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Background: The purpose of the study was to conduct a comprehensive genomic characterization of gene alterations, microsatellite instability (MSI), and tumor mutational burden (TMB) in submucosal-penetrating (Pen) early gastric cancers (EGCs) with varying prognoses., Methods: Samples from EGC patients undergoing surgery and with 10-year follow-up data available were collected. Tissue genomic alterations were characterized using Trusight Oncology panel (TSO500). Pathway instability (PI) scores for a selection of 218 GC-related pathways were calculated both for the present case series and EGCs from the TCGA cohort., Results: Higher age and tumor location in the upper-middle tract are significantly associated with an increased hazard of relapse or death from any cause (p = 0.006 and p = 0.032). Even if not reaching a statistical significance, Pen A tumors more frequently present higher TMB values, higher frequency of MSI-subtypes and an overall increase in PI scores, along with an enrichment in immune pathways. ARID1A gene was observed to be significantly more frequently mutated in Pen A tumors (p = 0.006), as well as in patients with high TMB (p = 0.027). Tumors harboring LRP1B alterations seem to have a higher hazard of relapse or death from any cause (p = 0.089), being mutated mainly in relapsed patients (p = 0.093)., Conclusions: We found that the most aggressive subtype Pen A is characterized by a higher frequency of ARID1A mutations and a higher genetic instability, while LRP1B alterations seem to be related to a lower disease-free survival. Further investigations are needed to provide a rationale for the use of these markers to stratify prognosis in EGC patients., (© 2024. The Author(s).)

Background/Objectives : The textbook outcome (TO) is a composite tool introduced to uniform surgical units and regulate surgical quality and outcomes. A patient is considered TO only if all predetermined items are met. In colorectal surgery, TO represents a new tool that can achieve important results given the prevalence of colorectal cancers. However, at present, there is a lack of uniformity in the TO's definition. This study utilized the Delphi process to define an Italian version of the TO in colorectal cancer. Methods : The survey consisted of two rounds of online questionnaires submitted to an expert panel in colorectal oncological surgery, renowned academic surgeons, who had attended multiple scientific conferences and who were authors of papers on this specific topic. Five main topics with 26 questions were investigated through an online modified Delphi method. Items with almost 75% agreement achieved consensus. Results : Twenty-eight Italian experts were selected and participated in the two rounds. The Italian version of the textbook outcome in colorectal surgery was defined as the presence of 90-day postoperative survival, negative margins and at least 12 lymph nodes, a minimally invasive approach, ostomy fashioning if preoperatively planned, postoperative complication < Clavien-Dindo 3b, at least 10 ERAS items, no readmission, proper CHT and RT regimens, complete colonoscopy after or before surgery and Tumor Board Evaluation. Conclusions : The textbook outcome in colorectal cancer patients is a quality instrument providing a complete overview of the care of such patients, from diagnosis to treatment. We hereby propose an Italian version of the TO with outcomes chosen by an expert panel.

Gastro-oEsophageal Cancers (GECs) are severe diseases whose management is rapidly evolving. The European Society of Surgical Oncology (ESSO) is committed to the generation and spread of knowledge, and promotes the multidisciplinary management of cancer patients through its core curriculum. The present work discusses the approach to GECs, including the management of oligometastatic oesophagogastric cancers (OMEC), the diagnosis and management of peritoneal metastases from gastric cancer (GC), the management of Siewert Type II tumors, the importance of mesogastric excision, the role of robotic surgery, textbook outcomes, organ preserving options, the use of molecular markers and immune check-point inhibitors in the management of patients with GECs, as well as the improvement of current clinical practice guidelines for the management of patients with GECs. The aim of the present review is to provide a concise overview of the state-of-the-art on the management of patients with GECs and, at the same time, to share the latest advancements in the field and to foster the debate between surgical oncologists treating GECs worldwide. We are sure that our work will, at the same time, give an update to the advanced surgical oncologists and help the training surgical oncologists to settle down the foundations for their future practice., Competing Interests: Declaration of competing interest Johnn Henry Herrera Kok, Luigi Marano, Jan Willem van den Berg, Preethi Shetty, Yogesh Vashist, Laura Lorenzon, Beate Rau, Richard van Hillegersberg, Giovanni de Manzoni, Andrea Spallanzani, Won Jun Seo, Hiromi Nagata, Clarisse Eveno, Stefan Mönig, Karen van der Sluis, Leonardo Solaini, Bas PL Wijnhoven, Francesco Puccetti, Mickael Chevallay, Eunju Lee, and Domenico D'Ugo declare that they have no conflict of interest., (© 2024 Published by Elsevier Ltd.)

Multimodal treatment in peritoneal metastases (PM) from colorectal neoplasms may improve overall survival (OS). In this study, we reported our experience in using cytoreductive surgery (CRS) combined with intraperitoneal chemohyperthermia (HIPEC) for the treatment of peritoneal metastases (PM) from colorectal neoplasms. The first aim was to evaluate the overall survival of these patients. Furthermore, using the results of the Prodige 7 Trial and incorporating them with the entropy balance statistical tool, we generated a pseudopopulation on which to test the use of CRS alone. We performed a retrospective analysis based on a prospective database of all 55 patients treated with CRS + HIPEC between March 2004 and January 2023. The median OS was 47 months, with 1-, 3- and 5-year survival rates of 90.8%, 58.7% and 42.7%, respectively. There was no significant difference in the data in the pseudogroup generated with entropy balance. This finding confirms the critical role of complete cytoreduction in achieving the best OS for patients with PM. PCI > 6 seems to be the most important prognostic factor influencing OS. At present, CRS + HIPEC seems to be the therapeutic strategy that guarantees the best results in terms of OS for patients with relatively low PCI and in whom a CCS ≤ 1 can be achieved.

Background: In this article we aimed to perform a subgroup analysis using data from the COVID-AGICT study, to investigate the perioperative outcomes of patients undergoing surgery for pancreatic cancers (PC) during the COVID-19 pandemic., Methods: The primary endpoint of the study was to find out any difference in the tumoral stage of surgically treated PC patients between 2019 and 2020. Surgical and oncological outcomes of the entire cohort of patients were also appraised dividing the entire peri-pandemic period into six three-month timeframes to balance out the comparison between 2019 and 2020., Results: Overall, a total of 1815 patients were surgically treated during 2019 and 2020 in 14 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (p = 0.846). During the pandemic, neoadjuvant chemotherapy (NCT) has dropped significantly (6.2% vs 21.4%, p < 0.001) and, for patients who didn't undergo NCT, the latency between diagnosis and surgery was shortened (49.58 ± 37 days vs 77.40 ± 83 days, p < 0.001). During 2020 there was a significant increase in minimally invasive procedures (p < 0.001). The rate of postoperative complication was the same in the two years but during 2020 there was an increase of the medical ones (19% vs 16.1%, p = 0.001)., Conclusions: The post-pandemic dramatic modifications in healthcare provision, in Italy, did not significantly impair the clinical history of PC patients receiving surgical resection. The present study is one of the largest reports available on the argument and may provide the basis for long-term analyses., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Rectal cancer presents a significant burden globally, often requiring multimodal therapy for locally advanced cases. Long-course chemoradiotherapy (LCRT) and short-course radiotherapy (SCRT) followed by surgery have been conventional neoadjuvant approaches. Recent trials favor LCRT due to improved local control. However, distant tumor recurrence remains a concern, prompting the exploration of total neoadjuvant therapy (TNT) as a comprehensive treatment strategy. Immune checkpoint inhibitors (ICIs) show promise, particularly in mismatch repair-deficient (dMMR) or microsatellite instability-high (MSI-H) tumors, potentially revolutionizing neoadjuvant regimens. Nonoperative management (NOM) represents a viable alternative post-neoadjuvant therapy for selected patients achieving complete clinical response (cCR). Additionally, monitoring minimal residual disease (MRD) using circulating tumor DNA (ctDNA) emerges as a non-invasive method for the assessment of treatment response. This review synthesizes current evidence on TNT, ICIs, NOM, and ctDNA, elucidating their implications for rectal cancer management and highlighting avenues for future research and clinical application., Competing Interests: The authors declare no conflicts of interest.

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA., Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up., Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections., Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception., (© 2024. The Author(s).)

Introduction: The Italian Research Group for Gastric Cancer developed a prospective database about stage IV gastric cancer, to evaluate how a pragmatic attitude impacts the management of these patients., Materials and Methods: We prospectively collected data about metastatic gastric cancer patients thanks to cooperation between radiologists, oncologists and surgeons and we analyzed survival and prognostic factors, comparing the results to those obtained in our retrospective study., Results: Three-hundred and eighty-three patients were enrolled from 2018 to September 2022. We observed a higher percentage of laparoscopic exploration with peritoneal lavage in the prospective cohort. In the registry only 3.6 % of patients was submitted to surgery without associated chemotherapy, while in the retrospective population 44.3 % of patients were operated on without any chemotherapy. At univariate and multivariate analyses, the different metastatic sites did not show any survival differences among each other (OS 20.0 vs 16.10 vs 16.7 months for lymphnodal, peritoneal and hepatic metastases, respectively), while the number of metastatic sites and the type of treatment showed a statistical significance (OS 16,7 vs 13,0 vs 4,5 months for 1, 2 and 3 different metastatic sites respectively, p < 0.001; 24,2 vs 12,0 vs 2,5 months for surgery with/without chemotherapy, chemotherapy alone and best supportive treatment respectively, p < 0.001)., Conclusions: Our data highlight that the different metastatic sites did not show different survivals, but survival is worse in case of multiple localization. In patients where a curative resection can be achieved, acceptable survival rates are possible. A better diagnostic workup and a more accurate staging impact favorably upon survival., Competing Interests: Declaration of competing interest All authors have no competing interests to declare., (© 2023 Published by Elsevier Ltd.)

Background: Interest in the field of metastatic gastric cancer has grown in recent years, and the identification of oligometastatic patients plays a critical role as it consents to their inclusion in multimodal treatment strategies, which include systemic therapy but also surgery with curative intent. To collect sound clinical data on this subject, The Italian Research Group on Gastric Cancer developed a prospective multicentric observational register of metastatic gastric cancer patients called META-GASTRO., Methods: Data on 383 patients in Meta-Gastro were mined to help our understanding of oligometastatic, according to its double definition: quantitative/anatomical and dynamic., Results: the quantitative/anatomical definition applies to single-site metastases independently from the metastatic site ( p < 0.001) to peritoneal metastases with PCI ≤ 12 ( p = 0.009), to 1 or 2 hepatic metastases ( p = 0.024) and nodal metastases in station 16 ( p = 0.002). The dynamic definition applies to a percentage of cases variable according to the metastatic site: 8%, 13.5 and 23.8% for hepatic, lymphatic and peritoneal sites, respectively. In all cases, the OS of patients benefitting from conversion therapy was similar to those of cases deemed operable at diagnosis and operated after neoadjuvant chemotherapy., Conclusions: META-GASTRO supports the two-fold definition of oligometastatic gastric cancer: the quantitative/anatomical one, which accounts for 30% of our population, and the dynamic one, observed in 16% of our cases.

Purpose: In this study, we aim to analyze the learning curve of each step of robotic transabdominal pre-peritoneal inguinal hernia repair (rTAPP) in two surgeons with varying degrees of expertise with the robotic platform but no experience with laparoscopic hernia repair., Methods: Data on 124 rTAPP cases performed by two surgeons were retrospectively reviewed. Cumulative sum (CUSUM) analysis was applied to visualize the learning curve of rTAPP on operation time of each step of the procedure [the peritoneal flap creation (T1), the completion of the critical view of the myopectineal orifice (T2), the mesh application (T3) and the peritoneal flap closure (T4)]. Each intraoperative and postoperative outcome was compared according to surgeon's experience with the robotic platform and learning phase. The robotic surgeon mentored the surgeon-in-training and was present during all surgeries in his learning period., Results: The surgeon in training with the robotic platform showed a learning phase till the 20th procedure followed by a gradual improvement in performances. The expert surgeon showed a learning phase till the 35th procedure after which a constant decrease of operative time was recorded till the last procedure included. The operative times of each step of the procedures of both surgeons were significantly improved after the learning phase. In the late phase, the surgeon in training could achieve operative times in T2 and T3, which are similar to those of an experienced robotic surgeon with no experience with TAPP before the completion of the learning phase., Conclusions: In conclusion, the learning phase of rTAPP surgery may vary between 20 and 35 cases, depending on the surgeon's experience in robotic surgery., (© 2023. The Author(s).)

The advantages of using the robotic platform may not be clearly evident in left colectomies, where the surgeon operates in an "open field" and does not routinely require intraoperative suturing. Current evidences are based on limited cohorts reporting conflicting outcomes regarding robotic left colectomies (RLC). The aim of this study is to report a bi-centric experience with robotic left colectomy in order to help in defining the role of the robotic approach for these procedures. This is a bi-centric propensity score matched study including patients who underwent RLC or laparoscopic left colectomy (LLC) between January 1, 2012 and May 1, 2022. RLC patients were matched to LLC patients in a 1:1 ratio. Main outcomes were conversion to open surgery and 30-day morbidity. In total, 300 patients were included. Of 143 (47.7%) RLC patients, 119 could be matched. After matching, conversion rate (4.2 vs. 7.6%, p = 0.265), 30-day morbidity (16.1 vs. 13.7%, p = 0.736), Clavien-Dindo grade ≥ 3 complications (2.4 vs 3.2%, p = 0.572), transfusions (0.8 vs. 4.0%, p = 0.219), and 30-day mortality (0.8 vs 0.8%, p = 1.000) were comparable for RLC and LLC, respectively. Median operative time was longer for RLC (296 min 260-340 vs. 245, 195-296, p < 0.0001). Early oral feeding, time to first flatus, and hospital stay were similar between groups. RLC has safety parameters as well as conversion to open surgery comparable with standard laparoscopy. Operative time is longer with the robotic approach., (© 2023. The Author(s).)

Background: Fredet's fascia represents a crucial landmark for vascular surgical anatomy, especially in minimally invasive complete mesocolic excision (CME) for right-sided colon adenocarcinoma. Fredet's fascia allows access to the gastrocolic trunk of Henle (GCTH), the most critical step in both open and minimally invasive right-sided CME techniques. Despite this, a recent workshop of expert surgeons on the standardization of the laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet's fascia or area. Hence, we undertook a systematic review of articles that include the terms "Fredet's fascia or area", or synonyms thereof, with special emphasis on the types of articles published, the nationality, and the relevance of this area to surgical treatments., Methods: We conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar., Results: The results of the study revealed that the term "Fredet's fascia" is poorly used in the English language medical literature. In addition, the study found controversial and conflicting data among authors regarding the definition of "Fredet's fascia" and its topographical limits., Conclusions: Knowledge of Fredet's fascia's surgical relevance is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric vascular pedicle during minimally invasive right hemicolectomies with CME. In order to avoid confusion and clarify this fascia for future use, we suggest moving beyond the use of the eponymous term by using a "descriptive term" instead, based on the fascia's anatomic structure. Fredet's fascia could, therefore, be more appropriately renamed "sub-mesocolic pre-duodenopancreatic fascia".

Italian Research Group for Gastric Cancer (GIRCG), during the 2013 annual Consensus Conference to gastric cancer, stated that laparoscopic or robotic approach should be limited only to early gastric cancer (EGC) and no further guidelines were currently available. However, accumulated evidences, mainly from eastern experiences, have supported the application of minimally invasive surgery also for locally advanced gastric cancer (AGC). The aim of our study is to give a snapshot of current surgical propensity of expert Italian upper gastrointestinal surgeons in performing minimally invasive techniques for the treatment of gastric cancer in order to answer to the question if clinical practice overcome the recommendation. Experts in the field among the Italian Research Group for Gastric Cancer (GIRCG) were invited to join a web 30-item survey through a formal e-mail from January 1st, 2020, to June 31st, 2020. Responses were collected from 46 participants out of 100 upper gastrointestinal surgeons. Percentage of surgeons choosing a minimally invasive approach to treat early and advanced gastric cancer was similar. Additionally analyzing data from the centers involved, we obtained that the percentage of minimally invasive total and partial gastrectomies in advanced cases augmented with the increase of surgical procedures performed per year (p = 0.02 and p = 0.04 respectively). It is reasonable to assume that there is a widening of indications given by the current national guideline into clinical practice. Propensity of expert Italian upper gastrointestinal surgeons was to perform minimally invasive surgery not only for early but also for advanced gastric cancer. Of interest volume activity correlated with the propensity of surgeons to select a minimally invasive approach., (© 2022. Italian Society of Surgery (SIC).)

Background: 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., Methods: 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., Results: 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)., Conclusion: 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., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background: The coronavirus pandemic had a major impact in Italy. The Italian health system's re-organization to face the emergency may have led to significant consequences especially in the diagnosis and treatment of malignancies. This study aimed to assess the impact of the pandemic in the diagnosis and treatment of gastric cancer in nine Gruppo Italiano RIcerca Cancro Gastrico (GIRCG) centers., Methods: All patients assessed for gastric adenocarcinoma at nine GIRCG centers between January 2019 and November 2020 were included. Patients were grouped according to the date of "patient 1's" diagnosis in Italy: preCOVID versus COVID. Clinico-pathological and outcome differences between the two groups were analyzed., Results: A total of 632 patients were included in the analysis (205 in the COVID group). The cT4 weighted ratios were higher in 2020 from April to September, with the greatest differences in May, August and September. The cM+ weighted ratio was significantly higher in July 2020. The mean number of gastrectomies had the greatest reduction in March and May 2020 compared with 2019. The median times from diagnosis to chemotherapy, to complete diagnostic work-up or to operation were longer in 2019. The median time from the end of chemotherapy to surgery was 17 days longer in the preCOVID group., Conclusions: A greater number of advanced or metastatic cases were diagnosed after the spread of SARS-CoV-2 infection, especially after the "full lockdown" periods. During the pandemic, once gastric cancer patients were referred to one of the centers, a shorter time to complete the diagnostic work-up or to address them to the best treatment option was required.

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., (© 2022. Italian Society of Surgery (SIC).)

Background: Evidence on the efficacy of minimally invasive (MI) segmental resection of splenic flexure cancer (SFC) is not available, mostly due to the rarity of this tumor. This study aimed to determine the survival outcomes of MI and open treatment, and to investigate whether MI is noninferior to open procedure regarding short-term outcomes., Methods: This nationwide retrospective cohort study included all consecutive SFC segmental resections performed in 30 referral centers between 2006 and 2016. The primary endpoint assessing efficacy was the overall survival (OS). The secondary endpoints included cancer-specific mortality (CSM), recurrence rate (RR), short-term clinical outcomes (a composite of Clavien-Dindo > 2 complications and 30-day mortality), and pathological outcomes (a composite of lymph nodes removed ≧12, and proximal and distal free resection margins length ≧ 5 cm). For these composites, a 6% noninferiority margin was chosen based on clinical relevance estimate., Results: A total of 606 patients underwent either an open (208, 34.3%) or a MI (398, 65.7%) SFC segmental resection. At univariable analysis, OS and CSM were improved in the MI group (log-rank test p = 0.004 and Gray's tests p = 0.004, respectively), while recurrences were comparable (Gray's tests p = 0.434). Cox multivariable analysis did not support that OS and CSM were better in the MI group (p = 0.109 and p = 0.163, respectively). Successful pathological outcome, observed in 53.2% of open and 58.3% of MI resections, supported noninferiority (difference 5.1%; 1-sided 95%CI - 4.7% to ∞). Successful short-term clinical outcome was documented in 93.3% of Open and 93.0% of MI procedures, and supported noninferiority as well (difference - 0.3%; 1-sided 95%CI - 5.0% to ∞)., Conclusions: Among patients with SFC, the minimally invasive approach met the criterion for noninferiority for postoperative complications and pathological outcomes, and was found to provide results of OS, CSM, and RR comparable to those of open resection., (© 2022. The Author(s).)

To evaluate the effect of patient blood management (PBM) since its introduction, we analyzed the need for transfusion and the outcomes in patients undergoing abdominal surgery for different types of tumor pre- and post-PBM. Patients undergoing elective gastric, liver, pancreatic, and colorectal surgery between 2017 and 2020 were included. The implementation of the PBM program was completed on May 1, 2018. The patients were grouped as follows: those who underwent surgery before the implementation of the program (pre-PBM) versus after the implementation (post-PBM). A total of 1302 patients were included in the analysis (445 pre-PBM vs. 857 post-PBM). The number of transfused patients per year decreased significantly after the introduction of PBM. A strong tendency for a decreased incidence of transfusion was evident in gastric and pancreatic surgery and a similar decrease was statistically significant in liver surgery. With regard to gastric surgery, a single-unit transfusion scheme was used more frequently in the post-PBM group (7.7% vs. 55% after PBM; p = 0.049); this was similar in liver surgery (17.6% vs. 58.3% after PBM; p = 0.04). Within the subgroup of patients undergoing liver surgery, a significant reduction in the use of blood transfusion (20.5% vs. 6.7%; p = 0.002) and a decrease in the Hb trigger for transfusion (8.5, 8.2-9.5 vs. 8.2, 7.7-8.4 g/dl; p = 0.039) was reported after the PBM introduction. After the implementation of a PBM protocol, a significant reduction in the number of patients receiving blood transfusion was demonstrated, with a strong tendency to minimize the use of blood products for most types of oncologic surgery., (© 2022. The Author(s).)

Background: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not., Methods: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not., Results: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]., Conclusions: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands., (© 2022. The Author(s).)

Background: 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., Materials and Methods: A network meta-analysis of randomized controlled trials was conducted., Results: 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., Conclusion: 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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Oncologic outcomes after laparoscopic gastrectomy for advanced gastric cancer in the West have been poorly investigated. The aim of the present study was to compare survival outcomes in patients undergoing curative-intent laparoscopic and open gastrectomy for advanced gastric cancer in several centres belonging to the Italian Research Group for Gastric Cancer., Methods: Data of patients operated between 2015 and 2018 were retrospectively analysed. Propensity Score Matching was performed to balance baseline characteristics of patients undergoing laparoscopic and open gastrectomy. The primary endpoint was 3-year overall survival. Secondary endpoints were 3-year disease-free survival and short-term outcomes. Multivariable regression analyses for survival were conducted., Results: Data were retrieved from 20 centres. Of the 717 patients included, 438 patients were correctly matched, 219 per group. The 3-year overall survival was 73.6% and 68.7% in the laparoscopic and open group, respectively (p = 0.40). When compared with open gastrectomy, laparoscopic gastrectomy showed comparable 3-year disease-free survival (62.8%, vs 58.9%, p = 0.40), higher rate of return to intended oncologic treatment (56.9% vs 40.2%, p = 0.001), similar 30-day morbidity/mortality. Prognostic factors for survival were ASA Score ≥ 3, age-adjusted Charlson Comorbidity Index ≥ 5, lymph node ratio ≥ 0.15, p/ypTNM Stage III and return to intended oncologic treatment., Conclusions: Laparoscopic gastrectomy for advanced gastric cancer offers similar rates of survival when compared to open gastrectomy, with higher rates of return to intended oncologic treatment. ASA score, age-adjusted Charlson Comorbidity Index, lymph node ratio, return to intended oncologic treatment and p/ypTNM Stage, but not surgical approach, are prognostic factors for survival., (© 2022. The Author(s) under exclusive licence to The International Gastric Cancer Association and The Japanese Gastric Cancer Association.)

The pursuit of this paper is to collect principal reviews and systematic reviews about hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS) used in colorectal cancer (CRC). We focus on principal biological aspects of CRC, hyperthermia effects, and surgical procedures. We searched PubMed/MEDLINE for the principal reviews and systematic reviews published from 2010 to 2021 regarding the bimodal treatment (CRS + HIPEC) against local and advanced CRC. In the literature, from several studies, it seems that the efficacy of bimodal treatment with an accurate CRS can extend overall survival. Despite these studies, there are not still any straight guidelines more detailed and scheduled about the use of combined treatment in patients with CRC. Even if the concept is still not very clear and shared, after a careful evaluation of the published data, and after some technical and pathophysiological descriptions, we concluded that it is possible to improve the overall survival and quality of life and to reduce the tumor relapse in patients affected by locally advanced (pT4) CRC with peritoneal metastases., Competing Interests: Conflict-of-interest statement: The authors have nothing to disclose., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background. More than 50% of operable GEA relapse after curative-intent resection. We aimed at externally validating a nomogram to enable a more accurate estimate of individualized risk in resected GEA. Methods. Medical records of a training cohort (TC) and a validation cohort (VC) of patients undergoing radical surgery for c/uT2-T4 and/or node-positive GEA were retrieved, and potentially interesting variables were collected. Cox proportional hazards in univariate and multivariate regressions were used to assess the effects of the prognostic factors on OS. A graphical nomogram was constructed using R software’s package Regression Modeling Strategies (ver. 5.0-1). The performance of the prognostic model was evaluated and validated. Results. The TC and VC consisted of 185 and 151 patients. ECOG:PS > 0 (p < 0.001), angioinvasion (p < 0.001), log (Neutrophil/Lymphocyte ratio) (p < 0.001), and nodal status (p = 0.016) were independent prognostic values in the TC. They were used for the construction of a nomogram estimating 3- and 5-year OS. The discriminatory ability of the model was evaluated with the c-Harrell index. A 3-tier scoring system was developed through a linear predictor grouped by 25 and 75 percentiles, strengthening the model’s good discrimination (p < 0.001). A calibration plot demonstrated a concordance between the predicted and actual survival in the TC and VC. A decision curve analysis was plotted that depicted the nomogram’s clinical utility. Conclusions. We externally validated a prognostic nomogram to predict OS in a joint independent cohort of resectable GEA; the NOMOGAST could represent a valuable tool in assisting decision-making. This tool incorporates readily available and inexpensive patient and disease characteristics as well as immune-inflammatory determinants. It is accurate, generalizable, and clinically effectivex.

Background: Incidence of gallstones in those aged ≥ 80 years is as high as 38%-53%. The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging., Aim: To assess the risk of morbidity of the "oldest-old" patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population., Methods: A retrospective study was conducted between 2010 and 2019. Perioperative variables were collected and compared between patients who had postoperative complications. A model was created and tested to predict severe postoperative morbidity., Results: The 269 patients were included in the study (193 complicated). The 9.7% of complications were grade 3 or 4 according to the Clavien-Dindo classification. Bilirubin levels were lower in patients who did not have any postoperative complications. American Society of Anesthesiologists scale 4 patients, performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo > 2 complications ( P < 0.001). The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11% and 32% of developing a severe complication., Conclusion: Patients with American Society of Anesthesiologists scale 4, higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course. Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to declare., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: This study aimed to investigate which gastric cancer patients could benefit the most from staging laparoscopy., Methods: A retrospective cohort study was carried out, including 316 (216 cM- and 100 cM+) gastric cancer patients who had undergone staging laparoscopy between 2010 and 2020 in seven GIRCG centers. A model including easily-accessible clinical, biochemical and pathological markers was constructed to predict the risk of carcinomatosis. ROC curve and decision curve analyses were used to verify its accuracy and net benefit., Results: In the cM-population staging laparoscopy could detect 67 cases who had peritoneal carcinomatosis or positive cytology, for a yield of 30.5%. In cM-patients, intestinal type tumors (0.25, 0.12-0.51; p = 0.002), cT4 tumors (2.18, 1.11-4.28; p = 0.023) and cancers of the lower third (0.31, 0.14-0.70; p = 0.004) were associated with the presence of peritoneal carcinomatosis and/or positive cytology. The ROC curve analysis of the model including the three variables showed an AUC of 0.75 (0.68-0.81, p &lt; 0.001). The decision curve analyses showed that the model had a higher net benefit than the treating all strategy between threshold probabilities of 15 and 50%., Conclusions: Staging laparoscopy is a useful tool to address the patient with gastric cancer to the most adequate treatment. In cM-patients the assessment of the location of the tumor, the Lauren's histotype and the cT status may help in providing additional elements in indicating or not the use of staging laparoscopy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

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., (© 2021. The Author(s).)

Background: This study aimed to review the new evidence to understand whether the robotic approach could find some clear indication also in left colectomy., Methods: A systematic review of studies published from 2004 to 2022 in the Web of Science, PubMed, and Scopus databases and comparing laparoscopic (LLC) and robotic left colectomy (RLC) was performed. All comparative studies evaluating robotic left colectomy (RLC) versus laparoscopic (LLC) left colectomy with at least 20 patients in the robotic arm were included. Abstract, editorials, and reviews were excluded. The Newcastle-Ottawa Scale for cohort studies was used to assess the methodological quality. The random-effect model was used to calculate pooled effect estimates., Results: Among the 139 articles identified, 11 were eligible, with a total of 52,589 patients (RLC, n = 13,506 versus LLC, n = 39,083). The rate of conversion to open surgery was lower for robotic procedures (RR 0.5, 0.5-0.6; p < 0.001). Operative time was longer for the robotic procedures in the pooled analysis (WMD 39.1, 17.3-60.9, p = 0.002). Overall complications (RR 0.9, 0.8-0.9, p < 0.001), anastomotic leaks (RR 0.7, 0.7-0.8; p < 0.001), and superficial wound infection (RR 3.1, 2.8-3.4; p < 0.001) were less common after RLC. There were no significant differences in mortality (RR 1.1; 0.8-1.6, p = 0.124). There were no differences between RLC and LLC with regards to postoperative variables in the subgroup analysis on malignancies., Conclusions: Robotic left colectomy requires less conversion to open surgery than the standard laparoscopic approach. Postoperative morbidity rates seemed to be lower during RLC, but this was not confirmed in the procedures performed for malignancies., (© 2022. The Author(s).)

Background: The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness., Methods: A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days., Results: Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations., Conclusion: Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened., (© 2022. The Author(s).)

Background: After the REGATTA trial, patients with stage IV gastric cancer could only benefit from chemotherapy (CHT). However, some of these patients may respond extraordinarily to palliative chemotherapy, converting their disease to a radically operable stage. We present a single centre experience in treating peritoneal carcinomatosis from gastric cancer., Methods: All patients with stage IV gastric cancer with peritoneal metastases as a single metastatic site operated at a single centre between 2005 and 2020 were included. Cases were grouped according to the treatment received., Results: A total of 118 patients were considered, 46 were submitted to palliative gastrectomy (11 were considered M1 because of an unsuspected positive peritoneal cytology), and 20 were submitted to Hyperthermic Intraperitoneal Chemotherapy (HIPEC) because of a <6 Peritoneal Cancer Index (PCI). The median overall survival (OS) after surgery plus HIPEC was 46.7 (95% CI 15.8-64.0). Surgery (without HIPEC) after CHT presented a median OS 14.4 (8.2-26.8) and after upfront surgery 14.7 (10.9-21.1). Patients treated with upfront surgery and considered M1 only because of a positive cytology, had a median OS of 29.2 (25.2-29.2). The OS of patients treated with surgery plus HIPEC were 60.4 months (9.2-60.4) in completely regressed cancer after chemotherapy and 31.2 (15.8-64.0) in those partially regressed ( p = 0.742)., Conclusions: Conversion surgery for peritoneal carcinomatosis from gastric cancer was associated with long survival and it should always be taken into consideration in this group of patients., Competing Interests: The Handling Editor declared a past co-authorship with the authors GE, LS and PM., (Copyright © 2022 Morgagni, Solaini, Saragoni, Monti, Valgiusti, Vittimberga, Frassineti, Framarini and Ercolani.)

Aim: Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage., Methods: The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured., Results: A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection., Conclusions: While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction., (© 2021 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Gastric cancer (GC) accounts for 4% of all cancers in Europe. Sarcopenia is a complex syndrome characterized by a loss of muscle mass and function associated with age, often present in neoplastic patients. Recently, several studies have shown a significant association between sarcopenia and poor prognosis in various pathological conditions. The current observational retrospective study investigates the association between sarcopenia and overall survival (OS) and recurrence-free survival (RFS) in patients with GC undergoing up-front surgery with curative intent. Resected GC patients' clinical records and CT images were retrospectively assessed. The preoperative CT calculation of the skeletal muscle index (SMI) at L3 level allowed us to categorize patients as sarcopenic or not. Kaplan-Meyer and univariate and multivariate Cox regression analyses were performed to determine the difference in survival and presence of independent prognostic factors. Fifty-five patients, 28 male and 27 female, out of 298 studied for gastric cancer were enrolled in the current study from two cancer referral centers in Italy. The preoperative CT calculation of the SMI at L3 level allowed us to identify 39 patients with and 16 without sarcopenia. A statistically significant difference between the sarcopenic and non-sarcopenic groups was observed in both OS and RFS (p < 0.023; p < 0.006). Moreover, sarcopenia was strongly correlated to a higher risk of recurrence in univariate and multivariate analysis (p < 0.02). Sarcopenia can be considered a critical risk factor for survival in patients with resectable GC treated with up-front surgery. Identifying sarcopenic patients at the time of diagnosis would direct selection of patients who could benefit from early nutritional and/or physical treatments able to increase their muscle mass and possibly improve the prognosis. More extensive multicenter studies are needed to address this issue., (© 2021. Italian Society of Surgery (SIC).)

Background: In the last decades, there has been an exponential diffusion of minimally invasive liver surgery (MILS) worldwide. The aim of this study was to evaluate our initial experience of 100 patients undergoing MILS resection comparing their outcomes with the standard open procedures., Materials and Methods: One hundred consecutive MILS from 2016 to 2019 were included. Clinicopathological data were reviewed to evaluate outcomes. Standard open resections were used as the control group and compared exploiting propensity score matching., Results: In total, 290 patients were included. The rate of MILS has been constantly increasing throughout years, representing the 48% in 2019. Of 100 (34.5%) MILS patients, 85 could be matched. After matching, the MILS conversion rate was 5.8% (n = 5). The post-operative complication rates were higher in the open group (45.9% vs. 31.8%, P = 0.004). Post-operative blood transfusions were less common in the MILS group (4.7% vs. 16.5%, P = 0.021). Biliary leak occurred in 2 (2.4) MILS versus 13 (15.3) open. The median comprehensive complication index was higher in the open group (8.7 [0-28.6] vs. 0 [0-10.4], P = 0.0009). The post-operative length of hospital stay was shorter after MILS (median 6 [5-8] vs 8 [7-13] days, P < 0.0001)., Conclusions: The rate of MILS has been significantly increasing throughout the years. The benefits of MILS over the traditional open approach were confirmed. The main advantages include lower rates of post-operative complications, blood transfusions, bile leaks and a significantly decreased hospital stay., Competing Interests: None

Background: The present study provides a snapshot of Italian patients with peritoneal metastasis from gastric cancer treated by surgery in Italian centers belonging to the Italian Research Group on Gastric Cancer. Prognostic factors affecting survival in such cohort of patients were evaluated with the final aim to identify patients who may benefit from radical intent surgery., Methods: It is a multicentric retrospective study based on a prospectively collected database including demographics, clinical, surgical, pathological, and follow-up data of patients with gastric cancer and synchronous macroscopic peritoneal metastases. Patients were surgically treated from January 2005 to January 2017. We focused on patients with macroscopic peritoneal carcinomatosis (PC) treated with upfront surgery in order to provide homogeneous evidences., Results: Our results show that patients with peritoneal carcinomatosis cannot be considered all lost. Strictly selected cases (R0/R1 and P1 patients) could benefit from an aggressive surgical approach performing an extended lymphadenectomy and HIPEC treatment., Conclusion: The main result of the study is that GC patients with limited peritoneal involvement can have a survival benefit from a surgery with "radical oncological intent", that means extended lymphadenectomy and R0 resection. The retrospective nature of this study is an important bias, and for this reason, we have started a prospective multicentric study including Italian stage IV patients that hopefully will give us more answers., (© 2021. The Author(s).)

Background: To validate a nodal regression system for gastric cancer and to verify its impact on prognosis., Methods: This is an ancillary study which included 47 patients of the GASTRODOC trial. The dedicated pathologists of each Institute were invited to revise all the lymph nodes included in the surgical specimens in order to classify the regression according to the grading system proposed by Tsekrekos et al. The association of the nodal regression system and the clinico-pathological characteristics and prognosis were investigated., Results: According to the classification of Tsekrekos et al., there were 19 (40.4%) patients with grade a, 14 (29.8%) with grade b and 14 (29.8%) with grade c nodal regression. This regression system showed significant statistical associations with pathological N status (p < 0.001), residual tumor classification (p = 0.003) and Becker regression system (p = 0.011). At multivariable analysis only Tsekrekos' grading regression system was significantly associated with the PFS (HR 10.1, 95% CI 1.3-75.5; p = 0.025)., Conclusions: The analyzed nodal regression system is significantly associated with Becker's regression system and it has a strong correlation with prognosis., (Copyright © 2021. Published by Elsevier Ltd.)

Purpose: Intrahepatic cholangiocarcinoma (ICC) has a poor prognosis, when unresectable; therefore, intra-arterial therapies (IAT) such as trans-arterial chemoembolization (TACE) and trans-arterial radioembolization (TARE) have been employed. With the present systematic review and meta-analysis, we aimed to analyse published studies to understand if one IAT can be superior to the alternative., Materials and Methods: A systematic search of PubMed and Web of Science databases was performed for articles published until 1 March 2020 relevant to IAT for ICC. Overall survival was the primary end point. Occurrence of clinical adverse events and tumour overall response were secondary outcome measures., Results: A total of 31 articles (of 793, n.1695 patients) were selected for data extraction, 13 were on TACE (906 patients) and 18 were on TARE (789 patients). Clinical and tumour characteristics showed moderate heterogeneity between the two groups. The median survival after TACE was 14.2 months while after TARE was 13.5 months (95%C.I.: 11.4-16.1). The survival difference was small (d = 0.112) at 1 year and negligible at 2 years (d = 0.028) and at 3 years (d = 0.049). The radiological objective response after TACE was 20.6% and after TARE was 19.3% (d = 0.032). Clinical adverse events occurred in 58.5% after TACE, more frequently than after TARE (43.0%, d = 0.314)., Conclusion: In conclusion, IATs are promising treatments for improving outcomes for patients with unresectable ICC. To date, TACE and TARE provide similar good outcomes, except for adverse events. Therefore, the decision about techniques is determined by ability to utilize these resources and patient specific factors (liver function or lesion dimension).

Introduction: To compare outcomes of robotic gastrectomy (RG) performed during the learning curve (P1) with those after its completion (P2)., Methods: In this retrospective study, all consecutive RG patients (n = 92) performed between 2008 and 2018 were included. Primary outcome was conversion rate., Results: D2 lymphadenectomies were more common in P2 (41, 97.6%) than P1 (41, 82.0%) (p = 0.019). Conversions were 11 (22%) in P1 versus 2 (4.8%) in P2 (p = 0.006). Postoperative morbidity was comparable between the groups. Median hospital stay was significantly shorter in P2. The only factor significantly associated with conversion was P2 (odds ratio = 0.18; 95% confidence interval, 0.04-0.85; p = 0.039). The 5-year overall survival in P1 was 79.6% versus 79.7% in P2 (p = 0.373)., Conclusions: The learning curve affected operative and postoperative outcomes: during the learning curve, conversion to open surgery was significantly more frequent, the number of D2 was higher and patients were discharged earlier., (© 2021 John Wiley & Sons Ltd.)

Purpose: To present the outcomes of gastric gastrointestinal stromal tumour (GIST) resection from five Italian centres, focussing the analysis on the comparison among open (OG), laparoscopic (LG) and robotic (RG) approaches., Methods: All consecutive gastric wedge resections for GIST between 2009 and 2019 were included., Results: In total 101 (OG = 14, LG = 63 and RG = 24) were included. No differences were seen in the preoperative characteristics among the groups. Robotic procedures were longer (RG 180 min vs. LG 100 vs. OG 110; p < 0.0001). Time-to-first flatus and length of hospital stay were significantly longer in the OG group. Complication rates were similar among the groups. A sub-analysis on minimally invasive (RG = 19 vs. LG = 20) wedge resections and hand/robot-sewn suture showed that operative time was longer in the RGs (p = 0.007). No conversions were recorded in the RG group versus three in the LG group (p = 0.231). Safety-related factors were similar., Conclusions: Gastric GIST can be safely treated with a minimally invasive approach which is also associated with improved postoperative outcomes., (© 2020 John Wiley & Sons Ltd.)

Background: The aim of this study is to estimate what would have happened if all patients treated with laparoscopy for rectal cancer had instead been treated with the robotic technique., Methods: To estimate the average treatment effect (ATE) of the robotic technique over the laparoscopic approach, data from patients treated at two centres between 2007 and 2018 were used to obtain counterfactual outcomes using an inverse probability weighting (IPW) adjustment., Results: This study enrolled 261 patients, of which 177 and 84 patients had undergone robotic surgery and standard laparoscopy, respectively. After IPW adjustment, the difference between the groups was similar in the pseudo-population. The average conversion rate would fall by an estimated 6.1% if all procedures had been robotic (p = 0.045). All other post-operative variables showed no differences regardless of the approach., Conclusion: ATE estimation suggests that robotic rectal cancer surgery could be associated with a lower conversion rate. The approach did not affect the post-operative morbidity rates or the operative time., (© 2020 John Wiley & Sons Ltd.)

Background : The current use of endoscopic stenting as a bridge to surgery is not always accepted in standard clinical practice to treat neoplastic colonic obstructions. Objectives: The role of colonic self-expandable metal stent (SEMS) positioning as a bridge to resective surgery versus emergency surgery (ES) for malignant obstruction, using all new data and available variables, was studied and we focused on short- and long-term results. Materials and Methods: A systematic review with meta-analysis was performed. PubMed, SCOPUS and Web of Science databases were included. The search comprised only randomized controlled trials (RCTs) investigating the interventions that included SEMS positioning versus ES. The primary outcomes were the rates of overall postoperative mortality, clinical and technical success. The secondary outcomes were the short- and long-term results. Results: A total of 12 studies were eligible for further analyses. A laparoscopic colectomy was the most common operation performed in the SEMS group, whereas the traditional open approach was commonly used in the ES group. Intraoperative colonic lavage was seldomly performed during ES. There were no differences in mortality rates between the two groups (RR 1.06, 95% CI 0.55 to 2.04; I 2 = 0%). In the SEMS group, the rate of successful primary anastomosis was significantly higher in of SEMS (69.75%) than in the ES (55.07%) (RR 1.26, 95% 245 CI 1.01 to 1.57; I 2 = 86%). Conversely, the upfront Hartmann procedure was performed more frequently in the ES (39.1%) as compared to the SEMS group (23.4%) (RR 0.61, 95% CI 0.45 to 0.85; I 2 = 23%). The overall postoperative complications rate was significantly lower in the SEMS group (32.74%) than in the ES group (48.25%) (RR 0.61, 95% CI 0.41 to 0.91; I 2 = 65%). Conclusions : In the presence of malignant colorectal obstruction, SEMS is safe and associated with the same mortality and significantly lower morbidity than the ES group. The rate of successful primary anastomosis was significantly higher than the ES group. Nevertheless, recurrence and survival outcomes are not significantly different between the two groups. The analysis of short- and long-term results can suggest the use of SEMS as a bridge to resective surgery when it is performed by an endoscopist with adequate expertise in both colonoscopy and fluoroscopic techniques and who performed commonly colonic stenting.

Background: Early Gastric Cancer (EGC) reaches 25% of the gastric cancers surgically treated in some areas of Northeastern Italy and is usually characterized by a good prognosis. However, among EGCs classified according to Kodama's criteria, Pen A subgroup is characterized by extensive submucosal invasion, lymph node metastases and worse prognosis, whereas Pen B subgroup by better prognosis. The aim of the study was to characterize the differences between Pen A, Pen B and locally advanced gastric cancer (T3N0) in order to identify biomarkers involved in aggressiveness and clinical outcome., Methods: We selected 33 Pen A, 34 Pen B and 20 T3N0 tumors and performed immunohistochemistry of mucins, copy number variation analysis of a gene panel, microsatellite instability (MSI), TP53 mutation and loss of heterozygosity (LOH) analyses., Results: Pen A subgroup was characterized by MUC6 overexpression (p = 0.021). Otherwise, the Pen B subgroup was significantly associated with the amplification of GATA6 gene (p = 0.002). The higher percentage of MSI tumors was observed in T3N0 group (p = 0.002), but no significant differences between EGC types were found. Finally, TP53 gene analysis showed that 32.8% of Pen tumors have a mutation in exons 5-8 and 50.0% presented LOH. Co-occurrence of TP53 mutation and LOH mainly characterized Pen A tumors (p = 0.022)., Conclusions: Our analyses revealed that clinico-pathological parameters, microsatellite status and frequency of TP53 mutations do not seem to distinguish Pen subgroups. Conversely, the amplification of GATA6 was associated with Pen B, as well as the overexpression of MUC6 and the TP53 mut/LOH significantly characterized Pen A.

Background: Studies reporting benchmark values for surgical procedures should provide instruments for comparison, gap analysis and adoption of corrective measures to improve the outcome., Methods: A systematic search was performed to identify articles containing the MESH terms "benchmarking" AND "hepatectomy". An Institutional Review Board-approved database of all hepato-biliary surgical procedures, performed in a new tertiary referral surgical unit was used for benchmarking results with the values reported in the literature., Results: Five articles were suitable for benchmarking: 3 based benchmark values (BMV) on the 75th percentiles of surgical outcomes among high-volume centers, one study provided BMV on the "Achievable Bench-mark of Care" and one study provided BMV on the 75th percentiles through a Bayesian prediction. When we benchmarked our surgical experience of 320 hepatic resections, we found margins for improvement for open major hepatectomies and for laparoscopic multiple resections/concomitant bowel resections but it was impossible to compare homogeneous sub-groups of patients for most of the procedures due to the lack of high-quality literature data., Conclusion: Benchmarking a surgical experience with the BMV provided in literature was attempted but unfortunately the lack of a standardized way for conducting benchmark analysis did not allow, at present, reliable quality comparison and improvement., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: This review aims to merge all the western studies dealing with robotic gastrectomies (RG) to provide pooled results and higher levels of evidence supporting the use of robotic gastrectomy for the treatment of gastric cancer also at western latitudes., Methods: A systematic literature search was performed in PubMed, Embase, and Scopus for studies published between 2010 and 2020 concerning RG in western centers. Case series and comparative studies (robotic versus open and robotic versus laparoscopic) were included., Results: After screening 1732 articles, 10 articles with a total of 988 patients undergoing RG in western centers were eligible for inclusion. Included studies showed a relatively low risk of bias. The pooled conversion rate was 3.9% (95% CI 1.2-7.9). The pooled overall complications rate was 15% (7.1-25.3) with a mortality rate of 2.5% (1.1-4.7). The pooled 5-year overall survival rate was 60.4% (46.0-74.1). The pooled analyses of the comparative studies (robotic versus open) included 132 robotic and 305 open gastrectomies and showed comparable safety parameters. The robotic group had a pooled 5-year overall survival of 55.2% (33.7-75.8) versus 50.8% (36.4-65.2) of the open group (RR 1.10, 0.78-1.55; p = 0.248 - I 2 51.8, 0.0-86.1; p = 0.125). The meta analyses of the results from the studies comparing the robotic (n = 679) and the laparoscopic (n = 1355) approach (LG) showed similar morbidity (RG 19.9%, 10.2-32.0 versus LG 15.6%, 8.7-24.0; p = 0.706) and mortality rates (RG 5.5%, 3.9-7.3 versus LG 4.3%, 3.3-5.4; p = 0.272). RG had longer operative time (RG 327 min, 297-358 versus LG 248, 222-275; p = 0.001) and lower blood loss (RG 99 ml, 96-103 versus LG 133, 104-161; p < 0.001) than laparoscopic gastrectomy., Conclusion: Based on the available data from western centers, robotic gastrectomy is comparable with the open and the laparoscopic approaches with regards to short term outcomes. Survival data of RG were similar to open gastrectomies, but studies on long-term outcomes are required to confirm these results., Competing Interests: Declaration of competing interest None., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Aim: 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)]. Material and Methods: A systematic literature search was performed in PubMed, Embase, and Scopus for studies published between 2010 and 2020 concerning LAR for HCC. Results: 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; P  = .001). Blood loss (179 versus 331 mL; P  = .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 ( P  = .002). The pooled rate of postoperative complications was higher in the OAR group (25.3 versus 13.8; P  = .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 ( P  > .05), respectively. Conclusions: 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.

Introduction: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach., Materials and Methods: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery., Results: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001)., Conclusions: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Neoadjuvant chemoradiotherapy followed by surgery is the mainstay treatment for locally advanced rectal cancer, leading to significant decrease in tumor size (downsizing) and a shift towards earlier disease stage (downstaging). Extensive histopathological work-up of the tumor specimen after surgery including tumor regression grading and lymph node status helped to visualize individual tumor sensitivity to chemoradiotherapy, retrospectively. As the response to neoadjuvant chemoradiotherapy is heterogeneous, however, valid biomarkers are needed to monitor tumor response. A relevant number of studies aimed to identify molecular markers retrieved from tumor tissue while the relevance of blood-based biomarkers is less stringent assessed. MicroRNAs are currently under investigation to serve as blood-based biomarkers. To date, no screening approach to identify relevant miRNAs as biomarkers in blood of patients with rectal cancer was undertaken. The aim of the study is to investigate the role of circulating miRNAs as biomarkers in those patients included in the TiMiSNAR Trial (NCT03465982). This is a biomolecular substudy of TiMiSNAR Trial (NCT03962088)., Methods: All included patients in the TiMiSNAR Trial are supposed to undergo blood collection at the time of diagnosis, after neoadjuvant treatment, after 1 month from surgery, and after adjuvant chemotherapy whenever indicated., Discussion: TiMiSNAR-MIRNA will evaluate the association of variation between preneoadjuvant and postneoadjuvant expression levels of miRNA with pathological complete response. Moreover, the study will evaluate the role of liquid biopsies in the monitoring of treatment, correlate changes in expression levels of miRNA following complete surgical resection with disease-free survival, and evaluate the relation between changes in miRNA during surveillance and tumor relapse., Trial Registration: Clinicaltrials.gov NCT03962088 . Registered on 23 May 2019.