Does Tri-Staple™ technology reduce the risk of anastomotic leakage in colorectal surgery? A propensity score matching analysis.

BACKGROUND AND OBJECTIVES: This study evaluates the Tri-Staple™ technology in colorectal anastomosis. METHODS: Patients who underwent rectosigmoidectomy between 2016 and 2022 were retrospectively evaluated and divided into two groups: EEA™ (EEA) or Tri-Staple™ (Tri-EEA). The groups were matched for age, sex, American Society of Anesthesiologists (ASA), and neoadjuvant radiotherapy using propensity score matching (PSM). RESULT: Three hundred and thirty-six patients were included (228 EEA; 108 Tri-EEA). The groups were similar in sex, age, and neoadjuvant therapy. The Tri-EEA group had fewer patients with ASA III/IV scores (7% vs. 33%; p < 0.001). The Tri-EEA group had a lower incidence of leakage (4% vs. 11%; p = 0.023), reoperations (4% vs. 12%; p = 0.016), and severe complications (6% vs. 14%; p = 0.026). There was no difference in complications, mortality, readmission, and length of stay. After PSM, 108 patients in the EEA group were compared with 108 in the Tri-EEA group. The covariates sex, age, neoadjuvant radiotherapy, and ASA were balanced, and the risk of leakage (4% vs. 12%; p = 0.04), reoperation (4% vs. 14%; p = 0.014), and severe complications (6% vs. 15%; p = 0.041) remained lower in the Tri-EEA group. CONCLUSION: Tri-Staple™ reduces the risk of leakage in colorectal anastomosis. However, this study provides only insights, and further research is warranted to confirm these findings.

Intracorporeal anastomosis could be associated with a higher lymph node yield in right colon cancer surgery: Results of the ICA-LATAM study, a retrospective, multicentre, comparative analysis in Latin America.

AIM: The aim of this work was to compare lymph node (LN) yield in patients operated on for right colon cancer (RCC) using a laparoscopic approach between those receiving an intracorporeal (ICA) or extracorporeal anastomosis (ECA). METHOD: This is a retrospective multicentre study involving patients operated on for RCC in nine tertiary referral centres in Latin America during a 2-year period. The main comparative outcome between groups was the number of LNs harvested between groups. RESULTS: The study included 416 patients, 261 (62.7%) in the ECA group and 155 (37.3%) in the ICA group. Patients in the ECA group were elderly (66 vs. 61 years, p < 0.001). Patients receiving an ICA achieved a significantly higher LN yield than those receiving an ECA (24 vs. 18, p < 0.001). This group also had a lower percentage of patients achieving a substandard LN yield (<12 LNs) (10% vs. 24.8%, p = 0.001) and more patients achieving a high number of harvested LNs (>32 LNs) (15.5% vs. 8.3%, p = 0.039). In the multivariate analysis, ICA was independently related to the primary outcome (LN yield) (OR 3.28, p = 0.027, 95% CI 1.14-9.38). CONCLUSION: In this retrospective study, patients operated on for RCC who received an ICA achieved a higher LN yield. Further studies are needed to reconfirm these findings, and also to find an explanation for these results.

Risk Factors for Early Lower Limb Re-Amputation in Vascular Diseases.

BACKGROUND: Numerous risk factors for lower limb amputations are known; however, this study aimed to identify risk factors for re-amputation in patients within 6 months from an initial lower limb amputation procedure. METHODS: This single-center retrospective cohort study was performed at the Hospital Regional Hans Dieter Schmidt in Brazil. The study included patients who were aged at least 18 years and had undergone lower limb amputation between 2013 and 2022. Patients who died while hospitalized and patients who were lost to follow-up after hospital discharge were excluded from the study. Patient age, sex, number of amputations, revision time, comorbidities, and potential risk factors were extracted from the physical therapy service database and electronic medical records of the hospital. Chi-squared test and student's t-test were used to identify statistical significance. RESULTS: A total of 652 patients were included, of which 35.2% (230) patients underwent re-amputation within 6 months of the first operation. We found that dialysis (P = 0.004; odds ratio [OR] 8.36, 95% confidence interval [CI] 3.09-20.5), smoking (P = 0.004; OR 1.67, 95% CI 1.18-2.35), and hypertension (P = 0.02; OR 1.55, 95% CI 1.09-2.19) were predictive factors for re-amputation within 6 months of lower limb amputation. CONCLUSIONS: Therefore, it is important to intervene early and provide additional support to patients undergoing lower limb amputation with these risk factors to reduce the potential for re-amputation in the future.

Surgical and medical outcomes in robotic compared to laparoscopic colectomy global prospective cohort from the American college of surgeons national surgical quality improvement program.

BACKGROUND: Evidence regarding the outcomes benefits of robotic approach, when compared to a laparoscopic approach, in colectomy remain limited. OBJECTIVE: This study aimed to analyze the value of robotic approach compared to laparoscopic approach in minimally invasive colectomy. DESIGN: Cohort study of the National Surgical Quality Improvement Program (NSQIP). SETTING: This study included data from the NSQIP from 1/2016 to 12/2021. PATIENT: Adult patients undergoing minimally invasive (laparoscopic or robotic) colorectal surgery. INTERVENTION: Robotic versus laparoscopic colectomy. OUTCOME MEASURES: Risk ratios for the incidence of medical and surgical morbidity and overall mortality. RESULTS: Compared to laparoscopic, robotic colectomy was associated with a significant decrease in postoperative morbidity [RR 0.84 (95%CI 0.72-0.96), P < 0.001], a significant reduction in postoperative mortality [RR 0.83 (95%CI 0.79-0.90), P 0.010)], and in post operative ileus [RR: 0.80 (95%CI 0.75-0.84), P < 0.001]. Yet, robotic approach was associated with a significant increase in total operative time despite a significant decrease in total length of stay. No benefit was observed regarding anastomotic leak. LIMITATIONS: Observational nature of the study cannot exclude residual bias. CONCLUSIONS: In this prospective cohort from the NSQIP, robotic colectomy was associated with a significant reduction in postoperative ileus, unplanned conversion to open surgery, morbidity, and overall mortality when compared to laparoscopic colectomy.

Bowel preparation for elective colectomy in Crohn's disease: results from a global cohort study using the NSQIP database.

AIM: The role of bowel preparation before colectomy in Crohn's disease patients remains controversial. This retrospective analysis of a prospective cohort study aimed to investigate the clinical outcomes associated with mechanical and antibiotic colon preparation in patients diagnosed with Crohn's disease undergoing elective colectomy. METHOD: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program participant user files from 2016 to 2021. A total of 6244 patients with Crohn's disease who underwent elective colectomy were included. The patients were categorized into two groups: those who received combined colon preparation (mechanical and antibiotic) and those who did not receive any form of bowel preparation. The primary outcomes assessed were the rate of anastomotic leak and the occurrence of deep organ infection. Secondary outcomes included all-cause short-term mortality, clinical-related morbidity, ostomy creation, unplanned reoperation, operative time, hospital length of stay and ileus. RESULTS: Combined colon preparation was associated with significantly reduced risks of anastomotic leak (relative risk 0.73, 95% CI 0.56-0.95, P = 0.021) and deep organ infection (relative risk 0.68, 95% CI 0.56-0.83, P < 0.001). Additionally, patients who underwent colon preparation had lower rates of ostomy creation, shorter hospital stays and a decreased incidence of ileus. However, there was no significant difference in all-cause short-term mortality or the need for unplanned reoperation between the two groups. CONCLUSION: This study shows that mechanical and antibiotic colon preparation may have clinical benefits for patients with Crohn's disease undergoing elective colectomy.

Production of Recombinant Zika Virus Envelope Protein by Airlift Bioreactor as a New Subunit Vaccine Platform.

The Zika Virus (ZIKV) is an emerging arbovirus of great public health concern, particularly in the Americas after its last outbreak in 2015. There are still major challenges regarding disease control, and there is no ZIKV vaccine currently approved for human use. Among many different vaccine platforms currently under study, the recombinant envelope protein from Zika Virus (rEZIKV) constitutes an alternative option for vaccine development and has great potential for monitoring ZIKV infection and antibody response. This study describes a method to obtain a bioactive and functional rEZIKV using an E. coli expression system, with the aid of a 5-L airlift bioreactor and following an automated fast protein liquid chromatography (FPLC) protocol, capable of obtaining high yields of approximately 20 mg of recombinant protein per liter of bacterium cultures. The purified rEZIKV presented preserved antigenicity and immunogenicity. Our results show that the use of an airlift bioreactor for the production of rEZIKV is ideal for establishing protocols and further research on ZIKV vaccines bioprocess, representing a promising system for the production of a ZIKV envelope recombinant protein-based vaccine candidate.

An Overview of Robotic Colorectal Surgery Adoption and Training in Brazil.

Background and Objectives: Robotic surgical systems have rapidly become integrated into colorectal surgery practice in recent years, particularly for rectal resections, where the advantages of robotic platforms over conventional laparoscopy are more pronounced. However, as with any technological advancement, the initial high costs can be a limiting factor, leading to unequal health service access, especially in middle- and lower-income countries. Materials and Method: A narrative review was conducted with the objective of providing an overview of the escalating adoption, current training programmes, and certification process of robotic colorectal surgery in Brazil. Results: Brazil has witnessed a rapid increase in robotic platforms in recent years. Currently, there are 106 robotic systems installed nationwide. However, approximately 60% of the medical facilities which adopted robotic platforms are in the Southeast region, which is both the most populous and economically prosperous in the country. The Brazilian Society of Coloproctology recently established clear rules for the training programme and certification of colorectal surgeons in robotic surgery. The key components of the training encompass theoretical content, virtual robotic simulation, observation, assistance, and supervised procedures in colorectal surgery. Although the training parameters are well established, no colorectal surgery residency programme in Brazil has yet integrated the teaching and training of robotic surgery into its curriculum. Thus far, the training process has been led by private institutions and the industry. Conclusion: Despite the fast spread of robotic platforms across Brazil, several challenges still need to be addressed to democratise training and promote the widespread use of these platforms. It is crucial to tackle these obstacles to achieve greater integration of robotic technology in colorectal surgery throughout the country.

Mesh repair versus non-mesh repair for incarcerated and strangulated groin hernia: an updated systematic review and meta-analysis.

BACKGROUND: Mesh repair in incarcerated or strangulated groin hernia is controversial, especially when bowel resection is required. We aimed to perform a meta-analysis comparing mesh and non-mesh repair in patients undergoing emergency groin hernia repair. METHODS: We performed a literature search of databases to identify studies comparing mesh and primary suture repair of patients with incarcerated or strangulated inguinal or femoral hernias who underwent emergency surgery. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. RESULTS: 1095 studies were screened and 101 were thoroughly reviewed. Twenty observational studies and four randomized controlled trials comprising 12,402 patients were included. We found that mesh-based repair had reduced recurrence (OR 0.36; 95% CI 0.19, 0.67; P = 0.001; I2 = 35%), length of hospital stay (OR - 1.02; 95% CI - 1.87, - 0.17; P = 0.02; I2 = 94%) and operative time (OR - 9.21; 95% CI - 16.82, - 1.61; P = 0.02; I2 = 95%) without increasing surgical site infection, mortality or postoperative complications such as seroma, chronic, ileus or urinary retention. In the subgroup analysis of patients that underwent bowel resection, we found that mesh repair was associated with an increased risk of surgical site infection (OR 1.74; 95% CI 1.04, 2.91; P = 0.04; I2 = 9%). CONCLUSIONS: Mesh repair for incarcerated and strangulated groin hernias reduces recurrence without an increase in postoperative complications and should be considered in clean cases. However, in the setting of bowel resection, mesh repair might increase the incidence of surgical site infection.

Keyhole Versus Sugarbaker Mesh Configuration in Parastomal Hernia Repair: A Systematic Review and Meta-analysis.

BACKGROUND: Parastomal hernia repairs (PHRs) are often complex and challenging, even for experienced abdominal wall surgeons. Although the ideal therapeutic option in the setting of a parastomal hernia is to restore intestinal continuity, this is often not feasible, and numerous techniques have been described for PHR. Current guidelines recommend using mesh for elective PHR, but there is a scarcity of evidence comparing different PHR techniques. We aimed to report a meta-analysis comparing the outcomes of the "Sugarbaker" and "Keyhole" mesh configuration in PHR. METHODS: A literature search of PubMed, Embase, Scopus, and Cochrane Library databases was performed to identify studies comparing Sugarbaker and Keyhole mesh configuration in PHR. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. RESULTS: A total of 3247 studies were screened, and 27 were fully reviewed. Ten studies and 632 patients were included in the meta-analysis. Three hundred five patients (48.3%) with Keyhole and 327 patients (51.7%) with Sugarbaker mesh configuration. Four hundred thirty-three patients (68.5%) underwent laparoscopic PHR with intraperitoneal onlay mesh. Sugarbaker mesh configuration was associated with lower hernia recurrence compared with Keyhole (odds ratio: 0.39; 95% CI: 0.19-0.83; P = 0.01; I2 = 46%). No differences were seen in overall complications, reoperations, stoma outlet obstruction, mesh infection, and postoperative bleeding. CONCLUSION: PHR with Sugarbaker mesh configuration is associated with decreased hernia recurrence compared with Keyhole and had similar rates of overall complications, reoperations, stoma outlet obstruction, mesh infection, and postoperative bleeding.

A multi-centre randomized controlled trial investigating Consolidation Chemotherapy with and without oxaliplatin in distal rectal cancer and Watch & Wait.

BACKGROUND: Neoadjuvant chemoradiation(nCRT) has been considered the preferred initial treatment strategy for distal rectal cancer. Advantages of this approach include improved local control after radical surgery but also the opportunity for organ preserving strategies (Watch and Wait-WW). Consolidation chemotherapy(cCT) regimens using fluoropyrimidine-based with or without oxalipatin following nCRT have demonstrated to increase complete response and organ preservation rates among these patients. However, the benefit of adding oxaliplatin to cCT compared to fluoropirimidine alone regimens in terms of primary tumor response remains unclear. Since oxalipatin-treatment may be associated with considerable toxicity, it becomes imperative to understand the benefit of its incorporation into standard cCT regimens in terms of primary tumor response. The aim of the present trial is to compare the outcomes of 2 different cCT regimens following nCRT (fluoropyrimidine-alone versus fluoropyrimidine + oxaliplatin) for patients with distal rectal cancer. METHODS: In this multi-centre study, patients with magnetic resonance-defined distal rectal tumors will be randomized on a 1:1 ratio to receive long-course chemoradiation (54 Gy) followed by cCT with fluoropyrimidine alone versus fluoropyrimidine + oxaliplatin. Magnetic resonance(MR) will be analyzed centrally prior to patient inclusion and randomization. mrT2-3N0-1 tumor located no more than 1 cm above the anorectal ring determined by sagittal views on MR will be eligible for the study. Tumor response will be assessed after 12 weeks from radiotherapy(RT) completion. Patients with clinical complete response (clinical, endoscopic and radiological) may be enrolled in an organ-preservation program(WW). The primary endpoint of this trial is decision to organ-preservation surveillance (WW) at 18 weeks from RT completion. Secondary endpoints are 3-year surgery-free survival, TME-free survival, distant metastases-free survival, local regrowth-free survival and colostomy-free survival. DISCUSSION: Long-course nCRT with cCT is associated with improved complete response rates and may be a very attractive alternative to increase the chances for organ-preservation strategies. Fluoropyrimidine-based cCT with or without oxaliplatin has never been investigated in the setting of a randomized trial to compare clinical response rates and the possibility of organ-preservation. The outcomes of this study may significantly impact clinical practice of patients with distal rectal cancer interested in organ-preservation. TRIAL REGISTRATION: www. CLINICALTRIALS: gov NCT05000697; registered on August 11th, 2021.

Preoperative Optimization Before Ventral Hernia Repair: A Systematic Review and Meta-analysis.

BACKGROUND: Obesity is associated with an increased risk of ventral hernia development and recurrence rates after ventral hernia repair (VHR). The metabolic derangements caused by obesity can also lead to many postoperative complications. Therefore, it is a common practice to attempt weight loss before VHR. However, there is still no consensus on optimal preoperative management for obese patients with a ventral hernia. This study aims to perform a meta-analysis to evaluate the effect of preoperative weight optimization on VHR outcomes. METHODS: We performed a literature search of PubMed, Scopus, and Cochrane Library databases to identify studies comparing obese patients who underwent surgical or non-surgical weight loss interventions before undergoing hernia repair surgery to obese patients who underwent hernia repair surgery without prehabilitation. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I 2 statistics. RESULTS: One thousand six hundred nine studies were screened and 13 were thoroughly reviewed. Five studies comprising 465 patients undergoing hernia repair surgery were included. No differences in hernia recurrence [odds ratio (OR) 0.66; 95% CI 0.23-1.89; P =0.44; I 2 =20%], seroma (OR 0.70; 95% CI 0.25-1.95; P =0.50; I 2 =5%), hematoma (OR 2.00; 95% CI 0.5-7.94; P =0.45; I 2 =0%), surgical site infection (OR 1.96; 95% CI 0.52-7.40; P =0.32; I 2 =0%), and overall complication (OR 0.80; 95% CI 0.37-1.74; P =0.58; I 2 =40%) rates were noted when comparing patients who underwent a preoperative weight loss intervention (prehabilitation or bariatric surgery) versus those who did not. In the subgroup analysis of patients who underwent bariatric surgery, we found no difference in hernia recurrence (OR 0.64; 95% CI 0.12-3.33; P = 0.59; I 2 =41%) or overall complications (OR 1.14; 95% CI 0.36-3.64; P =0.82; I 2 =64%). In the subgroup analysis of patients who lost weight versus patients who did not, there was no significant difference in overall complication rates (OR 0.86; 95% CI 0.34-2.21; P =0.76; I 2 =55%). CONCLUSIONS: We found similar hernia recurrence, seroma, hematoma, and surgical site infection rates in patients who underwent preoperative optimization. These findings underline the need for prospective studies to define the optimal role of preoperative optimization and weight loss in obese patients undergoing ventral hernia repair.

Penis metastasis in colon cancer: A case report of an unusual site of dissemination.

INTRODUCTION AND IMPORTANCE: Colorectal cancer is a leading cause of cancer-related deaths worldwide. It is estimated that approximately 1.93 million new cases of colorectal cancer were diagnosed and almost one million global colorectal cancer-caused deaths in 2020. The incidence of colorectal cancer has been dramatically rising at alarming rates worldwide in the last decades. The most often sites of metastases are lymph nodes, liver, lung, and peritoneum. CASE PRESENTATION: We present a rare case of a 63-year-old male patient presenting with a nodule in the penis after being treated for cancer in the hepatic flexure of the colon. Biopsy showed colorectal cancer recurrence in the penis. CLINICAL DISCUSSION: Metastasis from colorectal cancer to the penis is rare and poorly discussed, with scarce data in the literature. CONCLUSION: A high level of suspicion should be adopted for the correct diagnosis and early treatment.

Peptide linker increased the stability of pneumococcal fusion protein vaccine candidate.

Streptococcus pneumoniae is a bacterial pathogen exclusive to humans, responsible for respiratory and systemic diseases. Pneumococcal protein vaccines have been proposed as serotype-independent alternatives to currently used conjugated polysaccharide vaccines, which have presented limitations regarding their coverage. Previously in our group, pneumococcal surface protein A (PspA) and detoxified pneumolysin (PdT) were genetically fused and the hybrid protein protected mice against pneumococcal challenge, offered higher cross-protection against different strains and showed greater opsonophagocytosis rate than co-administered proteins. As juxtaposed fusion was unstable to upscale production of the protein, flexible (PspA-FL-PdT) and rigid (PspA-RL-PdT) molecular linkers were inserted between the antigens to increase stability. This work aimed to produce recombinant fusion proteins, evaluate their stability after linker insertion, both in silico and experimentally, and enable the production of two antigens in a single process. The two constructs with linkers were cloned into Escherichia coli and hybrid proteins were purified using chromatography; purity was evaluated by SDS-PAGE and stability by Western blot and high performance size exclusion chromatography. PspA-FL-PdT showed higher stability at -20°C and 4°C, without additional preservatives. In silico analyses also showed differences regarding stability of the fusion proteins, with molecule without linker presenting disallowed amino acid positions in Ramachandran plot and PspA-FL-PdT showing the best scores, in agreement with experimental results. Mice were immunized with three doses and different amounts of each protein. Both fusion proteins protected all groups of mice against intranasal lethal challenge. The results show the importance of hybrid protein structure on the stability of the products, which is essential for a successful bioprocess development.

Embolization of the Superior Rectal Arteries versus Closed Hemorrhoidectomy (Ferguson Technique) in the Treatment of Hemorrhoidal Disease: A Randomized Clinical Trial.

PURPOSE: To compare short-term and medium-term results of superior rectal artery embolization versus surgical hemorrhoidectomy in the treatment of patients with hemorrhoidal disease. MATERIAL AND METHODS: This study was a prospective randomized clinical trial following 33 patients with symptomatic hemorrhoidal disease Grades 2 and 3 who were randomly assigned to 2 different groups: the superior rectal artery embolization group (n = 15) and Ferguson closed hemorrhoidectomy surgical group (n = 14). Four patients were excluded from the analysis. Pain using the visual analog scale and the use of analgesics were evaluated 3 times daily during the first 7 days of the postoperative period. Recurrent symptoms and satisfaction with treatment were also evaluated in the subsequent first, third, sixth, and twelfth months. RESULTS: The mean pain during the first bowel movement after the procedure was 6.08 ± 4.41 in the surgery group and 0 in the embolization group (P = .001). The mean use of pain medication was higher in the surgery group (28.92 doses ± 15.78 vs 2.4 doses ± 5.21; P < .001). In the embolization group, the most prevalent preprocedural symptom was bleeding in 14 patients, with complete improvement in 12 (83.3%) patients. Mucus, skin tag, and pruritus were symptoms that showed little improvement in both groups. The frequency of symptoms (bleeding, pain, prolapse, and pruritus) was similar between the groups at 12 months (P = .691). No severe adverse events were observed in both groups. CONCLUSIONS: Despite no difference in outcomes, embolization of the superior rectal arteries for the treatment of hemorrhoidal disease showed pain levels lower than those observed after surgical treatment.

Response to Abemaciclib and Immunotherapy Rechallenge with Nivolumab and Ipilimumab in a Heavily Pretreated TMB-H Metastatic Squamous Cell Lung Cancer with CDKN2A Mutation, PIK3CA Amplification and TPS 80%: A Case Report.

Inactivation of the cyclin-dependent kinase inhibitor 2A (CDKN2A) gene is considerably more frequent in squamous cell lung cancer (SqCLC) than in other subtypes of lung cancer and may be a promising target for this histology. Here, we present the course of diagnosis and treatment of a patient with advanced SqCLC, harboring not only CDKN2A mutation but also PIK3CA amplification, Tumor Mutational Burden-High (>10 mutations/megabase), and a Tumor Proportion Score of 80%. After disease progression on multiple lines of chemotherapy and immunotherapy, he responded favorably to treatment with the CDK4/6i Abemaciclib and later achieved a durable partial response to immunotherapy rechallenge with a combination of anti-PD-1 and anti-CTLA-4, nivolumab, and ipilimumab.