Derangement of body composition has been associated with dismal long-term survival in several gastrointestinal cancers including rectal tumors treated with neoadjuvant therapies. The role of specific ...preoperative anthropometric indexes on the oncologic outcomes of patients undergoing upfront surgery for rectal cancer has not been investigated. The aim of the study is to evaluate the association of body composition and overall survival in this specific cohort.
Lumbar computed tomography images, obtained within the 30 days previous to surgery, between January 2009 and December 2016, were used to calculate population-specific thresholds of muscle mass (sarcopenia), subcutaneous and visceral adiposity, visceral obesity, sarcopenic obesity, and myosteatosis. These body composition variables were related with overall survival (OS), tumor-specific survival (TSS), and disease-free survival (DFS). OS, TSS, and DFS were evaluated by the Kaplan-Meier method. Cox regression analysis was used to identify independent predictors of mortality, tumor-specific mortality, and recurrence, and data were presented as hazard ratio (HR) and 95% confidence interval (CI).
During the study period, 411 patients underwent rectal resection for cancer, and among these, 129 were without neoadjuvant chemoradiation. The median follow-up was 96.7 months. At the end of the follow-up, 41 patients (31.8%) had died; of these, 26 (20.1%) died for tumor-related reasons, and 36 (27.1%) experienced disease recurrence. One-, three-, and five-year OS was 95.7%, 86.0%, and 76.8% for non-sarcopenic patients versus 82.4%, 58.8%, and 40.0% for sarcopenic ones respectively (p < 0.001). Kaplan-Meier survival curves comparing sarcopenic and non-sarcopenic patients showed a significant difference in terms of OS (log-rank < 0.0001). Through multivariate Cox regression, overall mortality risk was associated only with sarcopenia (HR 1.96; 95%CI 1.03-3.74; p = 0.041). Disease stage IV and III (HR 13.75; 95% CI 2.89-65.6; p < 0.001 and HR 4.72; 95% CI 1.06-21.1; p = 0.043, respectively) and sarcopenia (HR 2.62; 95% CI 1.22-5.6; p = 0.013) were independently associated with TSS. The other body composition indexes investigated showed no significant association with prognosis.
These results support the inclusion of body composition assessment for prognostic stratification of rectal cancer patients undergoing upfront resection.
While perioperative red blood cell transfusion has been widely associated with poor surgical outcomes, few studies have focused specifically on the preoperative transfusional risk-benefit ratio. The ...aim of the present study was to evaluate the effects of preoperative red blood cell transfusion on short-term surgical outcomes in a cohort of anemic colon cancer patients.
Moderate and severe anemic patients undergoing colectomy for cancer were divided into two groups based upon the receipt of preoperative transfusion and compared in terms of short-term outcomes.
A total of 271 patients with moderate or severe anemia were identified, 93 (34.3%) of whom were preoperatively transfused with a median of two units of packed red blood cells per patient (interquartile range: 2-4 units). The overall morbidity rate did not differ significantly between the two groups (35.5% vs. 36.2%; p = 0.63), while an increased incidence of major morbidity (Clavien-Dindo grade > 3a) observed in transfused patients 14% vs. 6.2% respectively; odds ratio (OR): 2.47, 95% confidence interval (CI): 1.06-5.75; p = 0.03. The increase in major morbidity was confirmed by multivariate analysis, adjusted for potential confounders (OR: 3.45; 95% CI: 1.32-9.04; p = 0.01).
Preoperative blood transfusion is associated with severe postoperative complications following colectomy in moderate and severe anemic cancer patients. Further studies are needed to establish an optimal preoperative transfusional cutoff value to optimize postoperative outcomes and balance clinical costs.
In cancer microenvironment, aberrant glycosylation events of ECM proteins and cell surface receptors occur. We developed a protocol to generate 3D bioprinted models of colorectal cancer (CRC) ...crosslinking hyaluronic acid and gelatin functionalized with three signalling glycans characterized in CRC, 3′-Sialylgalactose, 6′-Sialylgalactose and 2′-Fucosylgalactose. The crosslinking, performed exploiting azide functionalized gelatin and hyaluronic acid and 4arm-PEG-dibenzocyclooctyne, resulted in biocompatible hydrogels that were 3D bioprinted with commercial CRC cells HT-29 and patient derived CRC tumoroids. The glycosylated hydrogels showed good 3D printability, biocompatibility and stability over the time. SEM and synchrotron radiation SAXS/WAXS analysis revealed the influence of glycosylation in the construct morphology, whereas MALDI-MS imaging showed that protein profiles of tumoroid cells vary with glycosylation, indicating that sialylation and fucosylation of ECM proteins induce diverse alterations to the proteome of the tumoroid and surrounding cells.
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Baseline body composition has been associated with dismal outcomes in patients undergoing a variety of major abdominal operations. Whether specific anthropometric indexes can predict morbidity after ...rectal resection has been poorly investigated. The aims of this study were to assess whether there is a relationship between body mass index and the different computed tomography–assessed body composition indexes, and whether the analysis of different body compartments could be predictive of short-term outcomes in patients undergoing curative surgery for rectal cancer.
Computed tomography–derived measures of skeletal muscle and adipose tissue areas of patients undergoing surgery for rectal cancer between January 2009 and December 2016 were used to calculate population-specific thresholds of sarcopenia, subcutaneous adiposity, visceral adiposity, visceral obesity, sarcopenic obesity, and myosteatosis. Association between the aforementioned body composition features were related with overall complication, infection, and anastomotic leak.
During the study period, 311 patients received surgery and 173 were eligible for an accessible preoperative computed tomography imaging. After surgery, 59 (34.1%) patients experienced a complication, 29 an infection, and 10 an anastomotic failure. The overall morbidity rate was observed more frequently in patients with sarcopenia than in those without sarcopenia (39% versus 17.5%; P = 0.002) and infections (41.4% versus 21.5% respectively; P = 0.024). The presence of myosteatosis also was associated with a higher incidence of overall morbidity (33.9% versus 20.2% in patients without myoteatosis; P = 0.048). Anastomotic failure occurred in 6 of 10 patients with visceral obesity and in 24 of 112 (21.4%) patients without this condition (P = 0.007).
Some anthropometric indexes are accurate predictors of specific types of morbidity. These findings may allow a more accurate preoperative risk stratification.
•Specific anthropometric indexes, but not all, are accurate predictors of increased complication risk.•BMI is not an accurate estimator of anthropometric architecture and surgery-related morbidity.•There is a central role of visceral fat as an independent organ in affecting tissue healing.•Sarcopenia and myosteatosis are associated with an increase risk of surgery-related morbidity and failure to rescue.
Background
The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal ...obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies.
Methods
Subjects admitted to the authors’ department with colorectal obstruction (
n
= 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group:
n
= 49) or for definitive palliation (
n
= 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon.
Results
Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (
n
= 1, 1.2 %), migration (
n
= 4, 4.9 %), occlusion (
n
= 4, 4.9 %), colon bleeding (
n
= 3, 3.7 %), and abdominal pain (
n
= 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (
P
= 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %;
P
= 0.004), abdominal abscess (14.3 vs 39.2 %;
P
= 0.006), respiratory morbidity (10.2 vs 37.3 %;
P
= 0.002), and intensive care treatment (10.2 vs 33.3 %;
P
= 0.007). The median postoperative hospital stay was 10 versus 15 days (
P
= 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %;
P
= 0.04) and definitive stoma formation (6.3 vs 26.0 %;
P
= 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan–Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %.
Conclusions
In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.
Introduction
Acute appendicitis is one of the most common causes of abdominal pain in emergency departments worldwide. Despite the improvement in radiological and clinical investigations, negative ...appendectomy remains a debated topic as well as the optimal strategy for use in cases demonstrating a nonpathological appendix during a procedure for suspected appendicitis. The aim of the present study was thus to analyse clinical outcomes of histologically NA to better elucidate the burden associated with a potentially avoidable procedure.
Materials and methods
We retrospectively analysed a prospectively collected database of all patients undergoing appendectomy for suspected appendicitis. Patients who underwent an elective appendectomy or an appendectomy for other causes than suspected appendicitis or even an appendectomy during the course of another procedure were excluded from the analysis.
Results
Data of 627 patients undergoing an emergency procedure for suspected appendectomy were registered. Of the 627 patients, 533 (85%) were found to have acute appendicitis (378 uncomplicated, 155 severe), while the NA rate was 14.9%. A preoperative CT scan was performed in 148 patients (23.6%), an ultrasound evaluation was conducted in 427 patients (68.1%), and 127 patients (20.3%) underwent no imaging prior to surgical intervention. The large majority of procedures was performed laparoscopically (77.7%) and the median procedure duration was 70 min (range 17–270 min). The cumulative conversion rate (both AA and NA) was 5.7%. Leucocytes were significantly lower in cases of NA, while C-reactive protein (CRP) level was found to be increased fourfold in cases of severe versus uncomplicated appendicitis and NA. An increased use of endoloop in appendiceal stump closure was noted in the NA group (88.3% loop vs. 11.7% stapler), while endostapler usage increased in the severe appendicitis group up to 38.1%. Most patients with NA underwent only preoperative ultrasound (71.3%), with just 8.5% of patients in this group having a CT scan before surgery. Ultrasound sensivity was 0.648 and specificity was 0.438. For CT scan, sensivity was 0.949 and specificity was 0.625. LOS in the NA patient group was comparable to that of patients affected by uncomplicated appendicitis, while patients with severe appendicitis experienced a 2-day-longer median recovery. Complications were significantly higher in the severe appendicitis group but comparable in the other two groups. Surgical site infections were the most frequently reported complications.
Conclusions
Young women are particularly at risk for NA. Increasing the use of preoperative CT and incorporating imaging into the overall assessment of a patient seems to be actually the only way to reduce the incidence of NA without increasing the rates of perforation. Considering the relatively high morbidity after an NA procedure, every surgeon must carefully consider the risk–benefit balance prior to performing an appendectomy during diagnostic laparoscopy for suspected acute appendicitis showing a macroscopically noninflamed appendix.
Growing evidence suggests that conventional dendritic cells (cDCs) undergo aberrant maturation in COVID‐19, which negatively affects T‐cell activation. The presence of effector T cells in patients ...with mild disease and dysfunctional T cells in severely ill patients suggests that adequate T‐cell responses limit disease severity. Understanding how cDCs cope with SARS‐CoV‐2 can help elucidate how protective immune responses are generated. Here, we report that cDC2 subtypes exhibit similar infection‐induced gene signatures, with the upregulation of IFN‐stimulated genes and IL‐6 signaling pathways. Furthermore, comparison of cDCs between patients with severe and mild disease showed severely ill patients to exhibit profound downregulation of genes encoding molecules involved in antigen presentation, such as MHCII, TAP, and costimulatory proteins, whereas we observed the opposite for proinflammatory molecules, such as complement and coagulation factors. Thus, as disease severity increases, cDC2s exhibit enhanced inflammatory properties and lose antigen presentation capacity. Moreover, DC3s showed upregulation of anti‐apoptotic genes and accumulated during infection. Direct exposure of cDC2s to the virus in vitro recapitulated the activation profile observed in vivo. Our findings suggest that SARS‐CoV‐2 interacts directly with cDC2s and implements an efficient immune escape mechanism that correlates with disease severity by downregulating crucial molecules required for T‐cell activation.
DC2s and DC3s show similar gene signatures in response to SARS‐CoV‐2 infections, and their activation responses are dominated by ISGs. cDC2 subtypes enhance their inflammatory properties and progressively lose antigen presenting functions as disease severity increases. DC2s and DC3s can be activated by direct viral sensing.
(1) Introduction: To date, the sensitivity of the Comprehensive Complication Index (CCI) in a homogeneous cohort of colonic resections for oncologic purposes has not been reported. The present study ...aims to compare the CCI with the conventional Clavien-Dindo classification (CDC) in colon cancer patients. (2) Methods: The clinical data of patients submitted to an elective colectomy for adenocarcinoma were retrieved from a prospectively maintained database. Postoperative complications and length of stay were reviewed, and CDC and CCI scores were calculated for each patient. The association of the CCI and the CDC with the length of stay, prolongation of stay and readmission rate were assessed and compared. (3) Results: The overall postoperative morbidity was 26.9%. In particular, 157 (20.4%) patients had more than one complication. A strong correlation between the two scoring systems was observed (r = 99.4%; 95%CI: 99.3-99.5%). In multivariate analysis, CCI had a higher predictive ability for all endpoints. Regarding subgroup analysis, the difference between the CCI and CDC was progressively increased when evaluating outcome measures in complicated and multi-complicated patients. (4) Conclusion: Both scoring systems adequately report the overall burden of postoperative complications. The CCI showed a greater ability than the CDC to predict hospital stay, particularly in patients with multiple postoperative complications.
(1) Background: Anaemia is a common finding in patients with colon cancer and is commonly corrected by blood transfusion prior to surgery. However, the prognostic role of perioperative transfusions ...is still debated. The aim of the present study was to investigate the role of preoperative anaemia and preoperative blood transfusion in influencing the prognosis in colon cancer. (2) Patients and Methods: Patients undergoing elective surgery for colon cancer at a tertiary referral university hospital between January 2010 and December 2018 were included in a retrospective review of a prospectively collected database. Univariate and regression analyses were performed to identify the prognostic role of preoperative anaemia and preoperative transfusions in this homogeneous cohort of patients. (3) Results: A total of 780 patients were included in the final analysis. The estimated five-year overall survival rate was significantly worse in the anaemic group (83.8% in non-anaemic patients, 60.6% in mild anaemic patients, 61.3% in moderate anaemic patients and 58.4% in severe anaemic patients; log-rank < 0.001 vs. non-anaemic patients). Anaemic status was found to be an independent adverse prognostic factor (hazard ratio (HR): 1.46; 95% confidence interval (CI): 1.02-2.07) during multivariate analysis. Among moderate to severe anaemic patients, no significant association was found between preoperative transfusions and the risk of mortality or recurrence. (4) Conclusions: Preoperative anaemia, regardless of its severity, and not preoperative blood transfusion, was independently associated with a worse prognosis after surgery in patients with colonic cancer.
Early postoperative low compliance to enhanced recovery protocols has been associated with morbidity following colon surgery. The purpose of this study is to evaluate the possible causes of early ...postoperative low compliance to the enhanced recovery pathway and its relationship with morbidity following rectal surgery for cancer. A total of 439 consecutive patients who underwent elective surgery for rectal cancer have been included in the study. Compliance to enhanced recovery protocol on postoperative day (POD) 2 was evaluated in all patients. Indicators of compliance were naso-gastric tube and urinary catheter removal, recovery of both oral feeding and mobilization, and the stopping of intravenous fluids. Low compliance on POD 2 was defined as non- adherence to two or more items. One-third of patients had low compliance on POD 2. Removal of urinary catheter, intravenous fluids stop, and mobilization were the items with lowest adherence. Advanced age, duration of surgery, open surgery and diverting stoma were predictive factors of low compliance at multivariate analysis. Overall morbidity and major complications were significantly higher (p < 0.001) in patients with low compliance on POD 2. At multivariate analysis, failure to remove urinary catheter on POD 2 (OR = 1.83) was significantly correlated with postoperative complications. Low compliance to enhanced recovery protocol on POD 2 was significantly associated with morbidity. Failure to remove the urinary catheter was the most predictive indicator. Advanced age, long procedure, open surgery and diverting stoma were independent predictive factors of low compliance.
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