Summary
Background
While mucosal healing has been proved to predict relevant clinical outcomes in Crohn's disease (CD), little is known about the long‐term significance of transmural healing.
Aims
To ...prospectively assess the 1‐year clinical outcomes in CD patients achieving transmural healing following treatment with biologics, and to compare them with those in patients reaching only mucosal healing or no healing.
Methods
Observational longitudinal study, evaluating 1‐year outcomes in terms of steroid‐free clinical remission, rate of hospitalisation and need for surgery in a group of CD patients treated with anti‐tumour necrosis factor (TNF) alpha for 2 years. Bowel sonography was used in all patients to determine transmural healing.
Results
Of 218 patients who completed a 2‐year treatment course with anti‐TNF alpha, 68 (31.2%) presented transmural (plus mucosal) healing (bowel wall thickness ≤3 mm at bowel sonography), 60 (27.5%) mucosal healing only, and 90 (41.3%) did not achieve any intestinal healing. Transmural healing was associated with a higher rate of steroid‐free clinical remission (95.6%), lower rates of hospitalisation (8.8%) and need for surgery (0%) at 1 year compared to mucosal (75%, 28.3% and 10%, respectively) and no healing (41%, 66.6% and 35.5%, respectively) (P < 0.001). Furthermore, transmural healing was associated with longer intervals until clinical relapse (HR, hazard ratio 0.87, P = 0.01), hospitalisation (HR 0.88, P = 0.002) and surgery (HR 0.94, P = 0.008) than mucosal healing. Also among patients discontinuing treatment with biologics, transmural healing predicted better clinical outcomes at 1 year than mucosal healing (P = 0.01).
Conclusions
Transmural healing is an ambitious and powerful treatment goal associated, to a greater extent than mucosal healing, with improvement of all clinical outcomes. Additionally, transmural healing is associated with better long‐term clinical outcomes than mucosal healing also after discontinuation of biologics.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Following the Food and Drug Administration approval, robot-assisted colorectal surgery has gained more acceptance among surgeons. One of the open issues about robotic surgery is the ...economic sustainability. The aim of our study is to evaluate the economic sustainability of robotic as compared to laparoscopic right colectomy for the Italian National Health System.
Methods
We performed a retrospective multicentre case-matched study including 94 patients for each group from four different Italian surgical departments. An economic evaluation gathered from a real-world data was performed to assess the sustainability of the robotic approach for right colectomy in the Italian National Health System. In particular, a differential cost analysis between the two procedures was performed.
Results
No statistical differences were found between the two groups for postoperative outcomes. After a careful review of the literature on the cost assessment for the operative room, medical devices and hospital stay according with our data, we estimated the followings: (a) the mean operative room cost for robotic group was 2179 ± 476 € vs. 1376 ± 322 € for laparoscopic group; (b) the mean hospital stay cost for robotic group was 3143 ± 1435 € vs. 3292 ± 1123 € for laparoscopic group; and (c) the mean cost for instruments was 6280 € for robotic group vs. 1504 € for laparoscopic group. The total mean cost of robotic right colectomy was 11,576 ± 1915 € vs. 6196 ± 1444 € for laparoscopic right colectomy.
Conclusion
In conclusion, to date, robotic right colectomy with intracorporeal anastomosis does not provide any significant clinical advantages, which may justify the additional costs, as compared to its laparoscopic counterpart. Further evolution of robotic technology and experience may lead to a reduction of costs, especially if the robotic platform is used in an appropriate healthcare setting.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
S100B protein bridges chronic mucosal inflammation and colorectal cancer given its ability to activate NF‐kappaB transcription via RAGE signalling and sequestrate pro‐apoptotic wtp53. Being an S100B ...inhibitor, pentamidine antagonizes S100B‐wtp53 interaction, restoring wtp53‐mediated pro‐apoptotic control in cancer cells in several types of tumours. The expression of S100B, pro‐inflammatory molecules and wtp53 protein was evaluated in human biopsies deriving from controls, ulcerative colitis and colon cancer patients at baseline (a) and (b) following S100B targeting with niosomal PENtamidine VEhiculation (PENVE), to maximize drug permeabilization in the tissue. Cultured biopsies underwent immunoblot, EMSA, ELISA and biochemical assays for S100B and related pro‐inflammatory/pro‐apoptotic proteins. Exogenous S100B (0.005‐5 μmol/L) alone, or in the presence of PENVE (0.005‐5 μmol/L), was tested in control biopsies while PENVE (5 μmol/L) was evaluated on control, peritumoral, ulcerative colitis and colon cancer biopsies. Our data show that S100B level progressively increases in control, peritumoral, ulcerative colitis and colon cancer enabling a pro‐inflammatory/angiogenic and antiapoptotic environment, featured by iNOS, VEGF and IL‐6 up‐regulation and wtp53 and Bax inhibition. PENVE inhibited S100B activity, reducing its capability to activate RAGE/phosphor‐p38 MAPK/NF‐kappaB and favouring its disengagement with wtp53. PENVE blocks S100B activity and rescues wtp53 expression determining pro‐apoptotic control in colon cancer, suggesting pentamidine as a potential anticancer drug.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
OBJECTIVE:This trial aimed to provide randomized controlled data comparing Kono-S anastomosis and stapled ileocolic side-to-side anastomosis.
BACKGROUND:Recently, a new antimesenteric, functional, ...end-to-end, hand-sewn ileocolic anastomosis (Kono-S) has shown a significant reduction in endoscopic recurrence score and surgical recurrence rate in Crohn disease (CD).
METHODS:Randomized controlled trial (RCT) at a tertiary referral institution. Primary endpointendoscopic recurrence (ER) (Rutgeerts score ≥i2) after 6 months. Secondary endpointsclinical recurrence (CR) after 12 and 24 months, ER after 18 months, and surgical recurrence (SR) after 24 months.
RESULTS:In all, 79 ileocolic CD patients were randomized in Kono group (36) and Conventional group (43). After 6 months, 22.2% in the Kono group and 62.8% in the Conventional group presented an ER P < 0.001, odds ratio (OR) 5.91. A severe postoperative ER (Rutgeerts score ≥i3) was found in 13.8% of Kono versus 34.8% of Conventional group patients (P = 0.03, OR 3.32). CR rate was 8% in the Kono group versus 18% in the Conventional group after 12 months (P = 0.2), and 18% versus 30.2% after 24 months (P = 0.04, OR 3.47). SR rate after 24 months was 0% in the Kono group versus 4.6% in the Conventional group (P = 0.3). Patients with Kono-S anastomosis presented a longer time until CR than patients with side-to-side anastomosis (hazard ratio 0.36, P = 0.037). On binary logistic regression analysis, the Kono-S anastomosis was the only variable significantly associated with a reduced risk of ER (OR 0.19, P < 0.001). There were no differences in postoperative outcomes.
CONCLUSIONS:This is the first RCT comparing Kono-S anastomosis and standard anastomosis in CD. The results demonstrate a significant reduction in postoperative endoscopic and clinical recurrence rate for patients who underwent Kono-S anastomosis, and no safety issues.ClinicalTrials.gov ID NCT02631967.
The response to neoadjuvant chemoradiation (nCRT) is a critical step in the management of locally advanced rectal cancer (LARC) patients. Only a minority of LARC patients responds completely to ...neoadjuvant treatments, thus avoiding invasive radical surgical resection. Moreover, toxic side effects can adversely affect patients' survival. The difficulty in separating in advances responder from non-responder patients affected by LARC highlights the need for valid biomarkers that guide clinical decision-making. In this context, microRNAs (miRNAs) seem to be promising candidates for predicting LARC prognosis and/or therapy response, particularly due to their stability, facile detection, and disease-specific expression in human tissues, blood, serum, or urine. Although a considerable number of studies involving potential miRNA predictors to nCRT have been conducted over the years, to date, the identification of the perfect miRNA signatures or single miRNA, as well as their use in the clinical practice, is still representing a challenge for the management of LARC patients. In this review, we will first introduce LARC and its difficult management. Then, we will trace the scientific history and the key obstacles for the identification of specific miRNAs that predict responsiveness to nCRT. There is a high potential to identify non-invasive biomarkers that circulate in the human bloodstream and that might indicate the LARC patients who benefit from the watch-and-wait approach. For this, we will critically evaluate recent advances dealing with cell-free nucleic acids including miRNAs and circulating tumor cells as prognostic or predictive biomarkers.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Aim
Crohn's disease has debilitating effects on patients' quality of life. Currently, there are limited data on the effect of anastomotic configuration on health‐related quality of life after ...ileocaecal resection for Crohn's disease. This study aimed to assess the impact of Kono‐S anastomosis on quality of life after ileocolic resection, compared to the conventional side‐to‐side anastomosis.
Method
Patients with primary or recurrent Crohn's disease participating in the ongoing SuPREMe‐CD trial were interviewed about quality of life using the Inflammatory Bowel Disease Questionnaire (IBDQ). The primary endpoint was disease‐specific quality of life, assessed with IBDQ. Secondary outcomes were quality of life related to bowel symptoms, systemic symptoms, social function and emotional function.
Results
Of the 94 patients included, 51 (54%) received the conventional side‐to‐side anastomosis and 43 (46%) the Kono‐S anastomosis. Demographics were comparable between the two groups. The IBDQ was assessed at a mean follow‐up of 54.0 ± 18.7 months from surgical intervention. The mean total IBDQ score was 155.1 ± 28.07 in the conventional group and 163.8 ± 25.23 in the Kono‐S group (P = 0.11). When considering bowel symptoms and social function, mean scores were 50.7 and 23.5 in the conventional group, and 56.3 and 26.5 in the Kono‐S group (P = 0.002 and P = 0.02, respectively). Kono‐S anastomosis was independently associated with improved quality of life regarding bowel symptoms (P = 0.006) and social function (P = 0.03) after correcting for other confounding factors on linear regression analysis.
Conclusion
Compared to conventional side‐to‐side anastomosis, patients with Kono‐S anastomosis presented significantly better bowel symptoms and social function scores at 54 months after surgery.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
This study aimed to assess clinical results in terms of intraoperative outcomes, recovery and recurrence of our robotic technique for the treatment of patients affected by simultaneous ...inguinal and umbilical hernia, providing technical details to facilitate multiquadrant surgery in robotic hernia repair.
Methods
Data from patients affected by simultaneous primary inguinal and umbilical hernia who underwent robotic repair with our dual docking technique was retrospectively analysed.
Results
Fifteen patients were included. No intraoperative complications occurred. All patients achieved complete mobilisation within 7 h. The mean length of hospital stay was 21.6 h, with five patients discharged on the same day of surgery. There was no major complication and no recurrence within the median follow‐up period of 673 days.
Conclusions
This surgical technique shows optimal postoperative outcomes, such as early mobilisation and short length of stay. Our study provides an aid to surgeons performing multiquadrant robotic surgery for the treatment of abdominal hernias.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
No clear consensus on the need to perform an intracorporeal anastomosis (IA) after laparoscopic right colectomy is currently available. One of the potential benefits of intracorporeal anastomosis may ...be a reduction in surgical stress. Herein, we evaluated the surgical stress response and the metabolic response in patients who underwent right colonic resection for colon cancer. Fifty-nine patients who underwent laparoscopic resection for right colon cancer were randomized to receive an intracorporeal or an extracorporeal anastomosis (EA). Data including demographics (age, sex, BMI and ASA score), pathological (AJCC tumour stage and tumour localization) and surgical results were recorded. Moreover, to determine the levels of the inflammatory response, mediators, such as C-reactive protein (CRP), tumour necrosis factor (TNF), interleukin 1β (IL-1β), IL-6, IL-10, and IL-13, were evaluated. Similarly, cortisol and insulin levels were evaluated as hormonal responses to surgical stress. We found that the proinflammatory mediator IL-6, CRP, TNF and IL-1β levels, were significantly reduced in IA compared to EA. Concurrently, an improved profile of the anti-inflammatory cytokines IL-10 and IL-13 was observed in the IA group. Relative to the hormone response to surgical stress, cortisol was increased in patients who underwent EA, while insulin was reduced in the EA group. Based on these results, surgical stress and metabolic response to IA justify advocating the adoption of a totally laparoscopic approach when performing a right colectomy for cancer.This trial is registered on ClinicalTrials.gov (ID: NCT03422588).
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background
TME has revolutionized the surgical management of rectal cancer, and since the introduction of robotic TME (RTME), many reports have shown the feasibility and the safety of this approach. ...However, concerns persist regarding the advantages of robotic in surgery for the completeness of TME. The aim of this review is to compare robotic versus laparoscopic total mesorectal excision (TME) in rectal cancer, focusing on the completeness of TME.
Methods
A systematic search was performed in the electronic databases for all available studies comparing RTME versus conventional laparoscopic LTME with declared grade of mesorectum excision. Data regarding sample size, clinical and demographic characteristics, number of complete, nearly complete, and incomplete TME were extracted. Primary outcome was the number of complete TME in robotic and laparoscopic procedures. Secondary outcomes were the numbers of nearly complete and incomplete TME in robotic and laparoscopic rectal resections.
Results
Twelve articles were included in the final analysis. Complete TME was reported by all authors, involving 1510 procedures, showing a significant difference in favor of robotic surgery (OR = 1.83, 95% CI 1.08–3.10,
p
= 0.03). Nearly complete and incomplete TME showed no significant difference between the procedures. Meta-regression analysis showed that none of patients’ and tumors’ characteristics significantly impacted on complete TME.
Conclusions
Our results underline that the robotic approach to rectal resection is the better way to obtain a complete TME. However, it is mandatory that randomized clinical trials should be performed to assess definitively if robotic minimally invasive surgery is better than a laparoscopic resection.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The risk of gastric and/or esophageal cancers after bariatric surgery has been previously discussed in literature. A systematic review was performed to identify articles published between June 2012 ...and December 2018 reporting new cases of esophageal or gastric cancer not included in previous systematic reviews. Ten gastric malignancies, 28 esophageal cancers, and 2 gastro-intestinal stromal tumors (GIST) were identified. Primary bariatric surgery was a restrictive procedure in 26 cases, a purely malabsorptive procedure in 1 subject, and a gastric bypass in 13 patients. Although the vast majority of bariatric procedures seem to present a negligible relationship with any esophagogastric (EG) malignancy, published data remain incomplete. It was however considered of interest to update the number of EG neoplasms arisen following bariatric surgery.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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