Comparison of perioperative outcomes between standard laparoscopic and robot-assisted approach in patients with rectosigmoid endometriosis

Introduction: Robot-assisted laparoscopic surgery (RALS) has gained widespread application in several surgical specialties. Previous studies on the feasibility and safety of RALS vs standard laparoscopy (S-LPS) for rectosigmoid endometriosis are limited and reported conflicting data. This study aims to compare S-LPS and RALS in patients with rectosigmoid endometriosis in terms of perioperative surgical and clinical data. Material and methods: This is a multicentric, observational, prospective cohort study including 44 patients affected by rectosigmoid endometriosis referred to two tertiary referral centers for endometriosis from September 2018 to September 2019. Patients were divided into two groups: 22 patients underwent S-LPS, and 22 underwent RALS. Our primary outcome was to compare operative time (from skin incision to suture) between the two groups. Secondary outcomes included: operative room time (patient entry into operative room and patient out), estimated blood loss, laparotomic conversion rate, length of hospital stay, perioperative complications, and evaluation of endometriosis-related symptoms at 12-month follow up. Results: The two groups were comparable regarding preoperative and surgical data, except for higher rates of hysterectomies and bilateral uterosacral ligament removal procedures in the RALS group. Also after adjusting for these discrepancies, operative time was similar between S-LPS and RALS. Operative room time was statistically longer in the RALS group compared with that of S-LPS. No statistically significant difference was found concerning other study outcomes. Pain and bowel symptoms improved in both groups at 12-month follow up. Conclusions: If performed by expert teams, RALS provides similar perioperative outcomes compared with S-LPS in rectosigmoid endometriosis surgical treatment, except for longer operative room time

Assessment of the 2020 NICE criteria for preoperative radiotherapy in patients with rectal cancer treated by surgery alone in comparison with proven MRI prognostic factors: a retrospective cohort study

BACKGROUND: Selection of patients for preoperative treatment in rectal cancer is controversial. The new 2020 National Institute for Health and Care Excellence (NICE) guidelines, consistent with the National Comprehensive Cancer Network guidelines, recommend preoperative radiotherapy for all patients except for those with radiologically staged T1-T2, N0 tumours. We aimed to assess outcomes in non-irradiated patients with rectal cancer and to stratify results on the basis of NICE criteria, compared with known MRI prognostic factors now omitted by NICE. METHODS: For this retrospective cohort study, we identified patients undergoing primary resectional surgery for rectal cancer, without preoperative radiotherapy, at Basingstoke Hospital (Basingstoke, UK) between Jan 1, 2011, and Dec 31, 2016, and at St Marks Hospital (London, UK) between Jan 1, 2007, and Dec 31, 2017. Patients with MRI-detected extramural venous invasion, MRI-detected tumour deposits, and MRI-detected circumferential resection margin involvement were categorised as MRI high-risk for recurrence (local or distant), and their outcomes (disease-free survival, overall survival, and recurrence) were compared with patients defined as high-risk according to NICE criteria (MRI-detected T3+ or MRI-detected N+ status). Kaplan-Meier and Cox proportional hazards analyses were used to compare the groups. FINDINGS: 378 patients were evaluated, with a median of 66 months (IQR 44-95) of follow up. 22 (6%) of 378 patients had local recurrence and 68 (18%) of 378 patients had distant recurrence. 248 (66%) of 378 were classified as high-risk according to NICE criteria, compared with 121 (32%) of 378 according to MRI criteria. On Kaplan-Meier analysis, NICE high-risk patients had poorer 5-year disease-free survival compared with NICE low-risk patients (76% [95% CI 70-81] vs 87% [80-92]; hazard ratio [HR] 1·91 [95% CI 1·20-3·03]; p=0·0051) but not 5-year overall survival (80% [74-84] vs 88% [81-92]; 1·55 [0·94-2·53]; p=0·077). MRI criteria separated patients into high-risk versus low-risk groups that predicted 5-year disease-free survival (66% [95% CI 57-74] vs 88% [83-91]; HR 3·01 [95% CI 2·02-4·47]; p<0·0001) and 5-year overall survival (71% [62-78] vs 89% [84-92]; 2·59 [1·62-3·88]; p<0·0001). On multivariable analysis, NICE risk assessment was not associated with either disease-free survival or overall survival, whereas MRI criteria predicted disease-free survival (HR 2·74 [95% CI 1·80-4·17]; p<0·0001) and overall survival (HR 2·44 [95% CI 1·51-3·95]; p=0·00027). 139 NICE high-risk patients who were defined as low-risk based on MRI criteria had similar disease-free survival as 118 NICE low-risk patients; therefore, 37% (139 of 378) of patients in this study cohort would have been overtreated with NICE 2020 guidelines. Of the 130 patients defined as low-risk by NICE guidelines, 12 were defined as high-risk on MRI risk stratification and would have potentially been missed for treatment. INTERPRETATION: Compared to previous guidelines, implementation of the 2020 NICE guidelines will result in significantly more patients receiving preoperative radiotherapy. High-quality MRI selects patients with good outcomes (particularly low local recurrence) without radiotherapy, with little margin for improvement. Overuse of radiotherapy could occur with this unselective approach. The high-risk group, with the most chance of benefiting from preoperative radiotherapy, is not well selected on the basis of NICE 2020 criteria and is better identified with proven MRI prognostic factors (extramural venous invasion, tumour deposits, and circumferential resection margin). FUNDING: None

School refusal behavior. role of personality styles, social functioning, and psychiatric symptoms in a sample of adolescent help-seekers

Objective: School refusal (SR) in adolescence represents an important risk factor associated with adverse consequences. Although many clinical features of adolescents presenting with SR have been studied, the relationship between SR and personality styles-specifically in the help-seeking population-remains unclear. The present study aimed at investigating differences in personality style, adaptive functioning, and symptomology between Italian help-seeking adolescents who refused (SRa) and did not refuse (non-SRa) to attend school, to provide preliminary evidence of personality patterns in adolescent help-seekers presenting with SR.Method: The study sample was comprised of 103 help-seeking adolescents (54 female, 49 male) aged 14-18 years. Participants were recruited during their first clinical visit and evaluated using the Shedler and Westen Assessment Procedure - Adolescent version (SWAP-A), the Hamilton Rating Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A), the Maniac Rating Scale (MRS), the Global Assessment of Functioning (GAF), the Global Functioning Social Scale (GFSS), and the Global Functioning Role Scale (GFRS). Differences in the studied variables between SRa and non-SRa were measured and a multivariable logistic regression analysis was performed to identify possible predictive factors of SR.Results: SRa presented with more anxious and depressive symptomatology and worse social functioning compared to non-SRa. With respect to personality, SRa displayed more schizoid and schizotypal characteristics and fewer adaptive and healthy personality features. Irrespective of any differences between groups, SRa were largely characterized by inhibited-self-constricted and emotionally dysregulated personality styles.Conclusions: The results suggest that personality styles arc clinical features that may contribute to broadening our knowledge of SR behavior and aid in the detection of SRa, also in the help-seeking population. The findings have clinical, social, and political implications for prevention, diagnosis, and treatment, in both clinical and non-clinical settings. However, more data are needed on personality features to clarify their contribution to the more complex phenomenon of school absenteeism

Current practice and surgical outcomes of neoadjuvant chemotherapy for early breast cancer : UK NeST study

Funding Information: This work was funded by a grant from the Association of Breast SurgeryPeer reviewedPublisher PD

Appendectomy during the COVID-19 pandemic in Italy: a multicenter ambispective cohort study by the Italian Society of Endoscopic Surgery and new technologies (the CRAC study)

Major surgical societies advised using non-operative management of appendicitis and suggested against laparoscopy during the COVID-19 pandemic. The hypothesis is that a significant reduction in the number of emergent appendectomies was observed during the pandemic, restricted to complex cases. The study aimed to analyse emergent surgical appendectomies during pandemic on a national basis and compare it to the same period of the previous year. This is a multicentre, retrospective, observational study investigating the outcomes of patients undergoing emergent appendectomy in March-April 2019 vs March-April 2020. The primary outcome was the number of appendectomies performed, classified according to the American Association for the Surgery of Trauma (AAST) score. Secondary outcomes were the type of surgical technique employed (laparoscopic vs open) and the complication rates. One thousand five hundred forty one patients with acute appendicitis underwent surgery during the two study periods. 1337 (86.8%) patients met the inclusion criteria: 546 (40.8%) patients underwent surgery for acute appendicitis in 2020 and 791 (59.2%) in 2019. According to AAST, patients with complicated appendicitis operated in 2019 were 30.3% vs 39.9% in 2020 (p = 0.001). We observed an increase in the number of post-operative complications in 2020 (15.9%) compared to 2019 (9.6%) (p &lt; 0.001). The following determinants increased the likelihood of complication occurrence: undergoing surgery during 2020 (+ 67%), the increase of a unit in the AAST score (+ 26%), surgery performed &gt; 24 h after admission (+ 58%), open surgery (+ 112%) and conversion to open surgery (+ 166%). In Italian hospitals, in March and April 2020, the number of appendectomies has drastically dropped. During the first pandemic wave, patients undergoing surgery were more frequently affected by more severe appendicitis than the previous year's timeframe and experienced a higher number of complications. Trial registration number and date: Research Registry ID 5789, May 7th, 202

An effective stress based shear strength criterion for unsaturated compacted double-porosity clays

An effective stress based shear strength criterion is proposed taking into account the fundamental effects of microstructure characteristics on retention properties of compacted double-porosity clays and their overall coupled hydro-mechanical behaviour. Results of triaxial compression tests carried out on saturated and unsaturated samples of a compacted scaly clay show that points representative of failure conditions depict a unique failure envelope when the macropore degree of saturation is used in the definition of the effective stress and its evolution with the suction is taken into account. Furthermore, the proposed criterion is very effective to consider the most relevant aspects of suction influence on the shear strength of double porosity unsaturated soils

Robot-Assisted Nerve-sparing Resection of Bilateral Parametrial Deep Infiltrating Endometriosis

Objective: To demonstrate the surgical steps used to perform a robotic radical parametrectomy in a woman with deep infiltrating endometriosis. Design: Description of the procedure using video. Setting: University hospital, referral center for endometriosis and minimally invasive surgery. Interventions: A 47-year-old woman, with a body mass index of 31 kg/m2, who had undergone a supracervical hysterectomy for fibromatosis 5 years earlier, presented for definitive surgical management of parametrial and rectal endometriosis-associated pain. Robot-assisted nerve-sparing eradication of endometriosis, trachelectomy, and rectal shaving were planned. On the right side, the retroperitoneum was opened to widely expose the ureter, and a right adnexectomy was performed, gently separating the ureter from the diffuse periadnexal fibrosis. Right medial pararectal space was developed, and after right partial uterolysis, a nerve-sparing resection of the posterior parametrial endometriosis was performed. On the left side, endometriotic infiltration penetrated into the lateral and anterior (cranial portion) parametrium, wrapping the left uterine artery and the ureter. Left paravesical and pararectal spaces were developed. The left uterine artery was clipped at its origin, and the resection of the lateral and anterior parametrial nodules was completed following the shape of the nodule, dividing the lesion in 2 parts, and following the plane of the deep uterine vein to avoid excision of the nerve branches from the left inferior hypogastric plexus. Rectal endometriosis was removed by shaving, and the surgery ended with trachelectomy and robotic suture of the vaginal cuff. Conclusion: Robot-assisted laparoscopy is a safe and effective technique for nerve-sparing resection of parametrial endometriosis