Prognostic role of intestinal ultrasound in Crohn's disease.

The majority of patients affected by Crohn's disease (CD) develop a chronic condition with persistent inflammation and relapses that may cause progressive and irreversible damage to the bowel, resulting in stricturing or penetrating complications in around 50% of patients during the natural history of the disease. Surgery is frequently needed to treat complicated disease when pharmacological therapy failes, with a high risk of repeated operations in time. Intestinal ultrasound (IUS), a non-invasive, cost-effective, radiation free and reproducible method for the diagnosis and follow-up of CD, in expert hands, allow a precise assessment of all the disease manifestations: Bowel characteristics, retrodilation, wrapping fat, fistulas and abscesses. Moreover, IUS is able to assess bowel wall thickness, bowel wall stratification (echo-pattern), vascularization and elasticity, as well as mesenteric hypertrophy, lymph-nodes and mesenteric blood flow. Its role in the disease evaluation and behaviour description is well assessed in literature, but less is known about the potential space of IUS as predictor of prognostic factors suggesting response to a medical treatment or postoperative recurrence. The availability of a low cost exam as IUS, able to recognize which patients are more likely to respond to a specific therapy and which patients are at high risk of surgery or complications, could be a very useful instrument in the hands of IBD physician. The aim of this review is to present current evidence about the prognostic role that IUS can show in predicting response to treatment, disease progression, risk of surgery and risk of post-surgical recurrence in CD.

Dramatic decrease of surgical emergencies during COVID-19 outbreak.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) outbreak, a general decrease in surgical activity was observed. There is perception that this phenomenon has involved also surgical emergency, but no extensive data have been presented to date. The aim of this study was to analyze the real number of admissions and procedures for emergency surgical disease during COVID-19 pandemic. METHODS: This is a multicenter study including 18 general surgery units performing emergency surgery in hospitals of the "Red Zone" in Lombardy. Data about admissions from emergency department and surgical emergency procedures performed during March 2019 and March 2020 were collected in an online database. Additional data were collected according to the different indications for surgical treatment. The primary outcomes were the overall rate of admissions for emergent surgical disease and the overall rate of emergency surgical procedures in the study periods. The secondary outcome was the overall surgical rates (among all the diagnosed surgical diseases). RESULTS: Emergency surgical admissions and surgical operations significantly decreased with a fall in value of 45% (p < 0.001) and 41% (p = 0.001), respectively. This reduction was confirmed by the analysis according to different surgical indications, with the exceptions of admissions and operations for gastrointestinal bleeding and operations for abdominal trauma. The overall ratio between surgical procedures and diseases was not significantly different (54% vs. 63%; p = 0.619). This ratio was significantly different only for bowel obstruction and for gastrointestinal perforation. CONCLUSIONS: It seems correct to consider "true" the dramatic decrease of surgical problems during COVID-19 outbreak, despite any therapeutic strategies and logistic difficulties. LEVEL OF EVIDENCE: Epidemiological, level III.

Multifocal early gastric cancer in a patient with atrophic gastritis and pernicious anemia.

INTRODUCTION: Pernicious anemia (PA) caused by vitamin B12 deficiency is associated with Autoimmune Metaplastic Atrophic Gastritis (AMAG). Patients with AMAG have threefold risk of the development of gastric cancer. PRESENTATION OF CASE: We describe a case of a 66 year old man with a history of PA and atrophic antral-corpus gastritis. After endoscopic and chromoendoscopic evaluation the patient was treated with subtotal gastrectomy plus D2 lymphadenectomy. The tumor was diagnosed as Stage Ia; pT1a pN0 pM0 G2 with multiple foci of high grade dysplasia and intramucosal adenocarcinoma. DISCUSSION: Multifocal Early Gastric Cancer can be a problem for minimally invasive treatment such as endoscopic excision. Surgical management where it is not possible Endoscopic Mucosal Resection or Submucosal Resection (EMR/ESD) should include D1 or more type of lymphadenectomy because of the risk of nodes metastases. The chromoendoscopic evaluation may be helpful in the preoperative work-up and during the follow-up period. CONCLUSION: Multidisciplinary approach is very important to reduce the under-treatment risk in multifocal early gastric cancer. Further studies will be needed to evaluate the safety of Subtotal vs Total Gastrectomy in this kind of disease.

Conversion surgery for gastric cancer patients: A review.

Gastric cancer (GC) is the third most common cancer-related cause of death worldwide. In locally advanced tumors, neoadjuvant chemotherapy has recently been introduced in most international Western guidelines. For metastatic and unresectable disease, there is still debate regarding correct management and the role of surgery. The standard approach for stage IV GC is palliative chemotherapy. Over the last decade, an increasing number of M1 patients who responded to palliative regimens of induction chemotherapy have been subsequently undergone surgery with curative intent. The objective of the present review is to analyze the literature regarding this approach, known as "conversion surgery", which has become one of the most commonly adopted therapeutic options. It is defined as a treatment aiming at an R0 resection after chemotherapy in initially unresectable tumors. The 13 retrospective studies analyzed, with a total of 411 patients treated with conversion therapy, clearly show that even if standardization of unresectable and metastatic criteria, post-chemotherapy resectability evaluation and timing of surgery has not yet been established, an R0 surgery after induction chemotherapy with partial or complete response seems to offer superior survival results than chemotherapy alone. Additional larger sample-size randomized control trials are needed to identify subgroups of well-stratified patients who could benefit from this multimodal approach.

Correction to: Surgical and oncological outcomes after complete mesocolic excision in right-sided colon cancer compared with conventional surgery: a retrospective, single-institution study.

The publisher regrets that some errors were introduced during the production process. The errors are now presented correctly in this article.

Surgical and oncological outcomes after complete mesocolic excision in right-sided colon cancer compared with conventional surgery: a retrospective, single-institution study.

PURPOSE: The aim of the study was whether complete mesocolic excision (CME) with central vascular ligation (CVL) is associated with a survival benefit compared with traditional procedure in right-sided colon cancer. METHODS: Overall, 251 consecutive patients underwent surgery for right colon cancer between 2007 and 2012. After exclusion, 95 subjects received non-CME surgery before 2010, and 97 subjects received CME surgery after January 2010, when we started to perform CME systematically. The number of lymph nodes, morbidity, and mortality was analyzed. Overall survival (OS) and disease-specific survival (DSS) were investigated. RESULTS: The median number of examined lymph nodes was 33.28 in the CME group and 26.92 in the non-CME group, p < 0.001. Postoperative complications were 21.6% in the CME group and 17.8% in the non-CME group, without significant difference. One out of 192 patients died. Three-year OS was 88% in the CME group and 71% in the non-CME group (p = 0.003). In stage II, 3-year DSS was 97% in the CME group and 86% in the non-CME group. In stage III, the 3-year DSSs in the CME and in the non-CME groups were 86 and 67%, respectively (p < 0.001). Cox's regression showed that CME (p = 0.0012), the number of lymph nodes (p = 0.029), and TNM stage (p < 0.001) were significant independent predictors of DSS at 3 years. CONCLUSION: Surgical standardization of CME with CVL for right-sided colon cancer is associated with better staging and prognosis, particularly in UICC stage II and III. This study shows that CME is safe and reproducible with acceptable morbidity.

Splenic Artery Transposition Graft for Hepatic Artery Aneurysm and Occlusion.

BACKGROUND: Hepatic artery aneurysms are rare but potentially fatal if undiagnosed or left untreated. Several open surgical and endovascular techniques for hepatic artery aneurysm (HAA) repair have been described. Splenic artery transposition has been reported in selected cases. CASE REPORT: We herein present the case of a 73-year-old man with asymptomatic HAA and concomitant occlusion at the most proximal tract. The aneurysm involved the common and proper hepatic artery and was supplied by the gastroduodenal artery. Aneurysmectomy was performed, and the arterial blood flow was restored to the liver by splenic artery transposition graft. No signs of liver or spleen ischemia were detected at control computed tomography angiography. The patient is doing fine 3 months after surgery. CONCLUSIONS: This case presented multiple challenges because of HAA location and extension and lack of a traditional inflow site for hepatic revascularization. In such setting, splenic artery transposition was shown to represent a feasible and successful technique.

Sixth and seventh tumor-node-metastasis staging system compared in gastric cancer patients.

AIM: To investigate the clinical relevance and prognosis regarding survival according to the changes of the tumor-node-metastasis (TNM) in gastric cancer patients. METHODS: We retrospectively studied 347 consecutive subjects who underwent surgery for gastric adenocarcinoma at the Division of General Surgery, Hospital of Busto Arsizio, Busto Arsizio, Italy between June 1998 and December 2009. Patients who underwent surgery without curative intent, patients with tumors of the gastric stump and patients with tumors involving the esophagus were excluded for survival analysis. Patients were staged according to the 6(th) and 7(th) edition TNM criteria; 5-year overall survival rates were investigated, and the event was defined as death from any cause. RESULTS: After exclusion, our study population included 241 resected patients with curative intent for gastric adenocarcinoma. The 5-year overall survival (5-year OS) rate of all the patients was 52.8%. The diagnosed stage differed in 32% of 241 patients based on the TNM edition used for the diagnosis. The patients in stage II according to the 6(th) edition who were reclassified as stage III had significantly worse prognosis than patients classified as stage II (5-year OS, 39% vs 71%). According to the 6(th) edition, 135 patients were classifed as T2, and 75% of these patients migrated to T3 and exhibited a significantly worse prognosis than those who remained T2, regardless of lymph node involvement (37% vs 71%). The new N1 patients exhibited a better prognosis than the previous N1 patients (67% vs 43%). CONCLUSION: 7(th) TNM allows new T2 and N1 patients to be selected with better prognosis, which leads to different staging. New stratification is important in multimodal therapy.