Duodenocaval fistula after bevacizumab therapy: case presentation and complete overview of the literature.

Duodenocaval fistula (DCF) is a very rare condition and is associated with a 41.1% of mortality rate. Although ingested foreign bodies, peptic ulcer disease and radiotherapy are often the etiologies described, only three patients have been described who developed DCF after bevacizumab therapy. We report a case of a 58-year-old woman with a history of ovarian neoplasia and subsequent surgical treatments, adjuvant radiotherapy and chemotherapy with bevacizumab with the appearance of a spontaneous DCF after 6 months at the end of this therapy. The multidisciplinary approach between oncologist and vascular surgeon together with the support of the anesthesiology team allowed the DFC to be treated surgically through the suture of the inferior vena cava and the duodenal breach. The patient was discharged on the 14th postoperative day and we found no postoperative morbidities both immediately and after 30 and 60 days.

Emergency duodenal resection for giant GIST with acute gastrointestinal bleeding A case report.

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract, which cover about 1-2% of gastrointestinal neoplasms. They are more common in the stomach (40-60%) while a minor part in jejunum/ileus (25- 30%), duodenum (<5%), colorectal (5-15%) and esophagus (<1%). The clinical presentation depends on the primary localization of the neoplasma and tumor size, however in 18% it is asymptomatic. Gastrointestinal bleeding is the most dangerous complication, often necessitating emergency surgery and represents a common symptom of duodenal GIST. We present a case of a 82-year-old male presented with abdominal pain, asthenia and melena with haemodynamically stable. The patient underwent a recent coronary angioplasty and currently on double antiplatelet therapy. During observation a palpable mass was detected in the periumbilical region and right hypochondrium. A superior digestive endoscopy was performed which revealed an ab estrinseco compression of second duodenal segment and bleeding of third duodenal mucosa segment. No local haemostasis could be accomplished. An Angio-CT showed a large exophytic tumor arising from the 3th duodenal segment with approximately 13x9 cm, with apparent intratumoral bleeding. No indication for possible angioembolization. Due to gradual modification of the haemodynamic , the patient was submitted to emergency laparotomy. A segmental enterectomy was performed and the post-operative period ran without complications. The histopathologic exam showed a gastro-intestinal stromal tumor of epithelioid cell nature with low mitotic count (2 per 50HPF). The immunohistochemical analysis revealed positivity for CD117 (c-Kit) and DOG1 with Ki67<1%. KEY WORDS: Bleeding, Duodenal GIST, Gastrointestinal, Gastrointestinal stromal tumor.

A Serum Metabolomics Classifier Derived from Elderly Patients with Metastatic Colorectal Cancer Predicts Relapse in the Adjuvant Setting.

Adjuvant treatment for patients with early stage colorectal cancer (eCRC) is currently based on suboptimal risk stratification, especially for elderly patients. Metabolomics may improve the identification of patients with residual micrometastases after surgery. In this retrospective study, we hypothesized that metabolomic fingerprinting could improve risk stratification in patients with eCRC. Serum samples obtained after surgery from 94 elderly patients with eCRC (65 relapse free and 29 relapsed, after 5-years median follow up), and from 75 elderly patients with metastatic colorectal cancer (mCRC) obtained before a new line of chemotherapy, were retrospectively analyzed via proton nuclear magnetic resonance spectroscopy. The prognostic role of metabolomics in patients with eCRC was assessed using Kaplan-Meier curves. PCA-CA-kNN could discriminate the metabolomic fingerprint of patients with relapse-free eCRC and mCRC (70.0% accuracy using NOESY spectra). This model was used to classify the samples of patients with relapsed eCRC: 69% of eCRC patients with relapse were predicted as metastatic. The metabolomic classification was strongly associated with prognosis (p-value 0.0005, HR 3.64), independently of tumor stage. In conclusion, metabolomics could be an innovative tool to refine risk stratification in elderly patients with eCRC. Based on these results, a prospective trial aimed at improving risk stratification by metabolomic fingerprinting (LIBIMET) is ongoing.

Barbed versus traditional suture for enterotomy closure after laparoscopic right colectomy with intracorporeal mechanical anastomosis: a case-control study.

Our aim was to establish the safety and efficacy of barbed suture for enterotomy closure after laparoscopic right colectomy with intracorporeal anastomosis. This study included 47 patients who underwent laparoscopic right hemicolectomy with intracorporeal mechanical anastomosis and barbed suture enterotomy closure (barbed suture closure-BSC) for adenocarcinoma (with the exception of T4 lesions and metastasis), compared with 47 matched patients who underwent laparoscopic right hemicolectomy with intracorporeal mechanical anastomosis and conventional suture enterotomy closure (conventional suture closure-CSC) during the same period. Controls were matched for stage, age, and gender via a statistically generated selection of all laparoscopic right hemicolectomies performed from January 2009 until December 2015. There was no difference between the two groups in terms of age, sex, BMI, ASA, co-morbidity, previous abdominal surgery, cancer site and cancer staging. In terms of operating time (median 120 min for BSC and 127.5 min for CSC), histopathological results, surgical site complications (2.1% for BSC and 8.5% for CSC), hospitalization (median 6 days for BSC and 5 days for CSC), readmission rate (0%), there were no differences between the groups (p > 0.05). No significant differences were noted between the two groups in terms of the postoperative course. Our results support that the use of knotless barbed sutures for enterotomy closure after laparoscopic right colectomy with intracorporeal mechanical anastomosis is safe and reproducible.

Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery.

The aim of this prospective cohort study was to identify the patient factors that predict postoperative deviation from each item of a fast-track colorectal surgery protocol (FT) and these factors' influences on postoperative outcomes. A total of 606 patients with colorectal pathology from 2005 to 2011 were analyzed to assess the relationships between patient factors, the outcome variables, and the items of the FT program. The median length of stay was 5 days, and readmission rate was 2.3%. The morbidity rate was 26.7%. Independent predictors of prolonged length of stay were older than 75 years of age, ASA grade 3 and 4, and the presence of an ileostomy. Independent predictors of morbidity were age above 75 years old and ASA grade, whereas age was confirmed as an independent predictor of mortality. Male sex, age above 75 years old, and ASA 3 and 4 were identified as independent predictors of negative compliance to most of the postoperative FT items.

Laparoscopic surgery improves postoperative outcomes in high-risk patients with colorectal cancer.

BACKGROUND: Patients with significant comorbidities often are denied laparoscopic colorectal resections, because they are thought to be too "high-risk." This study was designed to examine the feasibility and safety of laparoscopic colorectal resections in high-risk colorectal cancer patients and to compare them with a similar cohort of patients undergoing open resections in the same time period. METHODS: This was a single-center, prospective, cohort study conducted at a high-volume, nonuniversity, tertiary care hospital. From a database of 616 patients submitted to elective colorectal surgery for cancer within a fast-track protocol (January 2005 to November 2011), 188 patients who met at least one minor (age >80 years and body mass index (BMI) >30 m/kg(2)) and one major (cardiac, pulmonary, renal or liver disease, diabetes mellitus) criterion were classified as high-risk. Differences in baseline characteristics, intraoperative outcomes, and short-term (30-day) postoperative outcomes, as well as the pathology findings and the readmission and reoperation rates, were compared between the open and laparoscopic cohorts in both high- and low-risk groups and between high- and low-risk groups. RESULTS: During the study period, 68 high-risk patients underwent laparoscopic resections and 120 had open surgeries. A shorter length of postoperative stay (6 vs. 9 days, p < 0.0001) and fewer postoperative nonsurgical complications (4 % vs. 19 %, p = 0.003) were observed among the laparoscopic group. Postoperative major (p = 0.774) and minor complications (p = 0.3) and reoperations (p = 0.196) were similar between the two groups, and a significantly lower rate of mortality (1.5 vs. 7.5 %, p = 0.038) was observed in the laparoscopic group than in the open group. CONCLUSIONS: Laparoscopic colorectal resection can be safely performed on "high-risk" surgical patients with better results than a similar group of high-risk patients undergoing open colon resections.

Fast-track colorectal surgery: protocol adherence influences postoperative outcomes.

PURPOSE: This single-center prospective cohort study, conducted outside of a clinical trial, tried to identify the importance of each fast-track surgery procedure and protocol adherence level on clinical outcomes after colorectal surgery. METHODS: From a prospectively maintained database, 606 patients who underwent elective laparoscopic or open colorectal resection within a well established fast-track surgery (FT) protocol, between 2005 and 2011, were identified. Univariate and multivariate analysis were performed to assess the relationship between each FT procedure with an adherence rate <100 % and the outcome variables (length of stay-LOS, 30-day morbidity and readmission rate). Patients were divided into four adherence level groups to FT procedures-100 %, 85-95 %,70-80 %, and <65 %. Each adherence group was compared with the other groups to evaluate differences in clinical outcome variables. RESULTS: Group comparisons revealed that higher levels of FT protocol adherence corresponded to significantly improved LOS and morbidity rates. Readmission rates were only significantly different between the full fast-track pathway and the less implemented groups. Multivariate analyses revealed that the fast removal of bladder catheter positively influenced length of stay (p < 0.0001) and 30-day morbidity (p < 0.0001). Laparoscopy surgery, no drain positioning and enforced mobilization improved LOS (p = 0.027, p < 0.0001, p = 0.002, respectively). Early solid feeding improved LOS (p < 0.0001), morbidity (p < 0.0001) and readmission rate (p = 0.011). CONCLUSION: Postoperative outcomes after colorectal surgery are directly proportional to FT protocol adherence. The early removal of the bladder catheter and early postoperative solid feeding independently influenced the length of hospital stay and 30-day morbidity rates.

General surgeons' views on Oncologic Multidisciplinary Group meetings as part of colorectal cancer care.

This study aimed to assess the current effectiveness of Oncologic Multidisciplinary Groups (OMGs) meetings across central Tuscany through surgeons' reports and their individual perceived benefits on colorectal cancer management. One hundred and sixty-seven general surgeons received a questionnaire with 21 questions covering organizational characteristics of OMGs and the individual perceived benefits of OMGs. The responses were analyzed by hospital setting (teaching vs. community hospital). The reply rate was 62.8 %, and 82 respondent surgeons (49.1 %) were involved in the treatment of colorectal cancer patients. At community hospitals, there was a more frequent participation of medical oncologists, radiation oncologists and pathologists; a less selection of discussed cases was performed; and almost all decisions were inserted into official patient charts (p < 0.05). Community hospital surgeons perceived more of a benefit than academic surgeons: OMGs ensure that all treatment options are considered and improve timeliness of care, patient outcomes, patient satisfaction and communication with patients (p < 0.05). The surveyed surgeons reported that OMGs offer a modest degree of protection from malpractice but improve communications between colleagues and are an opportunity for personal professional development. Professionals regularly participating in well-conducted and well-organized OMGs for colorectal cancer felt that the multidisciplinary strategy may be advantageous to both patients and caregivers.