Impact of body mass index in elderly patients treated with laparoscopic liver resection for hepatocellular carcinoma.

BACKGROUND: The impact of obesity on surgical outcomes in elderly patients candidate for liver surgery is still debated. AIM: To evaluate the impact of high body mass index (BMI) on perioperative and oncological outcome in elderly patients (> 70 years old) treated with laparoscopic liver resection for hepatocellular carcinoma (HCC). METHODS: Retrospective multicenter study including 224 elderly patients (> 70 years old) operated by laparoscopy for HCC (196 with a BMI < 30 and 28 with BMI ≥ 30), observed from January 2009 to January 2019. RESULTS: After propensity score matching, patients in two groups presented comparable results, in terms of operative time (median range: 200 min vs 205 min, P = 0.7 respectively in non-obese and obese patients), complications rate (22% vs 26%, P = 1.0), length of hospital stay (median range: 4.5 d vs 6.0 d, P = 0.1). There are no significant differences in terms of short- and long-term postoperative results. CONCLUSION: The present study showed that BMI did not impact perioperative and oncologic outcomes in elderly patients treated by laparoscopic resection for HCC.

Liver resection versus radiofrequency ablation in octogenarian patients for hepatocellular carcinoma: a propensity score multicenter analysis.

BACKGROUND: Liver resection (LR) and radiofrequency ablation (RFA) are considered curative options for hepatocellular carcinoma (HCC). The aim of this study was to compare outcomes after LR and RFA in octogenarian patients with HCC. MATERIALS AND METHODS: This multicenter retrospective study included 102 elderly patients (> 80 years old) treated between January 2009 and January 2019, who underwent LR or RFA for HCC (65 and 37 with, respectively). RESULTS: After Propensity Score Matching, the postoperative course of LR was burdened by a higher rate of complications than RFA group (64% vs 14%, respectively, p: 0.001). The LR group had also significantly longer operative time (207 ± 85 min vs 33 ± 49 min, p < 0.001) and postoperative hospital stays than the RFA group (7 d vs 2 d, p = 0.019). Overall survival at 1-, 2-, and 3-year were 86%, 86%, and 70% for the LR group and 82%, 64%, and 52% for the RFA group (p = 0.380). Disease-free survival at 1-, 2-, and 3-year were 89%, 74%, and 56% for the LR group, and 51%, 40%, and 40% for the RFA group (p = 0.037). CONCLUSION: Despite a higher rate of Dindo-Clavien I-II post-operative complications, a longer operative time and length of hospital stay, LR in octogenarian patients can provide comparable 90d mortality than RFA and better long-term outcomes.

Peri-operative score for elderly patients with resectable hepatocellular carcinoma.

BACKGROUND: Liver resection is the mainstay for a curative treatment for patients with resectable hepatocellular carcinoma (HCC), also in elderly population. Despite this, the evaluation of patient condition, liver function and extent of disease remains a demanding process with the aim to reduce postoperative morbidity and mortality. AIM: To identify new perioperative risk factors that could be associated with higher 90- and 180-d mortality in elderly patients eligible for liver resection for HCC considering traditional perioperative risk scores and to develop a risk score. METHODS: A multicentric, retrospective study was performed by reviewing the medical records of patients aged 70 years or older who electively underwent liver resection for HCC; several independent variables correlated with death from all causes at 90 and 180 d were studied. The coefficients of Cox regression proportional-hazards model for six-month mortality were rounded to the nearest integer to assign risk factors' weights and derive the scoring algorithm. RESULTS: Multivariate analysis found variables (American Society of Anesthesiology score, high rate of comorbidities, Mayo end stage liver disease score and size of biggest lesion) that had independent correlations with increased 90- and 180-d mortality. A clinical risk score was developed with survival profiles. CONCLUSION: This score can aid in stratifying this population in order to assess who can benefit from surgical treatment in terms of postoperative mortality.

Laparoscopic major hepatectomy for hepatocellular carcinoma in elderly patients: a multicentric propensity score­based analysis.

BACKGROUND: Considering the increase in overall life expectancy and the rising incidence of hepatocellular carcinoma (HCC), more elderly patients are considered for hepatic resection. Traditionally, major hepatectomy has not been proposed to the elderly due to severe comorbidities. Indeed, only a few case series are reported in the literature. The present study aimed to compare short-term and long-term outcomes between laparoscopic major hepatectomy (LMH) and open major hepatectomy (OMH) in elderly patients with HCC using propensity score matching (PSM). METHODS: We performed a multicentric retrospective study including 184 consecutive cases of HCC major liver resection in patients aged ≥ 70 years in _8 European Hospital Centers. Patients were divided into LMH and OMH groups, and perioperative and long-term outcomes were compared between the 2 groups. RESULTS: After propensity score matching, 122 patients were enrolled, 38 in the LMH group and 84 in the OMH group. Postoperative overall complications were lower in the LMH than in the OMH group (18 vs. 46%, p < 0.001). Hospital stay was shorter in the LMH group than in the OMH group (5 vs. 7 days, p = 0.01). Mortality at 90 days was comparable between the two groups. There were no significant differences between the two groups in terms of overall survival (OS) and disease-free survival (DFS) at 1, 3, and 5 years. CONCLUSION: LMH for HCC is associated with appropriate short-term outcomes in patients aged ≥ 70 years as compared to OMH. LMH is safe and feasible in elderly patients with HCC.

Extended right colectomy, left colectomy, or segmental left colectomy for splenic flexure carcinomas: a European multicenter propensity score matching analysis.

BACKGROUND: The surgical resection of the splenic flexure carcinoma (SFC) is challenging and the optimal surgical procedure for SFCs remains a matter of debate. The present study aimed to compare in a multicenter European sample of patients the short- and long-term outcomes of extended right (ERC) vs. left (LC) vs. segmental left colectomy (SLC) for SFCs. METHODS: This retrospective multicenter study analyzed the surgical and oncological outcomes of SFC patients undergoing elective curative intent surgery between 2000 and 2018. Descriptive and exploratory analyses were first conducted on the whole sample. Outcomes of the different procedures (ERC vs. LC vs. SLC) were then compared using propensity score matching for multilevel treatment. Overall (OS) and disease-free survival (DFS) were evaluated by Kaplan-Meier method. RESULTS: From a total of 399 SFC patients, 143 (35.8%) underwent ERC, 131 (32.8%) underwent LC, and 125 (31.4%) underwent SLC. Overall, 297 (74.4%) were laparoscopic procedures. An increase in operative time, time to flatus, time to regular diet, and hospital stay was observed with the progressive extension of SFC resection. ERC was associated with significantly increased risk of postoperative ileus compared to both LC and SLC. A significantly greater number of lymph nodes were retrieved by ERC, but the objective of at least 12 retrieved lymph nodes was achieved in 85% of patients, without procedure-related differences. No differences were observed in OS or DFS between ERC, LC, and SLC. CONCLUSION: The present study supports the resection of SFCs by colon-sparing surgical techniques, such as SLC.

Predicting Difficult Laparoscopic Total Mesorectal Excision for Locally-advanced Mid-low Rectal Cancer: The EuMaRCS Score Validation.

BACKGROUND/AIM: The European MRI and Rectal Cancer Surgery (EuMaRCS) score was proposed to identify preoperatively difficult laparoscopic total mesorectal excision (L-TME) for locally advanced rectal cancer (LARC). This study aimed to test EuMaRCS's validity. PATIENTS AND METHODS: Data were retrieved from a European multicenter database, including patients with mid/low LARC, treated with neoadjuvant chemoradiation therapy and L-TME with primary anastomosis. The EuMaRCS score was calculated on: BMI>30 (3 points), interspinous distance<96.4 mm (2 points), ymrT stage≥T3b (4 points), and male sex (1 point). RESULTS: The sample was composed of 141 patients, of whom 23 (16.3%) had a difficult L-TME. The EuMaRCS score demonstrated high accuracy in predicting difficult surgery (AROC: 0.806, 95%CI=0.72-0.88), with a cut-off >3 being associated with the best balance in sensitivity (82.6%) and specificity (66.1%). CONCLUSION: The EuMaRCS score represents a validated tool to predict preoperatively difficult L-TME in LARC patients.

Liver transplantation for hepatocellular carcinoma after successful treatment of macrovascular invasion - a multi-center retrospective cohort study.

Macrovascular invasion is considered a contraindication to liver transplantation for hepatocellular carcinoma (HCC) due to a high risk of recurrence. The aim of the present multicenter study was to explore the outcome of HCC patients transplanted after a complete radiological regression of the vascular invasion by locoregional therapies and define sub-groups with better outcomes. Medical records of 45 patients were retrospectively reviewed, and imaging was centrally assessed by an expert liver radiologist. In the 30 patients with validated diagnosis of macrovascular invasion, overall survival was 60% at 5 years. Pretransplant alpha-fetoprotein (AFP) value was significantly different between patients with and without recurrence (P = 0.019), and the optimal AFP cutoff was 10ng/ml (area under curve = 0.78). Recurrence rate was 11% in patients with pretransplant AFP < 10ng/ml. The number of viable nodules (P = 0.008), the presence of residual HCC (P = 0.036), and satellite nodules (P = 0.001) on the explant were also significantly different between patients with and without recurrence. Selected HCC patients with radiological signs of vascular invasion could be considered for transplantation, provided that they previously underwent successful treatment of the macrovascular invasion resulting in a pretransplant AFP < 10 ng/ml. Their expected risk of post-transplant HCC recurrence is 11%, and further prospective validation is needed.

Comparison of Different Nodal Staging in Patients With Locally Advanced Mid-low Rectal Cancer After Long-term Neoadjuvant Chemoradiation Therapy.

BACKGROUND/AIM: The aim of this study was to compare the ability of different lymph nodal staging systems to predict cancer recurrence in a multicenter European series of patients who underwent proctectomy after neoadjuvant chemoradiotherapy for locally advanced rectal cancer. PATIENTS AND METHODS: Data on 170 consecutive patients undergoing proctectomy after neoadjuvant therapy for cT3-4 or cN+ rectal adenocarcinoma were retrieved from the European MRI and Rectal Cancer Surgery database. The prognostic role of the number of retrieved and examined nodes, nodal ratio, and log odds of positive lymph nodes (LODDS) was analyzed and compared by receiver operating characteristic curves, Pearson test, and univariate and multivariate analysis. RESULTS: At multivariate analysis, ypN, nodal ratio, and LODDS were all significantly associated with disease-free survival, but LODDS showed the strongest association (hazard ratio(HR)=2.39; 95% confidence interval(CI)=1.05-5.48; p=0.039). CONCLUSION: LODDS appears to be a useful prognostic indicator in the prediction of disease-free survival of patients undergoing neoadjuvant chemoradiotherapy and proctectomy for locally advanced rectal cancer.

Predictors of surgical outcomes and survival in rectal cancer patients undergoing laparoscopic total mesorectal excision after neoadjuvant chemoradiation therapy: the interest of pelvimetry and restaging magnetic resonance imaging studies.

BACKGROUND: Locally advanced rectal cancer (LARC) requires a multimodal therapy tailored to the patient and tumor characteristics. Pretreatment magnetic resonance imaging (MRI) is necessary to stage the primary tumor, while restaging MRI, which is not systematically performed, may be of interest to identify poor responders to neoadjuvant chemoradiation therapy (NCRT), and redefine therapeutic approach. The EuMaRCS study group aimed to investigate the role and accuracy of pretreatment (including pelvimetry) and restaging MRIs in predicting surgical difficulties and surgical outcomes in LARC therapy. METHODS: Patients with mid or low LARC who were administered NCRT, who underwent laparoscopic total mesorectal excision, and for whom pretreatment and restaging MRIs were available, were included. RESULTS: MRIs of 170 patients (median age: 61 years) were reanalyzed by the same radiologist. Pelvimetry differed significantly between males and females, but no gender difference was noted in the clinical and tumor characteristics. Tumor volume and tumor height assessed on the restaging MRI were associated, respectively, with operative time and estimated blood loss. Conversion was predicted by tumor volume, interischial distance and pubic tubercle height. The quality of the surgical resection was found to be a predictor of overall and disease-free survival. The sensitivity and specificity of tumor regression grade 1 to identify a pathologic complete response were 76.9% and 89.3%, respectively. CONCLUSIONS: In LARC management, pelvimetry and restaging MRI may be useful to predict surgical difficulties and surgical outcomes. However, the main independent predictor of patient survival appears to be the achievement of a successful surgical resection.

Multicentre propensity score-matched analysis of laparoscopic versus open surgery for T4 rectal cancer.

BACKGROUND: The use of laparoscopy for advanced-stage rectal cancer remains controversial. This study aimed to compare the operative and oncologic outcomes of laparoscopic (LAR) versus open anterior rectal resection (OAR) for patients with pT4 rectal cancer. METHODS: This is a multicenter propensity score matching (PSM) study of patients undergoing elective curative-intent LAR or OAR for pT4 rectal cancer (TNM stage II/III/IV) between 2005 and 2015. RESULTS: In total, 137 patients were included in the analysis. After PSM, demographic, clinical and tumor characteristics were similar between the 52 LAR and the 52 OAR patients. Overall, 52 tumors were located in the high rectum, 25 in the mid-rectum and 27 in the low rectum. Multivisceral resection was performed in 26.9% of LAR and 30.8% of OAR patients (p = 0.829). Conversion was required in 11 LAR patients (21.2%). The LAR group showed significantly shorter time to flatus (3.13 vs. 4.97 days, p = 0.001), time to regular diet (3.59 vs. 6.36 days, p < 0.0001) and hospital stay (15.49 vs. 17.96 days, p = 0.002) compared to the OAR group. The 90-day morbidity and mortality were not different between groups. In the majority of patients (85.6%), R0 resection was achieved. A complete mesorectal excision was obtained in 82.7% of LAR and 78.8% of OAR patients (p = 0.855). The 1-, 2- and 3-year overall survival rates were, respectively, 95.6, 73.8 and 66.7% for the LAR group and 86.7, 66.9 and 64.1% for the OAR group (p = 0.219). The presence of synchronous metastases (hazard ratio 2.26), R1 resection (HR 2.71) and lymph node involvement (HR 2.24) were significant predictors of overall survival. CONCLUSION: The present study suggests that LAR for pT4 rectal cancer can achieve good pathologic and oncologic outcomes similar to open surgery despite the risk of conversion. Moreover, laparoscopy offers the benefits of a faster recovery and a shorter hospital stay.

Laparoscopic vs. open surgery for T4 colon cancer: A propensity score analysis.

PURPOSE: The study aimed to compare, using propensity score matching (PSM) analyses, the short- and long-term results of laparoscopic colectomy (LC) versus open colectomy (OC) in a bicentric cohort of patients with T4 colon cancer. METHODS: This is a retrospective PSM analysis of consecutive patients undergoing elective LC or OC for pT4 colon cancer (TNM stage II/III) between 2005 and 2014. RESULTS: Overall, 237 patients were selected. After PSM, 106 LC-and 106 OC-matched patients were compared. LC was associated with longer operative time and lower blood loss than OC (220 vs. 190 min, p < 0.0001; 116 vs. 150 mL, p = 0.002, respectively). LC patients showed a faster recovery, which translated into a shorter hospital stay compared to OC (10.5 vs. 15.3 days, p < 0.0001). Conversion was required in 13 (12.2 %) LC patients. No group difference was observed for 30- and 90-day mortality. R0 resection was achieved in the majority of LC and OC patients (93.9 %). The 1-, 3-, and 5-year overall survival was 99, 76.8, and 58.6 %, respectively, for the LC group and 98, 70.1, and 59.9 %, respectively, for the OC group (p = 0.864). The 1-, 3-, and 5-year disease-free survival was 86.3, 66, 57.6 %, respectively, for the LC group and 79.1, 55.1, and 50.2 % for the OC group (p = 0.261). CONCLUSION: With an acceptable conversion rate, laparoscopy can achieve complete oncologic resections of T4 colon cancer similar to open surgery and can be considered a safe and feasible alternative approach that confers the advantage of a faster recovery.

Molecular networks in melanoma invasion and metastasis.

Metastatic melanoma accounts for approximately 80% of skin cancer-related deaths. Up to now there has been no effective treatment for stage IV melanoma patients due to the complexity and dissemination potential of this disease. Melanomas are heterogeneous tumors in which conventional therapies fail to improve overall survival. Targeted therapies are being developed, but the final outcome can be hampered by the incomplete knowledge of the process of melanoma progression. Even if the intracellular pathways are similar, the interaction of the cells with the surrounding environment should be taken into consideration. This article seeks to highlight some of the advances in the understanding of the molecular mechanisms underlying melanoma dissemination.

[Haemorrhoidal disease: role of conservative outpatient treatments]. / La malattia emorroidaria: ruolo dei trattamenti ambulatoriali conservativi.

AIM: This study is a critical review of conservative office treatments of haemorrhoidal disease. MATERIAL OF STUDY: Many are outpatient techniques proposed in current literature; several with small series, anecdotal ones or some ones yet abandoned for excessive morbidity (for example anal divulsion, dilatation and so on); among most used we describe procedure, indications, contraindications, results and limits about rubber band ligation, sclerotherapy, cryotherapy, infrared photocoagulation, bipolar diathermy and direct current therapy. RESULTS: Each method has its supporters, indications and limits; therefore in literature there are discordant opinions even when randomized studies are compared. Indeed each technique is been compared with one or more other ones but there is not a randomized trial which compares all these treatments. CONCLUSIONS: Conservative office techniques, and rubber band ligation in particular, have an important role in second degree haemorrhoidal disease, in non-responsive to medical treatment first degree and also in third degree haemorrhoids in elderly patients with comorbidity or with sectorial or moderate prolapse.