Is Systemic Chemotherapy Useful in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Colorectal Peritoneal Metastases? A Propensity-Score Analysis.

PURPOSE: Multimodal treatment of colorectal (CRC) peritoneal metastases (PM) includes systemic chemotherapy (SC) and surgical cytoreduction (CRS), eventually with hyperthermic intraperitoneal chemotherapy (HIPEC), in select patients. Considering lack of clear guidelines, this study was designed to analyze the role of chemotherapy and its timing in patients treated with CRS-HIPEC. METHODS: Data from 13 Italian centers with PM expertise were collected by a collaborative group of the Italian Society of Surgical Oncology (SICO). Clinicopathological variables, SC use, and timing of administration were correlated with overall survival (OS), disease-free survival (DFS), and local (peritoneal) DFS (LDFS) after propensity-score (PS) weighting to reduce confounding factors. RESULTS: A total of 367 patients treated with CRS-HIPEC were included in the propensity-score weighting. Of the total patients, 19.9% did not receive chemotherapy within 6 months of surgery, 32.4% received chemotherapy before surgery (pregroup), 28.9% after (post), and 18.8% received both pre- and post-CRS-HIPEC treatment (peri). SC was preferentially administered to younger (p = 0.02) and node-positive (p = 0.010) patients. Preoperative SC is associated with increased rate of major complications (26.9 vs. 11.3%, p = 0.0009). After PS weighting, there were no differences in OS, DFS, or LDFS (p = 0.56, 0.50, and 0.17) between chemotherapy-treated and untreated patients. Considering SC timing, the post CRS-HIPEC group had a longer DFS and LDFS than the pre-group (median DFS 15.4 vs. 9.8 m, p = 0.003; median LDFS 26.3 vs. 15.8 m, p = 0.026). CONCLUSIONS: In patients with CRC-PM treated with CRS-HIPEC, systemic chemotherapy was not associated with overall survival benefit. The adjuvant schedule was related to prolonged disease-free intervals. Additional, randomized studies are required to clarify the role and timing of systemic chemotherapy in this patient subset.

Barbed suture in gastro-intestinal surgery: A review with a meta-analysis.

BACKGROUND: The laparoscopic approach is a very popular technique for many gastrointestinal operations and barbed sutures may improve the difficulties of intracorporeal anastomosis by eliminating the need for knot tying. The aim of this systematic review with a meta-analysis is to explore literature to establish the security profile of barbed suture compared with conventional laparoscopic sutures. MATERIALS AND METHODS: A systematic search was performed in all electronic databases (PubMed, Web of Science, Scopus, EMBASE) and 12 studies were included in the analysis, involving 27,133 patients, whereof 3372 cases (patients undergone barbed suture usage) and 23,761 controls (patients undergone conventional suture usage). We found 3 studies discussing differences between barbed and conventional sutures in colorectal surgery and 8 studies presenting results in bariatric surgery, both in Roux-en-y gastric bypass and Mini Gastric/One Anastomosis Gastric Bypass. RESULTS: We found comparable rate of leaks, bleedings and stenosis. The meta-regression analysis demonstrated that, both in case of bariatric and colorectal surgery, the demographic characteristic of patients and the oncological features of neoplasms did not impact of these findings. As expected, operative time is significantly shorter when barbed suture is used. CONCLUSION: Our analysis on current literature define an acceptable security profile for barbed suture with effective results particularly in terms of shorter operative time.

Microsatellite and RAS/RAF Mutational Status as Prognostic Factors in Colorectal Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

BACKGROUND: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) leads to prolonged survival for selected patients with colorectal (CRC) peritoneal metastases (PM). This study aimed to analyze the prognostic role of micro-satellite (MS) status and RAS/RAF mutations for patients treated with CRS. METHODS: Data were collected from 13 Italian centers with PM expertise within a collaborative group of the Italian Society of Surgical Oncology. Clinical and pathologic variables and KRAS/NRAS/BRAF mutational and MS status were correlated with overall survival (OS) and disease-free survival (DFS). RESULTS: The study enrolled 437 patients treated with CRS-HIPEC. The median OS was 42.3 months [95% confidence interval (CI), 33.4-51.2 months], and the median DFS was 13.6 months (95% CI, 12.3-14.9 months). The local (peritoneal) DFS was 20.5 months (95% CI, 16.4-24.6 months). In addition to the known clinical factors, KRAS mutations (p = 0.005), BRAF mutations (p = 0.01), and MS status (p = 0.04) were related to survival. The KRAS- and BRAF-mutated patients had a shorter survival than the wild-type (WT) patients (5-year OS, 29.4% and 26.8% vs 51.5%, respectively). The patients with micro-satellite instability (MSI) had a longer survival than the patients with micro-satellite stability (MSS) (5-year OS, 58.3% vs 36.7%). The MSI/WT patients had the best prognosis. The MSS/WT and MSI/mutated patients had similar survivals, whereas the MSS/mutated patients showed the worst prognosis (5-year OS, 70.6%, 48.1%, 23.4%; p = 0.0001). In the multivariable analysis, OS was related to the Peritoneal Cancer Index [hazard ratio (HR), 1.05 per point], completeness of cytoreduction (CC) score (HR, 2.8), N status (HR, 1.6), signet-ring (HR, 2.4), MSI/WT (HR, 0.5), and MSS/WT-MSI/mutation (HR, 0.4). Similar results were obtained for DFS. CONCLUSION: For patients affected by CRC-PM who are eligible for CRS, clinical and pathologic criteria need to be integrated with molecular features (KRAS/BRAF mutation). Micro-satellite status should be strongly considered because MSI confers a survival advantage over MSS, even for mutated patients.

Roux-en-Y gastric bypass versus one anastomosis-mini gastric bypass as a rescue procedure following failed restrictive bariatric surgery. A systematic review of literature with metanalysis.

BACKGROUND: Although different procedures have been proposed as revisional surgery for patients who had previously undergone a failed primary restrictive procedure, the ideal revisional procedure is still a matter of debate. METHODS: A systematic search was performed in all electronic databases to find studies comparing one anastomosis-mini gastric bypass (OAGB-MGB) or Roux-en-Y gastric bypass (RYGB) as revisional bariatric surgery for weight regain or intolerance/complications of a primary restrictive procedure. The data regarding sample size, patients' gender, age, primary surgery type, number of perioperative complications, operative time, pre- and post-revisional body mass index (BMI), and excess weight loss % (EWL%) at 1-year follow-up were extracted. Five studies were included in the analysis. RESULTS: The primary bariatric procedures were represented by vertical banded gastroplasty (VBG), laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG). About perioperative complications, both RYGB and OAGB-MGB showed a similar rate of leaks but OAGB-MGB had a lower rate of bleedings; considering the progression from pre- to post-revisional BMI, OAGB-MGB reveals a better outcome as well as a shorter operative time. CONCLUSIONS: Our meta-analysis has shown OAGB-MGB, used as revisional intervention after failed restrictive surgery, achieves outcomes comparable to RYGB in terms of perioperative complications providing a simpler and more effective technique.

Long-term results of a randomized clinical trial comparing endoscopic versus conventional treatment of pilonidal sinus.

BACKGROUND: In the new era of minimally invasive surgery, recent studies encouraged the adoption of endoscopic approaches as the most effective way to treat (pilonidal sinus disease) PSD but little is known about long-term results of minimally invasive procedures. MATERIALS AND METHODS: A total of 145 patients with chronic non recurrent pilonidal sinus were enrolled for this randomized controlled trial. The follow-up rate was 97% at 5 years for a total of 74 patients assigned to the minimally invasive treatment group and 67 patients assigned to the conventional Bascom cleft lift treatment group. We evaluated the following outcomes: long-term recurrence rate, patients' satisfaction, cosmetic outcome and cost-effectiveness results. RESULTS: Long-term data confirm that the recurrence rate was similar in both groups and, in minimally invasive patients, there were a higher satisfaction and better cosmetic results. Costs analysis revealed improved outcome in favour of VAAPS with a much lower mean global cost. CONCLUSION: Minimally invasive treatment has all the characteristics of an ideal approach to PSD with advantages including minimal patient inconveniences, high satisfaction and good aesthetics results. It was also more cost effective to carry out the treatment.

Barbed Suture and Gastrointestinal Surgery. A Retrospective Analysis.

Although minimally invasive surgery is recognized as the gold standard of many surgical procedures, laparoscopic suturing is still considered as the most difficult skill in laparoscopic surgery. The introduction of barbed sutures facilitates laparoscopic suturing because it is not necessary to tie a knot. The efficacy of this method has been evaluated in different types of surgery; however, less is known about general surgery. We retrospectively analysed data from 378 patients who had undergone bariatric or surgical treatment for colic or gastric malignancy requiring a closure of gastroentero, entero-entero or enterocolotomy from January 2014 to January 2019, admitted to the General Surgery Unit and Operative Unit of Surgical Endoscopy of the University Federico II (Naples, Italy). We registered 12 anastomotic leaks (3.1%), 16 anastomotic intraluminal bleedings (4.2%) and 7 extraluminal bleedings. Other complications included 23 cases of postoperative nausea and vomit (6%), 14 cases of postoperative ileus (3.7%) and 3 cases of intra-abdominal abscess (0.8%). Overall complications rate was 19.8% (75/378). No postoperative death was registered. Thus, by pooling together 378 patients, we can assess that barbed suture could be considered safe and effective for closure of holes used for the introduction of a branch of mechanical stapler to perform intracorporeal anastomosis.

Minimally Invasive Pilonidal Sinus Treatment: A Narrative Review.

The management of chronic pilonidal disease remains controversial, but recently, new minimal invasive approaches have been proposed. Whereas in the conventional surgical treatment an elliptical wedge of skin and subcutaneous tissue is created to remove the sinus and its lateral tracks, the basis for our new treatment is to create a minimal elliptical wedge of the subcutaneous tissue, including all the inflamed tissue and debris while leaving the overlying skin intact. The mechanism of an endoscopic approach relies on use of the endoscope without cutaneous tissue damage. Advantages include shorter operative time and time to discharge, which impact resource management in both primary and secondary care: patients undergoing endoscopic technique have a high satisfaction rate, probably due to the low level of postoperative pain and early return to work and daily activities. However, it is mandatory that further studies would analyze surgical approaches to pilonidal sinus disease (PSD) with a consistent and adequate follow-up of at least 5 years. Both sinusectomy and endoscopic approach to PSD were found to be safe and effective compared with conventional techniques. Publishedresults of studies of newer approaches have demonstrated a low short-term complication rate, comparable to conventional surgery results.

Esophagogastric Neoplasms Following Bariatric Surgery: an Updated Systematic Review.

The risk of gastric and/or esophageal cancers after bariatric surgery has been previously discussed in literature. A systematic review was performed to identify articles published between June 2012 and December 2018 reporting new cases of esophageal or gastric cancer not included in previous systematic reviews. Ten gastric malignancies, 28 esophageal cancers, and 2 gastro-intestinal stromal tumors (GIST) were identified. Primary bariatric surgery was a restrictive procedure in 26 cases, a purely malabsorptive procedure in 1 subject, and a gastric bypass in 13 patients. Although the vast majority of bariatric procedures seem to present a negligible relationship with any esophagogastric (EG) malignancy, published data remain incomplete. It was however considered of interest to update the number of EG neoplasms arisen following bariatric surgery.

No Difference in Ghrelin-Producing Cell Expression in Obese Versus Non-obese Stomach: a Prospective Histopathological Case-Control Study.

BACKGROUND: To understand the role of ghrelin in the mechanism of action of laparoscopic sleeve gastrectomy (LSG), a prospective cohort case-control study to assess the expression of ghrelin-producing cells (GPC) in two groups of patients was designed. METHODS: Specimens of resected stomach from 26 obese patients who underwent LSG (group A), were compared by immunohistochemistry to control stomach samples from 26 non-obese patients (group B) resected for other pathologies or during autopsy; (GIST: 6 cases, inflammatory diseases: 4 cases, post-mortem autopsy cases with stomachs from healthy persons victims of traumatic accidents: 16 cases). Immunohistochemistry investigation was performed with the use of Ventana Benchmark ultra, anti-ghrelin antibody NOVUS, mouse monoclonal 2F4, diluted at 1:100. RESULTS: No significant difference in the expression of GPC number between group A and B was found (p = 0.87). No significant correlation between patients presenting a GPC number above (subgroup 1) or below (subgroup 2) the average, and EWL% changes, both at 1 and 6 years of follow-up, was recorded. CONCLUSIONS: Our study has shown that the expression of GPC is similar in the stomach of obese and non-obese controls, being mostly influenced by the inflammatory status of the gastric mucosa. A variation in the preoperative number of GPC has not influenced the weight loss in patients who underwent LSG.