Light and shadow of watch-and-wait strategy in rectal cancer: oncological result, clinical outcomes, and cost-effectiveness analysis.

BACKGROUND: The watch-and-wait (WW) strategy is a potential option for patients with rectal cancer who obtain a complete clinic response after neoadjuvant therapy. The aim of this study is to analyze the long-term oncological outcomes and perform a cost-effectiveness analysis in patients undergoing this strategy for rectal cancer. MATERIAL AND METHODS: The data of patients treated with the WW strategy were prospectively collected from January 2015 to January 2020. A control group was created, matched 1:1 from a pool of 480 patients undergoing total mesorectal excision. An independent company carried out the financial analysis. Clinical and oncological outcomes were analyzed in both groups. Outcome parameters included surgical and follow-up costs, quality-adjusted life years (QALYs), and the incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). RESULTS: Forty patients were included in the WW group, with 40 patients in the surgical group. During a median follow-up period of 36 months, metastasis-free survival (MFS) and overall survival (OS) were similar in the two groups. In the WW group, nine (22%) local regrowths were detected in the first 2 years. The permanent stoma rate was slightly higher after salvage surgery in the WW group compared to the surgical group (48.5% vs 20%, p < 0.01). The cost-effectiveness analysis was slightly better for the WW group, especially for low rectal cancer compared to medium-high rectal cancer (ICER = - 108,642.1 vs ICER = - 42,423). CONCLUSIONS: The WW strategy in locally advanced rectal cancer offers similar oncological outcomes with respect to the surgical group and excellent results in quality of life and cost outcomes, especially for low rectal cancer. Nonetheless, the complex surgical field during salvage surgery can lead to a high permanent stoma rate; therefore, the careful selection of patients is mandatory.

New era of robotic surgery: first case in Spain of right hemicolectomy on Hugo RAS surgical platform.

We describe the first robot-assisted right hemicolectomy performed in Spain using the new Hugo RAS (robotic-assisted surgery) (Medtronic, Minneapolis, Minnesota, USA). No conversion was registered, and no intraoperative complications or technical failures of the system were recorded. The operative time was 200 min, the docking time was 5 min and the length of the hospital stay was 8 days. We conclude that a right hemicolectomy using the Hugo RAS system is safe and feasible. Our earlier experience provides important skills for those who are starting to use this new robotic system.

First-reported case of vaginal late recurrence of Wilms tumor treated with complete pelvic exenteration.

Late relapses of Wilms tumour are extremely uncommon but still represent possible events. Even more rarely Wilms tumours present as extrarenal neoplasms, for which it could be difficult to diagnose and treat them promptly.We present a unique case of late recurrence of Wilms tumour 16 years after the primary diagnosis, with location in the gynaecological system. The relapse presented as a vaginal mass, and it gradually raised up to involve the majority of pelvic organs. We accurately studied the tumour extension, even realising a 3D preoperative reconstruction, and we managed to evaluate the patient with a multidisciplinary team involving general surgeons, urologists, gynaecologists and plastic surgeons. We finally decided for an extended surgical approach and realised a complete pelvic exenteration. Three months after surgery, the patient is in a good general condition, without major surgical complications and with no radiological signs of pelvic tumour relapse.

Can 3D imaging modeling recognize functional tissue and predict liver failure? A retrospective study based on 3D modelling of the major hepatectomies after hepatic modulation.

BACKGROUND: Thanks to the introduction of radiomics, 3d reconstruction can be able to analyse tissues and recognise true hypertrophy from non-functioning tissue in patients treated with major hepatectomies with hepatic modulation.The aim of this study is to evaluate the performance of 3D Imaging Modelling in predict liver failure. METHODS: Patients submitted to major hepatectomies after hepatic modulation at Sanchinarro University Hospital from May 2015 to October 2019 were analysed. Three-dimensional reconstruction was realised before and after surgical treatment. The volumetry of Future Liver Remnant was calculated, distinguishing in Functional Future Liver Remnant (FRFx) i.e. true hypertrophy tissue and Anatomic Future Liver Remnant (FRL) i.e. hypertrophy plus no functional tissue (oedema/congestion) These volumes were analysed in patients with and without post hepatic liver failure. RESULTS: Twenty-four procedures were realised (11 ALPPS and 13 PVE followed by major hepatectomy). Post hepatic liver failure grade B and C occurred in 6 patients. The ROC curve showed a better AUC for FRFxV (74%) with respect to FRLV (54%) in prediction PHLF > B. The increase of anatomical FRL (iFRL) was superior in the ALPPS group (120%) with respect to the PVE group (73%) (p = 0,041), while the increase of functional FRFX (iFRFx) was 35% in the ALLPS group and 46% in the PVE group (p > 0,05), showing no difference in the two groups. CONCLUSION: The 3D reconstruction model can allow optimal surgical planning, and through the use of specific algorithms, can contribute to differential functioning liver parenchyma of the FLR.

Robot-assisted cholecystectomy with the new HUGO™ robotic-assisted system: first worldwide report with system description, docking settings, and video.

Robotic surgery has gained worldwide acceptance in the past decade, and several studies have shown that this technique is safe and feasible. The innovation of this system is the open surgical console with an HD-3D display, a system tower, and four independent arm carts. We describe the first robot-assisted cholecystectomy performed with the new Hugo RAS (robotic-assisted surgery) system (Medtronic, Minneapolis, MN, USA) in Spain. The procedure was completed without conversion. No intraoperative complication or technical failure of the system was recorded. The operative time was 70 min. The docking time was 3 min. Hospital length of stay was 1 days. This case report shows the safety and feasibility of cholecystectomy with the Hugo RAS system and provides relevant data that may be of help to early adopters of this surgical platform.

Pancreatic head resection with segmental duodenectomy for the treatment of benign and malign pancreatic diseases. Case series experience of a single center.

INTRODUCTION AND IMPORTANCE: Duodenum-preserving pancreatic resections (DPPHR) is a reasonable surgical option for benign or low-grade malignant tumours of the pancreatic head. Several techniques have been proposed, with or without common biliary duct preservation. CASE PRESENTATION: We report for the first time two cases of pancreas divisum treated with this technique and we illustrate two other cases of pancreatic disease in which this procedure was realized from January 2015 to January 2020 in the HM Sanchinarro University Hospital. CLINICAL DISCUSSION: Pancreatic head resection with pancreatic parenchyma sparing, and duodenal preservation has been commonly accepted in the treatment of benign pancreatic head disease. CONCLUSION: This technique offers a wide application in the treatment of pancreatic and duodenal benign disease, including pancreatic malformation such as pancreas divisum and duodenal tumour that require segmental resection, in order to assure complete pancreatic head resection and to avoid duodenal and biliary duct ischemia.

Robot-assisted Nissen fundoplication with the new HUGO™ Robotic assisted system: First worldwide report with system description, docking settings and video.

BACKGROUND: Robotic surgery has gained worldwide acceptance over the past decade, with several studies showing that this technique is safe and feasible. METHODS: We describe the first robot-assisted Nissen fundoplication for hiatal hernia performed with the new Hugo™ RAS (Robotic assisted surgery) system (Medtronic, Minneapolis, MN, USA) in Spain. The innovation of this system is the open surgical console with a 3D-HD display, a system tower and four independent arm carts. RESULTS: The surgical procedures were completed without conversion. No intraoperative complications or technical failures of the system were recorded. The operative time was 97 min, the docking time was 3 min, and the length of hospital stay was three days. CONCLUSIONS: This case report shows the safety and feasibility of Nissen fundoplication for hiatal hernia with the Hugo™ RAS system and provides relevant data that may assist early adopters of this surgical platform.

Closed hyperthermic intraperitoneal chemotherapy with CO2 recirculation system compared with the open Coliseum technique in peritoneal malignity treatment.

BACKGROUND: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis can be performed in two ways: first, the standard open abdominal technique (Open HIPEC); or second, the closed technique. In recent years, a new technique has been introduced to perform closed HIPEC; the Peritoneal Recirculation System (PRS-1.0 Combat) with CO2 recirculation technology (PRS Closed HIPEC). The objective of this study is to present our experience with the PRS Closed HIPEC by comparing the intraoperative, postoperative and oncological results with the standard Open HIPEC technique (the Coliseum technique). METHODS: Data on patients undergoing CRS and HIPEC at the Sanchinarro University Hospital, Madrid from October 2012 to June 2021 were collected in a prospective database. The inclusion criteria were patients with primary or recurrent peritoneal metastases in gastrointestinal malignancies or ovarian cancer. The presence of an unresectable peritoneal carcinomatosis, the coexistence of another oncological disease, unresectable and distant metastases were the exclusion criteria. RESULTS: From October 2014 to June 2021, 84 patients underwent CRS and HIPEC at the Sanchinarro University Hospital, Madrid with curative intent. Since the introduction of the PRS Closed HIPEC technique in 2016, 65 patients have been treated. Before the introduction of PRS Closed HIPEC, 19 cases were performed using the Coliseum technique (the Open HIPEC group). The intraoperative results were similar in the two groups. Complete cytoreduction was achieved in all cases in the Open HIPEC group and in 98% in the PRS Closed HIPEC group. The rate of major complications was similar between the groups. Median Overall Survival (OS) resulted better in the Closed HIPEC group (67 months) with respecto to the Open group (43 months) (p < 0,001). Median Disease-Free Survival (DFS) was 15 months in the Open HIPEC group and 40 months in the PRS Closed HIPEC group (p < 0.001). CONCLUSION: The Peritoneal Recirculation System with CO2 recirculation technology (PRS Closed HIPEC) is a reproducible and safe technique and may represent a valid alternative for the administration of HIPEC.

Radiofrequency-assisted transection of the pancreas versus stapler in distal pancreatectomy: study protocol for a multicentric randomised clinical trial (TRANSPAIRE).

INTRODUCTION: To date, no pancreatic stump closure technique has been shown to be superior to any other in distal pancreatectomy. Although several studies have shown a trend towards better results in transection using a radiofrequency device (radiofrequency-assisted transection (RFT)), no randomised trial for this purpose has been performed to date. Therefore, we designed a randomised clinical trial, with the hypothesis that this technique used in distal pancreatectomies is superior in reducing clinically relevant postoperative pancreatic fistula (CR-POPF) than mechanical closures. METHODS AND ANALYSIS: TRANSPAIRE is a multicentre randomised controlled trial conducted in seven Spanish pancreatic centres that includes 112 patients undergoing elective distal pancreatectomy for any indication who will be randomly assigned to RFT or classic stapler transections (control group) in a ratio of 1:1. The primary outcome is the CR-POPF percentage. Sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-ß), expected POPF in control group of 32%, expected POPF in RFT group of 10% and a clinically relevant difference of 22%. Secondary outcomes include postoperative results, complications, radiological evaluation of the pancreatic stump, metabolomic profile of postoperative peritoneal fluid, survival and quality of life. Follow-ups will be carried out in the external consultation at 1, 6 and 12 months postoperatively. ETHICS AND DISSEMINATION: TRANSPAIRE has been approved by the CEIM-PSMAR Ethics Committee. This project is being carried out in accordance with national and international guidelines, the basic principles of protection of human rights and dignity established in the Declaration of Helsinki (64th General Assembly, Fortaleza, Brazil, October 2013), and in accordance with regulations in studies with biological samples, Law 14/2007 on Biomedical Research will be followed. We have defined a dissemination strategy, whose main objective is the participation of stakeholders and the transfer of knowledge to support the exploitation of activities. REGISTRATION DETAILS: ClinicalTrials.gov Registry (NCT04402346).

Giant fibrovascular polyps of the esophagus. Trans oral versus surgical approach. Case report and systematic literature review.

INTRODUCTION: Giant fibrovascular esophageal polyp is a rare benign intraluminal tumour. The aim of this study is to perform a review of the most recent literature in order to describe and analyse the current range of possible diagnostics and treatment strategies. CASE REPORT: We present two cases of giant fibrovascular esophageal polyp treated with a combined minimally invasive transluminal approach at Sanchinarro University Hospital. Further, we perform a literature review. CONCLUSION: We present two cases of grant fibrovascular polyp submitted to minimally invasive transluminal approach. Furthermore, 54 original articles reporting 59 cases have been analysed. In the surgical group, an esophagotomy and polyp resection were performed in 31 (91 %) patients and a total esophagectomy in two patients (5,8 %). Severe morbidity occurred in two patients (5,8 %.) The median hospital stay was 9.25 days. A total of two (5,8 %) cases of recurrence have been registered. In the minimally invasive transluminal approach group, 27 patients had a polyp resection performed completely by endoscopy/transoral. There were no complications but there was one case of recurrence. CONCLUSION: The transluminal approach is safe and should be considered also in the treatment of large esophageal polyps.

Case-matched analysis of robotic versus open surgical enucleation for pancreatic tumours: A comparative cost-effectiveness study.

BACKGROUND: Enucleation has widely spread as an alternative strategy in the treatment of small pancreatic tumours and cystic lesions. To date there are limited data on perioperative outcomes after pancreatic enucleation performed using a minimally invasive robotic technique, particularly regarding the risk factors associated with postoperative pancreatic fistula (POPF). We perform a comparative study of robotic pancreatic enucleation (RPE) and open enucleation (OPE) with the aim of evaluating clinical and cost-effective outcomes. METHODS: This is a case-matched analysis of patients who underwent robotic and open pancreatic enucleation performed at Sanchinarro University Hospital, Madrid, from October 2014 to December 2021. Patient data were obtained retrospectively. Clinicopathologic characteristics and perioperative and postoperative outcomes were recorded and analysed. Two groups of demographically similar patients were analysed: the robotic group (n = 20) and the open group (n = 20). The patient characteristics of the two groups have been compared. From February 2015, quality-adjusted life years (QALYs) are also included and prospectively recorded in the database and used to measure the effectiveness of the treatment. RESULT: A total of 20 RPE and 20 OPE have been included. The incremental cost of the robotic approach versus open was €2617.85(CI 95% 1601.48; 3634.24) and the incremental utility was 0.0879 QALYs (CI 95% 0.0834; 0.0925). The estimated ICER for patients was €29,782.13 (CI 95% 17,313.29; 43,576.01) per QALY gained. Robotic resection resulted a shorter postoperative hospital stay, less wound infections, faster recovery diet and a similar operating time. The two groups had similar complication rates. Pathological data were similar for both procedures. CONCLUSION: RPE resulted in a shorter hospital stay and less blood loss and morbidity, comparable with the outcomes of open enucleation. RPE may also be acceptable in terms of cost-effectiveness.

Sliding ureteral inguinal hernia: An uncommon embryological trick. Case report and literature review.

INTRODUCTION: Inguinoscrotal herniation of the bladder is a rare clinical entity, with a frequency between 0.5% and 4% of all inguinal hernias. When the whole bladder and ureters migrate into the scrotum, it may cause urinary disorders as hydronephrosis. CASE REPORT: A 77-year-old male patient suffering from hypertrophic obstructive cardiomyopathy, obesity and diabetic disease presented with urinary disorders and left-sided inguinoscrotal hernia. Under clinical suspicion of sigmoid colon involvement in the inguinal canal, abdominal and pelvic computed tomography (CT scan) with endovenous contrast was performed, revealing a left inguinoscrotal hernia, containing the sigmoid colon and the left pelvic ureter causing left hydronephrosis. DISCUSSION: Without create urinary bladder wall leakage, the content of the hernial sac was reduced into the abdominal cavity. Previous subarachnoid anesthesia a left hernioplasty was performed by means of Lichtenstein's method with self-fixating mesh (Bard Adhesix) and subsequent complete resolution of the hydronephrosis. CONCLUSION: Ureter involvement should be suspected when a clinical inguinal hernia is diagnosed concurrently with unexplained hydronephrosis, renal failure, or urinary tract infection, as in the case described. When suspected, the preoperative diagnosis, particularly with CT scan, is essential to avoid complications and to reduce risk of bladder and ureter injuries during hernia repair.

Robotic versus laparoscopic distal pancreatectomies: A systematic review and meta-analysis on costs and perioperative outcome.

AIM: The aim of this meta-analysis is to compare perioperative outcomes and costs of robotic and laparoscopic distal pancreatectomy (RDP and LDP). MATERIAL AND METHODS: In accordance with the PRISMA guidelines, we searched Medline, EMBASE, Cochrane and Web of Science for reports published before December 2020. RESULTS: The literature search identified 11 papers (1 187 patients). RDP showed a lower conversion rate (odds ratio: 2.56, 95% confidence intervals [CI]: 1.31 to 5.00) with no significant differences in bleeding and operative time, complications ≥ Clavien-Dindo grade III, pancreatic fistulas and length of stay. Despite RDP presenting higher costs in all included studies, none of these differences were significant. However, RDP showed higher total costs than LDP (standardized mean differences [SMD]: -1.18, 95% CI: -1.97 to -0.39). A subgroup analysis according to the continent of origin showed that studies coming from Asian research groups kept showing significant differences (SMD: -2.62, 95% CI: -3.38 to -1.85), while Western groups did not confirm these findings. CONCLUSION: Based on low-quality evidence, despite some potential technical advantages, RDP still seems to be costlier than LDP.

Case report: An epidural cavernous hemangioma mimicking a dumbbell-shaped neuroma.

INTRODUCTION AND IMPORTANCE: Spinal epidural cavernous hemangiomas are a rare occurrence. This particular case is made even more distinctive by the fact that the lesion mimicked a dumbbell-shaped neuroma. Moreover, it had a very unique localization (wholly epidural, at cervical-thoracic -C7-D1- level). The importance of this case is linked not only to its remarkable rarity, but also to the diagnostic avenues explored. The surgery was carried out by Prof. Riccardo Caruso, Head of the Neurosurgical Department of the Military Hospital of Rome and Professor of Neurosurgery of Sapienza University of Rome, assisted by Dr. Luigi Marrocco, Senior Neurosurgeon of the Military Hospital of Rome. Postsurgical recovery was managed by Dr. Venceslao Wierzbicki, Senior Neurosurgeon of the Military Hospital of Rome. CASE PRESENTATION: In 2020, a 71 year-old man, suffering from intense pain in the left scapular region and in the ulnar area of the left forearm, underwent surgery for the removal of a spinal epidural cavernous hemangioma involving the left C7-D1 foramen. Prior to surgery, the lesion had been misdiagnosed as a neuroma by a radiologist. CLINICAL DISCUSSION: In the Literature there are other, rare cases of hemangiomas partly located in the spinal canal, and partly located intra and extra foramen. In the case here presented, differential diagnosis as well as a potential Schwannoma, suggested by the dumbbell shape of the lesion, should have considered also the possibility of a meningioma. Two teams of radiologists examined the images, the radiologists of our team, Dr. Valentina Martines and Dr. Emanuele Piccione, thanks to a close inspection of the features of the lesion, postulated the extra-dural position. Other aspects of the scans were then analyzed to help guide future diagnosis of similar lesions. CONCLUSION: With a spinal tumor affecting the foramen, a close examination of the images allows for accurate presurgical differential diagnosis, differentiating between the more frequent neuroma and other rarer tumors, such as a hemangioma.

Right-side colectomy with complete mesocolic excision vs conventional right-side colectomy in the treatment of colon cancer: a systematic review and meta-analysis.

BACKGROUND: This meta-analysis aims to investigate the role of complete mesocolic excision (CME) in the treatment of right-side colon cancer when compared with standard right-side hemicolectomy, focusing on oncological outcomes, mortality and morbidity rates. MATERIALS AND METHODS: A systematic literature search was performed on MEDLINE and EMBASE archives, including studies on CME in right-side colon cancer. Primary outcomes were five-year disease-free survival and five-year overall survival. Secondary outcomes investigated were mortality and morbidity rates, intraoperative blood loss, anastomotic leakage, postoperative ileus, day of postoperative flatus, pulmonary infection, duration of hospital stay and number of lymph nodes harvested. RESULTS: Seventeen studies have been included in this meta-analysis for a total of 3918 patients. The five-year disease-free survival (DFS) and overall survival (OS) results improved in the CME group with respect to conventional right-side colectomy with an OR 1.88 (95% CI 1.02-3.45) and OR 2.77 (95% CI 1.33-5.74), respectively. The incidence of mortality and morbidity was comparable between the two groups. Moreover, conventional surgery time was faster than CME (MD 33.69 min, 95% CI 12.79-54.59), while no significant differences were reported in mean blood loss and hospital stay. Furthermore, the CME group showed a higher mean number of harvested lymph nodes (MD 7.08 lymph nodes 95% CI 4.90-9.27). CONCLUSION: Complete mesocolic excision of the right-side colectomy improves oncological outcomes without increasing mortality and morbidity rates compared to standard right-side hemicolectomy. CME should therefore be routinely performed in the treatment of right-side colon cancer.

Recurrent giant fibrovascualr oesophageal polyp: Benefits and pitfalls of a multimodal approach.

Fibrovascular polyp of the cervical esophagus represents about 0.5% to 1% of all benign oesophageal tumours. Usually asymptomatic, when FP protrudes into the oesophageal lumen, this may cause respiratory obstruction and provoke dysphagia, vomiting, dyspnoea, and retrosternal pain. In this article, we describe a multimodal approach in the treatment of a complex recurrent FP, for which surgical resection represents the safer and less invasive procedure.

Laparoscopic inguinal hernia repair: cost-effectiveness analysis of trend modifications of the technique.

The aim of this study is to evaluate the cost-effectiveness of different modifications of the trans-abdominal pre-peritoneal (TAPP) repair of groin hernia. Data were collected prospectively for all consecutive patients who underwent TAPP unilateral inguinal hernia repair between November 2017 and March 2019, and who completed a minimum of 1 year of follow-up. Costs and quality adjusted life year (QALY) gained were collected. Three TAPP variations were assessed: mesh fixation and peritoneal closure with staples (group 1); mesh fixation with fibrin glue and peritoneal closure with sutures (group 2); and mesh fixation and peritoneal closure with fibrin glue (group 3). A matched group of open repairs was established. The incremental cost-effectiveness ratio (ICER) and main intra-operative and post-operative outcomes were assessed. Overall 120 patients were included (group 1 n = 31; group 2 n = 27; group 3 n = 33; open group: 29). Operative time was shorter for groups 2 and 3, and the main post-operative outcomes were similar. The overall mean total cost of the open group (1185.95€) was lower compared with the laparoscopic group (group 1: 1682.39; group 2: 1538.54€; group 3: 1510.1€) (p = 0.026). However, the mean ICERs of groups 2 and 3 were significantly higher compared with group 1 (p = 0.021) and the open group (p = 0.032). At simulations analysis, the probability of cost-effectiveness was 33.32%, 36.26%, and 36.7% in TAPP groups 1, 2, and 3. In the long term, laparoscopic repair of groin hernia is cost-effective compared with open surgery. The use of fibrin glue for mesh fixation and/or for closing the peritoneum is the most cost-effective option and shortens operative times.

Role of 18F-PET-CT to predict pathological response after neoadjuvant treatment of rectal cancer.

OBJECTIVES: Neoadjuvant chemoradiation (nCRT) is universally considered to be a valid treatment to achieve downstaging, to improve local disease control and to obtain better resectability in locally advanced rectal cancer (LARC). The aim of this study is to correlate the change in the tumour 18F-FDG PET-CT standardized uptake value (SUV) before and after nCRT, in order to obtain an early prediction of the pathologic response (pR) achieved in patients with LARC. DATA DESCRIPTION: We performed a retrospective analysis of patients with LARC diagnosis who underwent curative resection. All patients underwent a baseline 18F-FDG PET-CT scan within the week prior to the initiation of the treatment (PET-CT SUV1) and a second scan (PET-CT SUV2) within 6 weeks of the completion of nCRT. We evaluated the prognostic value of 18F-FDG PET-CT in terms of disease-free survival (DFS) and overall survival (OS) in patients with LARC.A total of 133 patients with LARC were included in the study. Patients were divided in two groups according to the TRG (tumour regression grade): 107 (80%) as the responders group (TRG0-TRG1) and 26 (25%) as the no-responders group (TRG2-TRG3). We obtained a significant difference in Δ%SUV between the two different groups; responders versus no-responders (p < 0.012). The results of this analysis show that 18F-FDG PET-CT may be an indicator to evaluate the pR to nCRT in patients with LARC. The decrease in 18F-FDG PET-CT uptake in the primary tumour may offer important information in order for an early identification of those patients more likely to obtain a pCR to nCRT and to predict those who are unlikely to significantly regress.

Robotic-assisted right colectomy versus laparoscopic approach: case-matched study and cost-effectiveness analysis.

AIM: The aim of this study is to compare clinical and oncological outcomes of robot-assisted right colectomy with those of conventional laparoscopy-assisted right colectomy, reporting for the first time in literature, a cost-effectiveness analysis. METHODS: This is a case-matched prospective non-randomized study conducted from October 2013 to October 2017 at Sanchinarro University Hospital, Madrid. Patients with right-sided colonic adenocarcinoma or adenoma, not suitable endoscopic resection were treated with robot-assisted right colectomy and a propensity score-matched (1:1) was used to balance preoperative characteristics of a laparoscopic control group. Perioperative, postoperative, long-term oncological results and costs were analysed, and quality-adjusted life years (QALY), and the cost-effectiveness ratio (ICER) were calculated. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness-to-pay of 20,000 and 30,000 per QALY was used as a threshold to recognize which treatment was most cost effective. RESULTS: Thirty-five robot-assisted right colectomies were included and a group of 35 laparoscopy-assisted right colectomy was selected. Compared with the laparoscopic group, the robotic group was associated with longer operation times (243 min vs. 179 min, p < 0.001). No significant difference was observed in terms of total costs between the robotic and laparoscopic groups (9455.14 vs 8227.50 respectively, p = 0.21). At a willingness-to-pay threshold of 20,000 and 30,000, there was a 78.78-95.04% probability that the robotic group was cost effective relative to laparoscopic group. CONCLUSION: Robot-assisted right colectomy is a safe and feasible technique and is a cost-effective procedure.

Liver prometastatic reaction: Stimulating factors and responsive cancer phenotypes.

Cancer is first a localized tissue disorder, whose soluble and exosomal molecules and invasive cells induce a host response providing the stromal components of the primary tumor microenvironment (TME). Once the TME is developed, cancer-derived molecules and cells can more efficiently spread out and a whole-body response takes place, whose pathophysiological changes may result in a paraneoplastic syndrome. Remote organ-specific prometastatic reactions may also occur at this time, facilitating metastatic activities of circulating tumor cells (CTCs) through premetastatic niche development at targeted organs. However, additional signaling factors from the inter-organ communication network involved in the pathophysiology and comorbidities of cancer patients may also regulate prometastatic reaction-stimulating effects of cancer and non-cancer tissue factors. This article provides a conceptual overview of our ongoing clinical research on the liver prometastatic reaction (LPR) of patients with colorectal cancer (CRC), their portal vein- and hepatic artery-driven LPR-Stimulating Factors (LPR-SF), and their resulting LPR-derived Metastasis-Stimulating Factors (LPR-MSF) acting on liver-invading CRC cells. In addition, we also provide new insights on the molecular subtyping of LPR-responsive cancer phenotypes in patients with CRC and melanoma; and on how to investigate and interpret the prometastatic infrastructure in the real pathophysiological context of patients with cancer undergoing surgical procedures and receiving pharmacological treatments with multiple side effects, including those affecting the LPR, its stimulating factors and responsive cancer phenotypes.