Exploring 6 years of colorectal cancer surgery in rural Italy: insights from 648 consecutive patients unveiling successes and challenges.

The multidisciplinary management of patients suffering from colorectal cancer (CRC) has significantly increased survival over the decades and surgery remains the only potentially curative option for it. However, despite the implementation of minimally invasive surgery and ERAS pathway, the overall morbidity and mortality remain quite high, especially in rural populations because of urban - rural disparities. The aim of the study is to analyze the characteristics and the surgical outcomes of a series of unselected CRC patients residing in two similar rural areas in Italy. A total of 648 consecutive patients of a median age of 73 years (IQR 64-81) was enrolled between 2017 and 2022 in a prospective database. Emergency admission (EA) was recorded in 221 patients (34.1%), and emergency surgery (ES) was required in 11.4% of the patients. Tumor resection and laparoscopic resection rates were 95.0% and 63.2%, respectively. The median length of stay was 8 days. The overall morbidity and mortality rates were 23.5% and 3.2%, respectively. EA was associated with increased median age (77.5 vs. 71 ys, p < 0.001), increased mean ASA Score (2.84 vs. 2.59; p = 0.002) and increased IV stage disease rate (25.3% vs. 11.5%, p < 0.001). EA was also associated with lower tumor resection rate (87.3% vs. 99.1%, p < 0.001), restorative resection rate (71.5 vs. 89.7%, p < 0.001), and laparoscopic resection rate (36.2 vs. 72.6%, p < 0.001). Increased mortality rates were associated with EA (7.2% vs. 1.2%, p < 0.001), ES (11.1% vs. 2.0%, p < 0.001) and age more than 80 years (5.8% vs. 1.9%, p < 0.001). In rural areas, high quality oncologic care can be delivered in CRC patients. However, the surgical outcomes are adversely affected by a still too high proportion of emergency presentation of elderly and frail patients that need additional intensive care supports beyond the surgical skill and alternative strategies for earlier detection of the disease.

Real-Life Experience of the Prognostic Significance of the Primary Tumor Location on the Timing of Colorectal Liver Metastases: A Retrospective Analysis.

Background Numerous research studies have looked into how the primary tumor location (PTL) affects patients' prognosis for colorectal cancer (CRC). Our research aimed to investigate the prognostic effects of PTL in patients with synchronous (SM) and metachronous (MM) colorectal cancer liver metastases (CRCLM). Material and methods From 2016 to 2021, we looked back at the records of patients at our institute who were affected by CRCLM. Results 109 patients were included, of whom 21.1% received CRCLM resection (R0=73.9%), with 57.7% having left-sided colon cancer (LCC) and 42.2% having right-sided colon cancer (RCC). SM predominated (69.7%). The median duration of follow-up was 21,3 months (95%CI=15,4-25,2). ≥5 hepatic metastases prevailed in the SM group (N=61; 83.5%). 21% of all patients underwent CRCLM resection (R0=78.2%). We observed a double rate of patients unresponsive to standard systemic antineoplastic treatments in the SM group (35.8% vs. 17.9% of the MM group) (p=0.27). We found a significantly longer median overall survival (OS) in patients with MM-LCC compared with the other groups (27.7 months; HR=0.3797; 95%CI=0.19-0.74; p=0.0205). The median OS, regardless of PTL, was higher in the MM group (16,5 months vs. 16,1 months; HR=0,29; 95%CI=0,13-0,67; p=0.0038) as well as progression-free survival (PFS) (11 months vs. 10,2 months; HR=0,61; 95%CI=0,33-1,12; p=0.11). Finally, in patients undergoing liver surgery, a noteworthy median OS was shown to be significantly in favor of patients with metachronous liver metastases from the primary left tumor (37.0 months; HR=0.47; 95%CI=0.11-1.96; p=0.0041). Conclusions Our real-life study demonstrated that patients with LCC, particularly MM-LCC, have the highest survival and that the timing of CRCLM should be a prognostic factor.

Correlation of Tumor Location to Clinical Outcomes in Colorectal Cancer: A Single-institution Retrospective Analysis.

BACKGROUND/AIM: Recent data highlighted that location of metastatic colorectal cancer (mCRC) may have a prognostic impact and also a predictive value of the outcomes of first-line therapy. MATERIALS AND METHODS: The records of mCRC patients who underwent first-line therapy from 2011 to April 2018 at our Institute were retrospectively reviewed. Progression-free survival (PFS), overall survival (OS) and objective response rate (ORR) according to the primary tumor location were investigated. RESULTS: Overall, 130 patients were eligible. Two-year OS was 82.9% in left-sided colon cancers (LCC) and 67.5% in right-sided (RCC) (p=0.32). One-year mPFS was statistically longer in LCC (46.8% vs. 24.2%, p=0.0005). mPFS was longer in LCC treated with anti-VEGF vs. anti-EGFR (p=0.06). ORR was 51.1% in LCC, 25% in RCC (p=0.008). Overall, 11 complete responses all in LCC were observed (p=0.03). CONCLUSION: Tumor location has a prognostic impact and might influence the outcomes of mCRC patients.

Advantages of the Maneuver of Intestinal Derotation for Pancreaticoduodenectomy.

BACKGROUND AND AIMS: Pancreaticoduodenectomy (PD) is the surgical treatment of choice for cephalopancreatic cancer representing the only hope of cure. Since its first description in 1935 by Allan Whipple, several modifications have been proposed. The execution of the Cattell-Braasch maneuver of intestinal derotation (ID) in the course of PD, by restoring the entire bowel to its embryological position, could represent a further and multiexpedient variant. MATERIALS AND METHODS: We retrospectively studied 45 consecutive pancreatic cancer patients treated with Whipple-Child PD in which the Cattell-Braasch procedure of ID was performed as integrative part of the intervention. Additionally, we compared our results with the ones of conventional PD performed through open, laparoscopy, and robotic surgery. Continuous variables of ID-PD were calculated using Student's t-test whereas Mantel-Haenszel method was used for comparison with other non-ID PD techniques. RESULTS: The average operative time was 342 min (range 250-435 min). The median estimated intraoperative blood loss was 460 ml (range 350-570 ml) (p < .0001); no intraoperative blood transfusion was required. The average number of lymph nodes harvested per specimen was 19.4 (range 17-25) (p < .0001). Morbidity and mortality rate was 28.8% and 4.4% (respectively p < .0001 and p = .1596). CONCLUSION: Our data are in keeping with the classical PDs performed without ID. The association of the maneuver of ID with PD seems to bring some important advantages such as wider exposure of the operative field, safer dissection of anatomical structures, less intraoperative blood loss and higher number of sampled lymph nodes.

[Left paraduodenal hernia: a case report and review of the literature]. / Ernia paraduodenale sinistra: case report e review della letteratura.

Paraduodenal hernia is a rare internal congenital hernia due to an embryological abnormality. It is often associated with non-specific abdominal symptoms. In this report the authors describe the case of a woman who was referred to the emergency ward for intestinal obstruction. Preliminary examinations (x-ray and computed tomography scan) failed to yield a clear diagnosis. The patient underwent a surgical procedure and a left paraduodenal hernia was diagnosed. A sound knowledge of embryological anatomy is essential for safe, effective surgical treatment of such internal hernias. A review of the literature confirms that this congenital abnormality is rare and that its diagnosis is the most difficult step in its therapeutic management.

Selected treatments for duodenal perforation after ERCP. A report of three cases.

Perforation is one of the most serious complications of endoscopic sphincterotomy. In the last decade, the management has shifted towards a more selective approach. Three cases are reported here involving three different treatments. In one case, the patient was submitted to a surgical procedure, while a conservative strategy was preferred in the other two, consisting in a naso-biliary drain and endoscopic clip placement, respectively. In this way, the safety of surgical and nonsurgical management of ERCP-related duodenal perforations was tested.

[Laparoscopic appendectomy: retrospective studies of 172 consecutive procedures]. / Appendicectomia laparoscopica: analisi retrospettiva su 172 procedure consecutive.

The aim of our study was to assess the efficacy and safety of laparoscopic appendectomy, as performed by experienced and trainee surgeons in a Unit of General Surgery. From June 1997 to May 2002, 172 patients underwent laparoscopic appendectomy. Age below 13 years was an exclusion criterion. There was no single protocol for the diagnosis and surgical technique adopted by the different surgeons. The average operating time was 65.3 min (range: 41-106 min). There were 9 conversions to open surgery (5.2%) and 9 postoperative complications (5.5%) out of a total of 162 patients undergoing the laparoscopic procedure. Oral intake was resumed on post-operative day 2 and the average hospital stay was 3.4 days (range: 3-5 days). In conclusion, laparoscopic appendectomy proved to be safe and effective, even when performed by surgeons with only limited experience of minimally invasive surgery.

Hemoperitoneum from a spontaneous rupture of a giant hemangioma of the liver: report of a case.

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, consumption coagulopathy, and rapid growth are mandatory surgical indications. We report a case of giant hemangioma of hepatic segments II and III, which presented as hemoperitoneum, and were treated successfully with preoperative transcatheter arterial embolization (TAE) and hepatic bisegmentectomy. A PubMed Medline search has identified up to now 32 cases of spontaneous rupture of hepatic hemangioma in adults (age >14 years) without a history of trauma, including the present case. Twenty-seven out of these were reviewed. Sixteen (84.2%) of 19 tumors of known size were giant hemangiomas (mean diameter 14.8 cm; range 6-25). Twenty-two (95.7%) patients underwent surgery. Thirteen patients (59.1%) had a resection, 5 (22.8%) were sutured, and 4 (18.1%) underwent tamponade. Three (23%) out of the 13 resected patients died. Four patients (30.8%) underwent TAE prior to elective hepatic resection without any operative mortality. Among the 5 sutured patients, 2 (40%) died as well as 3 (75%) out of 4 patients who underwent tamponade. The mortality rate of all surgery patients was 36.4% (8/22).

Surgical treatment of hepatocellular carcinoma in elderly cirrhotic patients: personal experience.

BACKGROUND: Due to the longer life expectancy of the world's population, the number of elderly cirrhotic patients undergoing surgery for hepatocellular carcinoma (HCC) is increasing. Our study evaluates the benefits of hepatic resections for HCC in cirrhotic patients aged over 65, analysing the early and long-term surgical results. PATIENTS AND METHODS: We retrospectively considered a series of 46 patients receiving hepatic resection for HCC. The clinicopathological data and surgical outcome of 14 (30.4%) patients aged 65 or older (group I) were evaluated and compared to the 32 (69.6%) younger than 65 (group II). RESULTS: No operative mortality was recorded in either group. The hospital mortality rate was 7.1% (1 out of 14) in group I and 9.4% (3 out of 32) in group II (p = 1.00). Hospital morbidity did not differ significantly in the two groups (21.4% vs 34.4%; p = 0.50). At follow-up (median 34 months, interquartile range: 12-63) 3 patients from group I (21.4%) and 16 patients from group II (50%) experienced tumor recurrence (p = 0.14). The five-year disease-free survival rate for group I and group II was 71.4% vs 28.2%, respectively (p = 0.05). The overall 5-year survival rate for group I and group II was, respectively, 77.4% vs 41.8%, (p = 0.3). CONCLUSION: Elderly cirrhotic patients with HCC can benefit from hepatic resection as well as younger patients; age by itself should not be considered a contraindication to surgery.