Editorial: Women in surgical oncology: 2021

Currently, female researchers represent merely a minority, accounting for an estimated 29.3% who end up covering this position worldwide, with a great variability according to each country (1). Specifically, Central Asia exhibits the greatest proportion of female researchers with an estimated 48.2% as opposed to South and West Asia with the lowest count globally (i.e. 18.5%) (1). In response to such a large gender gap in the scientific research community, the UNESCO Institute for Statistics (UIS) is in the midst of developing new indicators in order to better comprehend the reasons behind women’s decisions to pursue one career over another. Several could be the reasons implicated in limiting and discouraging women’s access to the scientific community, including ancient biases and gender stereotypes. By further understanding such issues, the UIS project concurrently aims at reducing the gender inequality in science, technology, engineering and mathematics (STEM) fields, by possibly promoting reforms in policies and implementing changes in favor of gender equality in all countries with the ultimate goal of empowering women (2

Response to Sleeve gastrectomy may double the risk of esophageal adenocarcinoma in morbidly obese patients

We would like to thank Papadia et al. for their interest in our article, “Esophageal Adenocarcinoma After Sleeve Gastrectomy: Actual or Potential Threat? Italian Series and Literature Review” [1]. We also greatly appreciated their attempt at evaluating the relative risk (RR) of developing esophageal adenocarcinoma (EAC) in patients who undergo sleeve gastrectomy (SG). To do so, they extrapolated the reported number of SGs performed in Italy over the 3-year period (2012–2015) in which the EAC cases belonging to our series occurred. Papadia et al. [1] show how SG may raise the risk of developing EAC by an estimated 11-fold compared with the general population. Furthermore, they highlight how the RR of EAC in the SG subpopulation appears to be substantially greater compared with patients affected by morbid obesity (RR of 11.9 versus 4.8, respectively). The authors also share our concern regarding the young age (40.3 ± 16.7 yr) and early presentation (27.3 ± 7.6 mo) of EAC after surgery, pointing out how the progression from a normal esophageal mucosa to Barrett’s esophagus (BE) generally befalls over a considerably longer timeframe in patients with GERD that did not have SG. This observation is supported by several studies published by our group demonstrating how the incidence of BE, 58 months after SG, is as high as 17.2%—consistent with other reported rates (i.e., 15%–18.8%) [2,3]—and is correlated to the increased presence of a biliary-type refluxate [[4], [5], [6]], likely to be responsible for the accelerated mucosal injury of the distal esophagus [7]. Emblematic is the case reported in literature of the patient who had a preoperatively diagnosed short-segment BE and who inevitably developed an EAC 36 months later [8]. Although a sporadically reported case, this further emphasizes not only the importance of performing a preoperative esophagogastroduodenoscopy (EGD) to detect any mucosal lesion, but also how BE should constitute an absolute contraindication to SG due to its innate risk of malignant evolution. Finally, loss to follow-up still represents a major, long-standing issue after bariatric surgery, which contributes to precluding the chance of performing protocols of secondary prevention for the identification of any esophageal malignancy at its earliest stages. To this regard, close endoscopic surveillance is of paramount importance for a prompt detection. We also would like to reiterate the necessity of having international online registries, which could allow physicians to determine the actual incidence of EAC after SG and to comprehend its pathogenesis, management, and outcomes possibly better. Despite this potential downside, SG persists as a safe and effective procedure for the cure of obesity and its co-morbid conditions, concurrently carrying low rates of long-term complications and nutritional deficiencies. Additionally, due to its greater technical simplicity and shorter operative time compared with other common bariatric procedures, SG is also the treatment of choice in the super-obese group, easily granting the option for revisional surgery (i.e., RYGB, one anastomosis gastric bypass [OAGB], duodenal switch [DS], single anastomosis duodeno-ileal sleeve [SADI-S]) in case of weight regain or insufficient weight loss. Hence, SG should yet be regarded as a fundamental and valuable bariatric operation to be performed after a thorough preoperative workup and a close endoscopic follow up

Obesity surgery and cancer. What are the unanswered questions?

Obesity has become a global epidemic with a soaring economic encumbrance due to its related morbidity and mortality. Amongst obesity-related conditions, cancer is indeed the most redoubtable. Bariatric surgery has been proven to be the most effective treatment for obesity and its associatedmetabolic and cardiovascular disorders. However, the understanding of whether and how bariatric surgery determines a reduction in cancer risk is limited. Obesity-related malignancies primarily include colorectal and hormone-sensitive (endometrium, breast, prostate) cancers. Additionally, esophago-gastric tumors are growing to be recognized as a new category mainly associated with post-bariatric surgery outcomes. In fact, certain types of surgical procedures have been described to induce the development and subsequent progression of pre-cancerous esophageal and gastric lesions. This emerging category is of great concern and further research is required to possibly prevent such risks. Published data has generated conflicting results. In fact, while overall cancer risk reduction was reported particularly in women, some authors showed no improvement or even increased cancer incidence. Although various studies have reported beneficial effects of surgery on risk of specific cancer development, fundamental insights into the pathogenesis of obesity-related cancer are indispensable to fully elucidate its mechanisms

Novel Modality of Endoluminal Anastomotic Integrity Assessment with Fluoroangiography After Left-sided Colorectal Resections

Background Several methods have been described for the intraoperative evaluation of colorectal anastomotic integrity. Technological evolution has allowed to progress from basic mechanical methods to the use of more sophisticated techniques. This study describes a novel endoluminal modality of colorectal anastomotic assessment through the use of a Disposable Rigid Scope Introducer (DRSI) also allowing for intraoperative endoluminal perfusion evaluation by indocyanine green (ICG) fluoroangiography in patients undergoing left-sided colorectal resection. Methods The DRSI consists of an endoluminal introducer device made up of an insertion tube and port connected to an insufflation bulb to manually insufflate the sigmoid and rectum and is compatible with any laparoscopic camera, also allowing for ICG fluoroangiography for perfusion purposes. Results The DRSI was successfully used to assess anastomotic integrity after left-sided colorectal resections performed in 16 consecutive patients. The DRSI allowed to visualize by fluoroangiography the quality of tissue perfusion at the anastomotic site in all cases, contributing to the decision of avoiding loop ileostomies in low rectal resections. In 2 cases, the DRSI showed the presence of significant anastomotic bleeding which was successfully controlled by laparoscopic suture placement. No adverse event resulted from the use of this device. Conclusions The DRSI combines direct endoluminal visualization of the anastomosis together with real-time evaluation of its blood flow. This device holds great potential for prompt intraoperative detection of anastomotic alterations, possibly reducing the risk of postoperative anastomotic bleeding or leaks related to mechanical construction/perfusion issues. Potential advantages of this device warrant larger cohort studies and prospective randomized trials

Esophageal adenocarcinoma after sleeve gastrectomy. Actual or potential threat? Italian series and literature review

Background:Sleeve gastrectomy (SG) leads to esophageal mucosal damage in an elevated percent-age of cases, configuring a clinical condition of Barrett’s esophagus (BE) in a proportion as high as15–18.8%. BE may rarely evolve into esophageal adenocarcinoma (EAC).Objectives:To raise awareness of BE as a precancerous lesion which may progress toward malig-nancy after this popular bariatric procedure.Setting:Bariatric referral centers, Italy.Methods:All patients referred to our bariatric center who developed an EAC after SG between 2012and 2019 were reviewed and consecutively included in this study. The available scientific literatureregarding this complication is additionally reviewed.Results:The 3 male patients comprised in this case series underwent laparoscopic SG between 2012and 2015 in different bariatric referral centers. Age and body mass index at baseline ranged from 21–54 years and 43.1–75.6 kg/m2, respectively. All patients were lost to follow-up early after surgery (3.761.4 months), and were diagnosed with EAC at a mean of 27.367.6 months after SG. The 4 re-ported cases in the scientific literature developed an EAC at a mean of 32.5623 months fromSG. Overall, a diagnosis of EAC was made approximately 30.3617.1 months postoperatively, whichseems relatively and worryingly early after surgery. Conclusion:Although the rate and probability of progression from BE to EAC is still not well defined,assuming that the rising popularity and execution of SG leads to a growth in the BE incidence, then thepreoperative identification and stratification of cancer risk factors in this subset of patients is stronglyencouraged. Clinical and endoscopic follow-ups are essential to allow for prevention and early diag-nosis and for epidemiologic data collection purposes

Spider surgical system versus multiport laparoscopic surgery. Performance comparison on a surgical simulator

BACKGROUND: The rising interest towards minimally invasive surgery has led to the introduction of laparo-endoscopic single site (LESS) surgery as the natural evolution of conventional multiport laparoscopy. However, this new surgical approach is hampered with peculiar technical difficulties. The SPIDER surgical system has been developed in the attempt to overcome some of these challenges. Our study aimed to compare standard laparoscopy and SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS). METHODS: Twenty participants were divided into two groups based on their surgical laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 laparoscopists in the experienced group. Participants performed the FLS pegboard transfers task and pattern cutting task on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales were used to compare conventional laparoscopy and SPIDER surgical system. RESULTS: Both groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER. Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005). Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007). Same aspects were highlighted for the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task. CONCLUSIONS: Even though the SPIDER is an innovative and promising device, our study proved that it is more challenging than conventional laparoscopy in a population with different degrees of surgical experience. We presume that a possible way to overcome such challenges could be the development of tailored training programs through simulation methods. This may represent an effective way to deliver training, achieve mastery and skills and prepare surgeons for their future clinical experience

Incidence of lymphomas in inflammatory bowel disease: report of an emblematic case, systematic review, and meta-analysis

IntroductionOver the past 20 years, the increasing use of combined therapy with immunosuppressants and biologic agents has markedly reduced the use of steroids in the management of inflammatory bowel diseases (IBD). However, medical therapy seems to promote, in the long run, carcinogenesis resulting in an increased risk of developing different types of malignancies, including lymphomas. The aim of this study was to systematically review the current incidence and prognosis of lymphoid neoplasms occurring in patients with IBD.MethodsStudies analyzing the incidence of lymphomas in subjects of age >18 years affected by IBD were included in this systematic review and meta-analysis. Studies focusing on pediatric populations, not reporting person-years of follow-up, or with a duration < 1 year were excluded. PubMed, Embase, Web of Science Core Collection, and Cochrane Central Register were searched from inception through January 2022. Publication bias within studies was assessed using Begg's and Egger's tests and random effects model. Quantitative results were synthesized using relative-risk meta-analysis. PRISMA guidelines were used to carry out this systematic review (PROSPERO Registration Number: CRD42023398348).ResultsA total of 345 studies published between 1985 and 2022, with a total of 6,17,386 patients were included in the meta-analysis. Substantial heterogeneity between studies prevented the pooling of estimates (I2 = 97.19%). Evidence of publication bias was overall low (p = 0.1941). Patients affected by Crohn's disease (CD) were 1,86,074 (30.13%), while 2,78,876 (46.17%) were diagnosed with UC. The remaining 23.7% of cases were diagnosed with indeterminate colitis. Immunomodulators and biologic therapy were used in 24,520 (5.27%), and 17,972 (3.86%) patients, respectively. Reported incidence rates for lymphoma in IBD ranged from 0.0/100,000 person/years (py) (95% CI 0.0–3.7/100,000) to 89/100,000 py (95% CI 36–160/100,000). Reported incidence rates of lymphoma in CD ranged from 0.0/100,000 py (95% CI 0.0–3.7/100,000) to 91/100,000 py (95% CI 18–164/100,000). For UC, the incidence rate ranged from 0.0/100,000 py (95% CI 0.0–3.7/100,000) to 95/100,000 py (95% CI 0–226/100,000). Male-to-female ratio was ~4:1. Therapy with immunomodulators was directly associated with an increased incidence of lymphoma (p < 0.0001). Evidence of publication bias was overall low (p = 0 .1941).ConclusionsThe evidence arising from this study highlights a correlation between the use of immunomodulators and subsequent lymphoma development. Combined multidisciplinary approach and long-term follow-up are warranted in order to decrease mortality deriving from the coexistence of both conditions.Systematic review registrationIdentifier: CRD42023398348

SICOB-endorsed national Delphi consensus on obesity treatment optimization: focus on diagnosis, pre-operative management, and weight regain/insufficient weight loss approach

Purpose: Overweight and obesity affects 60% of adults causing more than 1.2 million deaths across world every year. Fight against involved different specialist figures and multiple are the approved weapons. Aim of the present survey endorsed by the Italian Society of Bariatric Surgery (SICOB) is to reach a national consensus on obesity treatment optimization through a Delphi process. Methods: Eleven key opinion leaders (KOLs) identified 22 statements with a major need of clarification and debate. The explored pathways were: (1) Management of patient candidate to bariatric/metabolic surgery (BMS); (2) Management of patient not eligible for BMS; (3) Management of patient with short-term (2 years) weight regain (WR) or insufficient weight loss (IWL); (4) Management of the patient with medium-term (5 years) WR; and (5) Association between drugs and BMS as WR prevention. The questionnaire was distributed to 65 national experts via an online platform with anonymized results. Results: 54 out of 65 invited panelists (83%) respond. Positive consensus was reached for 18/22 statements (82%); while, negative consensus (s20.4; s21.5) and no consensus (s11.5, s17) were reached for 2 statements, respectively (9%). Conclusion: The Delphi results underline the importance of first-line interdisciplinary management, with large pre-treatment examination, and establish a common opinion on how to properly manage post-operative IWL/WR. Level of evidence v: Report of expert committees

Upper gut heat shock proteins HSP70 and GRP78 promote insulin resistance, hyperglycemia, and non-alcoholic steatohepatitis

A high-fat diet increases the risk of insulin resistance, type-2 diabetes, and non-alcoholic steato-hepatitis. Here we identified two heat-shock proteins, Heat-Shock-Protein70 and Glucose-Regulated Protein78, which are increased in the jejunum of rats on a high-fat diet. We demonstrated a causal link between these proteins and hepatic and whole-body insulin-resistance, as well as the metabolic response to bariatric/metabolic surgery. Long-term continuous infusion of Heat-Shock-Protein70 and Glucose-Regulated Protein78 caused insulin-resistance, hyperglycemia, and non-alcoholic steato-hepatitis in rats on a chow diet, while in rats on a high-fat diet continuous infusion of monoclonal antibodies reversed these phenotypes, mimicking metabolic surgery. Infusion of these proteins or their antibodies was also associated with shifts in fecal microbiota composition. Serum levels of Heat-Shock-Protein70 and Glucose-Regulated Protein78were elevated in patients with non-alcoholic steato-hepatitis, but decreased following metabolic surgery. Understanding the intestinal regulation of metabolism may provide options to reverse metabolic diseases