Preoperative lateral lymph node features and impact on local recurrence after neoadjuvant chemoradiotherapy and total mesorectal excision for locally advanced rectal cancer: results from a multicentre international cohort study.

AIM: Locally advanced rectal cancer (LARC) is commonly treated with neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME) to reduce local recurrence (LR) and improve survival. However, LR, particularly associated with lateral lymph node (LLN) involvement, remains a concern. The aim of this study was to investigate preoperative factors associated with LLN involvement and their impact on LR rates in LARC patients undergoing nCRT and curative surgery. METHOD: This multicentre retrospective study, including four academic high-volume institutions, involved 301 consecutive adult LARC patients treated with nCRT and curative surgery between January 2014 and December 2019 who did not undergo lateral lymph node dissection (LLND). Baseline and restaging pelvic MRIs were evaluated for suspicious LLNs based on institutional criteria. Patients were divided into two groups: cLLN+ (positive nodes) and cLLN- (no suspicious nodes). Primary outcome measures were LR and lateral local recurrence (LLR) rates at 3 years. RESULTS: Among the cohort, 15.9% had suspicious LLNs on baseline MRI, and 9.3% had abnormal LLNs on restaging MRI. At 3 years, LR and LLR rates were 4.0% and 1.0%, respectively. Ten out of 12 (83.3%) patients with LR showed no suspicious LLNs at the baseline MRI. Abnormal LLNs on MRI were not independent risk factors for LR, distant recurrence or disease-free survival. CONCLUSION: Abnormal LLNs on baseline and restaging MRI assessment did not impact LR and LLR rates in this cohort of patients with LARC submitted to nCRT and curative TME surgery.

Modest agreement between magnetic resonance and pathological tumor regression after neoadjuvant therapy for rectal cancer in the real world.

Magnetic resonance imaging (MRI) is routinely used for preoperative tumor staging and to assess response to therapy in rectal cancer patients. The aim of our study was to evaluate the accuracy of MRI based restaging after neoadjuvant chemoradiotherapy (CRT) in predicting pathologic response. This multicenter cohort study included adult patients with histologically confirmed locally advanced rectal adenocarcinoma treated with neoadjuvant CRT followed by curative intent elective surgery between January 2014 and December 2019 at four academic high-volume institutions. Magnetic resonance tumor regression grade (mrTRG) and pathologic tumor regression grade (pTRG) were reviewed and compared for all the patients. The agreement between radiologist and pathologist was assessed with the weighted k test. Risk factors for poor agreement were investigated using logistic regression. A total of 309 patients were included. Modest agreement was found between mrTRG and pTRG when regression was classified according to standard five-tier systems (k = 0.386). When only two categories were considered for each regression system, (pTRG 0-3 vs pTRG 4; mrTRG 2-5 vs mrTRG 1) an accuracy of 78% (95% confidence interval [CI] 0.73-0.83) was found between radiologic and pathologic assessment with a k value of 0.185. The logistic regression model revealed that "T3 greater than 5 mm extent" was the only variable significantly impacting on disagreement (OR 0.33, 95% CI 0.15-0.68, P = .0034). Modest agreement exists between mrTRG and pTRG. The chances of appropriate assessment of the regression grade after neoadjuvant CRT appear to be higher in case of a T3 tumor with at least 5 mm extension in the mesorectal fat at the pretreatment MRI.

Mid-term oncological outcomes after complete versus conventional mesocolic excision for right-sided colon cancer: a propensity score matching analysis.

BACKGROUND: The correct extent of mesocolic dissection for right-sided colon cancer (RCC) is still under debate. Complete mesocolic excision (CME) has not gained wide diffusion, mainly due to its technical complexity and unclear oncological superiority. This study aims to evaluate oncological outcomes of CME compared with non-complete mesocolic excision (NCME) during resection for I-III stage RCC. METHOD: Prospectively collected data of patients who underwent surgery between 2010 and 2018 were retrospectively analysed. 1:1 Propensity score matching (PSM) was used to balance baseline characteristics of CME and NCME patients. The primary endpoint of the study was local recurrence-free survival (LRFS). The two groups were also compared in terms of short-term outcomes, distant recurrence-free survival, disease-free survival, and overall survival. RESULTS: Of the 444 patients included in the study, 292 were correctly matched after PSM, 146 in each group. The median follow-up was 45 months (IQR 33-63). Conversion rate, complications, and 90-day mortality were comparable in both groups. The median number of lymph nodes harvested was higher in CME patients (23 vs 19, p = 0.034). 3-year LRFS rates for CME patients was 100% and 95.6% for NCME (log-rank p = 0.028). At 3 years, there were no differences between the groups in terms of overall survival, distant recurrence-free survival, and disease-free survival. CONCLUSION: Our PSM cohort study shows that CME is safe, provides a higher number of lymph nodes harvested, and is associated with better local recurrence-free survival.

Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy.

Surgical Approach to Transverse Colon Cancer: Analysis of Current Practice and Oncological Outcomes Using the National Cancer Database.

BACKGROUND: Surgical treatment for transverse colon cancer involves either extended colectomy or segmental resection, depending on the location of the tumor and surgeon perspective. However, the oncological safety of segmental resection has not yet been established in large cohort studies. OBJECTIVE: This study aims to compare segmental resection versus extended colectomy for transverse colon cancer in terms of oncological outcomes. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted using a nationwide cohort. PATIENTS: A total of 66,062 patients who underwent colectomy with curative intent for transverse stage I to III adenocarcinoma were identified in the National Cancer Database (2004-2015). MAIN OUTCOME MEASURES: Patients were divided in 2 groups based on the type of surgery received (extended versus segmental resection). The primary outcome was overall survival. Secondary outcomes were 30- and 90-day mortality, length of hospital stay, and readmission rate within 30 days of surgical discharge. RESULTS: Extended colectomy was performed in 44,417 (67.2%) patients, whereas 21,645 (32.8%) patients underwent segmental resection. Extended colectomy was associated with lower survival at multivariate analysis (HR, 1.07; 95% CI, 1.04-1.10; p < 0.001). The subgroup analysis showed that extended resection was independently associated with poorer survival in mid transverse colon cancers (HR, 1.08; 95% CI, 1.04-1.12; p < 0.001) and in stage III tumors (HR, 1.11; 95% CI, 1.04-1.18; p < 0.001). The number of at least 12 harvested lymph nodes was an independent predictor of improved survival in both overall and subgroup analyses. LIMITATIONS: This study was limited by its retrospective design. CONCLUSION: Extended colectomy was not associated with a survival advantage compared with segmental resection. On the contrary, extended colectomy was associated with slightly poorer survival in mid transverse cancers and locally advanced tumors. Segmental resection was found to be safe when appropriate margins and adequate lymph node harvest were achieved. See Video Abstract at http://links.lww.com/DCR/B454. ABORDAJE QUIRRGICO DEL CNCER DE COLON TRANSVERSO ANLISIS DE LA PRCTICA ACTUAL Y LOS RESULTADOS ONCOLGICOS UTILIZANDO LA BASE DE DATOS NACIONAL DE CNCER: ANTECEDENTES:El tratamiento quirúrgico para el cáncer de colon transverso implica colectomía extendida o resección segmentaria, según la ubicación del tumor y la perspectiva del cirujano. Sin embargo, la seguridad oncológica de la resección segmentaria aún no se ha establecido en estudios de cohortes grandes.OBJETIVO:Este estudio tiene como objetivo comparar la resección segmentaria versus la colectomía extendida para el cáncer de colon transverso en términos de resultados oncológicos.DISEÑO:Este fue un estudio de cohorte retrospectivo.ESCENARIO:Este estudio se realizó utilizando una cohorte a nivel nacional.PACIENTES:Un total de 66,062 pacientes que se sometieron a colectomía con intención curativa por adenocarcinoma de colon transverso en estadio I-III fueron identificados en la Base de Datos Nacional del Cáncer (2004-2015).PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en dos grupos según el tipo de cirugía recibida (resección extendida versus resección segmentaria). El resultado primario fue la supervivencia global. Los resultados secundarios fueron la mortalidad a los 30 y 90 días, la duración de la estancia hospitalaria y la tasa de reingreso dentro de los 30 días posteriores al alta quirúrgica.RESULTADOS:Se realizó colectomía extendida en 44,417 (67.2%) casos, mientras que 21,645 (32.8%) pacientes fueron sometidos a resección segmentaria. La colectomía extendida se asoció con una menor supervivencia en el análisis multivariado (HR 1.07 IC 95% 1.04-1.10; p <0.001). El análisis de subgrupos mostró que la resección extendida se asoció de forma independiente con una menor supervivencia en los cánceres de colon transverso medio (HR 1.08 IC 95% 1.04-1.12; p <0.001) y en tumores en estadio III (HR 1.11 IC 95% 1.04-1.18; p <0.001). Un número de al menos 12 ganglios linfáticos cosechados fue un predictor independiente de una mejor supervivencia en los análisis general y de subgrupos.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓN:La colectomía extendida no se asoció con una ventaja de supervivencia en comparación con la resección segmentaria. Por el contrario, la colectomía extendida se asoció con una supervivencia levemente menor en cánceres de colon transverso medio y tumores localmente avanzados. Se encontró que la resección segmentaria es segura cuando se logran los márgenes apropiados y la cosecha adecuada de ganglios linfáticos. Consulte Video Resumen en http://links.lww.com/DCR/B454.

Prognostic value of pathological tumor regression grade in locally advanced gastric cancer: New perspectives from a single-center experience.

BACKGROUND AND OBJECTIVE: Perioperative chemotherapy (PC) with radical surgery represents the gold standard of treatment for resectable advanced gastric cancer (GC). The prognostic value of pathological tumor regression grade (TRG) induced by neoadjuvant chemotherapy (NACT) is not clearly established. This study aimed to investigate the correlation between TRG and survival in GC. METHODS: Patients affected by advanced GC undergoing PC and radical surgery were considered. TRG was assessed for each patient according to Becker's grading system. The correlation between TRG and survival was investigated. RESULTS: One-hundred patients were selected; 25 showed a good response (GR) (TRG 1a/1b), while 75 had a poor response (PR) (TRG 2/3) to NACT. GR patients showed better disease-free survival (DFS) (52 vs. 19 months, p < .001) and disease-specific survival (DSS) (57 vs. 25 months, p < .0001) when compared to PR patients. On univariate analysis, TRG, lymph node ratio (LNR), tumor size, grading, and post-neoadjuvant therapy TNM stage were significantly correlated with survival. On multivariate analysis, TRG, LNR and tumor size were independent prognostic factors for DFS and DSS. CONCLUSIONS: TRG, LNR, and tumor size are independent prognostic factors for DFS and DSS in patients with advanced GC undergoing NACT.

Robotic surgery for rectal cancer as a platform to build on: review of current evidence.

Laparoscopy in colorectal surgery reduces the rate of postoperative complications, shortens the length of stay in hospital, and improves the quality of patient care. Despite these established benefits, the technical challenges of rectal resection for cancer have resulted in most operations being performed through open surgery in the USA. Moreover, controversy in the current literature questions the oncologic safety of a laparoscopic approach for rectal cancer. How then can surgeons innovate to overcome the technical challenges while preserving the critical oncological outcomes of high-quality rectal cancer surgery? Robotics may be a platform that allows us to overcome the technical challenges in the pelvis while maintaining both oncological outcomes and the benefits of a minimally invasive technique. Current evidence suggests that the quality of total mesorectal excision, the rates of circumferential margin involvement, and postoperative outcomes are comparable between robotic and laparoscopic surgery. While a robotic approach demonstrates lower conversion rates and reduced surgeon workload, the operative time is longer and initial costs are higher; however, time and future science will determine its true benefits. We review the current state of robotic surgery and its impact on rectal cancer surgery.

MRI-Pathology Agreement in Rectal Cancer: Real-World Data from a Prospective Rectal Cancer Registry.

Introduction: Magnetic Resonance Imaging (MRI) is routinely used in preoperative rectal cancer staging. The concordance of MRI staging with final pathologic exam, albeit improved, has not yet reached perfection. The aim of this study is to analyze the agreement between MRI and pathologic exam in patients operated on for mid-low rectal cancer. Material and Method: Patients undergoing neoadjuvant chemoradiation therapy (nCRT) or upfront surgery were analyzed. Between January 2019 to December 2019, 140 patients enrolled in the AIMS Academy rectal cancer registry were analyzed. Sixty-two patients received nCRT and 78 underwent upfront surgery. Results: Overall, the agreement between MRI and pathologic exam on T stage and N stage were 64.7% and 69.2%, respectively. The agreement between MRI and pathologic exam on T stage was 62.7% for patients who did not receive nCRT and 67.4% for patients who received nCRT (p = 0.62). The agreement on N stage was 76.3% for patients who did not receive nCRT and 60.0% for patients who received nCRT (p = 0.075). Conclusions: Real-world data shows MRI is still far from being able to correlate with the pathology findings which raises questions about the accuracy of the real-life decision-making process during cancer boards.

Readmissions Within 48 Hours of Discharge: Reasons, Risk Factors, and Potential Improvements.

BACKGROUND: Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs. OBJECTIVE: This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge. DESIGN: This is a retrospective cohort study. SETTINGS: This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway. PATIENTS: Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included. MAIN OUTCOME MEASURES: Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions. RESULTS: In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours. LIMITATIONS: Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study. CONCLUSIONS: Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237.

Preoperative immunonutrition in frail patients with colorectal cancer: an intervention to improve postoperative outcomes.

PURPOSE: The aim of this study is to evaluate whether preoperative immunonutrition can shorten length of stay and improve postoperative outcomes in frail patients who are candidates for major oncologic colorectal surgery. METHODS: A single center retrospective analysis of a prospectively collected database of frail patients, who underwent surgery with curative intent for colorectal cancer between January 2014 and December 2017, was performed. From March 2016, frail oncological patients undergoing major surgery were recommended to receive preoperative immunonutrition; their postoperative outcomes were compared to those of patients not treated with any preoperative nutritional support. Propensity score matching in a 1:1 ratio was used to balance patient characteristics. RESULTS: Overall, 175 patients were included in the study. Of 74 patients receiving immunonutrition, 65 were matched with the group not treated with immunonutrition (n = 101). Baseline characteristics were comparable after matching. Although differences in postoperative length of stay were nonsignificant (p = 0.38), patients who received immunonutrition showed a shorter gastrointestinal (GI) recovery time (3.00 [2.00-4.00] versus 4.00 [2.00-5.00], p = 0.04), a lower rate of situs site infections complications (0.31 [0.10, 0.94], p = 0.04) and less need of antibiotic treatment (0.19 [0.06, 0.64], p = 0.01). CONCLUSION: Preoperative immunonutrition was found to reduce both postoperative situs site infections and need of antibiotic treatment during the postoperative course. This study encourages the use of preoperative immune-enhancing nutrition as a part of multimodal prehabilitation programs in the management of frail colorectal cancer patients.

Compliance to Adjuvant Chemotherapy of Patients Who Underwent Surgery for Rectal Cancer: Report from a Multi-institutional Research Network.

INTRODUCTION: Adjuvant chemotherapy for locally advanced rectal cancer is associated with improved overall survival. However, recent evidence from randomized trials showed a compliance rate of 43 to 73%, which may affect efficacy. The aim of this multicenter retrospective analysis was to investigate the compliance rate to adjuvant treatment for patients who underwent rectal surgery for cancer. METHODS: Patients who underwent surgery with curative intent for rectal cancer in six Italian colorectal centers between January 2013 and December 2017 were retrospectively reviewed. Exclusion criteria were age less than 18 years, palliative or emergency surgery, and stage IV disease. Parameters of interest were patients' characteristics, preoperative tumor stage, neo-adjuvant chemoradiation therapy, intra-operative and postoperative outcomes. Although the participating centers referred to the same treatment guidelines for treatment, the chemotherapy regiment was not standardized across the institutions. Reasons for not starting adjuvant chemotherapy when indicated, interruption, and modification of drug regimen were collected to investigate compliance. RESULTS: A total of 572 patients were included in the analysis. Two hundred and fifty-two (44.1%) patients received neo-adjuvant chemoradiation therapy. All patients underwent high anterior rectal resection, low anterior rectal resection, or Miles' procedure. Of 399 patients with an indication to adjuvant chemotherapy, 176 (44.1%) completed the treatment as planned. Compliance for patients who started chemotherapy was 56% (95% CI 50.4-61.6%). Sixty-six patients interrupted the treatment, 76 patients significantly reduced the drug dose, and 41 patients had to switch to other therapeutic regimens. CONCLUSIONS: The present multicenter investigation reports a low compliance rate to adjuvant chemotherapy after rectal resection for cancer. Multidisciplinary teams should focus on future effort to improve compliance for these patients.

Streptococcus agalactiae infective endocarditis complicated by multiple mycotic hepatic aneurysms and massive splenic infarction: a case report.

BACKGROUND: The burden of disease caused by Streptococcus agalactiae has increased significantly among older adults in the last decades. Group B streptococcus infection can be associated with invasive disease and severe clinical syndromes, such as meningitis and endocarditis. CASE PRESENTATION: We present the case of a 56-year-old man who developed multiple mycotic aneurysms of the right hepatic artery and massive splenic infarction as rare complications of Streptococcus agalactiae infective endocarditis. The patient underwent urgent right hepatic artery ligation and splenectomy. The postoperative course was complicated by an episode of hemobilia due to the rupture of a partially thrombosed mycotic aneurysm into the biliary tree. Thus, selective radiological embolization of the left hepatic artery branches was necessary. CONCLUSION: To our knowledge, this is the first case reported of infected aneurysms of visceral arteries caused by Group B streptococcus infection. Clinical and laboratory findings were non-specific, while imaging features with computed tomography scan and angiography were highly suggestive. In our case, early recognition, culture-specific intravenous antibiotics and urgent surgical treatment combined with interventional radiology played a decisive role in the final result.

Should Laparoscopic Complete Mesocolic Excision Be Offered to Elderly Patients to Treat Right-Sided Colon Cancer?

BACKGROUND: Despite its potential oncologic benefit, complete mesocolic excision (CME) has rarely been offered to elderly patients. The present study evaluated the effect of age on postoperative outcomes among patients undergoing laparoscopic right colectomies with CME for right-sided colon cancer (RCC). METHODS: Data of patients undergoing laparoscopic right colectomies with CME for RCC between 2015 and 2018 were retrospectively analyzed. Selected patients were divided into two groups: the under-80 group and the over-80 group. Surgical, pathological, and oncological outcomes among the groups were compared. RESULTS: A total of 130 patients were selected (95 in the under-80 group and 35 in the over-80 group). No difference was found between the groups in terms of postoperative outcomes, except for median length of stay and adjuvant chemotherapy received, which were in favor of the under-80 group (5 vs. 8 days, p < 0.001 and 26.3% vs. 2.9%, p = 0.003, respectively). No difference between the groups was found regarding overall survival and disease free survival. Using multivariate analysis, only the ASA score > 2 (p = 0.01) was an independent predictor of overall complications. CONCLUSIONS: laparoscopic right colectomy with CME for RCC was safely performed in elderly patients ensuring similar oncological outcomes compared to younger patients.

5 year oncological outcomes of the HIGHLOW randomized clinical trial.

INTRODUCTION: The oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA MATERIALS AND METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled. RESULTS: Five-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years. CONCLUSION: We confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.

Completely intracorporeal anastomosis in robotic left colonic and rectal surgery: technique and 30-day outcomes.

As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p = < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA).

Preoperative predictive risk to cancer quality in robotic rectal cancer surgery.

BACKGROUND: Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery. METHODS: This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated. RESULTS: A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35-36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33-17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72-33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present. CONCLUSION: Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes.

The Diverticular Disease Registry (DDR Trial) by the Advanced International Mini-Invasive Surgery Academy Clinical Research Network: Protocol for a Multicenter, Prospective Observational Study.

Diverticular disease is an increasingly common issue, with a variety of clinical presentations and treatment options. However, very few prospective cohort studies explore outcomes between the different presentations and treatments. The Diverticular Disease Registry (DDR Trial) is a multicenter, prospective, observational cohort study on behalf of the Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network. The DDR Trial aims to investigate the short-term postoperative and long-term quality of life outcomes in patients undergoing surgery or medical treatments for diverticular disease. DDR Trial is open to participation by all tertiary-care hospitals. DDR Trial has been registered at ClinicalTrials.gov (NCT04907383). Data collection will be recorded on Research Electronic Data Capture (REDCap) starting on June 1st, 2021 and will end after 5 years of recruitment. All adult patients with imaging-proven colonic diverticular disease (i.e., symptomatic colonic diverticulosis including diverticular bleeding, diverticulitis, and Symptomatic Uncomplicated Diverticular Disease) will be included. The primary outcome of DDR Trial is quality of life assessment at 12-month according to the Gastrointestinal Quality of Life Index (GIQLI). The secondary outcome is 30-day postoperative outcomes according to the Clavien-Dindo classification. DDR Trial will significantly advance in identifying the optimal care for patients with diverticular disease by exploring outcomes of different presentations and treatments. HIGHLIGHTS: Diverticular disease (i.e., diverticulitis, bleeding) has different treatments.This is a clinical protocol for the Diverticular Disease Registry (DDR Trial).DDR Trial is a multicenter, prospective, observational cohort study open to participation.DDR Trial will study short-term postoperative and long-term quality of life outcomes.Medical treatments, interventional radiology and surgery will be explored.

Functional and Short-term Outcomes in Elective Laparoscopic Colectomy for Symptomatic Diverticular Disease With Either Low Ligation or Inferior Mesenteric Artery Preservation: A Randomized Trial.

BACKGROUND: The current treatment of symptomatic diverticular disease is left colectomy/sigmoidectomy with low ligation of the inferior mesenteric artery versus the inferior mesenteric artery preservation. Up to now, there is no strong evidence in favor of one of the 2 strategies. The aim of this study is to compare the bowel-specific quality of life and functional outcomes between these 2. METHODS: Between June 2015 and February 2019, patients were randomly assigned to inferior mesenteric artery low ligation or inferior mesenteric artery preservation during elective laparoscopic sigmoidectomy for diverticular disease. Gastrointestinal, genitourinary functions and surgical outcomes were compared postoperatively between groups. RESULTS: One-hundred sixty-eight patients were randomized providing 2 homogenous groups. Gastrointestinal and genitourinary functions were not significantly different between groups after 1 and 6 months postoperative. In both groups, the function was restored to the preoperative level 6 months after surgery. There was no statistically significant difference in terms of conversion rate, blood loss, length of surgery, between groups. There was no difference in the overall complication rate and the anastomotic leak rate among groups. CONCLUSIONS: Inferior mesenteric artery low ligation or inferior mesenteric artery preservation during elective laparoscopic sigmoidectomy for a diverticular disease can be considered equivalent in affecting the postoperative bowel-related quality of life, genitourinary function, and surgical outcomes.

Spontaneous rupture of a non-functioning pancreatic neuroendocrine tumor A case report of a rare cause of acute abdomen.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are a group of rare tumors that account for 2% of all pancreatic malignancies, even though their incidence has been increasing over the past 20 years. Most PNETs are sporadic and tend to affect older individuals. Differently from functional tumors, which present with symptoms resulting from the specific hormone being elaborated, non-functioning pancreatic neuroendocrine tumors (NF-PNETs) typically present with symptoms related to local mass effect or metastatic disease. Today, due to the increasing use of abdominal imaging, NFPNETs are frequently discovered incidentally. CASE REPORT: A 32-year-old woman was admitted to our emergency department for worsening upper abdominal pain radiating to the back. Shortly after the admission, shock and peritoneal signs developed. An abdominal computerized tomography scan showed a solid mass (9 x 12 cm) of the pancreatic tail with severe hemoperitomeum. Exploratory laparotomy and subsequent distal splenopancreasectomy were performed for a bleeding tumor. Histopathological report showed a neuroendocrine, well differentiated tumor (G1). The postoperative course was uneventful and the patient was successfully discharged on 10th postoperative day. CONCLUSION: Spontaneous rupture of solid neuroendocrine neoplasms of the pancreas can cause acute abdomen with potentially devastating effects. KEY WORDS: Abdominal pain, acute abdomen, Hemorrhagic shock, Pancreatic neuroendocrine tumor.