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Locally advanced extraperitoneal rectal cancer represents a significant clinical challenge, and currently, the standard treatment is based on neoadjuvant chemoradiation therapy (CRT) followed by radical surgical resection with total mesorectal excision (TME). In the last 30 years, its management has undergone significant changes due to the improvement of complementary radio- and chemotherapy treatments, the improvement of minimally invasive surgical approaches and the diffusion of organ-sparing approaches, such as nonoperative management, commonly called "watch and wait" (NOM) and local excision (LE), in highly selected patients who achieve a major or complete response to neoadjuvant CRT. This review aimed to critically examine the efficacy and oncological safety of NOM and LE compared to those of standard TME in rectal cancer patients after neoadjuvant CRT. Both the pros and cons of these approaches were strictly analyzed, providing a comprehensive and critical overview of these novel management strategies for rectal cancer.
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Neoadjuvant Therapy , Rectal Neoplasms , Rectal Neoplasms/therapy , Rectal Neoplasms/radiotherapy , Humans , Watchful Waiting , Chemoradiotherapy , Treatment Outcome , Chemoradiotherapy, AdjuvantABSTRACT
The influencing role of resection margin (R) status on long-term outcomes, namely overall (OS) and disease-free survival (DFS), after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is not still clear. The aim of this study is to evaluate the prognostic impact of R status after PD and to define tumor characteristics associated with a positive resection margin (R1). All PDs for PDAC performed between 2012 and 2023 were retrospectively enrolled. The effect of R status, patient clinico-demographic features, and tumor features on OS and DFS were assessed. One-hundred and sixty-seven patients who underwent PD for PDAC were included in the study. R0 was achieved in 105 cases (62.8%), while R1 was evidenced in 62 patients (37.1%). R1 was associated with a decreased OS (23 (13-38) months) as compared to R0 (36 (21-53) months) (p = 0.003). Similarly, DFS was shorter in R1 patients (10 (6-25) months) as compared to the R0 cohort (18 (9-70) months) (p = 0.004), with a consequent higher recurrence rate in cases of R1 (74.2% vs. 64.8% in the R0 group; p = 0.04). In the multivariate analysis, R1 and positive lymph nodes (N+) were the only independent influencing factors for OS (OR: 1.6; 95% CI: 1-2.5; p = 0.03 and OR: 1.7; 95% CI: 1-2.8; p = 0.04) and DFS (OR: 1.5; 95% CI: 1-2.1; p = 0.04 and OR: 1.8; 95% CI: 1.1-2.7; p = 0.009). Among 111 patients with N+ disease, R1 was associated with a significantly decreased DFS (10 (8-11) months) as compared to R0N+ patients (16 (11-21) months) (p = 0.05). In conclusion, the achievement of a negative resection margin is associated with survival benefits, particularly in cases of N1 disease. In addition, R0 was recognized as an independent prognostic feature for both OS and DFS. This further outlines the relevant role of radical surgery on long-term outcomes.
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PURPOSE: Post-operative pancreatic fistula (POPF) remains the main complication after distal pancreatectomy (DP). The aim of this study is to evaluate the potential benefit of different durations of progressive stapler closure on POPF rate and severity after DP. METHODS: Patients who underwent DP between 2016 and 2023 were retrospectively enrolled and divided into two groups according to the duration of the stapler closure: those who underwent a progressive compression for < 10 min and those for ≥ 10 min. RESULTS: Among 155 DPs, 83 (53.5%) patients underwent pre-firing compression for < 10 min and 72 (46.5%) for ≥ 10 min. As a whole, 101 (65.1%) developed POPF. A lower incidence rate was found in case of ≥ 10 min compression (34-47.2%) compared to < 10 min compression (67- 80.7%) (p = 0.001). When only clinically relevant (CR) POPFs were considered, a prolonged pre-firing compression led to a lower rate (15-20.8%) than the < 10 min cohort (32-38.6%; p = 0.02). At the multivariate analysis, a compression time of at least 10 min was confirmed as a protective factor for both POPF (OR: 5.47, 95% CI: 2.16-13.87; p = 0.04) and CR-POPF (OR: 2.5, 95% CI: 1.19-5.45; p = 0.04) development. In case of a thick pancreatic gland, a prolonged pancreatic compression for at least 10 min was significantly associated to a lower rate of CR-POPF compared to < 10 min (p = 0.04). CONCLUSION: A prolonged pre-firing pancreatic compression for at least 10 min seems to significantly reduce the risk of CR-POPF development. Moreover, significant advantages are documented in case of a thick pancreatic gland.
Subject(s)
Pancreatectomy , Pancreatic Fistula , Postoperative Complications , Surgical Stapling , Humans , Pancreatic Fistula/prevention & control , Pancreatic Fistula/etiology , Pancreatectomy/adverse effects , Pancreatectomy/methods , Male , Female , Retrospective Studies , Middle Aged , Aged , Postoperative Complications/prevention & control , Postoperative Complications/etiology , Surgical Stapling/methods , Surgical Staplers , Adult , Time Factors , Pancreatic Neoplasms/surgeryABSTRACT
PURPOSE: Anomalies of the right hepatic artery (RHA) may represent an additional challenge in pancreatoduodenectomy (PD). The aim of this study is to assess the potential impact of variations in hepatic arterial anatomy on perioperative outcomes. METHODS: PDs performed for periampullary malignancies between 2017 and 2022 were retrospectively enrolled and subdivided in two groups: modal pattern of vascularization (MPV) and anomalous pattern of vascularization (APV). A propensity score matching (PSM) analysis was conducted to homogenize the two study populations. The two groups were then compared in terms of perioperative outcomes and pathological findings. RESULTS: Thirty-eight patients (16.3%) out of 232 presented a vascular anomaly: an accessory RHA in 7 cases (3%), a replaced RHA in 26 cases (11.2%), and a replaced HA in 5 cases (2.1%). After PSM, 76 MPV patients were compared to the 38 APV patients. The incidence rate of postoperative complications was comparable between the two study populations (p=0.2). Similarly, no difference was detected in terms of histopathological data, including margin status. No difference was noted in terms of intraoperative hemorrhage and vascular resection. CONCLUSION: When PDs are performed in high-volume centers, the presence of an APV of the RHA does not relate to a significant impact on perioperative complications. Moreover, no influence was noted on histopathological findings.
Subject(s)
Duodenal Neoplasms , Hepatic Artery , Humans , Hepatic Artery/surgery , Retrospective Studies , Tertiary Care Centers , Pancreaticoduodenectomy , Duodenal Neoplasms/surgeryABSTRACT
Post-pancreatectomy acute pancreatitis (PPAP) is a potentially life-threating complication. Although multiple authors demonstrated PPAP as a predisposing feature for a more detrimental clinical course, no evidence is currently present on its potential impact on long-term outcomes. The aim of this study is to evaluate how PPAP onset may influence overall (OS) and disease-free survival (DSF) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Patients who underwent PD for PDAC from 2006 to 2021 were enrolled. PPAP was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definition. Propensity score matching (PSM) was performed in order to reduce potential selection biases. After PSM, 32 patients out of 231 PDs who developed PPAP (PPAP group) were matched to 32 patients who did not present PPAP (no-PPAP group). PPAP patients more frequently presented major post-operative complications (p = 0.02) and post-operative pancreatic fistula (POPF) (p = 0.003). Median follow-up was 26.2 months, with no difference between the two groups (p = 0.79). A comparable rate of local or distant metastases was noted in the two cohorts (p = 0.2). Five-year OS was comparable between the two populations (39.3% and 35.7% for the no-PPAP and PPAP populations, respectively; p = 0.53). Conversely, despite not being statistically significant, a worse 5-year DFS was evidenced in the case of PPAP (23.2%) as compared to the absence of PPAP (37.4%) (p = 0.51). With the limitations due to the small sample size, PPAP may potentially relate to worse long-term outcomes in terms of DFS. However, further studies with wider study populations are still needed in order to better clarify the prognostic role of PPAP.
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Background: The introduction of multidisciplinary tumor boards (MDTBs) for the diagnostic and therapeutic pathway of several oncological disease significantly ameliorated patients' outcomes. However, only few evidences are currently present on the potential impact of the MDTB on pancreatic cancer (PC) management. Aim of this study is to report how MDTB may influence PC diagnosis and treatment, with particular focus on PC resectability assessment and the correspondence between MDTB definition of resectability and intraoperative findings. Methods: All patients with a proven or suspected diagnosis of PC discussed at the MDTB between 2018 and 2020 were included in the study. An evaluation of diagnosis, tumor response to oncological/radiation therapy and resectability before and after the MDTB was conducted. Moreover, a comparison between the MDTB resectability assessment and the intraoperative findings was performed. Results: A total of 487 cases were included in the analysis: 228 (46.8%) for diagnosis evaluation, 75 (15.4%) for tumor response assessment after/during medical treatment, 184 (37.8%) for PC resectability assessment. As a whole, MDTB led to a change in treatment management in 89 cases (18.3%): 31/228 (13.6%) in the diagnosis group, 13/75 (17.3%) in the assessment of treatment response cohort and 45/184 (24.4%) in the PC resectability evaluation group. As a whole, 129 patients were given indication to surgery. Surgical resection was accomplished in 121 patients (93.7%), with a concordance rate of resectability between MDTB discussion and intraoperative findings of 91.5%. Concordance rate was 99% for resectable lesions and 64.3% for borderline PCs. Conclusions: MDTB discussion consistently influences PC management, with significant variations in terms of diagnosis, tumor response assessment and resectability. In this last regard, MDTB discussion plays a key role, as demonstrated by the high concordance rate between MDTB resectability definition and intraoperative findings.
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BACKGROUND: Post-pancreatectomy acute pancreatitis (PPAP) is an increasingly described complication after pancreatic resection. No uniform definition criteria were present in the literature until the recent proposal of the International Study Group of Pancreatic Surgery (ISGPS). Aim of this study is to evaluate the clinical significance of the novel ISGPS definition of PPAP. METHODS: Patients who underwent pancreatoduodenectomy (PD) between 2006 and 2022 were enrolled. PPAP was defined and graded according to the ISGPS criteria. RESULTS: Among 520 PDs, 120 (23%)patients developed post-operative hyperamylasemia (POH), while PPAP occurred in 63(12.1%) cases. PPAP occurrence related to a higher rate of more severe complications (48-76.1%vs118-25.8%; p < 0.0001), delayed gastric emptying (DGE) (27-42.9%vd114-24.9%; p = 0.003) and post-operative pancreatic fistula (POPF) (57-90.5%vs186-40.8%; p < 0.0001). When stratified for PPAP severity, grade B and C patients more frequently developed major complications (p < 0.0001), POPF (p < 0.0001), DGE (p = 0.02) and post-operative hemorrhage (p < 0.0001) as compared to POH. At the multivariable analysis, soft pancreatic texture (p = 0.01)and a Wirsung diameter ≤3 mm (p = 0.01) were recognized as prognostic factors for PPAP onset, while a pancreatic duct ≤3 mm was the only feature significantly influencing a more severe course of PPAP (p = 0.01). CONCLUSION: The ISGPS classification is confirmed as a valuable method for a uniform definition and clinical course evaluation. Further studies in a prospective manner are still needed for a further confirmation.
Subject(s)
Pancreaticoduodenectomy , Pancreatitis , Humans , Pancreaticoduodenectomy/adverse effects , Prospective Studies , Acute Disease , Pancreatitis/complications , Risk Factors , Pancreatic Fistula/etiology , Postoperative ComplicationsABSTRACT
PURPOSE: Circular staplers for colorectal anastomoses significantly ameliorated post-operative outcomes after rectal resection. The more recent three-row technology was conceived to improve anastomotic resistance and, thus, lower the incidence of anastomotic complications. The aim of this study was to evaluate potential advantages of three-row circular staplers (Three-CS) on anastomotic leakage (AL), stenosis (AS), and hemorrhage (AH) rates after rectal resection as compared to two-row circular staplers (Two-CS). METHODS: All rectal resections for rectal cancer between 2016 and 2021 were retrospectively included. Patients were classified according to the circular stapler employed in Two-CS and Three-CS cohorts. AL, AS, and AH rates were compared between the two populations. Additionally, the prognostic role of the type of circular stapler on AL onset was evaluated. RESULTS: Three-hundred and seventy-five patients underwent a rectal resection with an end-to-end anastomosis during the study period: 197 constituted the Two-CS group and 178 the Three-CS cohort. AL rate was 6.7%, significantly higher in the Two-CS group (19-9.6%) as compared to the Three-CS cohort (6-3.4%) (p = 0.01). No difference was noted in terms of AL severity. Although not statistically significant, a lower incidence rate of AL was evidenced even in the subset of patients with low rectal cancers (4.5% vs 12.5% in the two-row cohort; p = 0.33). At the multivariate analysis, Two-CS was a negative prognostic factor for AL onset (OR: 2.63; p = 0.03). No difference was noted between the two groups in terms of AS and AH. CONCLUSION: Three-row CSs significantly decrease the rate of AL after rectal resection. Further multicenter controlled trials are still needed to confirm the advantages of three-row CSs on anastomotic complications.
Subject(s)
Proctectomy , Rectal Neoplasms , Humans , Retrospective Studies , Anastomosis, Surgical/adverse effects , Proctectomy/adverse effects , Rectum/surgery , Anastomotic Leak/surgery , Rectal Neoplasms/surgery , Rectal Neoplasms/complicationsABSTRACT
Artificial intelligence (AI) and computer vision (CV) are beginning to impact medicine. While evidence on the clinical value of AI-based solutions for the screening and staging of colorectal cancer (CRC) is mounting, CV and AI applications to enhance the surgical treatment of CRC are still in their early stage. This manuscript introduces key AI concepts to a surgical audience, illustrates fundamental steps to develop CV for surgical applications, and provides a comprehensive overview on the state-of-the-art of AI applications for the treatment of CRC. Notably, studies show that AI can be trained to automatically recognize surgical phases and actions with high accuracy even in complex colorectal procedures such as transanal total mesorectal excision (TaTME). In addition, AI models were trained to interpret fluorescent signals and recognize correct dissection planes during total mesorectal excision (TME), suggesting CV as a potentially valuable tool for intraoperative decision-making and guidance. Finally, AI could have a role in surgical training, providing automatic surgical skills assessment in the operating room. While promising, these proofs of concept require further development, validation in multi-institutional data, and clinical studies to confirm AI as a valuable tool to enhance CRC treatment.
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INTRODUCTION: Pancreatic cancer (PC) represents an unfavorable prognosis condition, even in patients with resectable disease. The aim of this series was to investigate the role of treatment intensification with adjuvant chemoradiation (CRT) in radically resected PC patients. METHODS: Data from PC patients who underwent radical surgery, adjuvant chemotherapy (CT), and CRT throughout a 20-year period were retrospectively collected. Actuarial local control (LC) and the overall survival (OS) were the primary endpoints, with disease-free survival and metastasis-free survival (MFS) representing secondary endpoints. RESULTS: The analysis included 108 PC patients treated with adjuvant CRT and CT from January 2000 to August 2019. Median age was 66 years (range: 40-83), and all patients underwent radical surgical resection with adjuvant CT (88, 81.5%) plus concomitant CRT (101, 93.5%) or radiotherapy alone (7, 6.5%). The median dose delivered to the tumor bed was 50.4 Gy (range: 45-50.6 Gy), while median dose to regional lymphatic drainage stations was 39.6 Gy (range 39.6-45 Gy). Concomitant CT was a gemcitabine-based regimen in the vast majority of patients (87, 80.6%). Median follow-up time was 21 months; the 2- and 5-year LC rates were 75.8% and 59.1%, respectively. Perineural invasion at pathological assessment was found significantly associated with LC (p = 0.028). Median OS was 40 months with 2- and 5-year OS rates of 73.9% and 41.6%, respectively. CONCLUSIONS: The outcomes of this series suggest to investigate the possible impact of adding adjuvant CRT to CT in PC patients. Timing and combination of modern CRT with new systemic therapies need to be further investigated to personalize therapy and optimize clinical advantages.
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Pancreatic Neoplasms , Aged , Chemoradiotherapy, Adjuvant , Chemotherapy, Adjuvant , Fluorouracil , Humans , Pancreatic Neoplasms/drug therapy , Retrospective Studies , Pancreatic NeoplasmsABSTRACT
Background: The low anterior resection syndrome (LARS) score is a validated questionnaire developed in Denmark to measure the severity of bowel dysfunction after low anterior resection. This retrospective study aimed to assess the effectiveness of the LARS score in the Italian language in a population of Italian patients who underwent low anterior resection for rectal cancer. The convergent and discriminative validity and the test-retest reliability of the score were investigated. Methods: A cohort of two hundred and five patients treated with low anterior resection were enrolled in an Italian high-volume university hospital between January 2000 and April 2018. The Italian version of the LARS score (tested twice), as translated from English original version, a single question on quality of life and the EORTC QLQ-C30 questionnaire were submitted to patients. Results: A high proportion of patients showed a perfect or moderate fit between the LARS score and QoL categories (convergent validity, p < 0.0005). All differences regarding the items of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 (EORTC QLQ-C30) functional scales were statistically significant (p < 0.0005). The LARS score was able to discriminate between groups of patients who received or did not receive preoperative chemoradiotherapy (p < 0.0005) and those who received total or partial mesorectal excision (p < 0.0005). The test-retest reliability was excellent (intraclass correlation coefficient 0.96). Conclusion: The Italian translation of the LARS score is an easy and reliable tool for assessing bowel dysfunction after low anterior resection and its routine use in clinical practice should be recommended.Trial registration number at www.clinicaltrials.gov: NCT04406311.
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PURPOSE: Ampullary carcinomas (ACs) are classified as pancreatobiliary (Pb-AC), intestinal (Int-AC), or mixed (Mixed-AC). The influencing role of AC subtypes on long-term outcomes is still matter of debate. Aim of this study is to evaluate the prognostic role of the three histological variants on the overall (OS) and disease-free survival (DFS) after pancreaticoduodenectomy(PD). METHODS: All PDs for AC between 2004 and 2020 were included. Patients were classified according to the histological feature in Pb-AC, Int-AC, and Mixed-AC. Five-year OS and DFS were compared among the subtypes. Additionally, the prognostic role of the histological classification on OS and DFS was evaluated. RESULTS: Fifty-six (48.7%) Pb-ACs, 53 (46.1%) Int-ACs, and 6 (5.2%) Mixed-ACs were evaluated. A poorer 5-year OS was evidenced for the Pb-AC group (54.1%) as compared to the Int-AC cohort (80.7%) (p = 0.03), but similar to the Mixed-AC population (33%) (p = 0.45). Pb-AC presented a worse 5-year DFS (42.3%) in comparison to the Int-AC (74.8%) (p = 0.002), while no difference was evidenced in comparison to the Mixed-AC (16.7%) (p = 0.51). At the multivariate analysis, the Pb-/Mixed-AC histotype was recognized as negative prognostic factor for both OS (OR: 2.29, CI: 1.05-4.98; p = 0.04) and DFS (OR: 2.17, CI: 1-4.33; p = 0.02). CONCLUSION: Histological subtypes of AC play a relevant role in long-term outcomes after PD. Pb-ACs and Mixed-ACs show a more aggressive tumor biology and a consequent worse survival as compared to the Int-AC subtype.
Subject(s)
Ampulla of Vater , Common Bile Duct Neoplasms , Humans , Ampulla of Vater/surgery , Ampulla of Vater/pathology , Pancreaticoduodenectomy , Common Bile Duct Neoplasms/surgery , Tertiary Care Centers , Lead , PrognosisABSTRACT
Aims: Between 11 to 14% of patients with locally advanced rectal cancer (LARC) have positive lateral pelvic lymph nodes (LPLN) at diagnosis, related to a worse prognosis with a 5-year survival rate between 30 to 40%. The best treatment choice for this group of patients is still a challenge. The optimal radiotherapy (RT) dose for LPLN patients has been investigated. Methods: We retrospectively collected data from LARC patients with LPLN at the primary staging MRI, treated in our center from March 2003 to December 2020. Patients underwent a neoadjuvant concomitant chemo-radiotherapy (CRT) treatment on the primary tumor (T), mesorectum, and pelvic nodes, associated with a fluoride-based chemotherapy. The total reached dose was 45 Gy at 1.8 Gy/fr on the elective sites and 55 Gy at 2.2 Gy/fr on the disease and mesorectum. Patients were divided in two groups based on whether they received a simultaneous integrated RT boost on the LPLN or not. Overall Survival (OS), Disease Free Survival (DFS), Metastasis Free Survival (MFS), and Local Control (LC) were evaluated in the whole group and then compared between the two groups. Results: A total of 176 patients were evaluated: 82 were included in the RT boost group and 94 in the non-RT boost group. The median follow-up period was 57.8 months. All the clinical endpoint (OS, DFS, MFS, LC), resulted were affected by the simultaneous integrated boost on LPLN with a survival rate of 84.7%, 79.5%, 84.1%, and 92%, respectively, in the entire population. From the comparison of the two groups, there was a statistical significance towards the RT boost group with a p < 0.006, 0.030, 0.042, 0.026, respectively. Conclusions: Concomitant radiotherapy boost on positive LPLN has shown to be beneficial on the survival outcomes (OS, DFS, MFR, and LC) in patients with LARC and LPLN. This analysis demonstrates that a higher dose of radiotherapy on positive pelvic lymph nodes led not only to a higher local control but also to a better survival rate. These results, if validated by future prospective studies, can bring a valid alternative to the surgery dissection without the important side effects and permanent disabilities observed during the years.
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BACKGROUND: Few evidences are available on adhesive bowel obstruction (ASBO)management and outcomes in geriatric patients. METHODS: One-hundred-twenty-eight patients aged 65-79 years were retrospectively compared to 77 patients aged ≥80 years. Aim of this study was to compare ASBO management and in-hospital course between patients aged 65-79 years and those over 80 years. RESULTS: Upfront surgery in octogenarians related with a higher rate of major complications (23.7%vs4.9%; p = 0.009) and longer hospitalization (8.8vs7.3 days; p = 0.01). No difference according to age was noted in terms of clinical outcomes when the non-operative management (NOM) was employed. Patients aged ≥80 years managed conservatively presented shorter hospitalization (7.3vs8.8 days; p = 0.04), lower rate of intensive care unit (ICU)admission (0vs18.4%; p = 0.005) and cumulative major complications (2.6%vs23.7%; p = 0.007) as compared to ≥80 years old patients treated with upfront surgery. In this same group, NOM failure did not lead to worse outcomes in comparison to upfront surgery. CONCLUSIONS: NOM in≥80 years patients is associated with better in-hospital course. The acceptable clinical outcomes in case of NOM failure further support NOM as first treatment strategy to employ in this same subset of patients.
Subject(s)
Intestinal Obstruction , Octogenarians , Aged, 80 and over , Humans , Aged , Retrospective Studies , Tissue Adhesions/complications , Tissue Adhesions/surgery , Adhesives , Treatment Outcome , Intestinal Obstruction/etiology , Intestinal Obstruction/surgeryABSTRACT
Design: Neoadjuvant chemoradiotherapy (nCRT) followed by surgery is the standard of care for locally advanced rectal cancer (LARC).Several studies have shown a correlation between a longer interval between the end of nCRT and surgery (surgical interval - SI) and an increased pathological complete response (pCR) rate, with a maximum obtained between 10 and 13 weeks.The primary endpoint of this multicenter, 2-arm randomised trial is to investigate SI lengthening, evaluating the difference in terms of complete response (CR) and Tumor Regression Grade (TRG)1 rate in the two arms. Secondly, the impact of SI lengthening on survival outcomes and quality of life (QoL) will be investigated. Methods: Intermediate-risk LARC patients undergoing nCRT will be prospectively included in the study. nCRT will be administered with a total dose of 55 Gy in 25 fractions on Gross Tumor Volume (GTV) plus the corresponding mesorectum of 45 Gy in 25 fractions on the whole pelvis. Chemotherapy with oral capecitabine will be administered continuously.The patients achieving a clinical major or complete response assessed at clinical-instrumental re-evaluation at 7-8 weeks after treatment completion, will be randomized into two groups, to undergo surgery or local excision at 9-11 weeks (control arm) or at 13-16 weeks (experimental arm). Pathological response will be assessed on the surgical specimen using the AJCC TNM v.7 and the TRG according to Mandard. Patients will be followed up to evaluate toxicity and QoL.The promoter center of the trial will conduct the randomization process through an automated procedure to prevent any possible bias.For sample size calculation, using CR difference of 20% as endpoint, 74 patients per arm will be enrolled. Conclusions: The results of this study may prospectively provide a new time frame for the clinical re-evaluation for complete/major responders patients in order to increase the CR rate to nCRT.Trial registration:ClinicalTrials.gov Identifier: NCT03581344.
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INTRODUCTION: With the prolongation of life expectancy, an increasing number of elderly patients are evaluated for pancreatic surgery. However, the influence of increasing age on outcomes after pancreaticoduodenectomy (PD) is still unclear, especially in octogenarians. Aim of this study is to evaluate the perioperative characteristics and outcomes of octogenarians undergoing PD. METHODS: Data for 812 patients undergoing PD between 2019 and 2020 in 10 referral centers in Italy were reviewed. Patients aged 80 years or older were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients younger than 80 years. Propensity scores were calculated using 7 perioperative variables including gender, ASA score, neoadjuvant treatment (NAT), biliary stent positioning, type of surgical approach (open, laparoscopic, robot-assisted), associated vascular resections, type of lesion. Perioperative characteristics and short-term postoperative outcomes were compared before and after matching. RESULTS: Overall, 81 (10%) patients had 80 years or more. Before matching, octogenarians had a higher rate of ASA score≥ 3 (n = 35, 43.2% vs. n = 207, 28.3%; p = 0.005) and less frequently underwent NAT (n = 11, 13.6% vs. n = 213, 29.1%; p = 0.003). Matching was successfully performed for 70 octogenarians. After matching, no differences in preoperative and intraoperative characteristics were found. Postoperatively, ICU admission was more frequent in octogenarians (50% vs 30%; p = 0.01). Although in-hospital mortality was higher in octogenarians before matching (7.4% vs 2.9% in the younger cohort; p = 0.03), no difference was noted between the matched cohorts (p = 0.36). Postoperative morbidity was comparable between groups in the whole and selected populations. At the multivariate analysis, chronological age was not recognized as a prognostic factor for cumulative major complications, while ASA ≥3 was the only confirmed influencing feature (OR 2.98; 95%CI: 1.6-6.8; p = 0.009). CONCLUSIO: In high-volume centers, PD in octogenarians shows similar outcomes than younger patients. Age itself should not be considered an exclusion criterion for PD, but a focused preoperative assessment is essential for adequate patient selection.
Subject(s)
Carcinoma/surgery , Pancreatic Neoplasms/surgery , Pancreaticoduodenectomy/adverse effects , Postoperative Complications/epidemiology , Age Factors , Aged , Aged, 80 and over , Carcinoma/pathology , Female , Humans , Italy , Logistic Models , Male , Pancreatic Neoplasms/pathology , Propensity Score , Treatment OutcomeABSTRACT
BACKGROUND: Delayed gastric emptying (DGE) represents the most frequent complication after pancreaticoduodenectomy (PD). Aim of this study was to evaluate the impact of gastrojejunostomy (GJ)orientation on DGE incidence after PD. METHODS: One-hundred and twenty-one consecutive PDs were included in the analysis and divided in the horizontal (H-GJ group) and vertical GJ anastomosis groups (V-GJ group). Postoperative data and the value of the flow angle between the efferent jejunal limb and the stomach of the GJ anastomosis at the upper gastrointestinal series were registered. RESULTS: Seventy-five patients (62%)underwent H-GJ, while 46 patients (38%)underwent V-GJ. The incidence of DGE was significantly lower in the V-GJ group as compared to the H-GJ group (23.9%vs45.3%; p = 0.02). V-GJ was also associated to a less severe DGE manifestation (p = 0.006). The flow angle was significantly lower in case of V-GJ as compared to H-GJ (24.5°vs37°; p = 0.002). At the multivariate analysis, ASA score≥3 (p = 0.02), H-GJ (p = 0.03), flow angle>30°(p = 0.004) and Clavien-Dindo≥3 (p = 0.03) were recognized as independent prognostic factors for DGE. These same factors were independent prognostic features also for a more severe DGE manifestation. CONCLUSION: VGJ and the more acute flow angle appear to be associated to a lower incidence rate and severity of DGE. This modified technique should be considered by surgeons in order to reduce postoperative DGE occurrence.
Subject(s)
Gastric Bypass , Gastroparesis , Gastric Bypass/adverse effects , Gastric Emptying , Gastroparesis/etiology , Gastroparesis/prevention & control , Humans , Pancreaticoduodenectomy/adverse effects , Pancreaticoduodenectomy/methods , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Retrospective StudiesABSTRACT
BACKGROUND: Few evidences are available on the prognostic role of mesopancreas excision(MPe) for ampullary cancers(ACs). Aim of this study was to compare the long-term outcomes between pancreaticoduodenectomy(PD) with(PD-MPe group) and without(sPD group) MP. METHODS: Thirty-seven sPDs were matched and compared to 37 PD-MPes for perioperative outcomes, recurrence rate, disease-free(DFS) and overall survival(OS). RESULTS: The PD-MPe technique related to a significantly higher number of harvested lymph nodes[16 (±6)] as compared to the sPD [10 (±5); p < 0.0001]. Tumor recurrence was more frequent in the sPD cohort[21 (56.8%) vs 12 (32.4%) in the PD-MPe population; p = 0.03]. Although not statistically different, PD-MPe was associated with a better DFS(40% vs 35.7% for sPD; p = 0.08) and OS(59.3% vs 39.1% for sPD; p = 0.07). At the multivariate analysis, a higher number of lymph nodes retrieved and a more extensive lymphovascular clearance reached with the MPe technique, together with lymph nodes metastases, were recognized as independent prognostic factors for a worse OS and DFS. CONCLUSION: The PD-MPe technique is associated with a better oncological radicality thanks to the higher number of retrieved lymph nodes and to the more appropriate tumor clearance. This reflects in a lower incidence of tumor relapse and in improved outcomes in terms of OS and DFS.
Subject(s)
Ampulla of Vater , Ampulla of Vater/surgery , Humans , Lymph Nodes , Neoplasm Recurrence, Local/surgery , Pancreatectomy , Pancreaticoduodenectomy/adverse effects , Prognosis , Propensity Score , Retrospective StudiesABSTRACT
INTRODUCTION: The incidence of adhesive bowel obstruction (ASBO) progressively increases with age. Strong evidences on the influencing role of age on ASBO clinical course and management are still lacking. Aim of this study is to retrospectively analyze the clinical outcomes of patients older than 65 years of age admitted to a tertiary referral Emergency Department with a diagnosis of ASBO. MATERIALS AND METHODS: We reviewed the clinical records of patients admitted for ASBO in the period 2014-2019. Patients were divided in elderly (≥65 years) and non-elderly (<65 years). Primary endpoint was to compare the all-cause in-hospital mortality and the occurrence of major complications in the two groups. Secondary endpoint was a comparison of clinical presentation, clinical course and management. RESULTS: We enrolled 285 elderly and 492 non-elderly patients. Vomit was more frequent in the elderly (51.9% vs 34.6%; p < .001), while no difference was evidenced for the remaining symptoms of ASBO presentation. A higher rate of non-operative management (NOM) (26.3% vs 16.5%; p = .010), ICU admission (16% vs 0.6%; p < .001), mortality (2.1% vs 0.2%; p = .007) and cumulative major complications (8.8% vs 3.3%; p = .001), as well as a prolonged hospitalization (8.2 vs 5.4 days; p < .001) was evidenced in the ≥65 years group. Multivariate analysis identified increasing age (OR:2.8; 95%CI:1.09-7.2; p = .040) and Charlson comorbidity index ≥ 2 (OR:2.5; 95% CI:1.2-6.4; p = .050) as the only independent predictors of cumulative major complications. CONCLUSIONS: Despite the similarity in terms of clinical presentation, elderly patient present higher mortality rate and occurrence of major complications. A comprehensive geriatric assessment is recommended to optimize the diagnostic and clinical strategies in case of ASBO.
Subject(s)
Adhesives , Intestinal Obstruction , Aged , Humans , Middle Aged , Retrospective Studies , Tissue Adhesions/complications , Tissue Adhesions/therapy , Treatment OutcomeABSTRACT
BACKGROUND: Although minimally-invasive techniques are currently recognized as effective and validated treatment for small gastric gastrointestinal stromal tumors (GISTs), the role of laparoscopy is not yet established. The aim of this study was to evaluate the outcomes of laparoscopic treatment of gastric GISTs compared to the results obtained in a group of patients treated with conventional surgery. METHODS: A retrospective analysis was performed, using a prospectively maintained comprehensive database of 100 patients treated for gastric GIST in the period from 2000 to 2015. Thirty-six patients were treated laparoscopically, and 64 patients underwent conventional surgery. The analyzed medical data included clinical and pathological features of removed tumors, perioperative parameters as well as short and long-term results of surgical treatment. RESULTS: Histopathological examination confirmed radical resections for all patients. No deaths were reported in the 90-day postoperative period. Patients in laparoscopic group had significantly shorter length of hospital stay (5.5 vs. 7 days, P<0.0001), fewer extended and combined surgical procedures (11.2% vs. 34.4% and 2.8% vs. 39%; P=0.02 and P<0.001, respectively), and a smaller tumor size compared to laparotomic group (3 vs. 6 cm, P<0.0001). The median postoperative follow-up for the entire study population was 42 months. During this period, 11 patients died and 4 of them developed a tumor recurrence. None of them was in the laparoscopic group. CONCLUSIONS: Laparoscopy in the treatment of gastric GISTs has unquestionable advantages, but its choice is strictly related to tumor features.