Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events.

This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.

Duodenal Obstruction in a Patient Previously Treated With EndoVascular Aneurysm Sealing System Repair.

The Nellix® endovascular aneurysm sealing system (EVAS) is a relatively novel approach for the treatment of abdominal aortic aneurysms (AAAs). We present herein a case of duodenal obstruction (DO) which occurred following an EVAS treatment for the repair of an AAA. A 77-year old man was admitted to our hospital with acute abdominal pain and recurrent vomiting. Computed tomography (CT) revealed a retroperitoneal 66 × 59 × 90 mm (antero-posterior, AP; latero-lateral, LL; cranio-caudal: CC) solid mass located in the epigastrium, corresponding to the infrarenal abdominal aortic aneurysm sac, previously treated by EVAS. An exploratory laparotomy was performed, which revealed a retroperitoneal mass compressing the third and fourth parts of the duodenum. A gastroenteroanastomosis was performed in order to bypass the duodenal obstruction. An extensive search of biomedical literature databases was conducted to identify similar cases. To our knowledge, this is the first reported case of DO following an AAA repair with EVAS.

Contemporary snapshot of tumor regression grade (TRG) distribution in locally advanced rectal cancer: a cross sectional multicentric experience.

Pre-operative chemoradiotherapy (CRT) followed by surgical resection is still the standard treatment for locally advanced low rectal cancer. Nowadays new strategies are emerging to treat patients with a complete response to pre-operative treatment, rendering the optimal management still controversial and under debate. The primary aim of this study was to obtain a snapshot of tumor regression grade (TRG) distribution after standard CRT. Second, we aimed to identify a correlation between clinical tumor stage (cT) and TRG, and to define the accuracy of magnetic resonance imaging (MRI) in the restaging setting. Between January 2017 and June 2019, a cross sectional multicentric study was performed in 22 referral centers of colon-rectal surgery including all patients with cT3-4Nx/cTxN1-2 rectal cancer who underwent pre-operative CRT. Shapiro-Wilk test was used for continuous data. Categorical variables were compared with Chi-squared test or Fisher's exact test, where appropriate. Accuracy of restaging MRI in the identification of pathologic complete response (pCR) was determined evaluating the correspondence with the histopathological examination of surgical specimens.In the present study, 689 patients were enrolled. Complete tumor regression rate was 16.9%. The "watch and wait" strategy was applied in 4.3% of TRG4 patients. A clinical correlation between more advanced tumors and moderate to absent tumor regression was found (p = 0.03). Post-neoadjuvant MRI had low sensibility (55%) and high specificity (83%) with accuracy of 82.8% in identifying TRG4 and pCR.Our data provided a contemporary description of the effects of pre-operative CRT on a large pool of locally advanced low rectal cancer patients treated in different colon-rectal surgical centers.

Totally Laparoscopic Transgastric Resection of a Gastric Submucosal Fibrolipoma and Concomitant Sleeve Gastrectomy in a Morbidly Obese Patient.

INTRODUCTION: To evaluate feasibility and safety of a totally laparoscopic transgastric resection with concomitant sleeve gastrectomy in a morbidly obese presenting with benign lesion located along the lesser gastric curvature. MATERIALS AND METHODS: We report the case of a morbidly obese patient with an incidental submucosal lesion of the lesser curvature radiologically consistent with fibrolipoma at preoperative work-up. Benign nature of the mass was then confirmed EUS-biopsy. RESULTS: A combinated laparoscopic transgastric approach was successfully attempted resulting in a complete excision of the submucosal lesion and concomitant sleeve gastrectomy. Intraoperative and definitive histology confirmed the benign nature of the mass. Postoperative course was uneventful. CONCLUSION: Concomitant transgastric resection of submucosal benign lesions during laparoscopic sleeve gastrectomy represents both a safe and feasible surgical approach in morbidly obese patients. Preoperative work-up is of great importance in order to assess the benign nature of the lesion.

Enhanced Recovery after Bariatric Surgery: 202 Consecutive Patients in an Italian Bariatric Center.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways have been shown to improve postoperative outcomes. However, its application in bariatric surgery is still limited. The aim of the study was to define the safety of ERAS in bariatric patients with regard to postoperative complications, length of hospital stay (LOS), and readmission rates within 30 days from surgery. METHODS: The effectiveness and safety of an ERAS protocol was prospectively investigated in morbidly obese patients who underwent bariatric surgery in a single-institute experience over a 2-year period. RESULTS: Between June 2016 and September 2018, a total of 89 laparoscopic sleeve gastrectomy (SG), 105 Roux-en-Y gastric bypass (RYGB), and 8 one-anastomosis gastric bypass (OAGB) were performed. Twenty patients (9.9%) were revisional cases. Mean (standard deviation, SD) BMI and age at time of surgery were 43.2 (± 6.2) kg/m2 and 46 (± 11.3) years, respectively. Median (range) surgical time was 118 (45-255) minutes. Overall postoperative complication rate was 7.4%, with 6 (3.0%) patients developing grade III-IV complications according to the Clavien-Dindo classification. Median (range) LOS was 2 (1-50) days, with mean (SD) LOS of 2.3 (± 3.6) days. Overall, 36.6% of patients were discharged by first postoperative day and 77.7% by second postoperative day. Readmission rate was 4.5%. No mortality was observed during the study period. CONCLUSIONS: According to the results of the present study, ERAS in primary and revisional bariatric surgery is safe and feasible, with short LOS, low morbidity and readmission rates, and no mortality. A significant reduction of mean LOS was progressively noted over the study period.

Surgical treatment of gastric GIST with acute bleeding using laparoscopic sleeve gastrectomy: A report of two cases.

In this report, we want to emphasize how a laparoscopic bariatric surgical procedure, in experienced hands, has shown to be a valid alternative for the hemorrhage control and the removal of a gastrointestinal tumor in a life-threatening situation.

Sentinel lymph node mapping in the management of colorectal cancer: preliminary report.

AIM AND BACKGROUND: The problem of understaging the lymph node status in colorectal cancer because of missed micrometastases led authors to investigate the role of sentinel node (SN) mapping also in colorectal malignancies. The aim of this study was to evaluate the feasibility of the technique and to correlate the results with some characteristics of the primary tumor. METHODS: Sentinel lymph node mapping was performed in 23 patients who underwent a standard lymphadenectomy for colorectal cancer. The vital dye Patent Blue had been injected into the peritumoral subserosa in vivo in 17 cases and ex vivo in seven, including one case where the in vivo method did not allow to identify the sentinel node. The nodes that took up the dye were removed and analyzed with standard hematoxylineosin staining in serial sections. Immunohistochemistry (AE1-AE3 cytokeratin markers) was performed in hematoxylineosin-negative nodes. SN status was related to the status of the other lymph nodes in the surgical specimen analyzed with the standard technique and to the following characteristics of the primary tumor: stage, grade and diameter. RESULTS: The in vivo technique allowed to identify the SN in 16/17 cases (94.1%), the ex vivo technique in 7/7. A total of 336 lymph nodes dissected from the surgical specimens was analyzed, with an average of 14.6 nodes per patient (range, 7-35). Of these nodes 58 were SNs, with an average of 2.5 nodes per patient (range, 1-8). In the 19 cases where the SN was tumor negative, the non-SNs were also negative (specificity: 100%), whereas in the four cases where the non-SNs were positive, in two cases the SN was positive and in two cases of pT3 rectal carcinoma the SN was negative (sensitivity: 50%). Immunohistochemistry did not modify the negative results of the standard hematoxylin-eosin evaluation. CONCLUSIONS: The method used to identify the SN using vital dye proved to be easy to use both in vivo and ex vivo and allowed to identify the SN in all cases. The preliminary results indicate that there is a risk of false negative findings and therefore further studies are required to improve the sensitivity and the specificity of the technique and to evaluate the role of SN mapping in colorectal cancer management.

[Crohn disease: prognostic factors and therapeutic choices]. / Morbo di Crohn: fattori prognostici e scelte terapeutiche.

The treatment of Crohn's disease is still a debatable issue especially as regards the integrated implementation of medical and surgical therapy, the timing of surgery and the choice of surgical technique. Prognostic factors seem to be important in the choice and planning of therapeutic procedures. The authors retrospectively review 81 patients, 31 of whom submitted to surgery. The parameters observed were the presenting symptoms, the time from onset of symptoms to surgery, previous medical treatment, disease location, and complications. Bowel resection and the treatment of fistulas and abscesses were carried out. Emergency resections were performed in 14 patients (45%): 11 for bowel obstruction, 2 for perforation and 1 for bleeding. The mean follow-up (which included laboratory tests and endoscopy) was 132 months (range: 6 months to 32 years). In-hospital mortality was 2.3% and morbidity 12.9%. Long-term mortality amounted to 3 patients, only 1 of whom died of complications related to recurrence of the disease. Statistical analysis showed that the recurrence rate was 51.3% at 5 years after the first surgical treatment, 65.4% at 10 years and 88.1% at 20 years. Recurrences requiring surgery amounted to 15.3%, 20.5% and 42.5%, respectively. No statistically significant correlations were observed between recurrence rate and time of onset of the disease (p = 0.5601), time of the first surgical treatment, disease location, or specific medical therapy, (p = n.s.). Recurrence requiring surgical treatment was observed in 33.3% of patients when the disease was located only in the ileum, in 33.3% when it was located in both the ileum and colon, and in 28.6% when only the colon was involved (p = 0.9767). The quality of life was good in 66.6% of patients, fair in 26.6%, and poor in 6.6%. The authors conclude that the treatment of Crohn's disease must be multidisciplinary and surgery must be limited to complications. When surgery is indicated, it must be performed promptly, because, in these cases, persisting with medical treatment increases the postoperative morbidity. Short resections must be performed in order to preserve the bowel as much as possible. As far as risk factors are concerned, the most important are the location and the aggressiveness of the disease, whilst biological and laboratory parameters do not seem to influence the results.

[Prognostic importance of preoperative CEA in patients with colorectal cancer]. / Importanza prognostica del CEA preoperatorio nel paziente con cancro colorettale.

Carcinoembryonic antigen is an acid glycoprotein, the levels of which may increase in patients with colorectal carcinoma. The prognostic significance of preoperative carcinoembryonic antigen levels and their relationship to other risk factors are still debatable issues. Among 512 patients operated on for colorectal cancer, whose preoperative carcinoembryonic antigen concentrations were evaluated, linear correlations were established between carcinoembryonic antigen overexpression and carcinoma staging, diameter and grading, though these were not statistically significant. Moreover, metastatic cancers were significantly more frequent in patients with increased plasma concentrations of the marker (> 60 ng/ml). There were no correlations between increased carcinoembryonic antigen levels and age, ploidy, or site and shape of the cancers. As regards survival, patients with normal preoperative carcinoembryonic antigen levels had a better prognosis in terms both of lower local recurrence rates and long- term survival. In addition. In Dukes stages B and C elevation of carcinoembryonic antigen above the cut-off point can be considered a significant prognostic factor capable of identifying a group of patients at high risk who may be candidates for aggressive adjuvant therapies and follow-up. The findings of this study suggest that preoperative carcinoembryonic antigen levels are of prognostic importance in relation both to cancer staging and to long-term survival, which may have significant clinical applications.

Bowel obstruction after cardiac surgery due to diaphragmatic unrecognised hernia.

Diaphragmatic hernia is a very rare occurrence after cardiac surgery without complications. We report a case of a 66-year-old male who underwent double aortocoronary bypass surgery, mitral and tricuspidal annuloplasty developed bowel obstruction 5 months after the operation. X-ray demonstrated small bowel loops in the left side of the chest. A laparoscopy was performed, but during the reduction of the hernia, patient suffered bradycardia because of adhesions between bowel and pericardical sac. Operation was interrupted and patient was transferred to our hospital where a cardiac surgery unit is present. No hemodynamic or respiratory deterioration was observed. Thoracic abdominal entero-CT, transthoracical echocardiography were performed. Patient underwent second surgery in cooperation with the cardial surgical team. Sternotomy was carried out. Hernial content was drawn onto the abdomen, diaphragmatic defect was closed with a direct suture. Mini-laparotomy was performed to exclude that the herniated small bowel did not have ischaemic suffering. No morbidity was observed in the post-operative course. This case illustrates the importance of an accurate pre-operative diagnosis in order to obtain information on relationship between loops of bowel and mediastinal organs. If sternotomy is required, surgical team must be supported by a cardiac surgical team.

The reversal of a protective stoma is feasible before the complete healing of a colorectal anastomotic leak.

A proximal diverting stoma is recommended in "high-risk" conditions after total mesorectal excision. The aim of the study is to assess whether, after checking the anastomosis by using a water-soluble contrast enema (WCE), the closure of the ileostomy is feasible and safe, even in the presence of a persistent radiological leak. From 2003 to 2010, 210 colorectal anastomoses were performed. Ileostomy was carried out in "high-risk" anastomosis. A radiological control was performed 2 weeks later. If a leakage was present, conservative therapy controlled by serial WCEs was prescribed. Ileostomy closure was performed in the absence of leakage or with persistent leakage without clinical signs of pelvic infections. Seventy patients (33.3%) had a protective ileostomy. Fifty-eight of these (82.9%) had an uneventful course, whereas 12 (17.1%) had clinical leakage. All 70 patients were submitted to WCE after 2 weeks. Nine of 58 patients (15.5%) and eight of 12 patients with clinical anastomotic leakage showed a leakage at radiology. All these patients were scheduled another WCE 2 months later. It showed that the anastomosis had been healed in seven patients, whereas the 10 patients with leaks remained with ostomy until the third enema 1 month later. For all these patients, closure of the ileostomy was planned despite persistent radiological and subclinical leakage. A radiological study using WCE before closure of the stoma is essential and stoma closure, in the presence of a persistent leakage, is possible in selected patients.

Effects of formalin, methacarn, and fineFIX fixatives on RNA preservation.

Formalin-fixed tissues represent the most abundant clinical material for retrospective studies. However, formalin highly affects macromolecules, impairing their extraction and analysis. In this study, the suitability of some potential substitutes of formalin for RNA-based applications has been considered. Conventional formalin was compared with methacarn and the commercial FineFIX. Their impact on overall RNA preservation was investigated in a cell line-based model fixed during a time course treatment and in a series of fixed human tissues. RNA yield was detected by Nanodrop; ribosomal RNA (rRNA) integrity by electrophoresis and the Agilent Bioanalyzer; messenger RNA (mRNA) integrity by Northern blot and endpoint reverse transcription-polymerase chain reaction; and mRNA amount by real-time polymerase chain reaction. In the cell line model, formalin fixation showed time-dependent detrimental effects on overall RNA preservation. Methacarn and FineFIX were more conservative on both rRNA and mRNA preservation and their impact was time-independent. In tissues, high rRNA degradation levels were found in all fixed specimens, contrasting with the results found in the cells. Conversely, the effects of the fixatives on mRNA integrity reflected the observations shown in the cell line model. In methacarn-fixed samples mRNA amount was also preserved, whereas in formalin and FineFIX-fixed samples it was notably lower when compared with the fresh frozen control. Alcohol-based fixatives are a good solution for long-term fixation of both cytologic and tissue samples by virtue of their time-independent effects on mRNA preservation. In fixed tissue samples, however, the potential effects of preanalytical tissue-related factors should be considered when performing mRNA quantitative analysis.

Expression profiling of angiogenic genes for the characterisation of colorectal carcinoma.

The development of new blood and lymphatic vessels is a crucial event for cancer growth, metastatic spread and relapse after therapy. In this work, the expression levels of chemokines, angiogenic and angiostatic factors and their receptors were determined in paired mucosal and tumour samples of patients with colorectal carcinoma and correlated with clinical and histological parameters by advanced multivariate analyses. The most important predictors to discriminate between tumour and paired normal mucosa turned out to be the levels of expression of plexin-A1 and stromal cell-derived factor 1 (SDF-1), the former overexpressed and the latter downregulated in tumours. The levels of osteopontin and Tie-2 transcripts discriminated between the presence and absence of lymph node infiltration, the former overexpressed in the presence of infiltration whilst the latter providing a protective role. These results add support to the notion that the expression levels of selected genes involved in new blood and lymphatic vessel formation represent trustable biomarkers of tumour development and invasion and contribute to the identification of novel molecular classifiers for colorectal carcinoma.