Impatto della radio-chemioterapia preoperatoria sui risultati della linfoadenectomia nel trattamento chirurgico del carcinoma del retto extraperitoneale

La linfoadenectomia eseguita durante gli interventi di chirurgia del cancro rettale ha un ruolo importante in quanto fornisce un’adeguata stadiazione del tumore: maggiore è il numero dei linfonodi asportati più alta è la possibilità di trovarne coinvolti dalla neoplasia. La corretta stadiazione a sua volta, rappresenta un elemento chiave dal punto di vista prognostico: permette infatti, una migliore pianificazione terapeutica con un miglior out come per il paziente. Poiché un maggior numero di linfonodi esaminati si associa ad una maggiore sopravvivenza del paziente, le attuali linee guida raccomandano l’asportazione di almeno 12 linfonodi, reperibili dall’anatomo-patologo all’interno del campione operatorio. La radio-chemioterapia preoperatoria per i suoi notevoli benefici, è ormai utilizzata come trattamento standard per alcuni stadi del carcinoma del retto extraperitoneale: diminuisce il tasso di recidiva locale ed aumenta la sopravvivenza, con un impatto positivo sulla prognosi. Il tessuto linfonodale è particolarmente sensibile ai raggi, potendo andare incontro a riduzione delle dimensioni, fibrosi od atrofia se esposto all’irradiazione. Tali alterazioni strutturali possono inficiare in tal modo il riconoscimento delle stazione linfonodali nel campione operatorio. Pertanto, questo studio si pone l’obbiettivo di verificare l’effetto della radio-chemioterapia sui risultati della linfoadenectomia nel trattamento chirurgico del carcinoma del retto extraperitoneale, confrontando pazienti sottoposti a terapia neoadiuvante con altri direttamente condotti ad intervento chirurgico

Molecular genetic features and risk assessment in a series of 30 patients who underwent an operation for gastrointestinal stromal tumours

Background: The objective of the study was to investigate the relationship between molecular genetic features and the standard criteria of risk assessment in patients affected by gastrointestinal stromal tumours (GISTs). Methods: A review was conducted of a series of 30 patients, with a mean age of 67 years, who underwent surgery for primary GISTs. R0 resection was accomplished in 27 patients. CD117, CD34 desmin, vimentin, S-100 and smooth muscle actin were immunohistochemically tested to achieve a diagnosis of GIST. The loss of wild-type KIT or platelet-derived growth factor receptor alpha (PDGFRα) genes was investigated by sequencing the tumour DNA. Results: Tumour genes mutations were reported in 23 patients (77%), and wild-type in seven. Mutations on the KIT gene occurred in 18 patients, and mutations on the PDGFRα gene in five. The average sizes of the GIST were 8.7 cm, 5.4 cm and 5.9 cm for KIT gene-mutated, PDGFRα gene-mutated and wild-type tumours, respectively. KIT gene mutations were detected in 50% of gastric and in 70% of extragastric GISTs. Moreover, 70% of tumours with a mitotic rate ≥ 5 x 50 highpower fields (HPFs) underwent KIT gene mutations. Conversely, PDGFRα mutations were observed only in gastric GISTs with a mitotic rate ≤ 5 x 50 HPFs. By stratifying GISTs according to classes of risk, KIT mutation was shown in most of the high-risk tumours. PDGFRα mutations occurred exclusively in lower classes of risk. Conclusion: Molecular analysis data might have a role as a prognostic variable in models of risk assessment for patients with GISTs

SARS-CoV-2 vaccination modelling for safe surgery to save lives: Data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population

The LIFE TRIAD of emergency general surgery

Emergency General Surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital by general emergency surgeons and other specialists. It is the most diffused surgical discipline in the world. To live and grow strong EGS necessitates three fundamental parts: emergency and elective continuous surgical practice, evidence generation through clinical registries and data accrual, and indications and guidelines production: the LIFE TRIAD.Peer reviewe

A pandemic recap : lessons we have learned

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.Non peer reviewe

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Penetrating Traumatic Injuries of the Diaphragm: how much can we rely on pre-operative imaging findings to detect them?

Background: The diagnosis of penetrating isolated diaphragmatic injuries (DI) can be challenging because they are usually asymptomatic and may be missed on initial evaluation. Chest X-ray (CXR) may not be reliable for the diagnosis of penetrating DI, whereas CT scan has been reported to be more valuable in detecting them, with better sensitivity and specificity. This study’s aim was to review the radiological findings of the CXR and CT scan and to define the accuracy of these imaging in patients with an operative diagnosis of DI. Materials and Methods: Patients with penetrating DI who were admitted to a level I trauma center in the US (Los Angeles County Medical Center, University of Southern California, Los Angeles) between January 2009 and June 2019 were retrospectively identified from the trauma registry of the hospital. Patients without pre-operative imaging, non-operatively managed or with missing operative data were excluded. Demographics, injury data and outcomes were collected and analyzed; CXR, CT scan findings and operative notes were reviewed. Results: 230 patients with an intra-operative diagnosis of penetrating diaphragmatic injury (DI) met the inclusion criteria. 27.0% of the population (62 patients) had an “isolated DI”, while 168 patients (73.0%) had an associated injury (AAST grade ≥ 3) in the abdomen or in the chest. The overall mean age was 27 (IQR 21 - 36). Two-hundred and seventeen patients (94.3%) were male. CXR detected a traumatic diaphragmatic hernia in 4 cases (1.8%) while was normal in 86 patients (38.9%). The presence of a diaphragmatic injury was detected at the CT scan in 56 patients with a sensitivity of 44.4%. This was slightly higher (48%) in the group of patients with an isolated diaphragmatic injury. Conclusions: In patients who sustained a penetrating thoraco-abdominal trauma and without clinical indications for a laparotomy, CT scan findings may help narrowing down the population that needs to undergo further evaluation with diagnostic laparoscopy, that remain the gold standard for the detection of these injuries. Nevertheless, a highly grade of suspect and an aggressive policy in patients with positive or equivocal clinical and radiographic signs of DI is recommended in order to avoid delayed complications associated with diaphragmatic herniation