The Therapeutic Intensity Score as Predictor of Clinical Outcomes after Total and Partial Adrenalectomy for Unilateral Primary Aldosteronism: Results of a Multicentric Series.

BACKGROUND: To evaluate the ability of therapeutic intensity score (TIS) in predicting the clinical outcomes of partial (PA) and total adrenalectomy (TA) for UPA. METHODS: Between 2011 and 2022, a four-center adrenalectomy dataset was queried for "unilateral adrenal mass" and "UPA" (n = 90). Preoperative TIS of each antihypertensive medication were individually calculated and merged to create a single, cumulative variable. Probability of complete clinical, partial, and absent pooled success rates according to TIS were assessed for the overall cohort by Kaplan-Meier. Cox analyses were used to identify predictors of complete clinical and partial/absent success, respectively. For all analyses, a two-sided p < 0.05 was considered significant. RESULTS: At a median follow-up of 42 months (IQR 27-54) complete partial, and absent clinical success were observed in 60%, 17.7%, and 22.3%, respectively. On Kaplan-Meier analysis, TIS < 1 predicted higher complete success rates (p < 0.001), while TIS ≥ 1 was predictor of either partial and absent clinical success (p = 0.008). On multivariable analysis, TIS < 1 (HR 0.25; 95% CI 0.11-0.57; p = 0.001) and adenoma size (HR 1.11; 95% CI 1-1.23; p = 0.0049) were independent predictors of complete clinical success, while TIS ≥ 1 (HR 2.84; 95% CI 1.32-6.1; p = 0.007) was the only independent predictor of absent clinical success. CONCLUSIONS: TIS score and adenoma size may help to identify patients who are likely to be at risk of persistent hypertension after surgery.

Surgical Quality, Antihypertensive Therapy, and Electrolyte Balance: A Novel Trifecta to Assess Long-Term Outcomes of Adrenal Surgery for Unilateral Primary Aldosteronism.

BACKGROUND: To propose a trifecta that summarizes endpoints and predicts their maintenance after adrenalectomy (n = 90) for unilateral primary aldosteronism (UPA). METHODS: Trifecta was defined as coexistence of: ≥50% antihypertensive therapeutic intensity score reduction (∆TIS), no hypokalemia at 3 months, and no Clavien grade 2-5. Logistic regression was used to identify predictors of trifecta. Probability of clinical, biochemical, and simultaneous success according to trifecta were assessed by Kaplan-Meier. Cox regression was used to identify predictors of long-term clinical, biochemical, and simultaneous success. For all analyses, a two-sided p < 0.05 was considered significant. RESULTS: Simultaneous success rate was 50%. On multivariable analysis, TIS was an independent predictor of trifecta achievement (HR 3.28; 95% CI 1.07-10.9; p = 0.03). At Kaplan-Meier, trifecta predicted higher success for all endpoints (each p < 0.03). On multivariable Cox analysis, adenoma size (AS) ≥6 cm and trifecta were independent predictors of biochemical (AS: HR 2.87; 95% CI 1.53-5.36; trifecta: HR 2.1; 95% CI 1.13-3.90; each p < 0.02) and simultaneous success (AS: HR 3.81; 95% CI 1.68-8.65; trifecta: HR 4.29; 95% CI 2.08-8.86; each p < 0.01), while trifecta was an independent predictor of complete clinical success (HR 2.84; 95% CI 1.45-5.58; p < 0.01). CONCLUSIONS: Trifecta and AS are independent predictors of either long-term complete clinical, biochemical, or combined success after adrenalectomy for UPA.

Clinical cure vs a novel trifecta system for evaluating long-term outcomes of minimally-invasive partial or total adrenalectomy for unilateral primary aldosteronism: results of a multicentric series.

Introduction: Several predictive scores to evaluate outcomes of adrenal surgery for unilateral primary aldosteronism (UPA), have been conceived. We compared a novel trifecta that summarizes outcomes of adrenal surgery for UPA with the clinical cure proposed by Vorselaars. Material and methods: Between March 2011 and January 2022, a multi-institutional dataset was queried for UPA. Baseline, perioperative and functional data were collected. Clinical and biochemical complete and partial success rates according to Primary Aldosteronism Surgical Outcome (PASO) criteria were assessed for the overall cohort. Clinical cure was defined either as normotension without antihypertensive medications or normotension with lower or equal use of antihypertensive medications. Trifecta was defined as the coexistence of ≥50% antihypertensive therapeutic intensity score (TIS) reduction (ΔTIS), no electrolyte impairment at 3-months and no Clavien-Dindo (2-5) complications. Cox regression analyses were used to identify predictors of long-term clinical and biochemical success. For all analyses, a two-sided p <0.05 was considered significant. Results: Baseline, perioperative and functional outcomes were analyzed. Out of 90 patients, at a median follow-up of 42 months (IQR 27-54) a complete and partial clinical success was observed in 60% and 17.7% of cases while a complete and partial biochemical success was achieved in 83.3% and 12.3% of cases, respectively. Overall trifecta and clinical cure rates were 21.1% and 58.9%, respectively. On multivariable Cox regression analysis, trifecta achievement (HR 2.87; 95% CI 1.45-5.58; p = 0.02) was the only independent predictor of complete clinical success at long-term follow-up. Conclusions: Despite its complex estimation and more restrictive criteria, trifecta but not clinical cure allows to independently predict composite PASO endpoints on the long run.

Changes in volumes and severity of surgical urgencies during the first two COVID-19 pandemic waves in a regional hospital network.

Background and aim This study analyses the impact of the first two pandemic waves on surgical urgencies/emergencies and their consequences on an entire provincial hospital network's surgical activities. Methods  Clinical and epidemiological data of urgent/emergent surgical admissions and interventions in the Autonomous Province of Trento's hospital network were collected from the internal common electronic database. The investigation periods were March-May 2019 (reference period), March-May 2020 (phase-I), June - August 2020 (phase-II), and October - December 2020 (phase-III). The same data were divided and grouped for the six most represented diagnoses. Results: The number of admissions for surgical emergencies in the studied periods showed a sinusoidal trend. In the reference period of 2019, 957 patients were admitted in urgency, while in the three pandemic phases, urgent admissions were 511, 888 and 633 respectively (-47% in phase I, - 8% in phase II, -34% in phase III). This trend was also observed by stratifying admissions for single disease, except for gastrointestinal perforations and pancreatitis, which showed a slight increasing trend in phase-I. Among the studied population, the surgical rate was 35.2% in phase-I and 34.3% in phase-III; these data were significantly higher than in 2019 (25.6%).  Conclusions The effect of the COVID pandemic on surgical emergencies and urgencies (SUEs) was mainly indirect, manifesting itself with a significant reduction in the number of surgical admissions, particularly in phases-I and-III. Conversely, in the same phases, the surgical rate showed a significant increase compared to 2019.

Minimally Invasive Partial Versus Total Adrenalectomy for the Treatment of Primary Aldosteronism: Results of a Multicenter Series According to the PASO Criteria.

BACKGROUND: Determination of success after adrenal-sparing surgery for primary aldosteronism (PA) is limited by the lack of standardized definitions of outcomes. OBJECTIVE: To evaluate the safety and effectiveness of minimally invasive partial adrenalectomy (MIPA) for PA by comparing perioperative and functional outcomes with minimally invasive total adrenalectomy (MITA) according to the Primary Aldosteronism Surgical Outcome (PASO) criteria. DESIGN, SETTING, AND PARTICIPANTS: Between March 2011 and April 2020, a multicenter adrenalectomy dataset was queried for "unilateral adrenal mass, PA, MIPA (n = 29), or MITA (n = 61)"at four participating Institutions. INTERVENTION: MITA and MIPA for PA. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Differences between continuous variables were assessed with the Wilcoxon rank sum test, while Pearson's χ2 test was used for categorical data. Complete, partial, and absent clinical success rates were assessed for the overall cohort and compared between groups. RESULTS AND LIMITATIONS: The median tumor size was significantly higher in the MITA group (4.2 vs 2.7 cm; p = 0.001), while preoperative hypertension rate was significantly higher in the MIPA series (82.8% vs 57.4%, p = 0.01). The median length of hospital stay was increased in the MITA cohort (4 vs 3 d; p = 0.038). Overall, at a median follow-up of 42 mo (interquartile range 27-54 mo), complete, partial, and absent clinical success was observed in 60%, 17.7%, and 22.3% of cases, respectively. The complete clinical success rate was higher in the MIPA group (72.4% vs 54.1%), while a partial clinical success was higher in the MITA series (23% vs 6.8%). The absence of clinical success was comparable between groups (MITA 23% vs MIPA 20.7%). CONCLUSIONS: MIPA showed excellent perioperative results with a complete clinical success rate of 72.4%. Owing to the heterogeneity of the PASO criteria in the assessment of partial or absent success, the quest for a univocal definition of satisfactory clinical outcomes in the treatment of PA remains open. PATIENT SUMMARY: We compared minimally invasive partial adrenalectomy (MIPA) and minimally invasive total adrenalectomy for the treatment of unilateral primary aldosteronism, assessing the outcomes with the Primary Aldosteronism Surgical Outcome (PASO) criteria. MIPA seems to provide comparable perioperative outcomes and midterm clinical success rates.

Analysis of risk factors for lymph nodal involvement in early stages of rectal cancer: when can local excision be considered an appropriate treatment? Systematic review and meta-analysis of the literature.

Background. Over the past ten years oncological outcomes achieved by local excision techniques (LETs) as the sole treatment for early stages of rectal cancer (ESRC) have been often disappointing. The reasons for these poor results lie mostly in the high risk of the disease's diffusion to local-regional lymph nodes even in ESRC. Aims. This study aims to find the correct indications for LET in ESRC taking into consideration clinical-pathological features of tumours that may reduce the risk of lymph node metastasis to zero. Methods. Systematic literature review and meta-analysis of casistics of ESRC treated with total mesorectal excision with the aim of identifying risk factors for nodal involvement. Results. The risk of lymph node metastasis is higher in G ≥ 2 and T ≥ 2 tumours with lymphatic and/or vascular invasion. Other features which have not yet been sufficiently investigated include female gender, TSM stage >1, presence of tumour budding and/or perineural invasion. Conclusions. Results comparable to radical surgery can be achieved by LET only in patients with T(1) N(0) G(1) tumours with low-risk histological features, whereas deeper or more aggressive tumours should be addressed by radical surgery (RS).

[Surgical treatment of para-esophageal hernia. Our experience]. / Il trattamento chirurgico dell'ernia paraesofagea. Esperienza personale.

The authors report on 12 cases of para-oesophageal hernia surgically managed over the period from 1973 to 2001. They describe the etiopathogenetic factors responsible for the disease and the normal evolution of the clinical picture with the main complications, which are often the first manifestations. The main problems of surgical treatment are discussed with particular regard to the operative approach and to the usefulness of combining an antireflux procedure with the hiatoplasty.

[Stromal tumors of the small intestine. Retrospective analysis of 9 cases surgically treated]. / I tumori stromali dell'intestino tenue. Analisi retrospettiva di 9 casi trattati chirurgicamente.

The authors report on their experience with 9 patients with small bowel stromal tumours who underwent surgical treatment over the period 1974-2001. Seven were males and 2 females, with an average age of 63.1 years (range: 49-72 years). Histologically, 4 tumours showed evidence of differentiation towards smooth muscle elements (1 benign and 3 malignant), 4 towards neural elements (all malignant) and 1 lacked differentiation towards either cell type. Five tumours were located in the ileum, 3 in the jejunum and 1 in the duodenum. The main symptoms were abdominal pain and an abdominal mass, and the most sensitive diagnostic technique was abdominal CT scan. In the 8 jejunal or ileal stromal tumours we performed a typical intestinal resection, while undifferentiated duodenal stromal tumours were managed by pancreaticoduodenectomy. The diagnosis was only histological. There was no operative mortality, while 2 postoperative complications (1 pancreatic fistula and 1 myocardial infarction) occurred. The patient with jejunal benign muscular stromal tumour is still alive and in good health 73 months after the operation. Of the 3 patients with malignant muscular ileal stroma tumours, 1 is alive and free from disease 63 months after the operation, while the other 2 died of metastatic disease 39 and 29 months after surgery. Of the 4 patients with malignant neural stromal tumours (2 jejunal and 2 ileal) 1 with jejunal and 1 with ileal tumour were lost to follow-up, while 1 is still alive and in good health 101 months postoperatively; the 4th patient, with jejunal disease, developed liver metastasis 14 months after small bowel resection and died 12 months later. The patient with undifferentiated duodenal stromal tumour died of liver metastases 38 months after pancreaticoduodenectomy. Small bowel stromal tumours are more often than not malignant. The most frequent symptoms are abdominal pain and a palpable mass, but no specific signs have been detected. Abdominal CT scan is the most sensitive diagnostic technique in the evaluation of the location, size, invasion of adjacent organs and metastases. The treatment must be intestinal resection, and prognostic prediction on the basis of histological findings is difficult.