Sutureless repair for open treatment of inguinal hernia. Three techniques in comparison

: Currently, groin hernia repair is mostly performed with application of mesh prostheses fixed with or without suture. However, views on safety and efficacy of different surgical approaches are still partly discordant. In this multicentre retrospective study, three sutureless procedures, i.e., mesh fixation with glue, application of self-gripping mesh, and Trabucco's technique, were compared in 1034 patients with primary unilateral non-complicated inguinal hernia subjected to open anterior surgery. Patient-related features, comorbidities, and drugs potentially affecting the intervention outcomes were also examined. The incidence of postoperative complications, acute and chronic pain, and time until discharge were assessed. A multivariate logistic regression was used to compare the odds ratio of the surgical techniques adjusting for other risk factors. The application of standard/heavy mesh, performed in the Trabucco's technique, was found to significantly increase the odds ratio of hematomas (p = 0.014) and, most notably, of acute postoperative pain (p < 0.001). Among the clinical parameters, antithrombotic therapy and large hernia size were independent risk factors for hematomas and longer hospital stay, whilst small hernias were an independent predictor of pain. Overall, our findings suggest that the Trabucco's technique should not be preferred in patients with a large hernia and on antithrombotic therapy

Colorectal Cancer Stage at Diagnosis Before vs During the COVID-19 Pandemic in Italy

IMPORTANCE Delays in screening programs and the reluctance of patients to seek medical attention because of the outbreak of SARS-CoV-2 could be associated with the risk of more advanced colorectal cancers at diagnosis. OBJECTIVE To evaluate whether the SARS-CoV-2 pandemic was associated with more advanced oncologic stage and change in clinical presentation for patients with colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included all 17 938 adult patients who underwent surgery for colorectal cancer from March 1, 2020, to December 31, 2021 (pandemic period), and from January 1, 2018, to February 29, 2020 (prepandemic period), in 81 participating centers in Italy, including tertiary centers and community hospitals. Follow-up was 30 days from surgery. EXPOSURES Any type of surgical procedure for colorectal cancer, including explorative surgery, palliative procedures, and atypical or segmental resections. MAIN OUTCOMES AND MEASURES The primary outcome was advanced stage of colorectal cancer at diagnosis. Secondary outcomes were distant metastasis, T4 stage, aggressive biology (defined as cancer with at least 1 of the following characteristics: signet ring cells, mucinous tumor, budding, lymphovascular invasion, perineural invasion, and lymphangitis), stenotic lesion, emergency surgery, and palliative surgery. The independent association between the pandemic period and the outcomes was assessed using multivariate random-effects logistic regression, with hospital as the cluster variable. RESULTS A total of 17 938 patients (10 007 men [55.8%]; mean [SD] age, 70.6 [12.2] years) underwent surgery for colorectal cancer: 7796 (43.5%) during the pandemic period and 10 142 (56.5%) during the prepandemic period. Logistic regression indicated that the pandemic period was significantly associated with an increased rate of advanced-stage colorectal cancer (odds ratio [OR], 1.07; 95%CI, 1.01-1.13; P = .03), aggressive biology (OR, 1.32; 95%CI, 1.15-1.53; P < .001), and stenotic lesions (OR, 1.15; 95%CI, 1.01-1.31; P = .03). CONCLUSIONS AND RELEVANCE This cohort study suggests a significant association between the SARS-CoV-2 pandemic and the risk of a more advanced oncologic stage at diagnosis among patients undergoing surgery for colorectal cancer and might indicate a potential reduction of survival for these patients

Radio-guided occult lesion localization of cervical recurrences from differentiated thyroid cancer

Background: The aim of this work was to evaluate the application of he concept of ROLL (radio-guided occult lesion localisation) in order to identify non-palpable recurrences in the cervical region by differentiated hyroid cancer (DTC). This procedure makes it possible to perform minimally- invasive radio-guided surgery in a number of selected cases. Material and Methods: The new ROLL procedure was used in 32 DTC patients with loco-regional recurrent lesions. Three of the patients were subjected twice to the procedure. The patients had undergone total thyroidectomy and post-thyroidectomy 131I-ablation, and in somecases had been subjected to one or more cervical lymphadenectomies. Pre-operative labelling consists of ultrasound-guided intra-lesional administration of 99mTc-labeled human albumin macroaggregates (99mTc-MAA, 5e10MBq in 100e200 mL of saline), and was followed by scintigraphy of the cervical region, 2 to 18 hours before programmed surgery. A hand-held gamma-probe used intra-operatively made it possible to identify the labelled lesions. ROLL was employed by means of two different approaches: the former consisted of a selective minimally invasive excision of radiolabelled lesions in 12 patients (s-ROLL); the latter consisted of a modified radical neck dissection (MRND) after excision of radiolabelled lesions in 20 patients (d-ROLL). Results: A total of 59 lesions detected by ultrasound examination were radio-labelled by intra-lesional injection of 99mTc-MAA: of the 59 lesions, 41 were metastatic lymph nodes located in the latero-cervical regions, while 17 recurrent metastatic lesions were spotted in the suprajugular region (at VI level) and 1 lesion was in the high mediastinum. The mean echographic size of the lesions was 11.1_4.1 mm. Using the ROLL procedure, it was possible to localise and remove 59 out of 59 lesions (identification rate 100%), including those of 3 patients previously subjected to non-radioguided surgery, which had failed. Leakage of 99mTc-MAA in to the surrounding tissues during pre-operative labelling relatively hindered precise gamma-probe-guided identification of 3 lesions (in 2 patients). However, these lesions were identified and surgically removed on the basis of both radioactivity and palpation. Histopathological examination confirmed metastatic involvement in all the lesions and further metastases in the other nodes that had been removed. Furthermore, ROLL allows the extent of the cervical dissection to be maintained at a minimum. In our case, the procedure was particularly useful in the paratracheal region as there was no injury of the nerve or parathyroidectomy. After a median follow-up of 29 months, 19 patients showed no evidence of disease, whereas 12 patients developed loco-regional recurrences (in sites near to and/or different from those operated with ROLL), and 2 patients presented distant metastases. Statistical analyses showed no differences between the two surgical applications with regard to in-field relapse, diseasefree survival and overall survival. Conclusions: Radio-guided surgery carried out withROLLis possible in selected patients presenting with recurrent loco-regional DTC (including iodine- negative lesions). The ROLL procedure permits lesions that can be removed with limited invasiveness to be identified, in particular in patients who have already undergone cervical dissections. ROLL has proved to be particularly suitable in those cases in which the lesions were small, nonpalpableand/ or situated in sites that were surgically difficult to reach. Therefore, it is possible to use minimally invasive approaches, followed by shorter operating times and with reduced morbidity complications. Similar to other ROLLprocedures, the low radioactivity dose used does not produce significant radiation exposure either to the patients or to the staff members. In order to obtain optimal performance of the procedure, it is necessary to dispense with experts in ultrasound-guided tissue sampling in the cervical region, and to ensure close collaboration of a team that includes nuclear medicine specialists, surgeons and pathologists. The clinical importance of the ROLLprocedure in managing recurrentDTC should be debated, taking into account the information concerning the prognostic factors of the disease

Surgeon–Pathologist Team Approach Dramatically Affects Lymph Nodes Detection and Improves Patients’ Short-Term Outcome

The downstaging of gastric cancer has recently gained particular attention in the field of gastric cancer surgery. The phenomenon is mainly due to an inappropriate sampling of lymph nodes during standard lymphadenectomy. Hence, collection of the maximum number of lymph nodes is a critical factor affecting the outcome of patients. None of the techniques proposed so far have demonstrated a real efficiency in increasing the number of identified lymph nodes. To harvest the maximum number of lymph nodes, we designed a protocol for on-site macroscopic evaluation and sampling of lymph nodes according to the Japanese Gastric Cancer Association protocol. The procedure was carried out by a surgeon/pathologist team in the operating room. We enrolled one hundred patients, 50 of whom belonged to the study group and 50 to a control group. The study group included patients who underwent lymph node dissection following the proposed protocol; the control group encompassed patients undergoing standard procedures for sampling. We compared the number and maximum diameter of lymph nodes collected in both groups, as well as some postoperative variables, the 30-day mortality and the overall survival. In the study group, the mean number of lymph nodes harvested was higher than the control one (p = 0.001). Moreover, by applying the proposed technique, we sampled lymph nodes with a very small diameter, some of which were metastatic. Noticeably, no difference in terms of postoperative course was identified between the two groups, again supporting the feasibility of an extended lymphadenectomy. By comparing the prognosis of patients, a better overall survival (p = 0.03) was detected in the study group; however, to date, no long-term follow-up is available. Interestingly, patients with metastasis in node stations number 8, 9, 11 or with skip metastasis, experienced a worse outcome and died. Based on our preliminary results, the pathologist/surgeon team approach seems to be a reliable option, despite of a slight increase in sfaff workload and technical cost. It allows for the harvesting of a larger number of lymph nodes and improves the outcome of the patients thanks to more precise staging and therapy. Nevertheless, since a higher number of patients are necessary to confirm our findings and assess the impact of this technique on oncological outcome, our study could serve as a proof-of-concept for a larger, multicentric collaboration

Longitudinal Coupling between Eating Disorder Psychopathology and Depression in Patients with Anorexia Nervosa and Bulimia Nervosa Treated with Enhanced Cognitive Behavior Therapy: A One-Year Follow-Up Study

Background: The relationship between eating disorder (ED) specific psychopathology and depressive symptomatology in EDs is often debated. The aim of this study was to provide an explicative model regarding the mechanisms by which enhanced cognitive-behavior therapy (CBT-E) might determine an amelioration of depressive symptoms in patients with anorexia nervosa (AN) or bulimia nervosa (BN). Methods: A total of 157 women with AN or BN and no history of childhood trauma or bipolar disorder were evaluated before treatment and after 12 months of CBT-E. Self-administered questionnaires were used to measure ED psychopathology and depressive symptoms. Results: All psychopathological measures improved after treatment, with no significant additional improvement with the concomitant use of antidepressants. Structural equation modeling using the bivariate latent change score approach showed that higher levels of depressive symptoms at baseline were associated with a worse longitudinal trend of ED psychopathology, and vice versa. Finally, the amelioration of ED psychopathology predicted the improvement in depressive symptoms at follow-up, whereas data did not support the inverse path. Conclusion: This study elucidated the complex longitudinal interplay between ED psychopathology and depression during CBT-E, underlining the importance of addressing ED symptoms as a primary target in the case of comorbidity between AN or BN and depressive symptoms

Paving the Path for Immune Enhancing Nutrition in Colon Cancer: Modulation of Tumor Microenvironment and Optimization of Outcomes and Costs

Introduction. Published evidence suggests that immunonutrition has the potential to decrease postoperative complications and reduce length of stay in patients undergoing surgery for colorectal cancer. However, only a few studies have analyzed the effects of immunonutrition on tumor microenvironment and evaluated its prognostic impact. Material and methods. This is a single center retrospective study enrolling 50 patients undergoing elective surgery for colorectal cancer managed with immunonutrition and 50 patients managed with standard nutrition for comparison. Tumor microenvironment was analyzed before (on the biopsy at the time of diagnosis) and after (on the matched surgical specimen) administration of immunonutrition. Immune function related indicators, including cytotoxic T-lymphocytes, helper T-cells, antigen presenting cells, natural killer cells, T-exhausted lymphocytes, T-regulatory cells, M1 and M2 tumor associated macrophages and PD-L1 expression were assessed by immunohistochemistry. For both groups, clinicopathological data were collected and a 5-year follow-up was available. Results. We found that immunonutrition significantly activated the T-cell response against cancer, alter tumor microenvironment phenotype towards M2 polarization and inhibits the PD1/PD-L1 axis. A lower rate of postoperative complications and a shorter length of stay (p = 0.04) were observed in the immune nutrition group. Compared to standard nutrition group, patients managed wit immune nutrition showed a higher 5-year overall survival (p = 0.001). Finally, immune nutrition allowed to reduce the hospital care costs. Conclusions. Immunonutrition modulates tumor microenvironment by improving immune function and could prolong survival in patients undergoing elective surgery for colorectal cancer. Further studies are needed to optimize IN protocols and confirm their prognostic impact

A national survey on the current status of minimally invasive gastric practice on behalf of GIRCG

: Italian Research Group for Gastric Cancer (GIRCG), during the 2013 annual Consensus Conference to gastric cancer, stated that laparoscopic or robotic approach should be limited only to early gastric cancer (EGC) and no further guidelines were currently available. However, accumulated evidences, mainly from eastern experiences, have supported the application of minimally invasive surgery also for locally advanced gastric cancer (AGC). The aim of our study is to give a snapshot of current surgical propensity of expert Italian upper gastrointestinal surgeons in performing minimally invasive techniques for the treatment of gastric cancer in order to answer to the question if clinical practice overcome the recommendation. Experts in the field among the Italian Research Group for Gastric Cancer (GIRCG) were invited to join a web 30-item survey through a formal e-mail from January 1st, 2020, to June 31st, 2020. Responses were collected from 46 participants out of 100 upper gastrointestinal surgeons. Percentage of surgeons choosing a minimally invasive approach to treat early and advanced gastric cancer was similar. Additionally analyzing data from the centers involved, we obtained that the percentage of minimally invasive total and partial gastrectomies in advanced cases augmented with the increase of surgical procedures performed per year (p = 0.02 and p = 0.04 respectively). It is reasonable to assume that there is a widening of indications given by the current national guideline into clinical practice. Propensity of expert Italian upper gastrointestinal surgeons was to perform minimally invasive surgery not only for early but also for advanced gastric cancer. Of interest volume activity correlated with the propensity of surgeons to select a minimally invasive approach