 58 were correctly classified by TPUS (sensitivity: 90.6%; positive predictive value: 93.4%). Overall, TPUS correctly detected and classified the fistulae in 89% of patients and the agreement for classifying perianal fistulae between TPUS and MRI was excellent (K value: 0.783). In contrast, 11 of 23 abscesses were correctly diagnosed by TPUS (sensitivity: 47.8%); although 14 abscesses were diagnosed by TPUS, only 11 were confirmed by MRI (positive predictive value: 78.6%). Overall, TPUS correctly detected and classified fistulae and associated abscesses in 67.3% of patients. Agreement between MRI and TPUS in discriminating simple (15) and complex (29) perianal disease was fairly good (K value: 0.57). CONCLUSIONS: TPUS is a simple and accurate diagnostic method for classifying perianal fistulae in CD and could be used for the preliminary assessment and follow-up of perianal CD.