Is Laparoscopic CME Right Hemicolectomy an Optimal Indication for NET of the Right Colon and Terminal Ileum?

PURPOSE: Since lymphadenectomy is crucial in midgut neuroendocrine tumor (NET) surgery, we adopted laparoscopic CME right hemicolectomy (LRH-CME) for the treatment of right colon and terminal ileum NETs. In this report, we present a series of nine cases of terminal midgut NETs (TM-NETs) treated by LRH-CME with a video demonstrating oncological principles and the surgical technique. METHODS: From September 2014 to November 2019, nine patients affected by TM-NETs underwent LRH-CME at the Unit of General and Hepatobiliary Surgery, University of Verona Hospital Trust, ENETS Center of Excellence. Clinicopathological data, post-operative and oncological outcomes were prospectively collected and analyzed. RESULTS: Tumors were in ileocecal valve or terminal ileum (5 cases), right colon (3 cases), and appendix (one case). Surgery had a curative intent (R0 resection) in 7 cases. Surgical debulking was required in 2 metastatic cases. Mean surgical time was 212 + 41 min and blood loss 47 + 24 mL. No postoperative mortality was observed. Post-operative course was uneventful in all except one case (Clavien-Dindo III). Median number of harvested lymph nodes was 21 (range, 11-31) and eight out of 9 patients were node positive (median 3, range 0-6). At a median follow-up of 18 months (range, 6-50), none of the patients suffered from mesenteric locoregional recurrence and all R0 resected patients were disease-free. CONCLUSIONS: Terminal midgut NETs represent an optimal indication for LRH-CME which increases the chance of complete resection and allows optimal lymphadenectomy. In expert hands, laparoscopic approach should be favored in consideration of good short-term outcomes.

Impact of visceral obesity and sarcobesity on surgical outcomes and recovery after laparoscopic resection for colorectal cancer.

BACKGROUND & AIMS: Studies analyzing the impact of visceral fat excess on surgical outcomes after resection for colorectal cancer (CRC) have yielded conflicting results. Visceral obesity (VO) and sarcobesity (SO) have been recently addressed as risk factors for poor short-term results while no data are available for recovery goals after surgery. No data are available on the protective effect of ERAS in VO and SO patients. The aim of this study was to assess clinical implications of computed tomography (CT) assessed VO and SO on surgical and recovery outcomes after minimally invasive resection for CRC before and after ERAS protocol implementation. METHODS: Visceral adipose tissue (VAT) and skeletal muscle area (SMA) were retrospectively assessed using pre-operative CT studies of 261 patients who underwent laparoscopic resection for CRC between January 2012 and April 2019; ERAS protocol was adopted in 160 patients operated on after March 2014. Patients' surgical and recovery outcomes were compared according to BMI categories, VO and SO which was defined using the VAT/SMA ratio (Sarcobesity Index). Predictive factors for poor surgical and recovery outcomes were evaluated by univariate and multivariate analyses. RESULTS: Of the 261 patients, 12.6% were BMI obese while 68.6% presented visceral obesity. BMI was not associated to any of the outcomes considered. No differences in intra-operative results were found except for a lower number of retrieved lymph nodes both in VO and SO patients. While VO showed no impact on post-operative course, SO resulted an independent risk factor for cardiac complications and prolonged post-operative ileus (PPOI) at logistic regression analysis. Furthermore, sarcobese patients showed delayed recovery after surgery. Patients enrolled in the ERAS protocol showed improved recovery outcomes for both VO and SO groups, although ERAS did not result to be a protective factor for cardiac complications and PPOI. CONCLUSIONS: A high Sarcobesity Index is a risk factor for developing cardiac complications and PPOI after laparoscopic resection for CRC. A reduced number of lymph nodes retrieved is associated to VO and SO. These conditions should then be considered in clinical practice for the risk of down staging the N stage. Effect of VO and SO on recovery items after surgery should be further investigated. ERAS protocol application should be implemented to improve recovery outcomes in VO and SO patients undergoing laparoscopic colorectal resection.

Role of surgery in the treatment of intrahepatic cholangiocarcinoma.

Intrahepatic Cholangiocarcinoma (ICC) is the second most common primary liver cancer, accounting for 10% to 15% of primary hepatic malignancy, and its incidence is increasing in Western Countries. Surgery with curative intent is the only treatment that offers a chance of long-term survival, with a reported 5-year overall survival rate ranging from 17% to 48%. In the most of recent series postoperative mortality is lower than 5% and morbidity varied from 6% to 66%. The macroscopic classification of ICC, proposed by Liver Cancer Study Group of Japan (LCSGJ), reflects different biologic behaviours, pattern of tumor growth and clinicopathological findings. The most important prognostic factors after resection are positive resection margins, lymph-node metastases, tumor size, presence of macrovascular invasion and intrahepatic metastases. Unfortunately, recurrence is still frequent and it is the leading cause of death. The treatment of the recurrence varied according to the location and extension of the disease. Recently, expression of several genes found to be related with the carcinogenesis of ICC. These molecular findings are helpful to differentiate the biological behaviour and will provide evidence for the development of new target therapies.

Hepatolithiasis-associated cholangiocarcinoma: results from a multi-institutional national database on a case series of 23 patients.

AIMS: Few papers focused on association between hepatolithiasis (HL) and cholangiocarcinoma (CCC) in Western countries. The aims of this paper are to describe the clinical presentation, treatment, and postoperative outcomes of CCC with HL in a cohort of Western patients and to compare the surgical outcomes of these patients with patients with CCC without HL. MATERIALS AND METHODS: Among 161 patients with HL from five Italian tertiary hepato-biliary centers, 23 (14.3%) patients with concomitant CCC were analyzed. The results of surgery in these patients were compared with patients with CCC without HL. RESULTS: The 60.9% of patients with HL received the diagnosis of CCC intra- or postoperatively, with a resectability rate of 91.3%. The postoperative morbidity was 61.6%. The 1- and 3-year survival rates were 78.6% and 21.0%, respectively. The recurrence rate was 44.4% and the 3-year disease-free survival rates were 18.8%. The comparison with patients with CCC without HL showed a higher resectability rate (p = 0.02) and a higher frequency of earlier stage (p = 0.04) in CCC with HL. Biliary leakage was more frequent in CCC with HL group (p = 0.01) compared to CCC without HL group. We found no differences in overall and disease-free survival between the two groups. CONCLUSIONS: Patients with HL and CCC showed a high resectability rate but a higher morbidity. Nevertheless, overall and disease-free survival of patients with CCC and HL showed no differences compared to those of patients with CCC without HL. Also in Western countries, HL needs a careful management for the possible presence of CCC.

Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy.

BACKGROUND: Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure that enables the removal of benign and/or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this review was to evaluate the short- and long-term surgical results of CP from all published studies, and the results of comparative studies of CP versus distal pancreatectomy (DP). METHODS: Eligible studies published between 1988 and 2010 were reviewed systematically. Comparisons between CP and DP were pooled and analysed by meta-analytical techniques using random- or fixed-effects models, as appropriate. RESULTS: Ninety-four studies, involving 963 patients undergoing CP, were identified. Postoperative morbidity and pancreatic fistula rates were 45·3 and 40·9 per cent respectively. Endocrine and exocrine pancreatic insufficiency was reported in 5·0 and 9·9 per cent of patients. The overall mortality rate was 0·8 per cent. Compared with DP, CP had a higher postoperative morbidity rate and a higher incidence of pancreatic fistula, but a lower risk of endocrine insufficiency (relative risk (RR) 0·22, 95 per cent confidence interval 0·14 to 0·35; P < 0·001). The risk of exocrine failure was also lower after CP, although this was not significant (RR 0·59, 0·32 to 1·07; P = 0·082). CONCLUSION: CP is a safe procedure with good long-term functional reserve. In situations where DP represents an alternative, CP is associated with a slightly higher risk of early complications.