Is CT Radiomics Superior to Morphological Evaluation for pN0 Characterization? A Pilot Study in Colon Cancer.

The aim of this study was to compare CT radiomics and morphological features when assessing benign lymph nodes (LNs) in colon cancer (CC). This retrospective study included 100 CC patients (test cohort) who underwent a preoperative CT examination and were diagnosed as pN0 after surgery. Regional LNs were scored with a morphological Likert scale (NODE-SCORE) and divided into two groups: low likelihood (LLM: 0-2 points) and high likelihood (HLM: 3-7 points) of malignancy. The T-test and the Mann-Whitney test were used to compare 107 radiomic features extracted from the two groups. Radiomic features were also extracted from primary lesions (PLs), and the receiver operating characteristic (ROC) was used to test a LN/PL ratio when assessing the LN's status identified with radiomics and with the NODE-SCORE. An amount of 337 LNs were divided into 167 with LLM and 170 with HLM. Radiomics showed 15/107 features, with a significant difference (p < 0.02) between the two groups. The comparison of selected features between 81 PLs and the corresponding LNs showed all significant differences (p < 0.0001). According to the LN/PL ratio, the selected features recognized a higher number of LNs than the NODE-SCORE (p < 0.001). On validation of the cohort of 20 patients (10 pN0, 10 pN2), significant ROC curves were obtained for LN/PL busyness (AUC = 0.91; 0.69-0.99; 95% C.I.; and p < 0.001) and for LN/PL dependence entropy (AUC = 0.76; 0.52-0.92; 95% C.I.; and p = 0.03). The radiomics ratio between CC and LNs is more accurate for noninvasively discriminating benign LNs compared to CT morphological features.

Oncological Adequacy of Laparoscopic Surgery for Bulky Gastric Cancer: Results of a Western Single-Center Series.

BACKGROUND: Gastric cancer is increasing worldwide and one million new cases were estimated globally in 2020. Use of the laparoscopic approach is increasing especially for subtotal gastrectomy. However, to date, solid data on locally advanced bulky tumors are lacking. The aim of this study is to assess the role of laparoscopic surgery in bulky gastric tumors. METHODS: We performed an observational retrospective single-center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, intra-operative data, peri-operative data, and pathological data. Statistical analysis was conducted, including descriptive statistics and chi-squared test, to analyze the differences between categorical variables. RESULTS: O the 116 patients who underwent gastric surgery, 49 patients were included in the study protocol. All patients had bulky gastric tumors. Eighteen patients underwent laparoscopic gastrectomy and 31 open gastrectomy. The median number of lymph nodes removed was 28.5 (15-46) in the laparoscopic group and 23.05 (6-62) in the open group (p = 0.04). In total, 5.6% of patients of the laparoscopic group had <16 lymph nodes harvested and 35.5% in the open group (p = 0.035). No statistical differences were found between the open and laparoscopic groups in terms of surgical margins (p = 0.69). CONCLUSIONS: Laparoscopic surgery is still a subject of debate in locally advanced bulky gastric cancer. Limited data are available concerning Western patients. This study showed superiority in terms of the quality of lymphadenectomy and non-inferiority in terms of radical resection margins.

Low Anterior Resection Syndrome (LARS) after Surgery for Rectal Cancer: An Inevitable Price to Pay for Survival, or a Preventable Complication?

BACKGROUND: Rectal cancer is frequent and often treated with sphincter-saving procedures that may cause LARS, a syndrome characterized by symptoms of bowel disfunction that may severely affect quality of life. LARS is common, but its pathogenesis is mostly unknown. The aim of this study is to assess the incidence of LARS and to identify potential risk factors. METHODS: We performed an observational retrospective single center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, and intra- and peri-operative data. Statistical analysis was conducted, including descriptive statistics and multivariate logistic regression to identify independent risk factors. RESULTS: Total LARS incidence was 31%. Statistically significant differences were found in tumor distance from anal verge, tumor extension (pT and diameter) and tumor grading (G). Multivariate analysis identified tumor distance from anal verge and tumor extension as an independent predictive factor for both major and total LARS. Adjuvant therapy, although not significant at univariate analysis, was identified as an independent predictive factor. Time to stoma closure within 10 weeks seems to reduce incidence of major LARS. CONCLUSIONS: bold LARS affects a considerable portion of patients. This study identified potential predictive factors that could be useful to identify high risk patients for LARS.

Lymph Node Metastasis in Extraperitoneal Rectal Cancer After Neoadjuvant Therapy: An Unsolved Problem?

BACKGROUND/AIM: Thanks to the promising benefits obtained in terms of quality of life, there has been growing interest in organ-sparing approaches after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer, mainly represented by transanal local excision and watch-and-wait. The main mandatory criterion is complete lymph nodal response (pN0). However, considering the reduced specificity of current radiological means in identifying one-to-one correspondence between clinical and pathological staging, the problem of underestimating lymph nodal involvement remains unsolved. The aim of this study was to identify the true percentage of patients eligible for conservative surgery and possible predictive factors. PATIENTS AND METHODS: Data for 59 patients with rectal cancer treated with nCRT followed by total mesorectal excision were analyzed. Patients with metastatic tumors and tumors treated with up-front surgery were excluded. Our primary endpoint was the pathological lymph nodal response rate after neoadjuvant chemoradiotherapy. The secondary endpoint was to identify predictive factors for lymph nodal response. RESULTS: The percentage of patients with pN0 was 62.71%, while in 37.28%, an organ-sparing approach would have not been oncologically correct. Parameters associated with pN0 were lower tumor size (T0-T2) (p=0.013) and lower grading (

Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma.

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.

Magnetic-Assisted Capsule Endoscopy in Children With Crohn Disease: Feasibility and Impact on Gastric Transit Time.

OBJECTIVES: Standard capsule endoscopy (CE) is ineffective for upper gastrointestinal (GI) tract examination because it does not allow operator-controlled navigation of the capsule. Magnetically assisted capsule endoscopy (MACE) may offer a solution to these problems. This pilot study is aimed to evaluate the feasibility of MACE system in pediatric Crohn disease (CD) and if magnetic steering could enhance capsule gastric emptying when compared with standard CE. METHODS: Pediatric CD patients already studied by standard small bowel CE were enrolled. All participants swallowed a magnetically assisted CE and an external magnetic field navigator was used to guide the capsule through the upper GI tract. Maneuverability, completeness of the MACE examination, differences in the esophageal transit time (ETT), gastric transit time (GTT), and pyloric transit time (PTT) between standard CE and MACE were assessed. RESULTS: Ten patients [mean age 11.4 years (range 6-15); 60% male] were enrolled. Maneuverability was defined as good and fair in 60% and 40% of participants, respectively. Completeness of MACE examination was 95%, 65%, and 92.5% in the esophagus, proximal, and distal stomach, respectively. Transpyloric passage of the capsule under magnetic control was successfully performed in 80% of patients. Magnetic intervention significantly increased ETT ( P < 0.001) and reduced GTT and PTT ( P = 0.002). No significant adverse events occurred. CONCLUSIONS: MACE is a safe and feasible technique in children. Magnetic steering enhances capsule gastric emptying and facilitates capsule transpyloric passage when compared with standard CE.

Oncological outcomes of rectal cancer patients with anastomotic leakage: A multicenter case-control study.

Introduction: This study aimed to evaluate the impact of anastomotic leakage (AL) on oncological outcomes after restorative rectal cancer surgery. Methods: Patients who underwent anterior resection for rectal adenocarcinoma between January 2011 and December 2017 were retrospectively reviewed. Data were collected from three colorectal surgery centers. Patients with grade B and C leaks according to the International Study Group of Rectal Cancer classification were identified and compared with the control group. Estimated recurrence and survival rates were compared using the log-rank method and Cox regression analysis. Results: A total of 367 patients were included in the study, with a mean follow-up of 59.21 months. AL occurred in 64 patients (17.4%). Fifteen patients with AL (23.5%) developed local recurrence (LR) compared to 17 (4.8%) in the control group (p < 0.001). However, distant recurrence rates were similar (10.9% vs. 9.6%; p = 0.914) between the groups. Kaplan-Meier curves showed that patients with AL had a reduced 5-years local recurrence-free survival (96% vs. 78%, log-rank p < 0.001). AL (OR 4.576; 95% CI, 2.046-10.237; p < 0.001) and node involvement (OR 2.911; 95% CI, 1.240-6.835; p = 0.014) were significantly associated with LR in multivariate analysis. AL was significantly associated with DFS only at univariate analysis (HR 1.654; 95% CI: 1.024-2.672; p = 0.037), with a difference between 5-year DFS of patients with and without AL (71.6% vs. 86.4%, log-rank p = 0.04). Only male gender, pT3-4 stage, and node involvement were identified as independent prognostic factors for reduced DFS in the multivariate Cox regression analysis. Conclusion: In this cohort of patients, AL was associated with a significant risk of LR after rectal cancer surgery.

Radiomic Cancer Hallmarks to Identify High-Risk Patients in Non-Metastatic Colon Cancer.

The study was aimed to develop a radiomic model able to identify high-risk colon cancer by analyzing pre-operative CT scans. The study population comprised 148 patients: 108 with non-metastatic colon cancer were retrospectively enrolled from January 2015 to June 2020, and 40 patients were used as the external validation cohort. The population was divided into two groups­High-risk and No-risk­following the presence of at least one high-risk clinical factor. All patients had baseline CT scans, and 3D cancer segmentation was performed on the portal phase by two expert radiologists using open-source software (3DSlicer v4.10.2). Among the 107 radiomic features extracted, stable features were selected to evaluate the inter-class correlation (ICC) (cut-off ICC > 0.8). Stable features were compared between the two groups (T-test or Mann−Whitney), and the significant features were selected for univariate and multivariate logistic regression to build a predictive radiomic model. The radiomic model was then validated with an external cohort. In total, 58/108 were classified as High-risk and 50/108 as No-risk. A total of 35 radiomic features were stable (0.81 ≤ ICC < 0.92). Among these, 28 features were significantly different between the two groups (p < 0.05), and only 9 features were selected to build the radiomic model. The radiomic model yielded an AUC of 0.73 in the internal cohort and 0.75 in the external cohort. In conclusion, the radiomic model could be seen as a performant, non-invasive imaging tool to properly stratify colon cancers with high-risk disease.

From "Cure" to "Care": The Role of the MultiDisciplinary Team on Colorectal Cancer Patients' Satisfaction and Oncological Outcomes.

Background: MultiDisciplinary Team (MDT) are held to undertake decisions regarding the whole aspect of oncological diseases. Over the years, they acquired a collaborative approach where clinical decisions are shared by all members. Different guidelines recommend the implementation of MDT, in order to improve the outcomes of these patients. Our aim is to evaluate how the implementation of MDT affects the patients' satisfaction and adherence to treatment. Methods: A survey was submitted to every patient affected by colorectal cancer treated by the MDT of Sant'Andrea Hospital (Rome, IT). The investigation period was January 2017-March 2020. Data from patients inside the MDT were compared with patients outside the MDT to evaluate a reduction in waiting times. Results: A total of 591 patients were collected. A total of 355 patients with colorectal neoplasia were included in our analysis. Cumulative overall survival was 79%. The average waiting time for computed tomography or colonoscopy was 14.9 days for patients in the MDT versus 24.5. A total of 201 patients were eligible for our satisfaction survey. An 89.5% of patients felt followed in their treatment. A 93.5% of patients expressed a high grade of satisfaction for the MDT design. Conclusion: Our study confirms the importance of a well-structured MDT. Dedicated slots shorten the waiting time, leading to better satisfaction and faster diagnosis. Patients' satisfaction should be considered as an index of good practice when it comes to oncological patients' treatment.

Laparoscopic versus Open Surgery for Gastric Cancer in Western Countries: A Systematic Review and Meta-Analysis of Short- and Long-Term Outcomes.

Background. The advantages of a laparoscopic approach for the treatment of gastric cancer have already been demonstrated in Eastern Countries. This review and meta-analysis aims to merge all the western studies comparing laparoscopic (LG) versus open gastrectomies (OG) to provide pooled results and higher levels of evidence. Methods. A systematic literature search was performed in MEDLINE(PubMed), Embase, WebOfScience and Scopus for studies comparing laparoscopic versus open gastrectomy in western centers from 1980 to 2021. Results. After screening 355 articles, 34 articles with a total of 24,098 patients undergoing LG (5445) or OG (18,653) in western centers were included. Compared to open gastrectomy, laparoscopic gastrectomy has a significantly longer operation time (WMD = 47.46 min; 95% CI = 31.83−63.09; p < 0.001), lower blood loss (WMD = −129.32 mL; 95% CI = −188.11 to −70.53; p < 0.0001), lower analgesic requirement (WMD = −1.824 days; 95% CI = −2.314 to −1.334; p < 0.0001), faster time to first oral intake (WMD = −1.501 days; 95% CI = −2.571 to −0.431; p = 0.0060), shorter hospital stay (WMD = −2.335; 95% CI = −3.061 to −1.609; p < 0.0001), lower mortality (logOR = −0.261; 95% the −0.446 to −0.076; p = 0.0056) and a better 3-year overall survival (logHR 0.245; 95% CI = 0.016−0.474; p = 0.0360). A slight significant difference in favor of laparoscopic gastrectomy was noted for the incidence of postoperative complications (logOR = −0.202; 95% CI = −0.403 to −0.000 the = 0.0499). No statistical difference was noted based on the number of harvested lymph nodes, the rate of major postoperative complication and 5-year overall survival. Conclusions. In Western centers, laparoscopic gastrectomy has better short-term and equivalent long-term outcomes compared with the open approach, but more high-quality studies on long-term outcomes are required.

The Potential Role of Genomic Signature in Stage II Relapsed Colorectal Cancer (CRC) Patients: A Mono-Institutional Study.

Purpose: The absolute benefit of adjuvant chemotherapy in stage II CRC is only 3-4%. The identification of biomarkers through molecular profiling could identify patients who will more benefit from adjuvant chemotherapy. Patients and Methods: This retrospective analysis examined tissue blocks from 17 patients affected by relapsed stage II CRC, whose comprehensive genomic profiling of tumors was conducted through next-generation sequencing (NGS) via Roche-FoundationOne®. Results: Mutations were found in APC (76.5%), TP53 (58.8%) and KRAS (52.9%). Only KRAS wild-type samples showed FBXW7. APC frameshift mutations and MLH1 splice variant were conversely significant correlated (7% v 93%, P = 0.014). The median number of gene mutations reported was 6 (range 2-14). The TP53 mutation was associated most frequently with lung metastasis (P = 0.07) and high tumor budding (P = 0.03). Despite no statistical significance, lung recurrence, LVI/Pni, MSI and more than 6 genetic mutations were correlated to worse DFS and OS. Patients carried co-mutations of TP53-FBXW7 reported the worse DFS (4 v 14 months) and OS (4 v 65 months) compared to the other patients. Conclusion: According to the present analysis, the setting of relapsed CRC emerges as one of the fields of greatest utility for NGS, looking at personalized cancer care.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study.

BACKGROUND: Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA). METHODS: The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality. RESULTS: 182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications. CONCLUSIONS: Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.

Statistical models to preoperatively predict operative difficulty in laparoscopic cholecystectomy: A systematic review.

BACKGROUND: Laparoscopic cholecystectomy operative difficulty is highly variable and influences outcomes. This systematic review analyzes the performance and clinical value of statistical models to preoperatively predict laparoscopic cholecystectomy operative difficulty. METHODS: PRISMA guidelines were followed. PubMed, Embase, and the Cochrane Library were searched until June 2020. Primary studies developing or validating preoperative models predicting laparoscopic cholecystectomy operative difficulty in cohorts of >100 patients were included. Studies not reporting performance metrics or enough information for clinical implementation were excluded. Data were extracted according to CHARMS, and study quality was assessed using the PROBAST tool. RESULTS: In total, 2,654 articles were identified, and 22 met eligibility criteria. Eighteen were model development, whereas 4 were validation studies. Eighteen studies were at high risk of bias. However, 11 studies showed low concern for applicability. Identified models predict 9 definitions of laparoscopic cholecystectomy operative difficulty, the most common being conversion to open surgery and operating time. The most validated models predict an intraoperative difficulty scale and procedures >90 minutes with an area under the curve of >0.70 and >0.76, respectively. Commonly used predictors include demographic variables such as age and gender (9/18 models) and ultrasound findings such as gallbladder wall thickness (11/18). Clinical implementation was never studied. CONCLUSION: There is a longstanding interest in estimating laparoscopic cholecystectomy operative difficulty. Models to preoperatively predict laparoscopic cholecystectomy operative difficulty have generally good performance and seem applicable. However, an unambiguous definition of operative difficulty, validations, and clinical studies are needed to implement patients' stratification in laparoscopic cholecystectomy.

Evaluation of a Post-Operative Rehabilitation Program in Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Pilot Study.

This pilot study explores the effects of a post-operative physical exercise program on the quality of life (QoL) and functional and nutritional parameters of patients that underwent laparoscopic colorectal cancer surgery, compared to usual care alone. The intervention group (IG) attended a 2-month-long supervised and combined exercise-training program during the post-operative period. Both IG and control group (CG) participated in the QoL, functional, and nutritional assessments before exercise training (T0), 2 months after the beginning of the exercise (end of treatment) (T1), and 2 (T2) and 4 (T3) months from the end of treatment. Eleven patients with colorectal cancer that underwent laparoscopic surgery were enrolled (six intervention; five control). The IG showed significant improvements compared to the CG in "Physical functioning" (PF2) (p = 0.030), "Cognitive functioning" (CF) (p = 0.018), and "Fatigue" (FA) (p = 0.017) of the European Organization for Research and Treatment of Cancer Quality of Life-C30 Questionnaire (EORTC QLQ-C30) at T1; in SMWT (p = 0.022) at T1; in PF2 (p = 0.018) and FA (p = 0.045) of EORTC QLQ-C30 at T2, in phase angle (PhA) of bioelectrical impedance analysis (p = 0.022) at T3. This pilot study shows that a post-operative, combined, and supervised physical exercise program may have positive effects in improving the QoL, functional capacity, and nutritional status in patients that undergo laparoscopic colorectal cancer surgery.

Laparoscopic versus open rectal resection: a 1:2 propensity score-matched analysis of oncological adequateness, short- and long-term outcomes.

BACKGROUND: Laparoscopic resections for rectal cancer are routinely performed in high-volume centres. Despite short-term advantages have been demonstrated, the oncological outcomes are still debated. The aim of this study was to compare the oncological adequateness of the surgical specimen and the long-term outcomes between open (ORR) and laparoscopic (LRR) rectal resections. METHODS: Patients undergoing laparoscopic or open rectal resections from January 1, 2013, to December 31, 2019, were enrolled. A 1:2 propensity score matching was performed according to age, sex, BMI, ASA score, comorbidities, distance from the anal verge, and clinical T and N stage. RESULTS: Ninety-eight ORR were matched to 50 LRR. No differences were observed in terms of operative time (224.9 min. vs. 230.7; p = 0.567) and postoperative morbidity (18.6% vs. 20.8%; p = 0.744). LRR group had a significantly earlier soft oral intake (p < 0.001), first bowel movement (p < 0.001), and shorter hospital stay (p < 0.001). Oncological adequateness was achieved in 85 (86.7%) open and 44 (88.0%) laparoscopic resections (p = 0.772). Clearance of the distal (99.0% vs. 100%; p = 0.474) and radial margins (91.8 vs. 90.0%, p = 0.709), and mesorectal integrity (94.9% vs. 98.0%, p = 0.365) were comparable between groups. No differences in local recurrence (6.1% vs.4.0%, p = 0.589), 3-year overall survival (82.9% vs. 91.4%, p = 0.276), and disease-free survival (73.1% vs. 74.3%, p = 0.817) were observed. CONCLUSIONS: LRR is associated with good postoperative results, safe oncological adequateness of the surgical specimen, and comparable survivals to open surgery.

Effect of direct renin inhibition on vascular function after long-term treatment with aliskiren in hypertensive and diabetic patients.

OBJECTIVE: We tested the hypothesis that chronic treatment with the direct renin inhibitor aliskiren improves vascular function in resistance and conduit arteries of type two diabetic and hypertensive patients. METHOD: Sixteen patients with mild essential hypertension and with a previous diagnosis of noninsulin-dependent diabetes mellitus were included in the study. Patients were then randomized to aliskiren (150 mg once daily, n = 9), or ramipril (5 mg once daily, n = 7). Each patient underwent a biopsy of the subcutaneous tissue and small arteries were dissected and mounted on a pressurized micromyograph to evaluate endothelium dependent vasorelaxation in response to acetylcholine ±â€ŠN omega-nitro-L-arginine methyl ester hydrochloride in vessels precontracted with norepinephrine. Endothelial function has been quantified also in large conduit arteries by flow-mediated dilation. RESULTS: A similar office blood pressure-lowering effect was observed with the two drugs, although changes in DBP were not statistically significant in the ramipril group. Aliskiren significantly improved endothelium-dependent relaxation in subcutaneous resistance arteries, as well as increased flow-mediated dilation in conduit arteries, whereas the effects induced by ramipril did not reach statistical significance. Only aliskiren significantly increased the expression of p1177-endothelial nitric oxide synthase in the endothelium. Both aliskiren and ramipril had a negligible effect on markers of oxidative stress. CONCLUSION: Aliskiren restored endothelial function and induced a more prompt peripheral vasodilation in hypertensive and diabetic patients possibly through the increased production of nitric oxide via the enhanced expression and function of the active phosphorylated form of endothelial nitric oxide synthase.

The Emergency Surgery Frailty Index (EmSFI): development and internal validation of a novel simple bedside risk score for elderly patients undergoing emergency surgery.

BACKGROUND: Frailty assessment has acquired an increasing importance in recent years and it has been demonstrated that this vulnerable profile predisposes elderly patients to a worse outcome after surgery. Therefore, it becomes paramount to perform an accurate stratification of surgical risk in elderly undergoing emergency surgery. STUDY DESIGN: 1024 patients older than 65 years who required urgent surgical procedures were prospectively recruited from 38 Italian centers participating to the multicentric FRAILESEL (Frailty and Emergency Surgery in the Elderly) study, between December 2016 and May 2017. A univariate analysis was carried out, with the purpose of developing a frailty index in emergency surgery called "EmSFI". Receiver operating characteristic curve analysis was then performed to test the accuracy of our predictive score. RESULTS: 784 elderly patients were consecutively enrolled, constituting the development set and results were validated considering further 240 consecutive patients undergoing colorectal surgical procedures. A logistic regression analysis was performed identifying different EmSFI risk classes. The model exhibited good accuracy as regard to mortality for both the development set (AUC = 0.731 [95% CI 0.654-0.772]; HL test χ2 = 6.780; p = 0.238) and the validation set (AUC = 0.762 [95% CI 0.682-0.842]; HL test χ2 = 7.238; p = 0.299). As concern morbidity, our model showed a moderate accuracy in the development group, whereas a poor discrimination ability was observed in the validation cohort. CONCLUSIONS: The validated EmSFI represents a reliable and time-sparing tool, despite its discriminative value decreased regarding complications. Thus, further studies are needed to investigate specifically surgical settings, validating the EmSFI prognostic role in assessing the procedure-related morbidity risk.

Robotic versus open oncological gastric surgery in the elderly: a propensity score-matched analysis.

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥ 65 or 75 years is used. Even if robot-assisted surgery is a validated option for the elderly population, there are no specific indications for its application in the surgical treatment of gastric cancer. The aim of this study is to evaluate the safety and feasibility of robot-assisted gastrectomy and to compare the short and long-term outcomes of robot-assisted (RG) versus open gastrectomy (OG). Patients aged ≥ 70 years old undergoing surgery for gastric cancer at the Department of Surgery of San Donato Hospital in Arezzo, between September 2012 and March 2017 were enrolled. A 1:1 propensity score matching was performed according to the following variables: age, Sex, BMI, ASA score, comorbidity, T stage and type of resection performed. 43 OG were matched to 43 RG. The mean operative time was significantly longer in the RG group (273.8 vs. 193.5 min, p < 0.01). No differences were observed in terms of intraoperative blood loss, an average number of lymph nodes removed, mean hospital stay, morbidity and mortality. OG had higher rate of major complications (6.9 vs. 16.3%, OR 2.592, 95% CI 0.623-10.785, p = 0.313) and a significantly higher postoperative pain (0.95 vs. 1.24, p = 0.042). Overall survival (p = 0.263) and disease-free survival (p = 0.474) were comparable between groups. Robotic-assisted surgery for oncological gastrectomy in elderly patients is safe and effective showing non-inferiority comparing to the open technique in terms of perioperative outcomes and overall 5-year survival.

Early Induction of Bedside Pneumoperitoneum in the Management of Residual Pleural Space and Air Leaks After Pulmonary Resection.

BACKGROUND: The pneumoperitoneum to treat prolonged air leaks or pleural space problems after pulmonary resection has been successfully used for decades. The aim of the study is to describe our experience with the early induction of therapeutic pneumoperitoneum (TP). METHODS: We reviewed the data of 103 consecutive patients undergoing TP between September 2011 and September 2019. Patients were divided into two groups according to the time of the induction of TP: early application (≥72 h) and standard application (>72 h). RESULTS: In total, 52 early TP and 51 standard TP were analyzed. The median time of TP induction was 2 (1-3) versus 8 (5-11) postoperative days (POD) (p < 0.001). The time for obliteration of the residual pleural space (7 vs.9 days, p = 0.805) and the time of resolution of the air leaks (14 vs. 16 days, p = 0.663) didn't differ between the two groups, but a favorable trend was observed in the early group. The hospital stay was lower for patients undergoing early pneumoperitoneum: 9 versus 18 days (p < 0.001). The multivariate analysis showed that POD of induction of TP (p < 0.001), time of resolution of the air leak (p < 0.001) and Heimlich valve (p = 0.002) were independent variables associated with the hospital stay. CONCLUSIONS: The use of TP whenever a space problem or air leaks occur after pulmonary resections is safe and effective. Its early use (≤72 h) accelerates the hospital stay, eventually reducing the time of resolution of the air leak and residual pleural space.