Robotic-assisted harvest of latissimus dorsi muscle flap for breast reconstruction: review of the literature

Robotic-assisted surgery continues to gain ground over conventional surgical methods, due to reported better results regarding the aesthetic outcome and the decreased percentage of complications. Although latissimus dorsi flap harvesting for breast reconstruction has been already used for several years, a plethora of serious complications has been reported. Recently, minimally invasive surgical approaches, such as robotic-assisted technique, have been suggested with conflicting outcomes to overcome technical difficulties. Therefore, the literature review was conducted regarding robotic-assisted harvesting of the latissimus dorsi flap for breast reconstruction. A narrative review of the contemporary literature was performed in the PubMed database for the use of robotic-assisted surgery of latissimus dorsi muscle flap harvesting for breast reconstruction. Appropriate search terms were used, and specific inclusion and exclusion criteria were applied. Five studies met the inclusion criteria. A total of 32 cases of robotically assisted harvesting of pedicled latissimus dorsi muscle flap for implant-based breast reconstruction have been identified. All flaps were successfully harvested without converting in the traditional open procedure. There were no significant postoperative complications, expect from few cases of postoperative seromas, which were conservatively managed. Additionally, all patients were satisfied with their postoperative cosmetic outcome. The robotic-assisted harvesting technique of the latissimus dorsi flap for breast reconstruction is safe and comparable to the conventional methods. Reduced hospital stays and superior aesthetic outcome are the main advantages, while total cost and the difficulty of reaching the learning curve plateau are the main concerns regarding this modern and minimally invasive surgical approach

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Peroxisome proliferator-activated receptor-γ (PPAR-γ) ligands: Novel pharmacological agents in the treatment of ischemia reperfusion injury

Peroxisome proliferator-activated receptor-γ (PPAR-γ) ligands constitute important insulin sensitizers that have already been used for the treatment of human metabolic disorders, exerting also pleiotropic effects on inflammatory related diseases and cancer. Ischemia-reperfusion injury that is mainly associated with organ transplantation constitutes a serious complication with a great relevance in clinical practice. Accumulating experimental data have recently revealed that natural and synthetic PPAR-γ ligands exert beneficial effects against ischemia-reperfusion injury. The present review summarizes the available information on the role of PPAR-γ ligands in ischemia-reperfusion injury amongst the different organ systems. Taking into consideration the data so far, PPAR-γ ligands seem to represent potential therapeutic agents in the aim to reduce or even prevent injury associated with ischemia-reperfusion. © 2008 Bentham Science Publishers Ltd

Neovascularization: an attractive but tricky target in thyroid cancer

Introduction: Neovascularization in carcinogenesis and tumor progression is well-established. Molecular mediators implicated in different modes of vascular remodeling and expansion (e.g. sprouting angiogenesis (SA), vasculogenesis, vascular mimicry) are evaluated as prognostic biomarkers and therapeutic targets in different malignant tumors. Significant progress has been made in the understanding of the complex interplay between thyroid cancer (TC) cells and the tumor microenvironment, thus unraveling the role of angiogenic mediators. Areas covered: This review summarizes current research on neovascularization and TC. Current knowledge on vascular remodeling, in the context of carcinogenesis, is presented. Preclinical and clinical data from TC studies are also discussed. Expert opinion: There is a remarkable effort to pharmacologically target several key molecules of vessel-forming cascades. Despite encouraging preclinical results, clinical outcomes in TC are not optimal, possibly reflecting knowledge gaps in the pathophysiology of neovascularization in thyroid tissue. Increasing amounts of data support the possibility that redundancy of pathways that regulate vascular network remodeling allows tumors to adapt in different conditions. Hypothesizing that alternative forms of neovascularization upregulate when SA is pharmacologically blocked, targeting two or more different pathways of neovascularization could be a promising future strategy. Further research is required to explore molecular mechanisms of neovascularization in TC. © 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group

Long-term sequelae of the less than total thyroidectomy procedures for benign thyroid nodular disease

Introduction: Nodular goiter is the most common disorder of the thyroid gland. Less than total thyroidectomy procedures are considered the gold standard in the surgical management of nodular thyroid disease despite its propensity for recurrence. The aim of the study was to assess long-term sequelae of the less than total thyroidectomy procedures. Material and methods: In this single-center retrospective study, records of 154 patients that underwent less than total thyroidectomy, for nodular disease and/or hyperthyroidism between 1998 and 2013, were reviewed. Patients with malignant findings in the histology report and a follow-up of less than 5 years were excluded. Results: The mean age of the recorded patients was 65.1 ± 12.91 years of which 132 were females. Subtotal thyroidectomy was performed in 45.5% of the study population, 22.1% underwent partial thyroidectomy, while the remaining 32.5% underwent lobectomy. Long-term thyroxine supplementation was administered in 138 patients (89.6%). Recurrence of clinically important nodules (>1 cm) was observed in 68.2% of patients but only 11% of the population underwent completion thyroidectomy. In the univariate analysis, the duration of follow-up (p = 0.00005, C.I.: 0.903–0.965) as well as the type of operation (p = 0.035, C.I.: 1.031–2.348) appeared to have a significant correlation with nodular recurrence. The multivariate analysis identified the duration of follow-up (p = 0.0005, C.I.: 0.908–0.973) as the only significant predictive factor of nodular recurrence. Conclusion: This is the first study with such a long duration of post-operative follow-up. The high rate of nodular recurrence in less than total thyroidectomy procedures along with the lifelong need for thyroxine supplementation suggest that a more conservative surgical approach is needed. When surgery is recommended, we suggest total thyroidectomy as the treatment of choice to avoid the recurrence of disease, the high cost associated with frequent follow-ups by means of sonography as well as thyroxine replacement therapy. © 2018, Springer Science+Business Media, LLC, part of Springer Nature

Tumor microenvironment in adrenocortical carcinoma: Barrier to immunotherapy success?

Adrenocortical carcinoma is a rare malignancy with aggressive behavior, with up to 40% of patients presenting with metastases at the time of diagnosis. Both conventional chemotherapeutic regimens and novel immunotherapeutic agents, many of which are currently being tested in ongo-ing clinical trials, have yielded modest results so far, bringing the need for a deeper understanding of adrenal cancer behavior to the forefront. In the recent years, the tumor microenvironment has emerged as a major determinant of cancer response to immunotherapy and an increasing number of studies on other solid tumors have focused on manipulating the microenvironment in the favor of the host and discovering new potential target molecules. In the present review we aim to explore the characteristics of adrenocortical cancer’s microenvironment, highlighting the mechanisms of immune evasion responsible for the modest immunotherapeutic results, and identify novel potential strategies. © 2021 by the authors. Licensee MDPI, Basel, Switzerland