Telemedicine and Pancreatic Cancer: A Systematic Review

: Introduction: Pancreatic cancer requires a multidisciplinary approach in a high-volume center for all the steps of the diagnostic-therapeutic course. However, the most experienced centers are not evenly distributed throughout the country causing a real "health migration" that involves patients and families with relevant economic, time, and energy costs to bear. The COVID-19 pandemic had a deep impact on surgical and oncological care and the travel limits due to COVID-related restrictions, have delayed the care of cancer patient living far from the referral centers. In this scenario, several telemedicine approaches have been proposed to reduce the distance between clinicians and patients and to allow a fast and effective access to care even for patients distant from referral centers. The aim of the study is to analyze the evidence and describe the current utility of telemedicine tool for patients with pancreatic cancer. Methods: We systematically searched the literature in the following databases: Web of Science, PubMed, Scopus, and MEDLINE. The inclusion criteria were article describing a telemedicine intervention (virtual visits, telephone follow-up/counseling, mobile or online apps, telemonitoring) and focusing on adult patients with pancreatic cancer at any stage of the disease. Results: In total, 846 titles/abstracts were identified. Following quality assessment, the review included 40 studies. Telemedicine has been proposed in multiple clinical settings, demonstrating high levels of patient and health professional satisfaction. Conclusion: Successful telemedicine applications in patients with pancreatic cancer are telerehabilitation and nutritional assessment, remote symptom control, teledischarge after pancreatic surgery, tele-education and medical mentoring regarding pancreatic disease as well as telepathology

Trends in hospital volume and operative mortality in hepato-biliary surgery in Veneto region, Italy

Hepatobiliary resections are among the most complex and technically challenging surgical procedures. Even though robust evidence showed that complex surgical procedures such as hepatobiliary surgery have better short- and long-term outcomes and lower mortality rate when performed in high-volume centers, the minimal criteria of centers that can perform hepatobiliary activity are not clearly defined. We conducted a retrospective population study of patients who underwent hepatobiliary surgery for malignant disease in a single Italian administrative region (Veneto) from 2010 to 2021 with the aim to investigate the hospitals annual surgical volume for hepatobiliary malignant diseases and the effect of hospital volume on in-hospital, 30- and 90-day postoperative mortality. The centralization process of hepatobiliary surgery in Veneto is rapidly increasing over the past 10 years (rate of performed in highly specialized centers increased from 62% in 2010 to 78% in 2021) and actually it is really established. The crude and adjusted (for age, sex, Charlson Index) mortality rate after hepatobiliary surgery resulted significantly lower in centers with high-volume activity compared to them with low-volume activity. In the Veneto region, the "Hub and Spoke" model led to a progressive centralization of liver and biliary cancer treatment. High surgical volume has been confirmed to be related to better outcomes in terms of mortality rate after hepatobiliary surgical procedures. Further studies are necessary to clearly define the minimal criteria and associated numerical cutoffs that can help define the characteristics of centers that can perform hepatobiliary activities

Impact of age on feasibility and short-term outcomes of ERAS after laparoscopic colorectal resection

BACKGROUNDThere is still large debate on feasibility and advantages of fast-track protocols in elderly population after colorectal surgery.AIMTo investigate the impact of age on feasibility and short-term results of enhanced recovery protocol (ERP) after laparoscopic colorectal resection.METHODSData from 225 patients undergoing laparoscopic colorectal resection and ERP between March 2014 and July 2018 were retrospectively analyzed. Three groups were considered according to patients' age: Group A, 65 years old or less, Group B, 66 to 75 years old and Group C, 76 years old or more. Clinic and pathological data were compared amongst groups together with post-operative outcomes including post-operative overall and surgery-specific complications, mortality and readmission rate. Differences in post-operative length of stay and adherence to ERP's items were evaluated in the three study groups.RESULTSAmong the 225 patients, 112 belonged to Group A, 57 to Group B and 56 to Group C. Thirty-day overall morbidity was 32.9% whilst mortality was nihil. Though the percentage of complications progressively increased with age (25.9% vs 36.8% vs 42.9%), no differences were observed in the rate of major complications (4.5% vs 3.5% vs 1.8%), prolonged post-operative ileus (6.2% vs 12.2% vs 10.7%) and anastomotic leak (2.7% vs 1.8% vs 1.8%). Significant differences in recovery outcomes between groups were observed such as delayed urinary catheter removal (P = 0.032) and autonomous deambulation (P = 0.013) in elderly patients. Although discharge criteria were achieved later in older patients (3 d vs 3 d vs 4 d, P = 0.040), post-operative length of stay was similar in the 3 groups (5 d vs 6 d vs 6 d).CONCLUSIONERPs can be successfully and safely applied in elderly undergoing laparoscopic colorectal resection

Complete Mesocolic Excision Versus Standard Laparoscopic Colectomy in Right-Sided Colon Cancer: Analysis of Short-Term Results from a Single Italian Center

Background: Laparoscopic complete mesocolic excision (CME) right hemicolectomy is considered a demanding procedure and it is actually adopted in few centers from the West. The aim of the present study is to analyze the safety of laparoscopic CME right hemicolectomy and to compare its short-term results with standard right hemicolectomy in a single Western center. Materials and Methods: Prospectively collected data from 59 patients who underwent laparoscopic CME right hemicolectomy between September 2014 and February 2019 were retrospectively analyzed and compared with data from 55 patients submitted to standard laparoscopic right hemicolectomy between April 2013 and February 2019. Results: No differences were observed between CME and standard right hemicolectomy groups in terms of clinical characteristics. In the CME group, 37.3% of patients were ≥75 years old, 30.5% of patients were ASA class 3, 49.2% of patients had ≥2 comorbidities, 32.2% of patients had a BMI >28 and 13.6% of patients had ≥2 previous abdominal surgeries. No differences were observed in terms of duration of surgery (217±58min vs. 209±56min; P=0.456), intraoperative complications (5.1% vs. 3.6%; P=1) and blood loss (54±48mL Vs 75±63mL, P=0.089). between CME and S group. The percentage of overall (40.7% vs. 49.1%; P=0.451) and severe (Clavien-Dindo ≥3) complications (10.1% vs. 9.1%; P=0.862), redo surgery (5.1% vs. 7.3%; P=0.710) and readmission (5.1% vs. 5.5%; P=1) was comparable between CME group and S group. A significant difference was observed in the length of specimen (334±81mm vs. 273±95mm; P<0.001) as well as in the length of proximal (159±93mm vs.121±71mm; P=0.018) and distal margins (140±67mm vs.113±68mm; P=0.037) in favor of the CME group. The mean±SD number of lymph nodes harvested was higher in the CME group (26.6±11 vs. 21.7±9.2; P=0.011), as it was the percentage of cases with 12 or more retrieved lymph nodes (98.3% vs. 92.7%; P=0.195) though the difference did not reach statistical significance. Conclusions: This study demonstrated the safety of laparoscopic CME right hemicolectomy in a Western series. CME technique showed comparable short-term results and better quality specimens when compared with the standard procedure

Prognostic Value of Red Cell Distribution Width (RDW) In Colorectal Cancer. Results from a Single-Centre Cohort on 591 Patients

Aim: RDW has been extensively used to discriminate the types of anaemia, as it reflects the degree of heterogeneity of erythrocyte volume (anisocytosis). Recent studies suggested its role as an inflammatory marker, and an increased RDW has been regarded as a risk factor for mortality in a variety of acute and chronic conditions. Increasing evidence advocates the prognostic role of RDW in various tumours, including breast and ovarian cancer. The aim of this study was to investigate its role as a prognostic factor for overall (OS) and cancer-related survival (CRS) in patients who underwent surgery for colorectal cancer (CRC). Material and methods: From January 2005 to December 2016, 1347 patients underwent surgery for CRC at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust. Patients with evidence of infection or inflammatory conditions, and those who underwent emergency surgery were excluded; the minimum follow-up time was 24 months. The data were retrieved from a retrospective database. The optimal cut-off value for RDW was set at 14.1%; accordingly, two groups were considered: those with a value equal or lower than 14.1% (L-RDW), and those with a value higher than 14.1% (H-RDW). Results: A total of 591 patients met the inclusion criteria. The preoperative mean RDW value (±SD) was 15.2 (±3.2); 283 patients (47.9%) were classified as H-RDW. RDW was higher in patients with age above the median (p<0.001) and in colonic tumours (p<0.001). The mean value of RDW rose from pT1 to pT4 tumours (p=0.012). H-RDW correlated with age above the mean (p<0.001), colonic location of the lesion (p=0.012), pT (p=0.034) and TNM stage (p=0.049). Finally, H-RDW was significantly associated with the intent of surgery (p<0.001): almost 50% of patients who underwent a non-curative resection presented H-RDW, compared to 19.3% in R0 resections. OS was significantly lower in patients with H-RDW (p=0.043). Interestingly, OS was similar between groups up to 5 years after surgery (L-RDW 74.7% vs H-RDW 72.3%), whereas the difference increased on a longer follow-up (OS at 10 years 54% H-RDW vs 68.1% L-RDW). CRS was similar in the two groups (p=0.775). Survival rates were also examined stratifying patients according to TNM stage: worse OS was associated with H-RDW only in early stages (Stage 0-I; p=0.001), whereas there was no difference for stages II-IV. Multivariate analysis confirmed that H-RDW was not an independent prognostic factor. Conclusions: Although H-RDW correlated with some negative clinical-pathological factors, it did not seem to independently influence OS and CRS

Prognostic value of red cell distribution width (RDW) in colorectal cancer. Results from a single-center cohort on 591 patients

Increasing evidence advocates the prognostic role of RDW in various tumours. We analysed 591 patients to assess whether RDW is a prognostic factor for overall (OS) and cancer-related survival (CRS) for patients with colorectal cancer (CRC). The data were retrieved from a retrospective database. The optimal cut-off value for RDW was set at 14.1%; accordingly, two groups were considered: those with a value equal or lower than 14.1% (L-RDW), and those with a value higher than 14.1% (H-RDW). The mean value of RDW rose from pT1 to pT4 tumours. H-RDW correlated with age above the mean, colonic location of the lesion, pT and TNM stage. Finally, H-RDW was significantly associated with the intent of surgery: almost 50% of patients who underwent a non-curative resection presented H-RDW, compared to 19.3% in R0 resections. OS was significantly lower in patients with H-RDW. CRS was similar in the two groups. Stratifying patients according to TNM stage worse OS was associated with H-RDW only in early stages, whereas there was no difference for stages II-IV. Multivariate analysis confirmed that H-RDW was not an independent prognostic factor. Although H-RDW correlated with some negative clinical-pathological factors, it did not seem to independently influence OS and CRS

Current Role and Future Perspectives of Immunotherapy and Circulating Factors in Treatment of Biliary Tract Cancers

Biliary tract cancers (BTCs) are a heterogenous group of malignancies arising from the epithelial cells of the biliary tree and the gallbladder. They are often locally advanced or already metastatic at the time of the diagnosis and therefore prognosis remains dismal. Unfortunately, the management of BTCs has been limited by resistance and consequent low response rate to cytotoxic systemic therapy. New therapeutic approaches are needed to improve the survival outcomes for these patients. Immunotherapy, one of the newest therapeutic options, is changing the approach to the oncological treatment. Immune checkpoint inhibitors are by far the most promising group of immunotherapeutic agents: they work by blocking the tumor-induced inhibition of the immune cellular response. Immunotherapy in BTCs is currently approved as second-line treatment for patients whose tumors have a peculiar molecular profile, such as high levels of microsatellites instability, PD-L1 overexpression, or high levels of tumor mutational burden. However, emerging data from ongoing clinical trials seem to suggest that durable responses can be achieved in other subsets of patients. The BTCs are characterized by a highly desmoplastic microenvironment that fuels the growth of cancer tissue, but tissue biopsies are often difficult to obtain or not feasible in BTCs. Recent studies have hence proposed to use liquid biopsy approaches to search the blood circulating tumor cells (CTCs) or circulating tumor DNA (ctDNA) to use as biomarkers in BTCs. So far studies are insufficient to promote their use in clinical management, however trials are still in progress with promising preliminary results. Analysis of blood samples for ctDNA to research possible tumor-specific genetic or epigenetic alterations that could be linked to treatment response or prognosis was already feasible. Although there are still few data available, ctDNA analysis in BTC is fast, non-invasive, and could also represent a way to diagnose BTC earlier and monitor tumor response to chemotherapy. The prognostic capabilities of soluble factors in BTC are not yet precisely determined and more studies are needed. In this review, we will discuss the different approaches to immunotherapy and tumor circulating factors, the progress that has been made so far, and the possible future developments

Use of Packed Red Blood Cells after Laparoscopic and Open Resection for Colorectal Tumors. A Case-Matched Study on 620 Patients

Background: Advantages of laparoscopic surgery over open approach include earlier recovery, less depletion of the systemic immune function and less intraoperative blood loss. RCTs comparing laparoscopic and open resection for colorectal cancer (CRC) demonstrated a reduced blood loss of 70-100 mL in favor of minimally invasive surgery. Nonetheless, little data are available on the use of red blood cell (RBC) transfusions after laparoscopic and open CRC resection. The hypothesis of this case-matched study is that postoperative RBC requirement in patients undergoing elective resection for CRC is lower after laparoscopic compared to open surgery Materials and Methods: Data from 310 patients undergoing laparoscopic surgery for CRC at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between Apr 2013 and Dec 2017, were compared with data from 310 patients selected by case matching among 1108 patients undergoing open surgery between Jan 2005 and Dec 2017. Transfusion history included all data on RBCs transfused between 30 days before and 90 days after surgery. Results: Among the 1418 patients included in the dataset, 364 (25.7%) received one or more postoperative RBC transfusion, for a total number of units of 1234, a mean(SD) number of 0.9(2.0) units when considering the whole cohort and, a mean(SD) number of 3.4(2.8) units when considering transfused patients only. When matching laparoscopic and open cases for age and gender, the percentage of postoperatively transfused patients was doubled after open resection (26.1% vs. 15.8%; p<0.05). The total number of transfused RBC units was significantly higher after open surgery (353 vs. 180; p<0.01), while the mean(SD) number of units for transfused patients was comparable between the two groups [4.4 (3.7) vs 3.7 (3.4); p = 0.79]. Considering clinic-pathological variables, a significant difference was observed in R-category (p<0.01), pT (p<0.01), pN (p<0.01), M (p<0.01), preoperative Hb level (p<0.05) and preoperative RBC transfusion (p<0.05). Conversely, no differences were demonstrated for tumor location (p=0.87) and extent of surgery (p=0.55). When age, gender, extent of resection, R-category, pT, pN and M classes and preoperative Hb levels were used for case-matching, the percentage of patients requiring postoperative transfusion was comparable between open and laparoscopic surgery (18.1% vs. 15.8%; p=0.85). Similarly, the total number of transfused RBC units (174 vs. 180; p=0.86), the mean(SD) number of units in all the cohort [0.6(1.5) vs. 0.6(1.9); p=0.47] and the mean (SD) number of units in transfused patients only [3.1(3.3) vs. 3.7(3.5); p=0.86] were comparable between open and laparoscopic cases. Conclusions: Laparoscopic compared to open resection for CRC failed to demonstrate a lower requirement of RBC transfusions after case-matching for main clinic-pathological variable

Quality Versus Costs Related to Gastrointestinal Surgery: Disentangling the Value Proposition

Background There has been a dramatic increase in worldwide health care spending over the last several decades. Operative procedures and perioperative care in the USA represent some of the most expensive episodes per patient. In view of both the rising cost of health care in general and the rising cost of surgical care specifically, policymakers and stakeholders have sought to identify ways to increase thevalue-improving quality of care while controlling (or diminishing) costs. In this context, we reviewed data relative to achieving the "value proposition" in the delivery of gastrointestinal surgical care. Methods The National Library of Medicine online repository (PubMed) was text searched for human studies including "cost," "quality," "outcomes," "health care," "surgery," and "value." Results from this literature framed by the Donabedian conceptual model (identifying structures, processes, and outcomes), and the resulting impact of efforts to improve quality on costs. Results The relationship between quality and costs was nuanced. Better quality care, though associated with better outcomes, was not always reported as concomitant with low costs. Moreover, some centers reported higher costs of surgical care commensurate with higher quality. Conversely, higher costs in health care delivery were not always linked to improved outcomes. While higher quality surgical care can lead to lower costs, higher costs of care were not necessarily associated with better outcomes. Strategies to improve quality, reduce cost, or achieve both simultaneously included regionalization of complex operations to high-volume centers of excellence, overall reduction in complications, introducing evidence-based improvements in perioperative care pathways including as enhanced recovery after surgery (ERAS), and elimination of inefficient or low-value care. Conclusions The relationship between quality and cost following gastrointestinal surgical procedure is complex. Data from the current study should serve to highlight the various means available to improve the value proposition related to surgery, as well as encourage surgeons to become more engaged in the national conversation around the Triple Aim of better health care quality, lower costs, and improved health care outcomes