Endoscopic sinusectomy: 'a rose by any other name'. A systematic review of different endoscopic procedures to treat pilonidal disease.

AIM: Pilonidal sinus or Pilonidal Disease (PD) is a relatively common, benign but challenging condition. Although commonly encountered in practice, its ideal treatment is controversial. One of the most validated treatments is video-assisted surgery. In this context, very similar endoscopic techniques have been published under different names. The aim of this systematic review is to assess the differences among these proposed techniques and their outcomes. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during all stages of this systematic review. A systematic search of the English literature was performed on multiple databases from 1 January 2014 to 3 April 2022. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measures were the adherence to the IDEAL reporting guidelines, the Blencowe framework and the core outcome set (COS) for studies evaluating the introduction and evaluation of novel surgical techniques, the qualitative assessment using appropriate tools, the procedural variations and outcomes of each technique. RESULTS: A total of 38 articles were included reporting a very similar technique under eight different acronyms. The number of patients varied from 9 to 250. Mean follow-up ranged from 1 to 60 months. There was only one published study of IDEAL 3. The majority (58%) were IDEAL 2a studies. Reporting of domains in the IDEAL reporting guidelines and Blencowe framework was poor, with most studies not reporting the component steps of procedures or efforts to standardize them. Half of COS domains were markedly underreported. The quality of the evidence was categorized as having a risk of bias from moderate to critical level in all nine comparative non-randomized series. Postoperative complications occurred in 0%-6% of cases, including surgical site infection, poor or failed wound healing bleeding, granuloma, haematoma, and pain requiring intervention. The recurrence rate varied from 0% to 22%. CONCLUSION: The study demonstrates that reporting on technical aspects of interventions for PD is poor, thus warranting a better-quality control of surgical techniques. It is advisable to group all endoscopic procedures under the umbrella term of 'endoscopic sinusectomy', thus embracing the two main principles of this technique, that is, video assistance and PD ablation.

Long term results of video-assisted anal fistula treatment for complex anal fistula: another shattered dream?

AIM: Complex anal fistula represents a burden for patients, and its management is a challenge for surgeons. Video-assisted anal fistula treatment (VAAFT) is one sphincter-sparing technique. However, data on its long-term effectiveness are scant. We aimed to explore the outcomes of VAAFT in a retrospective cohort of patients referred to a tertiary centre. METHOD: Consecutive adult patients with a minimum of 2 years' follow-up after VAAFT were reviewed. Patients were followed up to 5 years postoperatively. Failure was defined as incomplete healing of the external orifice(s) during the first 6 months. Recurrence was defined as new radiologically and/or clinically confirmed onset of the fistula after primary healing. A generalized linear model was fitted to evaluate the association between failure and sociodemographic characteristics. Predictors of recurrence were determined in a subgroup analysis of patients found to be free from disease at 6 months postoperatively. RESULTS: Overall, 106 patients (70% male; mean age 41 years) were reviewed. Of these 86% had a previous seton placement. Fistulas were either high trans-sphincteric (74%), suprasphincteric (12%) or extrasphincteric (13%). Eight (7%) patients experienced postoperative complications, none of which required reintervention. Mean follow-up was 53 ± 13.2 months. VAAFT failed in 14 (13%) patients. The overall recurrence rate ranged from 29% at 1 year to 63% at 5 years. Multiple external orifices, suprasphincteric fistula, younger age, previous surgery and higher complexity of the fistulous tract were independent risk factors for recurrence. CONCLUSION: VAAFT is a safe sphincter-sparing technique. The initially high success rate decreases over time and relates to a higher degree of complexity.

Efficacy and safety of Propionibacterium extract gel versus glyceryl trinitrate ointment in the treatment of chronic anal fissure: a randomized controlled trial.

AIM: Chronic anal fissure (CAF) is an extremely frequent finding in clinical practice. Several topical agents have been proposed for its treatment with the common goal of increasing anodermal blood flow to promote healing. The aim of this study was to compare the efficacy and safety of a Propionibacterium extract gel (PeG) and 0.4% glyceryl trinitrate ointment (GTN) in patients with CAF. METHOD: Patients were randomly allocated to a PeG or GTN group and medication was administered every 12 h for 40 days. The primary outcome was the success rate, as measured by a decrease in the REALISE scoring system for anal fissure at 10, 20 and 40 days after initiating either treatment. The secondary outcomes recorded at the same time points were healing rate, visual analogue scales for itching and burning, rate of complications and adverse events, patient quality of life and satisfaction, and cost analysis. RESULTS: A total of 120 patients were enrolled, and 96 patients (PeG, n = 53; GTN, n = 43) completed the primary outcomes. A significant decrease over time in the REALISE score was observed in both groups. Adverse events occurred more frequently in the GTN group than in the PeG group, peaking at visit 1 [37 (63.8%) vs. 2 (3.4%), respectively], with headache being the most prevalent. The between-treatment cumulative average costs per patient were significantly higher for GTN than that for PeG at each follow-up visit. There were no other significant differences between the two groups for any of the other outcomes. CONCLUSION: While there was no difference in healing rates between the two treatments, PeG was more cost-effective and associated with fewer adverse events.

Alternative detection of SARS-CoV-2 RNA by a new assay based on mass spectrometry.

OBJECTIVES: Accurate detection of SARS-CoV-2 RNA is essential to stopping the spread of SARS-CoV-2. The aim of this study was to evaluate the performance of the recently introduced MassARRAY® SARS-CoV-2 Panel and to compare it to the cobas® SARS-CoV-2 Test. METHODS: The MassARRAY® SARS-CoV-2 Panel consists of five assays targeting different sequences of the SARS-CoV-2 genome. Accuracy was determined using national and international proficiency panels including 27 samples. For clinical evaluation, 101 residual clinical samples were analyzed and results compared. Samples had been tested for SARS-CoV-2 RNA with the cobas® SARS-CoV-2 Test. RESULTS: When accuracy was tested with the MassARRAY® SARS-CoV-2 Panel, 25 of 27 (92.6%) samples revealed correct results. When clinical samples were analyzed with the MassARRAY® SARS-CoV-2 Panel and compared to the cobas® SARS-CoV-2 Test, 100 samples showed concordant results. One sample was found to be inconclusive with the MassARRAY® SARS-CoV-2 Panel. When time-to-results were compared, the new assay showed longer total and hands-on times. CONCLUSIONS: The MassARRAY® SARS-CoV-2 Panel showed a good performance and proved to be suitable for use in the routine diagnostic laboratory. Especially during phases of shortage of reagents and/or disposables, the new test system appears as beneficial alternative to standard assays used for detection of SARS-CoV-2 RNA.

Endoscopic pilonidal sinus treatment (EPSiT) in recurrent pilonidal disease: a prospective international multicenter study.

BACKGROUND: Pilonidal disease (PD) is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative management options are available, but the ideal technique is still debatable. Recurrent PD after surgical treatment is frequent event for the 25-30% of cases. The present study evaluated endoscopic pilonidal sinus treatment (EPSiT) in recurrent and multi-recurrent PD. METHODS: Of the consecutive prospective patients with recurrent PD, 122 were enrolled in a prospective international multicenter study conducted at a secondary and tertiary colorectal surgery centers. Primary endpoint was to evaluate short- and long-term outcomes: healing rate/time, morbidity rate, re-recurrence rate, and patient's quality of life (QoL). RESULTS: Complete wound healing rate was occurred in 95% of the patient, with a mean complete wound healing time of 29 ± 12 days. The incomplete healing rate (5%) was significantly related to the number of external openings (p = 0.008), and recurrence was reported in six cases (5.1%). Normal daily activity was established on the first postoperative day, and the mean duration before patients returned to work was 3 days. QoL significantly increased between the preoperative stage and 30 days after the EPSiT procedure (45.3 vs. 7.9; p < 0.0001). CONCLUSIONS: The EPSiT procedure seems to be a safe and effective technique in treating even complex recurrent PD. It enables excellent short- and long-term outcomes than various other techniques that are more invasive.

5-Fluorouracil degradation rate could predict toxicity in stages II-III colorectal cancer patients undergoing adjuvant FOLFOX.

5-Fluorouracil is commonly used for gastrointestinal cancer treatment in an adjuvant setting; however, the toxicity can lead to a reduction, delay, or discontinuation of treatment. We retrospectively investigated the association between the 5-fluorouracil degradation rate (5-FUDR) and genetic polymorphisms of TSER, DPYD, and MHTFR with toxicity in colorectal cancer patients treated with adjuvant FOLFOX. Pretreatment 5-FUDR and MTHFR A1298T or C677T, TSER, and DPYD gene polymorphisms were characterized in stages II-III colorectal cancer patients. Patients were classified into three metabolic classes according to the 5-FUDR value. Association with toxicities was evaluated retrospectively using logistic regression analysis. Overall, 126 patients were selected (35 women, 91 men). Seven patients were poor metabolizers, 116 patients were normal metabolizers and three patients were ultra-rapid metabolizers. The median 5-FUDR was 1.53 ng/ml/10 cells/min (range: 0.42-2.57 ng/ml/10 cells/min). Severe, rate-limiting toxicities (grades 3-4) were encountered in 22.2% of patients. No associations between MTHFR or TSER polymorphisms and toxicity were detected, whereas 5-FUDR showed a statistically significant association with toxicity (P=0.0047). The DPYD heterozygous mutation was detected in only one patient, who showed grade 4 hematological toxicity and a lower 5-FUDR value. The 5-FUDR value seems not to be affected by MTHFR and TSER polymorphisms. Compared with the available pharmacogenomics tests, the pretreatment evaluation of 5-FUDR increases the proportion of identified colorectal patients at high risk for severe toxicity. Thus, it appears to be a suitable pretreatment toxicity biomarker in a subgroup of patients in whom dose-intensity maintenance is the key factor.

Early onset pancreatic cancer: risk factors, presentation and outcome.

BACKGROUND: About 10% of pancreatic cancer patients are aged ≤50 at diagnosis and defined as Early Onset Pancreatic Cancer (EOPC). There is limited information regarding risk factors for EOPC occurrence and their outcome. AIM: To investigate risk factors, presentation features and outcome of EOPC patients. METHODS: Consecutive, histologically confirmed, pancreatic cancer patients enrolled. Data regarding environmental and genetic risk factors, clinical and pathological information, treatment and survival were recorded. EOPC patients (aged ≤50 at diagnosis) were compared to older subjects. RESULTS: Twenty-five of 293 patients (8.5%) had EOPC. There was no difference regarding sex distribution, medical conditions and alcohol intake between EOPC and older subjects. EOPC patients were more frequently current smokers (56% vs 28% p = 0.001) and started smoking at a significantly lower mean age (19.8 years, 95%CI 16.7-22.9) as compared to older patients (26.1, 95%CI 24.2-28) (p = 0.001). Current smoking (OR 7.5; 95%CI 1.8-30; p = 0.004) and age at smoking initiation (OR 0.8 for every increasing year; 95%CI 0.7-0.9; p = 0.01) were significant and independent risk factors for diagnosis of EOPC. There were no differences regarding genetic syndromes and pancreatic cancer family history. EOCP presented less frequently with jaundice (16% vs 44%, p = 0.006) and had a higher rate of unresectable disease, albeit not significantly (84% vs 68%, p = 0.1). EOPC patients were more frequently fit for surgery or chemotherapy than their counterpart, resulting in similar stage-specific survival probability. CONCLUSION: EOPC seems related to active and early smoking but not to familial syndromes. Young patients display aggressive disease but not worse outcome.

Neoadjuvant chemotherapy for resectable colorectal liver metastases: what is the evidence? Results of a systematic review of comparative studies.

BACKGROUND: The role of preoperative chemotherapy for resectable colorectal liver metastases is still highly controversial. The purpose of this systematic review is to summarize the current evidence on this topic. METHODS: A systematic literature search was performed to identify all studies published from January 2003 up to and including January 2014 regarding patients with initially resectable colorectal liver metastases. Data were examined for information about indications, operation, neoadjuvant and adjuvant therapies, perioperative results, and survival. RESULTS: Fourteen retrospective studies published between 2003 and 2014 satisfied the inclusion criteria, including 1607 patients who underwent pre-operative chemotherapy and liver resection (NEO-CHT group), and 1785 patients submitted to hepatectomy with or without post-operative chemotherapy (SURG group). Postoperative mortality rates ranged from 0 to 5% in the NEO-CHT group and from 0 to 4% in SURG group. Complications ranged from 7 to 63% in both groups. Adopted pre-operative chemotherapy protocols were highly heterogeneous. The 5-year overall survival rates ranged from 38.9 to 74% in the NEO-CHT group and from 20.7 to 56% in the SURG group, with no significant difference in seven of eight studies. DISCUSSION: This review shows that there is a lack of clear evidence on the role of neoadjuvant chemotherapy in the treatment of resectable colorectal metastases in the literature. The majority of studies were retrospective and there was high heterogeneity among them in the treatment protocols. The EORTC 40983 trial and the majority of retrospective studies did not find any overall survival advantage in patients treated with neoadjuvant therapy. Additional high-quality studies (randomized) are needed to shed light on this topic.

Robotic right colectomy: A worthwhile procedure? Results of a meta-analysis of trials comparing robotic versus laparoscopic right colectomy.

BACKGROUND: Robotic right colectomy (RRC) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach is worthwhile in enhancing patient recovery and reducing post-operative complications, compared with laparoscopic right colectomy (LRC). Literature is still fragmented and no meta-analyses have been conducted to compare the two procedures. This work aims at reducing this gap in literature, in order to draw some preliminary conclusions on the differences and similarities between RRC and LRC, focusing on short-term outcomes. MATERIALS AND METHODS: A systematic literature review was conducted to identify studies comparing RRC and LRC, and meta-analysis was performed using a random-effects model. Peri-operative outcomes (e.g., morbidity, mortality, anastomotic leakage rates, blood loss, operative time) constituted the study end points. RESULTS: Six studies, including 168 patients undergoing RRC and 348 patients undergoing LRC were considered as suitable. The patients in the two groups were similar with respect to sex, body mass index, presence of malignant disease, previous abdominal surgery, and different with respect to age and American Society of Anesthesiologists score. There were no statistically significant differences between RRC and LRC regarding estimated blood loss, rate of conversion to open surgery, number of retrieved lymph nodes, development of anastomotic leakage and other complications, overall morbidity, rates of reoperation, overall mortality, hospital stays. RRC resulted in significantly longer operative time. CONCLUSIONS: The RRC procedure is feasible, safe, and effective in selected patients. However, operative times are longer comparing to LRC and no advantages in peri-operative and post-operative outcomes are demonstrated with the use of the robotic surgical system.

Prognostic assessment of different lymph node staging methods for pancreatic cancer with R0 resection: pN staging, lymph node ratio, log odds of positive lymph nodes.

BACKGROUND AND AIMS: Survival after surgical resection of pancreatic adenocarcinoma is poor. Several prognostic factors such as the status of the resection margin, lymph node status, or tumour grading have been identified. The aims of the present study were to evaluate and compare the prognostic assessment of different lymph nodes staging methods: standard lymph node (pN) staging, metastatic lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in pancreatic cancer after pancreatic resection. MATERIALS AND METHODS: Data were retrospectively collected from 143 patients who had undergone R0 pancreatic resection for pancreatic ductal adenocarcinoma. Survival curves (Kaplan-Meier and Cox proportional hazard models), accuracy, and homogeneity of the 3 methods (LNR, LODDS, and pN) were compared to evaluate the prognostic effects. RESULTS: Multivariate analysis demonstrated that LODDS and LNR were an independent prognostic factors, but not pN classification. The scatter plots of the relationship between LODDS and the LNR suggested that the LODDS stage had power to divide patients with the same ratio of node metastasis into different groups. For patients in each of the pN or LNR classifications, significant differences in survival could be observed among patients in different LODDS stages. CONCLUSION: LODDS and LNR are more powerful predictors of survival than the lymph node status in patients undergoing pancreatic resection for ductal adenocarcinoma. LODDS allows better prognostic stratification comparing LNR in node negative patients.

Changes in the surgical approach to colonic emergencies during a 15-year period.

PURPOSE: The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years. MATERIALS AND METHODS: A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed. RESULTS: Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001). CONCLUSIONS: Emergency colon surgery is today primarily performed for benign diseases, of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not.

Lymph-node ratio classification strongly correlates with cancer survivals of patients who underwent r0 resection for gastric cancer with more than 15 nodes harvested.

BACKGROUND: During the last few years, the gastric cancer nodal staging has been extensively revised. Lately, a new system emerged in this field with the purpose of implementing the prognostic stratification: the lymph-node ratio (LNR). The aim of this study was to investigate the prognostic value of the LNR in relation to cancer survivors undergoing resection for gastric adenocarcinoma. METHODS: Off 227 patients undergoing surgical resection for gastric cancer at our Department, 129 curative gastric resections with more than 15 nodes harvested were selected. The LNR was calculated and patients were stratified into 6 subgroups based on the ratio values. The subgroups were compared for data analysis. Survivals were calculated by the Kaplan-Meier method, and the mean follow-up period was 40 months. ROC curves were calculated in order to analyze the performance of the LNR system. RESULTS: LNR stratification correlated with the stage of the disease, with the rate of patients undergoing chemotherapy and patients presenting with a relapse of disease at follow-up. Moreover, an increased ratio correlated with a worse overall, a disease-free and a disease-specific survival of the patients. The ROC curves documented a significant performance of the stratification system with the endpoints of disease-free and disease-specific survivals. CONCLUSION: LNR stratification correlated with cancer-related survivals in our case series. It is a reliable system that might improve current nodal staging and thereby the identification of patients with a higher risk of recurrence or cancer-related mortality.

Duodenopancreatectomy: open or minimally invasive approach?

BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach may enhance patient recovery and reduce postoperative complications comparing to open pancreaticoduodenectomy (OPD), as demonstrated for other abdominal procedures. METHODS: A systematic literature review was conducted to identify studies comparing MIPD and OPD. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model. RESULTS: For the metaanalysis, 8 studies including 204 patients undergoing MIPD and 419 patients undergoing OPD were considered suitable. The patients in the two groups were similar with respect to age, sex and histological diagnosis, and different with respect to tumor size, rate of pylorus preservation, and type of pancreatic anastomosis. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. MIDP resulted in lower post-operative complication rates, less intra-operative blood loss, shorter hospital stays, lower blood transfusion rates, higher numbers of harvested lymph nodes, and improved negative margin status rates. However, MIPD was associated with longer operating times when compared to OPD. CONCLUSIONS: The MIPD procedure is feasible, safe, and effective in selected patients. MIPD may have some potential advantages over OPD, and should be performed and further developed by use in selected patients at highly experienced medical centers.

Post-operative morbidity and mortality in pancreatic surgery. The role of surgical Apgar score.

BACKGROUND: Morbidity and mortality rates after pancreatic resection still remain high. The surgical Apgar score (SAS) has been recently introduced as predictive value of perioperative outcomes after pancreatic surgery. Aim of the study was to detect significant parameters affecting post-operative outcomes in pancreatic surgery, and to evaluate the role of SAS in predicting morbidity, pancreatic fistulas and mortality. MATERIALS AND METHODS: Data were collected from 143 patients who had undergone pancreatic resection for pancreatic and periampullary adenocarcinoma. Pre-operative and intra-operative parameters were statistically analyzed to evaluate their potential prognostic effects. RESULTS: A low SAS (p = 0.001), hypo-albuminemia (p = 0.003), and the need for blood transfusions (p = 0.05) were significant independent predictors of postoperative morbidity. The SAS was demonstrated to significantly predict major complications (p = 0.001) surgical site infections (p = 0.001) and mortality (p = 0.001). CONCLUSION: The SAS provides a simple, immediate, and objective means of measuring patient outcomes in surgery. This score should be used to identify patients at high risk of major complications and death after pancreatic surgery and may be useful to optimize the use of postoperative critical care beds and hospital resources.

Malnutrition and pancreatic surgery: prevalence and outcomes.

BACKGROUND: Pancreatic surgery is associated with severe postoperative morbidity. Identification of patients at high risk may provide a way to allocate resources objectively and focus care on those patients in greater need. The Authors evaluate the prevalence of malnutrition and its effect on the postoperative morbidity of patients undergoing pancreatic surgery for malignant tumors. METHODS: Data were collected from 143 patients who had undergone pancreatic resection for cancer. Prevalence of malnutrition was evaluated by several validated screening tools and correlated to the incidence of surgical site infection, overall morbidity, mortality, and hospital stay. RESULTS: Overall, 88% of patients were at medium-high risk of malnutrition. Patients at high risk of malnutrition presented a fourfold longer postoperative hospitalization period and a higher morbidity rate (53.2%) than those patients at low risk of malnutrition. Malnutrition, evaluated by MUST and NRI, was an independent predictor of overall morbidity using multivariate analysis (P = 0.00145, HR = 2.6581, 95% CI = 1.3589-8.5698, and P = 0.07129, HR = 1.9953, 95% CI = 0.9723-13.548, respectively). CONCLUSION: Malnutrition is a relevant predictor of post-operative morbidity and mortality after pancreatic surgery. Patients underwent pancreatic resection for malignant tumors are usually malnourished. Preoperative malnutrition screening is mandatory in order to assess the risk and to treat the malnutrition.

Profiling the prognosis of gastric cancer patients: is it worth correlating the survival with the clinical/pathological and molecular features of gastric cancers?

BACKGROUND: The prognosis of gastric cancer patients still remains poor. The aim of this study was investigating the prognostic value of several clinical/pathological/molecular features in a consecutive series of gastric cancers. METHODS: 150 R0 gastrectomies plus 77 gastric cancer patients evaluated for the HER2 overexpression were selected. Survival was calculated and patients stratified according to the stage, the T-stage, the LNRs, the LNH, and the HER2 scoring system. ROC curves were calculated in order to compare the performance of the LRN and LNH systems. RESULTS: Prognosis correlated with the stage and with the T-stage. We documented a statistical correlation between the LNRs and the survival. Conversely, a LNH > 15 did not correlate with the outcomes. The ROC curves documented a significant performance of the LRN system, whereas a statistical correlation was documented for the LNH exclusively with the endpoint of disease-free survival. We documented a trend of worse prognosis for patients with an HER2 overexpression, even though it was not of statistical value. CONCLUSION: The LNR and the evaluation of the HER2 overexpression might be useful since they correlate with survival, might identify patients with a higher risk of recurrence, and might select patients for a tailored medical treatment.

A pilot study on staged surgery by delta video-assisted anal fistula treatment (dVAAFT) for complex anal fistula.

Complex anal fistulas (CAF) present a challenge in achieving healing while preserving anal sphincter function. This study aims to introduce a novel staged approach for CAF treatment, combining video-assisted anal fistula treatment (VAAFT), seton placement, and other staged approaches. Consecutive patients with CAF underwent the staged approach involving VAAFT and seton placement. Data on patient demographics, fistula characteristics, and operative findings were collected. Pre-operative work-up included clinical evaluation, endoanal ultrasonography (EAUS), and magnetic resonance imaging (MRI). Surgical techniques and outcomes were evaluated. Eighteen patients (median age 38 years) were included. Misplacement of a previously placed seton was observed in 64% of cases. VAAFT combined with seton placement achieved simplification and healing of secondary tracts in 66% of cases. Operative times significantly decreased across interventions. At a median follow-up of 14 months, complete healing was achieved in 2 patients, with 1 patient demonstrating persistence of the fistula. Post-operative complications were observed in 11% of patients, with no deterioration in continence. The staged approach combining VAAFT, seton placement, and staged procedures offers a potential solution for treating CAF. VAAFT provides diagnostic and therapeutic benefits, simplifying the fistula anatomy and optimizing seton placement. The approach allows subsequent procedures based on individual fistula characteristics.

The glasgow prognostic score as a predictor of survival in patients with potentially resectable pancreatic adenocarcinoma.

BACKGROUND: Survival rates after resection of pancreatic adenocarcinoma are poor; however, several tumor-related prognostic factors have been identified. There is increasing evidence that additional patient-related prognostic factors, such as ongoing systemic inflammatory response, are associated with poor outcomes in patients with common solid tumors. The purpose of this study was to evaluate the prognostic significance of the modified glasgow prognostic score (mGPS) in resected pancreatic ductal adenocarcinoma. METHODS: Data were collected from 101 patients who had undergone pancreatic resection for ductal adenocarcinoma. Tumor and host factors were analyzed by Kaplan-Meier and Cox proportional hazard models to evaluate their potential prognostic effects. RESULTS: An elevated mGPS was associated with lower overall survival rate after pancreatic resection. The median actuarial survival rate for patients with an mGPS of 0, 1, or 2 was 37.2, 11.5, and 7.3, respectively (p = 0.0001). The Cox proportional hazards model, including all the parameters statistically significant at univariate analysis, demonstrated that mGPS, lymph node ratio (LNR), and positive resection margins were independent negative prognostic factors CONCLUSIONS: Margin involvement, LNR, and the preoperative mGPS were identified as independent predictors of survival in patients undergoing potentially curative pancreatic resection. Based on the present results and existing validation literature, the mGPS should be included in the routine assessment of patients with pancreatic cancer to better stratify patients for entry into therapeutic trials.

Number of harvested lymph nodes is the main prognostic factor in Stage IIa colorectal cancer patients.

BACKGROUND: Current international guidelines on colorectal cancer (CRC) treatment suggest performing adjuvant chemotherapy only in Stage II patients presenting with high-risk prognostic factors. Aim of the study was to a the impact of these parameters on the survival of Stage IIa CRC patients, focusing on the prognostic value of the number of harvested lymph nodes (NHLN). PATIENTS AND METHODS: Out of 651 CRC patients undergoing surgical resection, 204 T3-N0-M0 were selected and reviewed. Univariate and multivariate survival analyses were adapted for the evaluation of the prognostic factors. RESULTS: The 5 years actuarial DFS, DSS, and OS rates of patients with a NHLN >12 were significantly better compared to those of patients with a NHLN <12 (respectively: 72.8% vs. 50.4% P=0.001; 82% vs. 56% P=0.001; 78.5% vs. 53.1% P=0.001). Multivariate analysis revealed that a NHLN >12 was the only independent parameter of statistical significance influencing DFS, DSS, and OS. CONCLUSIONS: According to our findings, the NHLN is the main predictor of survival in Stage IIa CRC patients. This would appear to suggest the need of a better stratification of Stage IIa CRC patients, sub-dividing patients with more or less than 12 NHLN.

Impact and prognostic implications of colon cancers stage II sub-classification through the years.

PURPOSE: According to the American Joint Committee on Cancer (AJCC) 7th edition, T4 colon cancers have been sub-divided into T4a and T4b, resulting in a stage II sub-classification (T3N0, T4aN0, and T4bN0). This study was aimed: (a) to investigate the impact of the AJCC 7th edition stage II sub-classification on the overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) of colon cancer patients who underwent surgical resection and (b) to compare the last three AJCC editions for identifying stage II patients with high-risk of progression. METHODS: One hundred seventy-eight stage II colon cancers out of 682 colorectal cancer patients who underwent surgical resection were selected. T4N0 were sub-divided in accordance with the AJCC 7th edition. Mean follow-up was 41.9 months. Kaplan-Meier method was employed to estimate the survival curves. RESULTS: OS analysis documented a significant difference between stage-sub-groups using the 6th edition; conversely, this difference was not seen if the 7th edition was applied (p = 0.03 and 0.12, respectively). Stage II DFS analysis reported a significant difference using both the AJCC 6th and 7th editions (p = 0.03 and 0.02, respectively). A significant difference was reported on stage II DSS analysis using the AJCC 6th edition (p = 0.03); however, when the 7th edition was applied, a substantial discrepancy between survival curves was noted with T3N0 and T4aN0 displaying similar outcomes (p = 0.006). CONCLUSIONS: The AJCC 7th edition is a reliable classification that might implement the identification of those stage II colon cancer patients with high-risk of progression, recurrence, and cancer mortality.