Background and objective: Different components of the immune system, including innate and adaptive immunity (T effector lymphocytes and T regulatory lymphocytes - TREGs) may be involved in the ...development of hypertension, vascular injury and inflammation. However, no data are presently available in humans about possible relationships between T-lymphocyte subtypes and microvascular oxidative stress. Our objective was to investigate possible relationships between T-lymphocyte subtypes and systemic and microvascular oxidative stress in a population of normotensive subjects and hypertensive patients.
Patients and methods: In the present study we enrolled 24 normotensive subjects and 12 hypertensive patients undergoing an elective surgical intervention. No sign of local or systemic inflammation was present. All patients underwent a biopsy of subcutaneous fat during surgery. A peripheral blood sample was obtained before surgery for assessment of T lymphocyte subpopulations by flow cytometry and circulating indices of oxidative stress.
Results: A significant direct correlation was observed between Th1 lymphocytes and reactive oxygen species (ROS) production (mainly in microvessels). Additionally, significant inverse correlations were observed between ROS and total TREGs, or TREGs subtypes. Significant correlations were detected between circulating indices of oxidative stress/inflammation and indices of microvascular morphology/Th1 and Th17 lymphocytes. In addition, a significant inverse correlation was detected between TREGs in subcutaneous small vessels and C reactive protein.
Conclusions: Our data suggest that TREG lymphocytes may be protective against microvascular damage, probably because of their anti-oxidant properties, while Th1-Th17 lymphocytes seem to exert an opposite effect, confirming an involvement of adaptive immune system in microvascular damage.
We sought to provide a meta-analysis and credibility assessment of available randomized controlled trials and propensity score matched studies when assessing early and oncologic outcomes of ...laparoscopic distal pancreatectomy compared with open distal pancreatectomy.
The MEDLINE, Scopus, Web of Science, and Cochrane databases were searched for pertinent literature up to June 2022. Random-effect meta-analyses were applied. Trial sequential analysis was applied to verify whether results were true- or false-positive or -negative findings.
Thirteen studies were identified (2 randomized controlled trials and 11 propensity score matched studies). The early outcomes were assessed on 12 studies, including 4,346 patients. In this population, laparoscopic distal pancreatectomy decreased postoperative stay (mean difference = 1.8 days; P = .001) and estimated blood loss (mean difference = 148 mL; P = .001), and trial sequential analysis confirmed these as true-positive findings. Laparoscopic distal pancreatectomy and open distal pancreatectomy had similar operating times (P = .165), and trial sequential analysis confirmed this as a true-negative finding. Major morbidity, mortality, and readmission were similar, but results were inconclusive by trial sequential analysis. Oncologic outcomes were assessed on 5 studies, including 2,430 patients. In this population, laparoscopic distal pancreatectomy showed higher R0 resection rate (OR = 1.46; P = .001) and shorter time to adjuvant therapy (mean difference 4.0 days P = .003). A survival benefit was observed at 1 year after laparoscopic distal pancreatectomy (OR = 1.45; P = .001), which was not confirmed at 3 years (P = .650).
Laparoscopic distal pancreatectomy is superior to open distal pancreatectomy for most of the early outcomes analyzed. The operating time was equalized as a result of the learning curve. Results from patients with pancreatic cancer suggest at least an oncologic noninferiority of laparoscopic distal pancreatectomy compared with open distal pancreatectomy.
BackgroundNo tools to predict the probability of extrahepatic disease progression (ePD) of initially unresectable, liver-limited metastatic colorectal cancer (mCRC) are currently available. To ...estimate the likelihood to develop ePD and to identify clinical and molecular factors that could predict extrahepatic progression-free survival (ePFS), we conducted an observational, retrospective, multicentre cohort study.MethodsWe retrospectively identified a cohort of 225 patients with initially unresectable liver-limited disease (LLD), treated from January 2004 to December 2017 with first-line doublets or triplet plus a biological agent at two Italian institutions.Results173 (77%) patients experienced ePD which occurred within 1, 2 or 3 years from the diagnosis of mCRC in 15%, 49% and 66% of patients, respectively. Globally, 164 (73%) patients underwent a liver resection at some point of their disease history, and 54 (33%) of them underwent a subsequent locoregional treatment. Age > 70 years, locoregional nodal involvement at diagnosis of colorectal cancer and ≥4 liver metastases were significantly associated with higher risk of ePD while liver resections were associated with reduced risk of ePD. In the multivariable model, number of liver metastases (subdistribution HR, SHR 1.63, 95% CI 1.12 to 2.36; p = 0.01) and liver resections (SHR 0.43, 95% CI 0.29 to 0.63; p = 0.001) were still associated with ePD. Number of liver metastases < 4, no nodal involvement at diagnosis and liver resections were also associated with prolonged ePFS.ConclusionsThe identified clinical factors could help physicians in personalising the intensity and aggressiveness of liver-directed treatments in patients with mCRC with initially unresectable LLD.
The aim of this study was to review the latest evidence on the robotic approach (RHR) for inguinal hernia repair comparing the pooled outcome of this technique with those of the standard laparoscopic ...procedure (LHR). A systematic literature search was performed in PubMed, Web of Science and Scopus for studies published between 2010 and 2021 concerning the comparison between RHR versus LHR. After screening 582 articles, 9 articles with a total of 64,426 patients (7589 RHRs) were eligible for inclusion. Among preoperative variables, a pooled higher ratio of ASA > 2 patients was found in the robotic group (12.4 vs 8.6%,
p
< 0.001). Unilateral hernia repair was more common in the laparoscopic group (79.9 vs 68.1,
p
< 0.001). Overall, operative time was longer in the robotic group (160 vs 90 min,
p
< 0.001); this was confirmed also in the sub-analysis on unilateral procedures (88 vs 68 min,
p
= 0.040). The operative time for robotic bilateral repair was similar to the laparoscopic one (111 vs 100,
p
= 0.797). Conversion to open surgery was 0% in the robotic group. The pooled rate of chronic pain and postoperative complications was similar between the groups. The standardized mean difference MD of the costs between LHR versus RHR was − 3270$ (95% CI – 4757 to − 1782,
p
< 0.001). In conclusion, laparoscopic and robotic inguinal hernia repair have similar safety parameters and postoperative outcomes. Robotic approach may require longer operative time if the unilateral repair is performed. Costs are higher in the robotic group.
Background
This cross-sectional survey aimed to determine whether fluorescence cholangiography using indocyanine green (ICG-FC) can improve the detection of the cystic duct and the main bile duct ...during laparoscopic cholecystectomy (LC).
Methods
The survey was distributed to 214 surgeons (residents/faculties) in 2021. The confidence in the identification of the cystic duct and of the main bile duct was elicited on a 10-point Likert scale before/after the use of ICG-FC. This was repeated for three LCs ranging from a procedure deemed easy to a LC for acute cholecystitis.
Results
There were 149 responses. ICG-FC increased the responders’ confidence in identifying the cystic duct, raising the median value from 6 (IQR, 5–8) with white light up to 9 (IQR, 9–10) with ICG-FC (paired
p
< 0.001). This increase was even more evident when identifying the main bile duct, where the median confidence value increased from 5 (IQR, 4–7) with white light to 9 (IQR, 8–10) with the use of ICG-FC (
p
< 0.001). ICG-FC significantly increased the detection of residents of the main bile duct in case of intermediate difficulty LCs and in LCs for acute cholecystitis.
Conclusions
The results support that the use of near-infrared imaging can ameliorate detection of biliary structures, especially of the main bile duct and this was particularly true for young surgeons and in more complex situations.
Sorafenib has been considered the standard of care for patients with advanced unresectable hepatocellular carcinoma (HCC) since 2007 and numerous studies have investigated the role of markers ...involved in the angiogenesis process at both the expression and genetic level and clinical aspect. What results have ten years of research produced? Several clinical and biological markers are associated with prognosis. The most interesting clinical parameters are adverse events, Barcelona Clinic Liver Cancer stage, and macroscopic vascular invasion, while several single nucleotide polymorphisms and plasma angiopoietin-2 levels represent the most promising biological biomarkers. A recent pooled analysis of two phase III randomized trials showed that the neutrophil-to-lymphocyte ratio, etiology and extra-hepatic spread are predictive factors of response to sorafenib, but did not identify any predictive biological markers. After 10 years of research into sorafenib there are still no validated prognostic or predictive factors of response to the drug in HCC. The aim of the present review was to summarize 10 years of research into sorafenib, looking in particular at the potential of associated clinical and biological markers to predict its efficacy in patients with advanced HCC.
Background
In literature, most of the comparative studies of robotic (RRC) versus laparoscopic (LRC) right colectomy are biased by the type of the anastomotic technique adopted. With this study, we ...aim to understand whether there is a role for robotics in performing right colectomies, comparing RRC versus LRC, both performed with intracorporeal anastomosis.
Methods
In this retrospective cohort study, all consecutive patients who underwent minimally invasive right colectomy (robotic or laparoscopic) with intracorporeal anastomosis in three Italian high-volume centers between February 1, 2007 and December 31, 2017 were included. Patients were grouped according to the method of surgery: RRC or LRC.
Results
A total of 389 patients were included in the study (305 RRC vs. 84 LRC). Patients’ baseline characteristics were comparable between the groups. Operative time was significantly longer in RRC (250 min, IQR 209–305) group than LRC group (160 min, IQR 130–200) (
p
< 0.001). The median number of lymph nodes harvested was 22 (IQR 18–29) in RRC group while it was 19 (IQR 15–27) in LRC one (
p
= 0.028). No significant differences between the groups were seen in terms of time-to-first flatus, postoperative complications and length of hospital stay. Re-admission rate was significantly higher in LRC (
n
= 3, 3.6%) group than in RRC group (
n
= 1, 0.3%) (
p
= 0.033).
Conclusions
In conclusion, RRC and LRC are comparable in terms of functional postoperative outcomes and length of hospital stay. RRC requires longer operative time, but the number of lymph nodes harvested may be higher.
Acute cholecystitis (AC) is largely diffused among population worldwide. Laparoscopic cholecystectomy is the treatment of choice. Current evidence suggests a clinical benefit of early ...cholecystectomy. The aim of the present study was to evaluate the different "timing" ("early" vs. "delayed" cholecystectomy), through the application of network meta-analyses, to define the most adequate interval associated with the best outcomes.
A network meta-analysis of randomized controlled trials was conducted.
Early cholecystectomy ≤72 hours from symptoms reduced conversion rate in comparison to: cholecystectomy ≤7 days from symptoms ( P =0.044), delayed cholecystectomy within 1 to 5 weeks from first admission ( P =0.010) and 6 to 12 weeks from symptoms resolutions ( P =0.009). Delaying cholecystectomy to 6 to 12 weeks reduces operating time in respect to early cholecystectomy ≤72 hours from symptoms ( P =0.001), within 24 hours from admission ( P =0.001), ≤72 hours from admission ( P =0.001) and ≤7 days from symptoms ( P =0.001). Cholecystectomy ≤24 hours from admission was the best strategy to reduce total in-hospital stay, whereas delaying cholecystectomy to 6 to 12 weeks was the worst strategy. The same applied when cholecystectomy was performed ≤72 hours from symptoms in respect to both delayed strategies ( P =0.001 for both comparisons) or when it was performed ≤72 hours from admission ( P =0.001 for both comparisons). Cholecystectomy ≤72 hours from symptoms onset was the best strategy to reduce postoperative complications, the worst was represented by delayed cholecystectomy at 1 to 5 weeks from first admission.
AC should be operated as soon as possible. AC surgical management should be considered in a dynamic time conception to optimize clinical, organizational, and economical outcomes.
Perioperative oncological treatment is currently the gold standard approach in Europe for Advanced Gastric Cancer patients. Unfortunately, patients dropping out due to worsening conditions has been ...frequently observed, but these data are seldomly considered and reported. To analyze frequency and propose solutions to support these patients, we reconsidered our results from the GASTRODOC randomized trial performed by blinded for reviewers and GIRCG on 91 patients. Thirty-four patients (37.4%) suspended chemotherapy and five (5.4%) did not reach surgery. Ten patients (11%) presented unacceptable toxicity related to gastrointestinal symptoms, six ended the treatment for investigator decision and six for progression, five patients withdrew their consent, five patients were excluded because of surgical complications and long hospitalization, and two patients died. Even though not significant, survival rates for patients who interrupted treatment in the whole trial were lower (5-year OS completed 64.6 vs. interrupted 41.8
p
0.07). Promptness in giving patient support for gastrointestinal symptoms, careful evaluation of anemia and patient nutritional status, and psychological programs from the beginning of the oncologic treatment may improve the final results.
To assess the impact of the laparoscopic anatomic resections (LARs) on hepatocellular carcinoma (HCC) patients, analyzing the pooled short- and long-term outcomes of this technique and comparing it ...with the standard open approach open anatomic resections (OAR).
A systematic literature search was performed in PubMed, Embase, and Scopus for studies published between 2010 and 2020 concerning LAR for HCC.
After screening 311 articles, 10 studies with a total of 398 patients who underwent LAR for HCC were included. The pooled cohort included mostly male (76.6%), Child A (98.2%), with hepatitis B virus (HBV)-related disease (60.5%). The pooled conversion rate was 7.3%. The pooled overall complication rate was 10.2 with a mortality rate of 1.0%. In the pooled analyses of only comparative studies, LAR group included 378 versus 455 in OAR. Operative time was longer in the LAR group (329 minutes versus 248;
= .001). Blood loss (179 versus 331 mL;
= .018) was lower in the LAR group. The pooled mean length of hospital stay was 8.4 days in LARs and 11.3 in OARs (
= .002). The pooled rate of postoperative complications was higher in the OAR group (25.3 versus 13.8;
= .009), while mortality rates were similar. The LAR group had a pooled 3- and 5-year overall survival of 90.1 and 81.9 versus 83.5 and 80.7 of the OARs (
> .05), respectively.
In conclusion, the LAR for HCC is safe and associated with decreased blood loss and length of hospital stay. Survival rates are comparable with those of the conventional open approach.
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