Pancreatojejunostomy: standing on the shoulders of giants. A single centre retrospective analysis.

Gaining experience in pancreatic surgery could be demanding especially when minimally invasive approach is used. Pancreatojejunostomy (PJ) is one of the most critical steps during pancreatoduodenectomy (PD). Our aim was to investigate the impact of a surgeon's experience in performing PJ, especially in a subgroup of patients undergoing laparoscopic PD (LPD). Data of consecutive patients undergoing PD from 2017 to 2022 were prospectively collected and retrospectively analyzed. Patients were divided into two groups: M group included patients in which PJ was performed by an experienced surgeon, D group included those receiving PJ by a less experienced one. The groups were compared in terms of postoperative outcomes. 187 patients were selected (157 in group M and 30 in group D). The cohorts differed in terms of median age (68 vs 74 years, p = 0.016), and previous abdominal surgery (41.4% vs 66.7%, p = 0.011), while no difference was found regarding risk of postoperative pancreatic fistula (POPF). The groups did not differ in terms of surgical outcomes. POPF rate was 15.9% and 10% in the M and D group (p = 0.578), respectively. Among patients undergoing laparoscopic PJ POPF rate was 16.0% and 17.7% in the M and D group (p = 0.867), respectively, without difference. No difference was found in terms of POPF in patients undergoing PD independently from the surgeon who performed the PJ, even during LPD. Moderate/high FRS, BMI > 30 kg/m2 and male sex, but not the surgeon who performed the PJ anastomosis, were independent predictors of POPF.

Independent effect of fat-to-muscle mass ratio at bioimpedance analysis on long-term survival in patients receiving surgery for pancreatic cancer.

Introduction: Malnutrition and alteration of body composition are early features in pancreatic cancer and appear to be predictors of advanced stages and dismal overall survival. Whether specific patient characteristics measured at the preoperative bioimpedance analysis (BIA) could be associated with long-term outcomes following curative resection has not been yet described. Methods: In a prospective multicenter study, all histologically proven resected pancreatic cancer patients were included in the analysis. BIA was measured for all patients on the day before surgery. Demographics, perioperative data, and postoperative outcomes were prospectively collected. Patients who experienced 90-day mortality were excluded from the analysis. Survival data were obtained through follow-up visits and phone interviews. Bioimpedance variables were analyzed according to the overall survival using the Kaplan-Meier curves and the univariate and multivariate Cox regression model. Results: Overall, 161 pancreatic cancer patients were included. The median age was 66 (60-74) years, and 27.3% received systemic neoadjuvant treatment. There were 23 (14.3%) patients malnourished in the preoperative evaluation. Median OS was 34.0 (25.7-42.3) months. Several bioimpedance variables were associated with OS at the univariate analysis, namely the phase angle [HR 0.85, 95% CI 0.74-0.98)], standardized phase angle [HR 0.91, 95% CI 0.82-0.99)], and an increased ratio between the fat and lean mass (FM/FFM) [HR 4.27, 95% CI 1.10-16.64)]. At the multivariate analysis, the FM/FFM ratio was a confirmed independent predictor of OS following radical resection, together with a positive lymph nodal status. Conclusion: Alteration of body composition at the preoperative bioimpedance vector analysis (BIVA) can predict dismal oncologic outcomes following pancreatic resection for cancer.

Should Laparoscopic Complete Mesocolic Excision Be Offered to Elderly Patients to Treat Right-Sided Colon Cancer?

BACKGROUND: Despite its potential oncologic benefit, complete mesocolic excision (CME) has rarely been offered to elderly patients. The present study evaluated the effect of age on postoperative outcomes among patients undergoing laparoscopic right colectomies with CME for right-sided colon cancer (RCC). METHODS: Data of patients undergoing laparoscopic right colectomies with CME for RCC between 2015 and 2018 were retrospectively analyzed. Selected patients were divided into two groups: the under-80 group and the over-80 group. Surgical, pathological, and oncological outcomes among the groups were compared. RESULTS: A total of 130 patients were selected (95 in the under-80 group and 35 in the over-80 group). No difference was found between the groups in terms of postoperative outcomes, except for median length of stay and adjuvant chemotherapy received, which were in favor of the under-80 group (5 vs. 8 days, p < 0.001 and 26.3% vs. 2.9%, p = 0.003, respectively). No difference between the groups was found regarding overall survival and disease free survival. Using multivariate analysis, only the ASA score > 2 (p = 0.01) was an independent predictor of overall complications. CONCLUSIONS: laparoscopic right colectomy with CME for RCC was safely performed in elderly patients ensuring similar oncological outcomes compared to younger patients.

Multidimensional evaluation of the learning curve for totally laparoscopic pancreaticoduodenectomy: a risk-adjusted cumulative summation analysis.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy (LPD) is a challenging procedure. We investigated the learning curve (LC) for LPD with a multidimensional analysis. METHODS: Data of patients undergoing LPD between 2017 and 2021, operated by a single surgeon, were considered. A multidimensional assessment of the LC was performed through Cumulative Sum (CUSUM) and Risk-Adjusted (RA)-CUSUM analysis. RESULTS: 113 patients were selected. Rates of conversion, overall postoperative complication, severe complication and mortality were 4%, 53%, 29% and 4%, respectively. RA-CUSUM analysis showed a LC with three phases: competency (procedures 1-51), proficiency (procedures 52-94), and mastery (after procedure 94). Operative time was lower in both phase two (588.17 vs 541.13 min, p = 0.001) and three (534.72 vs 541.13 min, p = 0.004) with respect to phase one. Severe complication rate was lower in mastery as compared to competency phase (42% vs 6%, p = 0.005). During mastery phase a greater number of lymph nodes was harvested in comparison to proficiency phase. CONCLUSIONS: According to our LC analysis, 52 procedures were required to achieve technical competency in LPD. Mastery, which corresponded to a reduction in operative time and surgical failures, was acquired after 94 procedures.

Long-term Outcomes After Laparoscopic, Robotic, and Open Pancreatoduodenectomy for Distal Cholangiocarcinoma: An International Propensity Score-matched Cohort Study.

OBJECTIVE: This study aimed to compare surgical and oncological outcomes after minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) for distal cholangiocarcinoma (dCCA). BACKGROUND: A dCCA might be a good indication for MIPD, as it is often diagnosed as primary resectable disease. However, multicenter series on MIPD for dCCA are lacking. METHODS: This is an international multicenter propensity score-matched cohort study including patients after MIPD or OPD for dCCA in 8 centers from 5 countries (2010-2021). Primary outcomes included overall survival (OS) and disease-free interval (DFI). Secondary outcomes included perioperative and postoperative complications and predictors for OS or DFI. Subgroup analyses included robotic pancreatoduodenectomy (RPD) and laparoscopic pancreatoduodenectomy (LPD). RESULTS: Overall, 478 patients after pancreatoduodenectomy for dCCA were included of which 97 after MIPD (37 RPD, 60 LPD) and 381 after OPD. MIPD was associated with less blood loss (300 vs 420 mL, P =0.025), longer operation time (453 vs 340 min; P <0.001), and less surgical site infections (7.8% vs 19.3%; P =0.042) compared with OPD. The median OS (30 vs 25 mo) and DFI (29 vs 18) for MIPD did not differ significantly between MIPD and OPD. Tumor stage (Hazard ratio: 2.939, P <0.001) and administration of adjuvant chemotherapy (Hazard ratio: 0.640, P =0.033) were individual predictors for OS. RPD was associated with a higher lymph node yield (18.0 vs 13.5; P =0.008) and less major morbidity (Clavien-Dindo 3b-5; 8.1% vs 32.1%; P =0.005) compared with LPD. DISCUSSION: Both surgical and oncological outcomes of MIPD for dCCA are acceptable as compared with OPD. Surgical outcomes seem to favor RPD as compared with LPD but more data are needed. Randomized controlled trials should be performed to confirm these findings.

Standardized right artery first approach during laparoscopic pancreaticoduodenectomy for periampullary neoplasms: technical aspects and perioperative outcomes.

BACKGROUND: The most debated aspects of laparoscopic pancreaticoduodenectomy (LPD) concern the dissection of the pancreas from the surrounding vessels and the achievement of adequate resection margins, especially in patients with pancreatic cancer. METHODS: Data of consecutive patients undergoing LPD with right artery first approach from September 2020 to September 2021 for periampullary neoplasms (pancreatic, ampullary, duodenal, distal common biliary duct) were prospectively collected and retrospectively analyzed. The overall cohort was divided into two groups: patients affected by pancreatic carcinoma (PC) and patients affected by other periampullary neoplasms (OP). Surgical and postoperative outcomes between PC and OP were compared. RESULTS: Thirty-one patients (15 PC and 16 OP) were selected. No difference was found between PC and OP in terms of baseline characteristics. Median resection time and overall surgical time of the entire cohort were 275 min and 530 min, respectively, without difference between the groups (p = 0.599 and 0.052, respectively). Blood loss was similar between the groups, being 350 ml in PC and 325 ml in OP (p = 0.762). One patient (3.2%) was converted to laparotomy. No difference was found between the groups in terms of pathological outcomes. Median number of retrieved lymph nodes was 17. The majority of the patients (83.9%) received an R0 resection (73.3% and 93.7% in PC and OP, respectively; p = 0.172). Postoperative surgical outcomes did not differ between the groups, excepting for overall complication rate that was higher in the OP group (26.7% vs 68.7% in PC and OP, respectively; p = 0.032). CONCLUSION: Standardized right artery first approach during LPD was feasible and did not show worse surgical and postoperative outcomes in patients with pancreatic cancer as compared to those affected by other periampullary neoplasms, except for a higher rate of minor complications.

Benchmarking of robotic and laparoscopic spleen-preserving distal pancreatectomy by using two different methods.

BACKGROUND: Benchmarking is an important tool for quality comparison and improvement. However, no benchmark values are available for minimally invasive spleen-preserving distal pancreatectomy, either laparoscopically or robotically assisted. The aim of this study was to establish benchmarks for these techniques using two different methods. METHODS: Data from patients undergoing laparoscopically or robotically assisted spleen-preserving distal pancreatectomy were extracted from a multicentre database (2006-2019). Benchmarks for 10 outcomes were calculated using the Achievable Benchmark of Care (ABC) and best-patient-in-best-centre methods. RESULTS: Overall, 951 laparoscopically assisted (77.3 per cent) and 279 robotically assisted (22.7 per cent) procedures were included. Using the ABC method, the benchmarks for laparoscopically assisted and robotically assisted spleen-preserving distal pancreatectomy respectively were: 150 and 207 min for duration of operation, 55 and 100 ml for blood loss, 3.5 and 1.7 per cent for conversion, 0 and 1.7 per cent for failure to preserve the spleen, 27.3 and 34.0 per cent for overall morbidity, 5.1 and 3.3 per cent for major morbidity, 3.6 and 7.1 per cent for pancreatic fistula grade B/C, 5 and 6 days for duration of hospital stay, 2.9 and 5.4 per cent for readmissions, and 0 and 0 per cent for 90-day mortality. Best-patient-in-best-centre methodology revealed milder benchmark cut-offs for laparoscopically and robotically assisted procedures, with operating times of 254 and 262.5 min, blood loss of 150 and 195 ml, conversion rates of 5.8 and 8.2 per cent, rates of failure to salvage spleen of 29.9 and 27.3 per cent, overall morbidity rates of 62.7 and 55.7 per cent, major morbidity rates of 20.4 and 14 per cent, POPF B/C rates of 23.8 and 24.2 per cent, duration of hospital stay of 8 and 8 days, readmission rates of 20 and 15.1 per cent, and 90-day mortality rates of 0 and 0 per cent respectively. CONCLUSION: Two benchmark methods for minimally invasive distal pancreatectomy produced different values, and should be interpreted and applied differently.

Benchmarking of minimally invasive distal pancreatectomy with splenectomy: European multicentre study.

BACKGROUND: Benchmarking is the process to used assess the best achievable results and compare outcomes with that standard. This study aimed to assess best achievable outcomes in minimally invasive distal pancreatectomy with splenectomy (MIDPS). METHODS: This retrospective study included consecutive patients undergoing MIDPS for any indication, between 2003 and 2019, in 31 European centres. Benchmarks of the main clinical outcomes were calculated according to the Achievable Benchmark of Care (ABC™) method. After identifying independent risk factors for severe morbidity and conversion, risk-adjusted ABCs were calculated for each subgroup of patients at risk. RESULTS: A total of 1595 patients were included. The ABC was 2.5 per cent for conversion and 8.4 per cent for severe morbidity. ABC values were 160 min for duration of operation time, 8.3 per cent for POPF, 1.8 per cent for reoperation, and 0 per cent for mortality. Multivariable analysis showed that conversion was associated with male sex (OR 1.48), BMI exceeding 30 kg/m2 (OR 2.42), multivisceral resection (OR 3.04), and laparoscopy (OR 2.24). Increased risk of severe morbidity was associated with ASA fitness grade above II (OR 1.60), multivisceral resection (OR 1.88), and robotic approach (OR 1.87). CONCLUSION: The benchmark values obtained using the ABC method represent optimal outcomes from best achievable care, including low complication rates and zero mortality. These benchmarks should be used to set standards to improve patient outcomes.

Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis.

PURPOSE: The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. METHODS: Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. RESULTS: A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. CONCLUSIONS: Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.

Low skeletal muscle index and myosteatosis as predictors of mortality in critically ill surgical patients.

OBJECTIVES: After elective surgeries, low muscle mass and other specific body composition indexes, assessed by computed tomography (CT), are associated with adverse outcomes such as an increased risk for postoperative complications and higher mortality. However, limited information is available about the role of these indexes on short- and long-term outcomes in surgical patients admitted to the intensive care unit (ICU). The aim of this study was to assess the association of body composition indexes with 90-d mortality in this specific patient cohort. METHODS: This was a retrospective study including adult surgical patients admitted to the ICU between 2014 and 2018 who underwent a CT scan at the time of admission. Total muscle area (TMA), total fat area (TFA), visceral fat area (VFA), and intramuscular fat area (IMFA) were measured. We then calculated skeletal muscle index (SMI; TMA/m2), myosteatosis (IMFA/TMA), and visceral fat-to-muscle ratio (VFA/TMA). We analyzed the effects of these indexes on mortality. RESULTS: The study included 204 patients. Overall, 90-d mortality was 28%. Log-rank test and Cox multivariate analysis on 90-d mortality showed a significant association of low SMI and myosteatosis with 90-d mortality. Myosteatosis was also significantly associated with prolonged mechanical ventilation and increased ICU length of stay. CONCLUSIONS: Specific body composition indexes may predict mortality in surgical patients admitted to the ICU. Low SMI and myosteatosis were independently associated with increased 90-d mortality.

Relation between skeletal muscle volume and prognosis in rectal cancer patients undergoing neoadjuvant therapy.

The prognostic role of body composition indexes, and specifically sarcopenia, has recently been explored in different cancer types. However, conflicting results have been reported. Heterogeneity in cancer type, cancer stage or oncological treatments, as well as different methodology and definition of sarcopenia, could be accounted for different conclusions retrieved from literature. When focusing on colorectal cancer, it clearly appears that colon and rectal cancers are often treated as a single entity though they have different behaviors and treatments. Particularly, patients with advanced rectal cancer represent a peculiar group of patients that according to current guidelines are treated with neoadjuvant chemotherapy and radiotherapy followed by radical surgery. This review was restricted to a homogeneous group of patients with advanced lower rectal cancer and the aim of exploring whether there is a correlation between skeletal muscle depletion and prognosis. Literature was searched for articles related to patients with advanced rectal cancer undergoing neoadjuvant chemo-radiotherapy (NCRT) followed by radical surgery, in whom muscle mass and/or change in muscle mass during neoadjuvant treatment were measured. Eight full-text articles were selected and included in the present review. The main findings of our review were: (1) The majority of the studies defined sarcopenia as muscle mass alone over muscle strength or physical performance; (2) There was a great deal of heterogeneity in the definition and measures of sarcopenia, in the definition of cut-off values, and in the method to measure change in muscle mass; (3) There was not full agreement on the association between sarcopenia at baseline and/or after chemo-radiotherapy and prognosis, and only few studies found a significance in the multivariate analysis; and (4) It seems that a loss in skeletal muscle mass during NCRT is associated with the worst outcomes in terms of disease-free survival. In conclusion, analysis of muscle mass might provide prognostic information on patients with rectal cancer, however more robust evidence is needed to define the role of muscle depletion and/or muscle change during neoadjuvant treatments, related to this specific group of patients. If a prognostic role would be confirmed by future studies, the role of preoperative intervention aimed at modifying muscle mass could be explored in order to improve outcomes.

Novel biodegradable internal stent as a mitigation strategy in high-risk pancreaticojejunostomy: technical notes and preliminary results.

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most feared complication after pancreaticoduodenectomy (PD), as it can lead to extremely poor outcomes. We herein report the preliminary results of an anastomotic technique based on the use of a novel internal biodegradable stent (IBS) to mitigate POPF sequelae. Between October 2020 and May 2021, all patients undergoing PD with high-risk pancreatic anastomosis received a pancreato-jejunal (PJ) anastomosis with an Archimedes™ IBS placement. Fifteen patients comprised our study cohort. In 11 cases, a 2-mm Archimedes™ stent was used, and in the remaining four patients, a 2.6-mm stent was used. Overall postoperative complications occurred in eight patients, with four cases being severe. Two patients developed CR-POPF, with one of them dying. In our small preliminary series, PJ anastomosis with an Archimedes™ IBS showed encouraging results in terms of CR-POPF incidence. Further studies are needed to confirm these findings.

Benchmarking postoperative outcomes after open liver surgery for cirrhotic patients with hepatocellular carcinoma in a national cohort.

BACKGROUND: Benchmark analysis for open liver surgery for cirrhotic patients with hepatocellular carcinoma (HCC) is still undefined. METHODS: Patients were identified from the Italian national registry HE.RC.O.LE.S. The Achievable Benchmark of Care (ABC) method was employed to identify the benchmarks. The outcomes assessed were the rate of complications, major comorbidities, post-operative ascites (POA), post-hepatectomy liver failure (PHLF), 90-day mortality. Benchmarking was stratified for surgical complexity (CP1, CP2 and CP3). RESULTS: A total of 978 of 2698 patients fulfilled the inclusion criteria. 431 (44.1%) patients were treated with CP1 procedures, 239 (24.4%) with CP2 and 308 (31.5%) with CP3 procedures. Patients submitted to CP1 had a worse underlying liver function, while the tumor burden was more severe in CP3 cases. The ABC for complications (13.1%, 19.2% and 28.1% for CP1, CP2 and CP3 respectively), major complications (7.6%, 11.1%, 12.5%) and 90-day mortality (0%, 3.3%, 3.6%) increased with the surgical difficulty, but not POA (4.4%, 3.3% and 2.6% respectively) and PHLF (0% for all groups). CONCLUSION: We propose benchmarks for open liver resections in HCC cirrhotic patients, stratified for surgical complexity. The difference between the benchmark values and the results obtained during everyday practice reflects the room for potential growth, with the aim to encourage constant improvement among liver surgeons.

Skeletal muscle wasting and long-term prognosis in patients undergoing rectal cancer surgery without neoadjuvant therapy.

BACKGROUND: Derangement of body composition has been associated with dismal long-term survival in several gastrointestinal cancers including rectal tumors treated with neoadjuvant therapies. The role of specific preoperative anthropometric indexes on the oncologic outcomes of patients undergoing upfront surgery for rectal cancer has not been investigated. The aim of the study is to evaluate the association of body composition and overall survival in this specific cohort. METHODS: Lumbar computed tomography images, obtained within the 30 days previous to surgery, between January 2009 and December 2016, were used to calculate population-specific thresholds of muscle mass (sarcopenia), subcutaneous and visceral adiposity, visceral obesity, sarcopenic obesity, and myosteatosis. These body composition variables were related with overall survival (OS), tumor-specific survival (TSS), and disease-free survival (DFS). OS, TSS, and DFS were evaluated by the Kaplan-Meier method. Cox regression analysis was used to identify independent predictors of mortality, tumor-specific mortality, and recurrence, and data were presented as hazard ratio (HR) and 95% confidence interval (CI). RESULTS: During the study period, 411 patients underwent rectal resection for cancer, and among these, 129 were without neoadjuvant chemoradiation. The median follow-up was 96.7 months. At the end of the follow-up, 41 patients (31.8%) had died; of these, 26 (20.1%) died for tumor-related reasons, and 36 (27.1%) experienced disease recurrence. One-, three-, and five-year OS was 95.7%, 86.0%, and 76.8% for non-sarcopenic patients versus 82.4%, 58.8%, and 40.0% for sarcopenic ones respectively (p < 0.001). Kaplan-Meier survival curves comparing sarcopenic and non-sarcopenic patients showed a significant difference in terms of OS (log-rank < 0.0001). Through multivariate Cox regression, overall mortality risk was associated only with sarcopenia (HR 1.96; 95%CI 1.03-3.74; p = 0.041). Disease stage IV and III (HR 13.75; 95% CI 2.89-65.6; p < 0.001 and HR 4.72; 95% CI 1.06-21.1; p = 0.043, respectively) and sarcopenia (HR 2.62; 95% CI 1.22-5.6; p = 0.013) were independently associated with TSS. The other body composition indexes investigated showed no significant association with prognosis. CONCLUSIONS: These results support the inclusion of body composition assessment for prognostic stratification of rectal cancer patients undergoing upfront resection.

Multidimensional evaluation of the learning curve for laparoscopic complete mesocolic excision for right colon cancer: a risk-adjusted cumulative summation analysis.

AIM: Despite the suggested potential benefit of complete mesocolic excision (CME) for right-sided colon cancer (RCC) for patient survival, concerns about its safety and feasibility have contributed to delayed acceptance of the procedure, especially when performed by a minimally invasive approach. Thus, the aim of this work was to evaluate the actual learning curve (LC) of laparoscopic CME for experienced colorectal surgeons. METHOD: Prospectively collected data for consecutive patients undergoing laparoscopic CME for RCC between October 2015 and January 2021 at our institution, operated on by experienced surgeons, were analysed. A multidimensional assessment of the LC was performed through cumulative sum (CUSUM) and risk-adjusted (RA) CUSUM analysis. RESULTS: Two hundred and two patients operated by on by three surgeons were considered. The CUSUM graphs based on operating time showed one peak of the curve between 17 and 27 cases. The CUSUM graphs based on surgical failure showed one peak of the curve between 20 and 24 cases The RA-CUSUM curve also showed one preeminent peak at 24-33 cases. Based on the CUSUM and RA-CUSUM analyses all the surgeons reached proficiency in 24-33 cases. CONCLUSIONS: Our study showed that an experienced minimally invasive colorectal surgeon acquires proficiency in laparoscopic CME for RCC after performing 24-33 cases.

Mid-term oncological outcomes after complete versus conventional mesocolic excision for right-sided colon cancer: a propensity score matching analysis.

BACKGROUND: The correct extent of mesocolic dissection for right-sided colon cancer (RCC) is still under debate. Complete mesocolic excision (CME) has not gained wide diffusion, mainly due to its technical complexity and unclear oncological superiority. This study aims to evaluate oncological outcomes of CME compared with non-complete mesocolic excision (NCME) during resection for I-III stage RCC. METHOD: Prospectively collected data of patients who underwent surgery between 2010 and 2018 were retrospectively analysed. 1:1 Propensity score matching (PSM) was used to balance baseline characteristics of CME and NCME patients. The primary endpoint of the study was local recurrence-free survival (LRFS). The two groups were also compared in terms of short-term outcomes, distant recurrence-free survival, disease-free survival, and overall survival. RESULTS: Of the 444 patients included in the study, 292 were correctly matched after PSM, 146 in each group. The median follow-up was 45 months (IQR 33-63). Conversion rate, complications, and 90-day mortality were comparable in both groups. The median number of lymph nodes harvested was higher in CME patients (23 vs 19, p = 0.034). 3-year LRFS rates for CME patients was 100% and 95.6% for NCME (log-rank p = 0.028). At 3 years, there were no differences between the groups in terms of overall survival, distant recurrence-free survival, and disease-free survival. CONCLUSION: Our PSM cohort study shows that CME is safe, provides a higher number of lymph nodes harvested, and is associated with better local recurrence-free survival.

Hepatic vascular anomalies during totally laparoscopic pancreaticoduodenectomy: challenging the challenge.

The presence of hepatic vascular anomalies may add challenges to an already difficult surgery such as pancreatoduodenectomy, particularly when performed laparoscopically. Thus, our aim was to assess the impact of an aberrant right hepatic artery (aRHA) on postoperative outcomes during laparoscopic pancreatoduodenectomy (LPD) . Data of patients who underwent LPD were prospectively gathered and retrospectively analyzed. Patients with types III, IV, VI, VII, VIII, and IX anomalies according to Michels' classification were included in the aRHA group and were compared with the remaining patients (nRHA group). 72 patients underwent LPD; 14 of these had an aRHA (19.4%). Except for BMI (p = 0.021), the two groups did not differ in terms of clinico-pathological characteristics. The two groups had similar postoperative complications (p = 0.123), pancreatic fistula (p = 0.790), biliary leakage (p = 0.209), postpancreatectomy hemorrhage (p = 0.790), reoperations (p = 0.416), and mortality (p = 0.312). The median number of lymph nodes harvested was higher in aRHA group (p = 0.032), while R0 resection rate was similar between groups (p = 0.635). At the multivariate analysis, only moderate/high FRS (OR 3.95, p = 0.039) was an independent predictor of postoperative complications. This study suggests that aRHA has no negative impact on surgical and oncological outcomes in patients undergoing LPD.

Laparoscopic complete mesocolic excision versus conventional resection for right-sided colon cancer: a propensity score matching analysis of short-term outcomes.

BACKGROUND: Complete mesocolic excision (CME) for right-sided colon cancer (RCC) is a demanding operation, especially when performed laparoscopically. The potential impact of CME in increasing postoperative complications is still unclear. The aim of our study was to evaluate the safety and feasibility of laparoscopic CME compared with laparoscopic non-complete mesocolic excision (NCME) during colectomy for RCC. METHODS: Data from a prospectively collected database of patients who underwent laparoscopic right and extended right colectomy at our institution between January 2008 and February 2020 were retrieved and analyzed. Short-term outcomes of patients undergoing CME and NCME were compared. A 1:1 propensity score matching (PSM) was used to balance baseline characteristics between groups. RESULTS: A total of 663 consecutive patients underwent resection of RCC in the study period. Among these, 500 met the inclusion criteria and after PSM a total of 372 patients were correctly matched, 186 in each group. A similar rate of overall postoperative complications was found between the CME and NCME groups (21.5% and 18.3%, p = 0.436). No difference was found in terms of conversion rate, severe complications, reoperations, readmissions, and mortality. The median number of harvested lymph nodes was higher in the CME group (22 versus 19, p = 0.003), with a lower rate of inadequate sampling (7.0% and 15.1%, p = 0.013). CONCLUSION: Laparoscopic CME for RCC is technically feasible and safe. It does not seem to be associated with a higher rate of complications or mortality compared with the "traditional" approach, but it allows better nodal sampling.

Clonally expanded EOMES+ Tr1-like cells in primary and metastatic tumors are associated with disease progression.

Regulatory T (Treg) cells are a barrier for tumor immunity and a target for immunotherapy. Using single-cell transcriptomics, we found that CD4+ T cells infiltrating primary and metastatic colorectal cancer and non-small-cell lung cancer are highly enriched for two subsets of comparable size and suppressor function comprising forkhead box protein P3+ Treg and eomesodermin homolog (EOMES)+ type 1 regulatory T (Tr1)-like cells also expressing granzyme K and chitinase-3-like protein 2. EOMES+ Tr1-like cells, but not Treg cells, were clonally related to effector T cells and were clonally expanded in primary and metastatic tumors, which is consistent with their proliferation and differentiation in situ. Using chitinase-3-like protein 2 as a subset signature, we found that the EOMES+ Tr1-like subset correlates with disease progression but is also associated with response to programmed cell death protein 1-targeted immunotherapy. Collectively, these findings highlight the heterogeneity of Treg cells that accumulate in primary tumors and metastases and identify a new prospective target for cancer immunotherapy.

ERAS pathway for gastric cancer surgery: adherence, outcomes and prognostic factors for compliance in a Western centre.

Adherence to an ERAS program guarantees an evidence-based approach for patient care, but the compliance to ERAS in patients undergoing surgery for gastric cancer in Western countries has not been clearly investigated. Our Institution has implemented an ERAS pathway (EP) for gastric surgery, composed of 24 items, since December 2016. We retrospectively analyzed the data of all consecutive patients undergoing surgery with curative intent for gastric cancer between January 2017 and December 2019 at our Institution, and were eligible for our EP. The primary endpoint was patients' compliance to the EP. Secondary endpoints were patients' adherence to each ERAS item and detection of variables associated with compliance failure. Seventy-three patients were included. Among these, 75.3% completed the EP, with a median number of items accomplished per patient of 21. Items with critical adherence were restrictive intraoperative fluid infusion (37%), avoidance of abdominal drain (14%), first clear liquid intake (67%), first solid food intake (48%). At univariate analysis age > 75 years, ASA > 2 and total gastrectomy were associated with failure to complete the EP. At multivariate analysis, ASA Score > 2 was the only preoperative factor associated with EP failure. Application of an ERAS program for malignant gastric surgery seems to be feasible with an acceptable completion rate in a tertiary referral Western centre. Preoperative factors, such as old age, advanced stage at diagnosis and neoadjuvant chemotherapy should not be considered as exclusion criteria for ERAS.