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

Predicting Post-Hepatectomy Liver Failure in HCC Patients: A Review of Liver Function Assessment Based on Laboratory Tests Scores

The assessment of liver function is crucial in predicting the risk of post-hepatectomy liver failure (PHLF) in patients undergoing liver resection, especially in cases of hepatocellular carcinoma (HCC) which is often associated with cirrhosis. There are currently no standardized criteria for predicting the risk of PHLF. Blood tests are often the first- and least invasive expensive method for assessing hepatic function. The Child–Pugh score (CP score) and the Model for End Stage Liver Disease (MELD) score are widely used tools for predicting PHLF, but they have some limitations. The CP score does not consider renal function, and the evaluation of ascites and encephalopathy is subjective. The MELD score can accurately predict outcomes in cirrhotic patients, but its predictive capabilities diminish in non-cirrhotic patients. The albumin–bilirubin score (ALBI) is based on serum bilirubin and albumin levels and allows the most accurate prediction of PHLF for HCC patients. However, this score does not consider liver cirrhosis or portal hypertension. To overcome this limitation, researchers suggest combining the ALBI score with platelet count, a surrogate marker of portal hypertension, into the platelet–albumin–bilirubin (PALBI) grade. Non-invasive markers of fibrosis, such as FIB-4 and APRI, are also available for predicting PHLF but they focus only on cirrhosis related aspects and are potentially incomplete in assessing the global liver function. To improve the predictive power of the PHLF of these models, it has been proposed to combine them into a new score, such as the ALBI-APRI score. In conclusion, blood test scores may be combined to achieve a better predictive value of PHLF. However, even if combined, they may not be sufficient to evaluate liver function and to predict PHLF; thus, the inclusion of dynamic and imaging tests such as liver volumetry and ICG r15 may be helpful to potentially improve the predictive capacity of these models

A Comparison between Open and Minimally Invasive Techniques for the Resection of Colorectal Liver Metastasis

The liver is the most common site of colorectal cancer metastasis. Liver surgery is a cornerstone in treatment, with progressive expansion of minimally invasive surgery (MIS). This study aims to compare short- and long-term outcomes of open surgery and MIS for the treatment of colorectal adenocarcinoma liver metastasis during the first three years of increasing caseload and implementation of MIS use in liver surgery. All patients treated between November 2018 and August 2021 at Careggi Teaching Hospital in Florence, Italy, were prospectively entered into a database and retrospectively reviewed. Fifty-one patients were resected (41 open, 10 MIS). Considering that patients with a significantly higher number of lesions underwent open surgery and operative results were similar, postoperative morbidity rate and length of hospital stay were significantly higher in the open group. No differences were found in the pathological specimen. The postoperative mortality rate was 2%. Mean overall survival and disease-free survival were 46 months (95% CI 42–50) and 22 months (95% CI 15.6–29), respectively. The use of minimally invasive techniques in liver surgery is safe and feasible if surgeons have adequate expertise. MIS and parenchymal sparing resections should be preferred whenever technically feasible

Under fungal attack on a metalliferous soil: ROS or not ROS? Insights from Silene paradoxa L. growing under copper stress

We investigated how the adaptation to metalliferous environments can influence the plant response to biotic stress. In a metallicolous and a non-metallicolous population of Silene paradoxa the induction of oxidative stress and the production of callose and volatiles were evaluated in the presence of copper and of the PAMP fungal protein cerato-platanin, separately and in combination. Our results showed incompatibility between the ordinary ROS-mediated response to fungal attack and the acquired mechanisms of preventing oxidative stress in the tolerant population. A similar situation was also demonstrated by the sensitive population growing in the presence of copper but, in this case, with a lack of certain responses, such as callose production. In addition, in terms of the joint behaviour of emitted volatiles, multivariate statistics showed that not only did the populations respond differently to the presence of copper or biotic stress, but also that the biotic and abiotic stresses interacted in different ways in the two populations. Our results demonstrated that the same incompatibility of hyperaccumulators in ROS-mediated biotic stress signals also seemed to be exhibited by the excluder metallophyte, but without the advantage of being able to rely on the elemental defence for plant protection from natural enemies

Conservation of (87)Sr/(86)Sr isotopic ratios during the winemaking processes of 'Red' wines to validate their use as geographic tracer

(87)Sr/(86)Sr has been determined in wines, musts grape juices, soils and rocks from six selected vineyards of 'Cesanese' wine area. Cesanese is a monocultivar wine from a small region characterised by different geologic substrata, a key locality to test the influence of both substratum and winemaking procedure on the (87)Sr/(86)Sr of wines. Experimental work has been performed on wines from different vintage years to check possible seasonal variations. The data reveal that (87)Sr/(86)Sr does not change through time, to validate the selection of wineries performed, and in addition no isotopic variations are observed during winemaking. Indeed, no significant isotopic variations have been observed in musts and wines. These findings reinforce the hypothesis that the isotopic signature of wines is strongly related to the bioavailable fraction of the soil rather than to its bulk. The data corroborate the possibility that Sr-isotopes of high-quality wines can be used as a reliable tool for fingerprinting wine geographic provenance

ROBOTIC COLORECTAL RESECTION WITH AND WITHOUT THE USE OF THE NEW DA VINCI TABLE MOTION: A CASE MATCHED STUDY

Background: The da Vinci Table Motion (dVTM) is a new device that enables patients to be repositioned with instruments in place within the abdomen and without undocking the robot. The present study was designed to compare operative and short-term outcomes of patients undergoing colorectal cancer surgery with the da Vinci Xi system with or without use of the dVTM. Materials and Methods: Ten patients underwent robotic colorectal resection for cancer with the use of dVTM (Xi-dVTM group) between May 2015 and October 2015 at our center. The intraoperative and short-term clinical outcome were compared, using case-control methodology (propensity scores approach to create 1:2 matched pairs), with a similar group of patients who underwent robotic colorectal surgery for cancer without the use of the dVTM device (Xi only group). Results: There was a significant difference between the two groups in mean overall robotic operative time (227 min in Xi-dVTM group versus 297 min in Xi only group, p= 0.04). Operations were executed fully robotic in all Xi-dVTM cases, while two cases of Xi only group required conversion to open surgery because of bulky tumors and difficult exposure. Postoperative medical complications, were higher in Xi only group (11 vs 1, p= 0.024). Conclusions: This preliminary experience, with the use of new dVTM in colorectal surgery, by enhancing the workflow during use of the da Vinci Xi, resulted in improved exposure of operative field and enables change in the patient’s position, without the need for removing instruments. These added benefits result in a reduced overall robotic operative time, possibly a lower conversion rates and lower postoperative medical morbidity probably due more favourable patient positioning during surgery needed for optimal exposure of operative field

UTILIZZO DELLE NUOVE SUTURATRICI LINEARI ROBOTICHE ENDOWRIST PER IL SISTEMA DA VINCI XI NELLA RESEZIONE ANTERIORE DEL RETTO: STUDIO CASO-CONTROLLO DI CONFRONTO CON SUTURATRICI LINEARI LAPAROSCOPICHE TRADIZIONALI

INTRODUZIONE Le nuove suturatrici robotiche lineari per il sistema Da Vinci Xi, inserite attraverso uno specifico trocar robotico da 12 mm, sono controllate direttamente dal chirurgo operatore in consolle e dotate di sistema EndoWrist. Il presente studio si propone di comparare i risultati operatori del primo gruppo di pazienti sottoposti a resezione anteriore del retto per cancro con il nuovo sistema Da Vinci Xi e le nuove suturatrici, versus un gruppo comparabile in cui erano state utilizzate le suturatrici articolate laparoscopiche tradizionali. MATERIALI E METODI Da Dicembre 2015 a Maggio 2016, dodici pazienti sono stati sottoposti a resezione anteriore del retto robotica con l’ausilio della suturatrice robotica EndoWrist 45 mm (gruppo Xi-RobSTAP) presso il Centro Multidisciplinare di Chirurgia Robotica dell’Azienda Ospedaliero-Universitaria Pisana. I risultati operatori sono stati messi a confronto, mediante metodologia caso-controllo, con un analogo pool di pazienti sottoposti allo stesso tipo di intervento con l’utilizzo di una endostapler 60 mm laparoscopica tradizionale (gruppo Xi-TradSTAP). RISULTATI Non sono state necessarie conversioni della tecnica chirurgica (laparoscopica o laparotomica), in entrambi i gruppi. Per quanto riguarda il tempo operatorio totale e il docking non sono state riscontrate differenze significative nei due gruppi (326 min Xi-RobSTAP versus 279 min gruppo Xi-TradSTAP, p=0.08). Nel gruppo Xi-RobSTAP sono state necessarie in media 2,1 cariche contro le 3,2 nel gruppo Xi-TradSTAP (p=0.001). I tassi di complicanze intraoperatorie e la degenza media non sono risultate dissimili (6,8giorni nel gruppo Xi-RobSTAP versus 6,7 giorni nel gruppo Xi-TradSTAP; p=0.8) nei campioni in studio. CONCLUSIONI Nella nostra esperienza preliminare le nuove suturatrici lineari robotiche si sono rivelate facili da usare ed in grado di agevolare la fase di transezione del retto. Il minor numero medio di cariche utilizzate per la sezione distale potrebbe tradursi in una minore incidenza di fistole anastomotiche, ma questi dati preliminari, sebbene incoraggianti,necessitano di conferme con ulteriori stud

First Series of Rectal Resection with the New Robotic Endo-wrist Staplers for da Vinci XI: A Case Match-Study vs Traditional Laparoscopic Staplers

Introduction: The new robotic linear stapler, for the da Vinci Xi, is a device equipped with an Endo-Wrist technology and directly controlled by the surgeon at the console. We compared the operative and short-term results between patients undergoing a robotic anterior rectal resection with total mesorectal excision (TME) for cancer with the new endo-wrist staplers, and those in which were used the traditional laparoscopic ones.. Materials and Methods: We collected data about fifteen patients underwent an anterior rectal resection with TME for cancer, using the robotic Endo-Wrist 45 mm staplers (group Xi-RobSTAP) at our multidisciplinary robotic center from December 2015 to July 2016.The case-control group was composed, using a case-control methodology, by a similar pool of patients who performed the same surgery with the use of a 60 mm traditional laparoscopic endo-stapler, applied by the bed-side assistant (Xi-TradSTAP group). A diverting ileostomy was fashioned in 13 patients of each group. Results:There were no significant differences in the two groups in mean operative time (315±59.2 min RobSTAP Xi group versus 295±60.8 min Xi-TradSTAP group, p=0.3). The mean number of stapler’s charges for each case, was significantly different (2.1±0.2 charges in Xi-RobSTAP group versus 2.9±0.5 in Xi-TradSTAP group; p=0.001). The rates of intra-operative complications and the average hospital stay were similar (7.5±2.7 days in Xi-RobSTAP group versus 6.8±1.3 days in the Xi-TradSTAP group; p= 0.5). No need to convert to laparoscopy or laparotomy in both groups. Anastomotic fistula at contrast enema (not symptomatic except for one case of Xi-TradSTAP group) performed during the follow up period, was higher in the Xi-TradSTAP group, although without statistically significance (3 leak versus 1 leak in the Xi-RobSTAP group; p=0.15).. Although not statistically significant, time elapse between the intervention and stoma closure was shorter in the Xi-RobSTAP group (4.2±3.1 month in Xi-TradSTAP and 2.7±2.1 month in Xi-RobSTAP group; p=0.17). Conclusion: In our preliminary experience the new robotic linear staplers seemed to give some advantages in terms of easy transection that could result in a reduction of average number of stapler firing used during rectal resection and with a lower incidence of anastomotic leakage. These promising data are very preliminary and need to be verified on a larger experiences

Use of a new integrated table motion for the da Vinci Xi in colorectal surgery

Background: Integrated table motion (ITM) is a new feature comprising a unique operating table by Trumpf Medical that communicates wirelessly with the da Vinci Xi surgical system. ITM has been specifically developed to improve multiquadrant robotic surgery such as that conducted in colorectal surgery. Herein we present one of the first case series using this device in human colorectal surgery in the European Union. Methods: Between May and October 2015, a prospective post-market study was conducted on ITM in the EU in 40 cases from different specialties. The colorectal study group comprised 10 patients. Primary end-points were ITM feasibility, safety and efficacy. Results: Seven patients underwent anterior rectal resection with total mesorectal excision, while two patients underwent right colectomy and one patient underwent sigmoidectomy. Mean number of ITM moves was three during anterior rectal resection, and four during right colectomy; there were 33 instances of table moves in the 10 procedures. All ITM moves were made to gain internal exposure. The endoscope remained inserted during 31 of the 33 table movements (94%), while the instruments remained inserted during 28 of the 33 moves (84.8%). No external instrument collisions or other problems related to the operating table were noted. There were no ITM safety-related observations and no adverse events. Conclusions: This preliminary study demonstrated the feasibility, safety and efficacy of ITM for the da Vinci Xi surgical system. ITM enabled patient repositioning without disrupting surgical workflow by allowing the surgeon to leave instruments and the endoscope docked to the patient. ITM was safe, with no adverse events related to its use. Further studies will be useful to define the real role and potential benefit of ITM