The pan - COVID - AGICT study. The impact of COVID-19 pandemic on surgically treated pancreatic cancer patients. A multicentric Italian study.

BACKGROUND: In this article we aimed to perform a subgroup analysis using data from the COVID-AGICT study, to investigate the perioperative outcomes of patients undergoing surgery for pancreatic cancers (PC) during the COVID-19 pandemic. METHODS: The primary endpoint of the study was to find out any difference in the tumoral stage of surgically treated PC patients between 2019 and 2020. Surgical and oncological outcomes of the entire cohort of patients were also appraised dividing the entire peri-pandemic period into six three-month timeframes to balance out the comparison between 2019 and 2020. RESULTS: Overall, a total of 1815 patients were surgically treated during 2019 and 2020 in 14 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (p = 0.846). During the pandemic, neoadjuvant chemotherapy (NCT) has dropped significantly (6.2% vs 21.4%, p < 0.001) and, for patients who didn't undergo NCT, the latency between diagnosis and surgery was shortened (49.58 ± 37 days vs 77.40 ± 83 days, p < 0.001). During 2020 there was a significant increase in minimally invasive procedures (p < 0.001). The rate of postoperative complication was the same in the two years but during 2020 there was an increase of the medical ones (19% vs 16.1%, p = 0.001). CONCLUSIONS: The post-pandemic dramatic modifications in healthcare provision, in Italy, did not significantly impair the clinical history of PC patients receiving surgical resection. The present study is one of the largest reports available on the argument and may provide the basis for long-term analyses.

Lemmel's syndrome: Case report of a not feasible endoscopic management.

INTRODUCTION: Lemmel's syndrome is a rare disease presenting with obstructive jaundice, secondary to common bile duct compression by duodenal diverticulum. PRESENTATION OF CASE: A 79-year-old female was admitted to our emergency department with cholangitis and obstructive jaundice, due to choledocal compression by two periampullary diverticula, with major papilla opening near the biggest one (periampullary diverticulum type III). Endoscopic retrograde cholangiopancreatography didn't succeed sphincterotomy, therefore laparoscopic rendez-vous was performed. DISCUSSION: This case is an example of an unusual cause of obstructive jaundice, which should be mentioned along with choledocolithiasis and biliary or ampullary neoplasms, in order to avoid delay in diagnosis and management. CONCLUSION: The commonest treatment of Lemmel's syndrome reported in literature is ERCP with sphincterotomy, but when endoscopic management fails, interventional radiology and surgery should also be considered.

NIR ICG-Enhanced Fluorescence: A Quantitative Evaluation of Bowel Microperfusion and Its Relation to Central Perfusion in Colorectal Surgery.

BACKGROUND: To date, no standardized protocols nor a quantitative assessment of the near-infrared fluorescence angiography with indocyanine green (NIR-ICG) are available. The aim of this study was to evaluate the timing of fluorescence as a reproducible parameter and its efficacy in predicting anastomotic leakage (AL) in colorectal surgery. METHODS: A consecutive cohort of 108 patients undergoing minimally invasive elective procedures for colorectal cancer was prospectively enrolled. The difference between macro and microperfusion (ΔT) was obtained by calculating the timing of fluorescence at the level of iliac artery division and colonic wall, respectively. RESULTS: Subjects with a ΔT ≥ 15.5± 0.5 s had a higher tendency to develop an AL (p < 0.01). The ΔT/heart rate interaction was found to predict AL with an odds ratio of 1.02 (p < 0.01); a cut-off threshold of 832 was identified (sensitivity 0.86, specificity 0.77). Perfusion parameters were also associated with a faster bowel motility resumption and a reduced length of hospital stay. CONCLUSIONS: The analysis of the timing of fluorescence provides a quantitative, easy evaluation of tissue perfusion. A ΔT/HR interaction ≥832 may be used as a real-time parameter to guide surgical decision making in colorectal surgery.

Symptomatic acinar cell cystadenoma of the pancreas.

Acinar cystic transformation (ACT), also known as 'acinar cell cystadenoma', is an uncommon cystic neoplasm of pancreas with unknown malignant potential. This case regards a woman with symptomatic pancreatic head ACT, revealed with pathological exam of specimen after pancreaticoduodenectomy. A 57-years-old patient presented mild hyperbilirubinemia and recurrent cholangitis; she underwent to ERCP, EUS and MRI, and these exams revealed a large cyst of the pancreatic head that caused biliary compression. The discussion of the case by the multidisciplinary group indicated surgical resection. Pancreatic ACT is so rare, and its preoperative diagnosis is difficult. The symptoms of the patients and the features of the cyst are the criteria to choose a surgical resection.

The MIS-COVID-AGICT Study: Trend of Minimally Invasive Surgery for Gastrointestinal Cancer Treatment During the First Waves of the COVID-19 Pandemic in Italy. Subgroup Analysis from the COVID-AGICT Study: COVID-19 and Advanced Gastrointestinal Cancer Surgical Treatment.

Background: A preliminary analysis from the COVID-Advanced Gastrointestinal Cancer Surgical Treatment (AGICT) study showed that the rate of minimally invasive surgery (MIS) for elective and urgent procedures did not decrease during the pandemic year. In this article, we aimed to perform a subgroup analysis using data from the COVID-AGICT study to evaluate the trend of MIS during the COVID-19 pandemic period in Italy. Methods: This study was conducted collecting data of MIS patients from the COVID-AGICT database. The primary endpoint was to demonstrate whether the SARS-CoV-2 pandemic scenario reduced MIS for elective treatment of gastrointestinal cancer (GIC) in Italy in 2020. The secondary endpoint was to evaluate the impact of the pandemic period on perioperative outcomes in the MIS group. Results: In the pandemic year, 62% of patients underwent surgery with a minimally invasive approach, compared to 63% in 2019 (P = .23). In 2020, the proportion of patients undergoing elective MIS decreased compared to the previous year (80% versus 82%, P = .04), and the rate of urgent MIS did not differ between the 2 years (31% and 33% in 2019 and 2020 - P = .66). Colorectal cancer was less likely to be treated with MIS approach during 2020 (78% versus 75%, P < .001). Conversely, the rate of MIS pancreatic resection was higher in 2020 (28% versus 22%, P < .002). Conversion to an open approach was lower in 2020 (7.2% versus 9.2% - P = .01). Major postoperative complications were similar in both years (11% versus 11%, P = .9). Conclusion: In conclusion, although MIS for elective treatment of GIC in Italy was reduced during the COVID-19 pandemic period, our study revealed that the overall proportion of MIS (elective and urgent) and postoperative outcomes were comparable to the prepandemic period. ClinicalTrial.gov (NCT04686747).

Robotic-assisted distal pancreatectomy with splenectomy in a paediatric patient for solid pseudopapillary tumour.

Solid pseudopapillary tumour is a rare low-grade malignant potential carcinoma of the pancreas that typically occurs in females in their third decade. It most commonly occurs in the tail of the pancreas, although any site can be affected. Surgical resection is the standard treatment and offers an excellent prognosis. We report a case of a 17-year-old female with an acute onset abdominal pain and a radiological diagnosis of a cystic lesion in the distal pancreas. A robotic-assisted distal pancreatectomy with splenectomy was performed. Robotic-assisted surgery is an emerging technique for the treatment of pancreatic neoplasms. This approach can be considered for younger patients, thanks to the potential advantages of the robotic Da Vinci Xi System.

The COVID - AGICT study: COVID-19 and advanced gastro-intestinal cancer surgical treatment. A multicentric Italian study on the SARS-CoV-2 pandemic impact on gastro-intestinal cancers surgical treatment during the 2020. Analysis of perioperative and short-term oncological outcomes.

BACKGROUND: This Italian multicentric retrospective study aimed to investigate the possible changes in outcomes of patients undergoing surgery for gastrointestinal cancers during the COVID-19 pandemic. METHOD: Our primary endpoint was to determine whether the pandemic scenario increased the rate of patients with colorectal, gastroesophageal, and pancreatic cancers resected at an advanced stage in 2020 compared to 2019. Considering different cancer staging systems, we divided tumors into early stages and advanced stages, using pathological outcomes. Furthermore, to assess the impact of the COVID-19 pandemic on surgical outcomes, perioperative data of both 2020 and 2019 were also examined. RESULTS: Overall, a total of 8250 patients, 4370 (53%) and 3880 (47%) were surgically treated during 2019 and 2020 respectively, in 62 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (P = 0.25). Nevertheless, the analysis of quarters revealed that in the second half of 2020 the rate of advanced cancer resected, tented to be higher compared with the same months of 2019 (P = 0.05). During the pandemic year 'Charlson Comorbidity Index score of cancer patients (5.38 ± 2.08 vs 5.28 ± 2.22, P = 0.036), neoadjuvant treatments (23.9% vs. 19.5%, P < 0.001), rate of urgent diagnosis (24.2% vs 20.3%, P < 0.001), colorectal cancer urgent resection (9.4% vs. 7.37, P < 0.001), and the rate of positive nodes on the total nodes resected per surgery increased significantly (7 vs 9% - 2.02 ± 4.21 vs 2.39 ± 5.23, P < 0.001). CONCLUSIONS: Although the SARS-CoV-2 pandemic did not influence the pathological stage of colorectal, gastroesophageal, and pancreatic cancers at the time of surgery, our study revealed that the pandemic scenario negatively impacted on several perioperative and post-operative outcomes.

Laparoscopic treatment of symptomatic Dunbar syndrome: a case report.

INTRODUCTION AND AIM OF THE STUDY: Dunbar syndrome is a rare disorder due to the external compression of the celiac trunk by the median arcuate ligament. The symptoms include abdominal pain, nausea and vomiting with a significative reduction in patients' quality of life. Laparoscopy has proven to be a safe procedure. The aim of this study is to present a case of Dunbar syndrome undergoing laparoscopic surgery. CASE PRESENTATION: A 40-year-old male patient presented at Emergency Room with upper abdominal pain and dyspepsia, related to food intake. A selective arteriography of the celiac trunk revealed stenosis due to compression of the celiac artery. CLINICAL DISCUSSION: Laparoscopic decompression of the celiac trunk by the median arcuate ligament was performed. Postoperative course was uneventful and the patient was discharged on the 5th postoperative day. CONCLUSION: Minimally invasive surgical division of the arcuate ligament is feasible and safe and it can restore patients' quality of life.

Laparoscopic lavage and drainage for Hinchey III diverticulitis: review of technical aspects.

The surgical treatment for patients with generalized peritonitis complicating sigmoid diverticulitis is currently debated; particularly in case of diffuse purulent contamination (Hinchey 3). Laparoscopic lavage and drainage (LLD) has been proposed by some authors as a safe and effective alternative to single- or multi-stage resective surgery. However, among all the different studies on LLD, there is no uniformity in terms of surgical technique adopted and data show significant differences in postoperative outcomes. Aim of this review was to analyze the differences and similarities among the authors in terms of application, surgical technique and outcomes of LLD in Hinchey 3 patients. A bibliographical research was performed by referring to PubMed and Cochrane. "Purulent peritonitis", "Hinchey 3 diverticulitis", "acute diverticulitis", "colonic perforation" and "complicated diverticulitis" were used as key words. Twenty-eight papers were selected, excluding meta-analysis, reviews and case reports with a very small number of patients. The aim of this review was to establish how LLD should be done, suggesting important technical tricks. We found agreement in terms of indications, preoperative management, ports' positioning, antibiotics, enteral feeding and drain management. On the contrast, different statements regarding indications, adhesiolysis and management of colonic hole and failure of laparoscopic lavage are reported. A widespread diffusion of LLD and standardization of its technique are impossible because of data heterogeneity and selection bias in the limited RCTs. It is necessary to wait for long terms results from randomized clinical trials (RCTs) in progress to establish the efficacy and safety of this technique. More importantly, an increased number of highly skilled and dedicated colorectal laparoscopic surgeons are required to standardized the procedure.

Robotic pelvic dissection as surgical treatment of complicated diverticulitis in elective settings: a comparative study with fully laparoscopic procedure.

BACKGROUND: Recently, minimally invasive treatment of complicated sigmoid diverticulitis is becoming a valid alternative to standard procedures. Robotic approach may be useful to allow more precise dissection in arduous pelvic dissection as in complicated diverticulitis. The aim of this study is to investigate effectiveness, potential benefits and short-term outcomes of robotic-assisted laparoscopic surgical resection, compared with fully laparoscopic resection in complicated diverticulitis. METHODS: Between January 2009 and December 2017, 156 consecutive patients with history of complicated diverticular disease were referred to our Department of General, Mininvasive and Robotic Surgery. All patients underwent elective colonic resections performed by the same colorectal surgeon and followed a perioperative ERAS program. Demographic and clinical features, surgical data, postoperative data, 30-day morbidity and mortality, VAS for surgeon's compliance were evaluated. RESULTS: One hundred and fifty-six consecutive patients underwent elective colonic resection: 92 fully laparoscopic (FL) colorectal resections and 64 procedures with robotic hybrid approach (RHA). Conversion rate was none in the RHA group versus 6.5% in the FL group, because of poor vision due to bowel distension, inflammatory pseudotumor and peritoneal adhesions. No 30-day mortality was observed. Mean operative time was 167.5 ± 54.4 min (80-420) in the FL group and 172.5 ± 55.64 min (110-325) in the RHA group (p 0.079), mean intraoperative blood loss was 144.6 ± 40.6 ml (40-200) with the FL technique and 138.4 ± 28.3 ml (20-185) with the RHA (p 0.295). Mean hospital stay for FL was 5 ± 4.1 days (range 3-45) and 5 ± 2.7 days (range 3-20) for RHA (p 0.974). Overall postoperative morbidity rate was 21.6% in the FL group and 12.3% in the RHA (p 0.067). Major postoperative morbidity (Clavien-Dindo 3 and 4) represented 13% and 4.6%, respectively (p 0.091). VAS for surgeon's compliance revealed a better performance in the robotic arm (p 0.059). CONCLUSIONS: This preliminary study highlights the potential benefits of robotic-assisted laparoscopy in colorectal resections for complicated diverticular disease in terms of surgical efficacy, postoperative morbidity and better surgeon's compliance.

Effects of Curative Colorectal Cancer Surgery on Exhaled Volatile Organic Compounds and Potential Implications in Clinical Follow-up.

OBJECTIVE: The aim of this study was to determine whether the volatile organic compounds (VOCs) pattern in colorectal cancer (CRC) patients is modified by curative surgery for a potential application in the oncologic follow-up. BACKGROUND: CRC has been proved to induce metabolic derangements detectable by high through-output techniques in exhaled breath showing a specific pattern of VOCs. METHODS: Forty-eight CRC patients and 55 healthy controls (HC) entered the study. Thirty-two patients (M/F: 1.4; mean age 63 years) attended the oncologic follow-up (mean 24 months) and were found disease-free. Breath samples were collected under similar environmental conditions into a Tedlar bags and processed offline by thermal-desorption gas chromatography-mass spectrometry (TD-GC-MS). VOCs were selected by U test to build a Probabilistic Neural Network (PNN) model to set-up a training phase, which was cross-validated using the leave-one out method. RESULTS: A total of 11 VOCs were finally selected for their excellent discriminant performance in identifying disease-free patients in follow-up from CRC patients before surgery, (sensitivity 100%, specificity 97.92%, accuracy 98.75%, and AUC: 1). The same VOCs pattern discriminated follow-up patients from HC, with a sensitivity of 100%, specificity of 90.91%, accuracy of 94.25%, and AUC 0.959. CONCLUSIONS: Exhaled VOCs pattern from CRC patients is modified by cancer removal confirming the tight relationship between tumor metabolism and exhaled VOCs. PNN analysis provides a high discriminatory tool to identify patients disease-free after curative surgery suggesting potential implications in CRC screening and secondary prevention.