ERAS with or without supplemental artificial nutrition in open pancreatoduodenectomy for cancer. A multicenter, randomized, open labeled trial (RASTA study protocol)

PurposeThe role of supplemental artificial nutrition in patients perioperatively treated according to enhanced recovery programs (ERAS) on surgery-related morbidity is not known. Therefore, there is a need of a clinical trials specifically designed to explore whether given a full nutritional requirement by parenteral feeding after surgery coupled with oral food “at will” compared to oral food “at will” alone, within an established ERAS program, could achieve a reduction of the morbidity burden.Materials and analysisRASTA will be a multicenter, randomized, parallel-arm, open labeled, superiority trial. The trial will be conducted in five Italian Institutions with proven experience in pancreatic surgery and already applying an established ERAS program. Adult patients (age ≥ 18 and < 90 years of age) candidate to elective open pancreatoduodenectomy (PD) for any periampullary or pancreatic cancer will be randomized to receive a full ERAS protocol that establishes oral food “at will” plus parenteral nutrition (PN) from postoperative day 1 to day 5 (treatment arm), or to ERAS protocol without PN (control arm). The primary endpoint of the trial is the complication burden within 90 days after the day of surgery. The complication burden will be assessed by the Comprehensive Complication Index, that incorporates all complications and their severity as defined by the Clavien-Dindo classification, and summarizes postoperative morbidity with a numerical scale ranging from 0 to 100. The H0 hypothesis tested is that he administration of a parenteral nutrition added to the ERAS protocol will not affect the CCI as compared to standard of care (ERAS). The H1 hypothesis is that the administration of a parenteral nutrition added to the ERAS protocol will positively affect the CCI as compared to standard of care (ERAS). The trial has been registered at ClinicalTrials.gov (number: NCT04438447; date: 18/05/2020).ConclusionThis upcoming trial will permit to establish if early postoperative artificial nutritional support after PD may improve postoperative outcomes compared to oral nutrition alone within an established ERAS program

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

The impact of adherence to enhanced recovery pathway elements on outcomes following bowel surgery

Introduction: Enhanced recovery pathways (ERPs) are evidence-based, multimodal, standardized care plans that integrate multiple steps and interventions in the perioperative period aiming to improve patient recovery after surgery. International guidelines recommend the incorporation of a large number of interventions into ERPs. However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The objective of the research contained within this thesis is two-fold: (1) to estimate the extent to which adherence to care process is associated with outcomes, and identify key ERP elements associated with successful recovery following bowel resection; (2) to assess the validity and usability of a novel mobile device app for patient education and self-reporting of adherence within an established ERP. Methods: A review of prospectively collected data entered in a registry specifically designed for ERPs was performed. Patients undergoing elective bowel resection between 2012 and 2014 at the Montreal General Hospital treated within an ERP comprising 23 care elements were included in the study. Primary outcome was successful recovery defined as: absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were: length of hospital stay (LOS), 30-day morbidity and severity (Comprehensive complication index, CCI, 0-100). Subsequently, we performed a prospective pilot study implementing a novel mobile device app specifically designed to provide patients with daily recovery milestones and to record adherence to different ERP processes and patient reported outcomes (PROs). Validity was measured by the agreement index (Cohen's kappa coefficient for categorical, and interclass correlation coefficient (ICC) for continuous variables) between patient reported data through the app and data recorded by a clinical auditor. Acceptability and usability of the app were measured by the System Usability Scale (SUS). Results: In our retrospective study, we analyzed data from 347 patients, with a median length of hospital stay of 4 days (IQR 3-7), and median adherence to 18 (IQR 16-20) elements. There was a positive association between adherence and successful recovery with no hospital readmission, length of stay, 30-day postoperative morbidity and the complication severity. Laparoscopy, early mobilization out of bed, and early termination of IV fluid infusion were significantly associated with improved outcomes. In our app validation study, we included 45 patients undergoing bowel surgery. Overall, patients completed 89% of the available perioperative questionnaires through the app. Substantial (kappa > 0.6) or almost-perfect agreement (kappa > 0.8) and strong correlation (ICC > 0.7) between data collected through the app and by the clinical auditor was found for 14 out of 15 ERP processes and 4 out of 6 PROs. Patient reported usability and satisfaction was high, and only few patients needed technical support to use the app. Forty (89%) patients found that the app was helpful to achieve their daily goals, and 34 (76%) thought it increased their motivation to recover after surgery. Conclusion: In an established ERP where overall adherence was high, we found that increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. Given the significant impact of adherence to postoperative elements, we successfully piloted a novel mobile device app which proved to be a valid tool to record patient adherence and patient reported outcomes, and had high usability and patient satisfaction. Our findings suggest that future studies should investigate the use of mobile device apps as strategies to increase adherence to ERP interventions and improve outcomes.Introduction: Les programmes multidisciplinaires de récupération accélérée (PMRA) sont des plans de soins standardisés, multimodaux et fondés sur des preuves. Les directives internationales recommandent l'incorporation de nombreuses interventions dans les PMRA. Cependant, l'impact de l'adhésion à ces programmes ainsi que la contribution relative de chaque intervention ne sont pas clairs. L'objectif principal de cette thèse est double: (1)estimer dans quelle mesure l'adhésion au processus de soins est associé aux résultats, et identifier les éléments clés de PMRA qui sont associés au rétablissement après une résection intestinale; (2)évaluer la validité et la convivialité d'une application mobile novatrice utilisée pour l'éducation des patients et pour l'auto-déclaration d'adhésion à un PMRA établi. Méthodes: Un registre spécifiquement conçu pour les PMRA qui contient des données recueillies prospectivement a été révisé. Les patients qui ont subi une chirurgie intestinale élective entre 2012 et 2014 à l'Hôpital général de Montréal et dans le cadre d'un PMRA qui comporte 23 éléments de soins ont été inclus dans l'étude. Le résultat principal a été le rétablissement avec succès défini comme: l'absence de complications, sortie d'hôpital au plus tard le quatrième jour après la chirurgie, et pas de réhospitalisation. Ensuite, nous avons effectué une étude pilote prospective qui met en œuvre une application mobile novatrice conçue pour les patients postopératoire. L'application indique les jalons quotidiens, permet l'enregistrement d'adhésion aux différents processus PMRA et recueillit les résultats déclarés par les patients ("Patient-reported outcomes", PRO). La validité a été mesurée par l'indice d'accord (le coefficient Kappa de Cohen pour les variables catégoriques, et le coefficient de corrélation interclasse (ICC) pour les variables continues) entre les données recueillies par l'application et les données enregistrées par l'auditeur clinique. Résultats: Dans notre étude rétrospective, nous avons analysé les données de 347 patients, avec une durée médiane de l'hospitalisation de 4 jours(écart interquartile 3-7), et en moyenne, adhésion à 18 éléments du PMRA(écart interquartile 16-20). Il y a eu une association positive entre l'adhésion et le rétablissement sans réhospitalisation, la durée du séjour, et la gravité des complications ainsi que la morbidité postopératoire à 30 jours. La laparoscopie, la mobilité précoce, et la cessation précoce des solutions intraveineuses a été associées à de meilleurs résultats de manière significative. Pour notre étude sur la validité de l'application mobile, nous avons inclus 45 patients qui subissent une chirurgie intestinale. Un accord substantiel (kappa > 0.6) ou un accord presque parfait(kappa > 0.8) et une forte corrélation(ICC > 0.7) entre les données recueillies par l'application et par l'auditeur clinique ont été retrouvés pour 14 processus du PMRA sur 15 et pour 4 PRO sur 6. Les patients ont déclaré un niveau de convivialité et de satisfaction élevé. Quarante(89%) patients croyaient que l'application a aidé à atteindre leurs objectifs quotidiens, et 34(76%) patients croyaient qu'elle a augmenté leur motivation de rétablissement après la chirurgie. Conclusion: L'étude a conclu que le plus une adhésion aux interventions PMRA a été élevée, le plus elle a été associée à un rétablissement accéléré et à une réduction de la gravité des complications et la morbidité postopératoire. Étant donné l'impact significatif d'adhésion sur les éléments postopératoires, nous avons réussi à piloter une application mobile novatrice et valide, capable d'enregistrer l'adhésion au PMRA et les PRO. Elle est également associée à un haut niveau de convivialité et de satisfaction. Selon nos constations, les recherches futures devraient viser à évaluer l'utilisation des application mobiles comme des stratégies pour l'augmentation d'adhésion aux interventions PMRA et pour de meilleurs résultats postopératoires

Pancreatic metastases: An increasing clinical entity

Pancreatic metastases, although uncommon, have been observed with increasing frequency recently, especially by high-volume pancreatic surgery centers. They are often asymptomatic and detected incidentally or during follow-up investigations even several years after the removal of the primary tumor. Renal cell cancer represents the most common primary tumor by far, followed by colorectal cancer, melanoma, sarcoma and lung cancer. Pancreatic metastasectomy is indicated for an isolated and resectable metastasis in a patient fit to tolerate pancreatectomy. Both standard and atypical pancreatic resection can be performed: a resection strategy providing adequate resection margins and maximal tissue preservation of the pancreas should be pursued. The effectiveness of resection for pancreatic metastases is mainly dependent on the tumor biology of the primary cancer; renal cell cancer is associated with the best outcome with a 5-year survival rate greater than 70%

Long-term outcomes after laparoscopic colectomy

AIM: To evaluate long-term outcomes in a large series of patients who randomly received laparoscopic or open colorectal resection

State-of-the-art review on the correlations between pathological and magnetic resonance features of cirrhotic nodules

Hepatocellular carcinoma (HCC) has become the second greatest cause of cancer-related mortality worldwide and the newest advancements in liver imaging have improved the diagnosis of both overt malignancies and premalignant lesions, such as cirrhotic or dysplastic nodules, which is crucial to improve overall patient survival rate and to choose the best treatment options. The role of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) has grown in the last 20 years. In particular, the introduction of hepatospecific contrast agents has strongly increased the definition of precursor nodules and detection of highgrade dysplastic nodules and early HCCs. Nevertheless, the diagnosis of liver tumours in cirrhotic patients sometimes remains challenging for radiologists, thus, in doubtful cases, biopsy and histological analysis become critical in clinical practice. This current review briefly summarizes the history of imaging and histology for HCC, covering the newest techniques and their limits. Then, the article discusses the links between radiological and pathological characteristics of liver lesions in cirrhotic patients, by describing the multistep process of hepato carcinogenesis. Explaining the evolution of pathologic change from cirrhotic nodules to malignancy, the list of analyzed lesions provides regenerative nodules, lowgrade and high-grade dysplastic nodules, small HCC and progressed HCC, including common subtypes (steatohepatitic HCC, scirrhous HCC, macrotrabecular massive HCC) and more rare forms (clear cell HCC, chromophobe HCC, neutrophil-rich HCC, lymphocyterich HCC, fibrolamellar HCC). The last chapter covers the importance of the new integrated morphologicalmolecular classification and its association with radiological feature

Enhanced recovery pathways in pancreatic surgery: State of the art

Pancreatic surgery is being offered to an increasing number of patients every year. Although postoperative outcomes have significantly improved in the last decades, even in high-volume centers patients still experience significant postoperative morbidity and full recovery after surgery takes longer than we think. In recent years, enhanced recovery pathways incorporating a large number of evidence-based perioperative interventions have proved to be beneficial in terms of improved postoperative outcomes, and accelerated patient recovery in the context of gastrointestinal, genitourinary and orthopedic surgery. The role of these pathways for pancreatic surgery is still unclear as high-quality randomized controlled trials are lacking. To date, non-randomized studies have shown that care pathways for pancreaticoduodenectomy and distal pancreatectomy are safe with no difference in postoperative morbidity, leading to early discharge and no increase in hospital readmissions. Hospital costs are reduced due to better organization of care and resource utilization. However, further research is needed to clarify the effect of enhanced recovery pathways on patient recovery and post-discharge outcomes following pancreatic resection. Future studies should be prospective and follow recent recommendations for the design and reporting of enhanced recovery pathways

Geographical Disparities and Patients’ Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy

Patients requiring complex treatments, such as pancreatic surgery, may need to travel long distances and spend extended periods of time away from home, particularly when healthcare provision is geographically dispersed. This raises concerns about equal access to care. Italy is administratively divided into 21 separate territories, which are heterogeneous in terms of healthcare quality, with provision generally decreasing from north to south. This study aimed to evaluate the distribution of adequate facilities for pancreatic surgery, quantify the phenomenon of long-distance mobility for pancreatic resections, and measure its effect on operative mortality. Data refer to patients undergoing pancreatic resections (in the period 2014–2016). The assessment of adequate facilities for pancreatic surgery, based on volume and outcome, confirmed the inhomogeneous distribution throughout Italy. The migration rate from Southern and Central Italy was 40.3% and 14.6%, respectively, with patients mainly directed towards high-volume centers in Northern Italy. Adjusted mortality for non-migrating patients receiving surgery in Southern and Central Italy was significantly higher than that for migrating patients. Adjusted mortality varied greatly among regions, ranging from 3.2% to 16.4%. Overall, this study highlights the urgent need to address the geographical disparities in pancreatic surgery provision in Italy and ensure equal access to care for all patients

Radiological Features of Microvascular Invasion of Hepatocellular Carcinoma in Patients with Non-Alcoholic Fatty Liver Disease

Background: The aim of the present study was to evaluate the presence and the prognostic value of the radiological signs of microvascular invasion (MVI) of hepatocellular carcinoma (HCC) in patients with non-alcoholic fatty liver disease (NAFLD). Methods: Between January 2015 and December 2017, all patients (91 patients) with de novo HCC or HCC recurrence occurring at least 2 years after the last treatment in NAFLD (36 patients) or with hepatitis C virus (HCV) liver disease (55 patients) were included. Each HCC was treated with liver resection and transplantation to obtain the anatomopathological confirmation of MVI. All patients had at least one available computed tomography (CT) scan or magnetic resonance imaging (MRI) performed no more than one month prior to the treatment. The clinical data of each patient, tumor burden (diameter, margins, two-trait predictor of venous invasion (TTPVI), and peritumoral enhancement), the recurrence rate (RR) after a 1-year follow-up, and the time to recurrence (TTR) were collected. Results: The NAFLD–HCC nodules were larger as compared to HCV–HCC (51 mm vs. 36 mm, p = 0.004) and showed a higher prevalence of TTPVI (38.9 vs. 20.0%, p = 0.058). At multivariate analysis, nodule diameter >50 mm was found to be the only independent prognostic factor of TTPVI (hazard ratio: 21.3, 95% confidence interval: 4.2–107.7, p p = 0.002). No correlations were found between TTR and irregular tumor margins or peritumoral enhancement. Conclusion: The NAFLD–HCC patients had larger tumors at diagnosis and showed a more frequent presence of radiological signs of MVI as compared to the HCV–HCC patients. The MVI was related to a more rapid recurrence after curative treatments, demonstrating the prognostic value of this radiological diagnosis