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The purpose of this case-control study was to evaluate the impact of hybrid minimally invasive esophagectomy for cancer on surgical stress response and nutritional status. All 34 consecutive patients undergoing hybrid minimally invasive esophagectomy for cancer at our surgical unit between 2008 and 2013 were retrospectively compared with 34 patients undergoing esophagectomy with open gastric tubulization (open), matched for neoadjuvant therapy, pathological stage, gender and age. Demographic data, tumor features and postoperative course (including quality of life and systemic inflammatory and nutritional status) were compared. Postoperative course was similar in terms of complication rate. Length of stay in intensive care unit was shorter in patients undergoing hybrid minimally invasive esophagectomy ( P = 0.002). In the first postoperative day, patients undergoing hybrid minimally invasive esophagectomy had lower C-reactive protein levels ( P = 0.001) and white cell blood count ( P = 0.05), and higher albumin serum level ( P = 0.001). In this group, albumin remained higher also at third ( P = 0.06) and seventh ( P = 0.008) postoperative day, and C-reactive protein resulted lower at third post day ( P = 0.04). Hybrid minimally invasive esophagectomy significantly improved the systemic inflammatory and catabolic response to surgical trauma, contributing to a shorter length of stay in intensive care unit. [ABSTRACT FROM AUTHOR]

B Background: b There are a number of treatment options to palliate patients with unresectable hepatocarcinoma (HCC), but they must be tailored carefully. Aim of this study was to evaluate the safety and efficacy of conventional transarterial chemoembolization (cTACE) in elderly patients treated at the Royal Infirmary of Edinburgh. B Conclusion: b Elderly patients treated with TACE for unresectable HCC have good OS with low complication rate. [Extracted from the article]

Abstract: Ex situ ex vivo liver surgery represents a method to expand the surgical indications to treat otherwise unresectable liver tumors. We report the case of a 38-year old woman with hepatic metastasis from a pancreatoblastoma that was judged to be unresectable due to the involvement of the three hepatic veins. To treat the primary tumor, she underwent a pancreaticoduodenectomy, adjuvant chemotherapy, and thermal ablation of a liver metastasis. After appropriate preoperative study and with the permission of the ethics committee, she underwent ex situ ex vivo liver resection. The hepatectomy was performed by removing the whole liver en bloc with the retrohepatic vena cava. The inferior vena cava was reconstructed by interposition of a prosthetic graft. The ex situ ex vivo hepatic resection, a left hepatic lobectomy included the lesion in segments 1-5-7-8. The two hepatic veins were reconstructed using patches of saphenous vein. The organ was preserved continuously for 6 hours using hypothermic perfusion with 4°C Celsior solution. The liver was then reimplanted performing an anastomosis between the reconstructed hepatic veins and the caval prostheses. The patient was discharged at postoperative day 22 and is currently disease-free at 8 months after surgery and 44 months after the initial diagnosis. Ex situ, ex vivo liver surgery offers an additional option for patients with both primary and secondary liver tumors considered to be unresectable using traditional surgical approaches. [Copyright &y& Elsevier]

Abstract: Surgical resection for malignant hepatic tumors, especially hepatocarcinoma (HCC), has been demonstrated to increase overall survival; however, the majority of patients are not suitable for resection. Radiofrequency ablation (RFA) is the most widely used modality for radical treatment of small HCC (<3 cm). It improves 5-year survival compared with standard chemotherapy and chemical ablation, allowing down-staging of unresectable hepatic masses. Microwave ablation (MWA) has been extensively applied in Asia and was recently introduced in the United States of America and Europe with excellent results, especially with regard to large unresectable HCC. Our single-center experience between May 2009 and October 2010 included application of MWA to 154 patients of median age ± standard deviation of 63.5 ± 8.5 years, 6 males, and 1 female, of mean Model for End-Stage Liver Disease (MELD) score (10.1 ± 3.8). The HCC included, hepatitis C virus (HCV)-related (n = 70; 45.5%); alcool (ETOH)-related (n = 42; 27%), hepatitis B virus (HBV)-related (n = 16; 10.5%); and cryptogenic cases (n = 26; 17%). The cases were performed for radical treatment down-staging for multifocal pathology or bridging liver transplantation to orthotopic (OLT) in selected patients with single nodules. A computed tomography (CT) scan was performed at 1 month after the surgical procedure to evalue responses to treatment. Among 6 selected patients who underwent OLT; 5 (83.3%) showed disease-free survival at one-year follow-up. The radical treatment achieved no intraoperative evidence of tumor spread or of pathological signs of active HCC among the explanted liver specimens. In conclusion, a MWA seemed to be a safe novel approach to treat HCC and could serve as a “bridge” to OLT and down-staging for patients with HCC. [Copyright &y& Elsevier]

B Background: b Laparoscopic liver resection (LLR) has been reported as safe and effective approach to the management of hepatocarcinoma (HCC). The aim of this study is to analyze the long term outcome of LLR versus transarterial chemoembolization (TACE) for treatment of HCC in Child B patients B Methods: b Patients treated with LLR at a single European center were compared with patients treated with TACE included in the ITA.LI.CA database (a national multicenter HCC database). [Extracted from the article]

Herein we aim to study, through the review of a prospectively maintained database, age influence on treatment of patients undergoing surgery for HC. B Results: b 63 patients were treated: G1 included 42 patients, G2 21. 56 patients required major hepatectomy, 7 common bile duct resection. [Extracted from the article]

Abstract: We previously reported that subnormothermic machine perfusion (sMP; 20°C) is able to improve the preservation of livers obtained from non–heart-beating donors (NHBDs) in rats. We have compared sMP and standard cold storage (CS) to preserve pig livers after 60 minutes of cardiac arrest. In the sMP group livers were perfused for 6 hours with Celsior at 20°C. In the CS group they were stored in Celsior at 4°C for 6 hours as usual. To simulate liver transplantation, both sMP- and CS-preserved livers were reperfused using a mechanical continuous perfusion system with autologus blood for 2 hours at 37°C. At 120 min after reperfusion aspartate aminotransferase levels in sMP versus CS were 499 ± 198 versus 7648 ± 2806 U/L (P < .01); lactate dehydrogenase 1685 ± 418 versus 12998 ± 3039 U/L (P < .01); and lactic acid 4.78 ± 3.02 versus 10.46 ± 1.79 mmol/L (P < .01) respectively. The sMP group showed better histopathologic results with significantly less hepatic damage. This study confirmed that sMP was able to resuscitate liver grafts from large NHBD animals. [Copyright &y& Elsevier]

Abstract: Background: Polycystic liver disease (PLD) is due to a genetic disorder and frequently coexists with polycystic kidney disease (PKD). If the cysts produce symptomatology owing to their number and size, many palliative treatments are available. When none of the liver parenchyma is spared, or kidney insufficiency is marked, the only potentially curable treatment is liver transplantation (LT). Case Report: A 49-year old woman, diagnosed with PLD and PKD, was listed in January 2008 for combined LT and kidney transplantation (KT). A compatible organ became available 8 months later. Despite preserved liver function, the patient''s clinical condition was poor; she experienced dyspnea, advanced anorexia, abdominal pain, and severe ascites. At LT, which took 9 hours and was performed using the classic technique, the liver was hard, massive in size (15.5 kg), and not dissociable from the vena cava. The postoperative course was complicated by many septic episodes, the last one being fatal for the patient at 4 months after transplantation. Discussion: LT for PLD in many series shows a high mortality rate. The Model for End-Stage Liver Disease (MELD) score does not stage patients properly, because liver function is usually preserved. The liver can achieve a massive size causing many symptoms, especially malnutrition and ascites; in this setting LT is the only possible treatment. Patients with a low MELD score undergo LT with severe malnutrition that predisposes them to greater susceptibility to sepsis. To identify predictor factors, beyond MELD criteria that relate to the increased liver volume before development of late symptoms is essential to expeditiously treat patients with the poorest prognosis to improve their outcomes. [Copyright &y& Elsevier]

Background: Long-term daily use of aspirin reduces incidence and mortality due to colorectal cancer (CRC). This study aimed to analyze the effect of aspirin on the tumor microenvironment, systemic immunity, and on the healthy mucosa surrounding cancer., Methods: Patients with a diagnosis of CRC operated on from 2015 to 2019 were retrospectively analyzed (METACCRE cohort). Expression of mRNA of immune surveillance-related genes (PD-L1, CD80, CD86, HLA I, and HLA II) in CRC primary cells treated with aspirin were extracted from Gene Expression Omnibus-deposited public database (GSE76583). The experiment was replicated in cell lines. The mucosal immune microenvironment of a subgroup of patients participating in the IMMUNOREACT1 (ClinicalTrials.gov NCT04915326) project was analyzed with immunohistochemistry and flow cytometry., Results: In the METACCRE Cohort, 12% of 238 patients analyzed were aspirin users. Nodal metastasis was significantly less frequent (p = .008) and tumor-infiltrating lymphocyte infiltration was higher (p = .02) among aspirin users. In the CRC primary cells and selected cell lines, CD80 mRNA expression was increased following aspirin treatment (p = .001). In the healthy mucosa surrounding rectal cancer, the ratio of CD8/CD3 and epithelial cells expressing CD80 was higher in aspirin users (p = .027 and p = .034, respectively)., Conclusions: These data suggested that regular aspirin use may have an active role in enhancing immunosurveillance against CRC., (© 2024 American Cancer Society.)

Background: Colon cancer in young patients is often associated with hereditary syndromes; however, in early-onset rectal cancer, mutations of these genes are rarely observed. The aim of this study was to analyse the features of the local immune microenvironment and the mutational pattern in early-onset rectal cancer., Methods: Commonly mutated genes were analysed within a rectal cancer series from the University Hospital of Padova. Mutation frequency and immune gene expression in a cohort from The Cancer Genome Atlas ('TCGA') were compared and immune-cell infiltration levels in the healthy rectal mucosa adjacent to rectal cancers were evaluated in the IMMUNOlogical microenvironment in REctal AdenoCarcinoma Treatment 1 and 2 ('IMMUNOREACT') series., Results: In the authors' series, the mutation frequency of BRAF, KRAS, and NRAS, as well as microsatellite instability frequency, were not different between early- and late-onset rectal cancer. In The Cancer Genome Atlas series, among the genes with the most considerable difference in mutation frequency between young and older patients, seven genes are involved in the immune response and CD69, CD3, and CD8β expression was lower in early-onset rectal cancer. In the IMMUNOlogical microenvironment in REctal AdenoCarcinoma Treatment 1 and 2 series, young patients had a lower rate of CD4+ T cells, but higher T regulator infiltration in the rectal mucosa., Conclusion: Early-onset rectal cancer is rarely associated with common hereditary syndromes. The tumour microenvironment is characterized by a high frequency of mutations impairing the local immune surveillance mechanisms and low expression of immune editing-related genes. A constitutively low number of CD4 T cells associated with a high number of T regulators indicates an imbalance in the immune surveillance mechanisms., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Mealtime insulin dosing is a major challenge for people living with type 1 diabetes (T1D). This task is typically performed using a standard formula that, despite containing some patient-specific parameters, often leads to sub-optimal glucose control due to lack of personalization and adaptation. To overcome the previous limitations here we propose an individualized and adaptive mealtime insulin bolus calculator based on double deep Q-learning (DDQ), which is tailored to the patient thanks to a personalization procedure relying on a two-step learning framework. The DDQ-learning bolus calculator was developed and tested using the UVA/Padova T1D simulator modified to reliably mimic real-world scenarios by introducing multiple variability sources impacting glucose metabolism and technology. The learning phase included a long-term training of eight sub-population models, one for each representative subject, selected thanks to a clustering procedure applied to the training set. Then, for each subject of the testing set, a personalization procedure was performed, by initializing the models based on the cluster to which the patient belongs. We evaluated the effectiveness of the proposed bolus calculator on a 60-day simulation, using several metrics representing the goodness of glycemic control, and comparing the results with the standard guidelines for mealtime insulin dosing. The proposed method improved the time in target range from 68.35% to 70.08% and significantly reduced the time in hypoglycemia (from 8.78% to 4.17%). The overall glycemic risk index decreased from 8.2 to 7.3, indicating the benefit of our method when applied for insulin dosing compared to standard guidelines.

Background: Providing real-time magnitude and direction of glucose rate-of-change (ROC) via trend arrows represents one of the major strengths of continuous glucose monitoring (CGM) sensors in managing type 1 diabetes (T1D). Several literature methods were proposed to adjust the standard formula (SF) used for insulin bolus calculation by accounting for glucose ROC, but each of them provides different suggestions, making it difficult to understand which should be applied in practice. This work aims at performing an extensive in-silico assessment of their performance and safety., Methods: The methods of Buckingham (BU), Scheiner (SC), Pettus/Edelman (PE), Klonoff/Kerr (KL), Aleppo/Laffel (AL), Ziegler (ZI), and Bruttomesso (BR) were evaluated using the UVa/Padova T1D simulator, in single-meal scenarios, where ROC and glucose at mealtime varied between [-2,+2] mg/dL/min and [80,200] mg/dL, respectively. Efficacy of postprandial glucose control was quantitatively assessed by time in, above and below range (TIR, TAR, and TBR, respectively)., Results: For negative ROCs, all methods proved to increase TIR and decrease TAR and TBR vs SF, with KL, PE, and BR being the most effective. For positive ROCs, a general worsening of the performances is present, only BR improved the glycemic control when mealtime glucose was close to hypoglycemia, while SC resulted the safest in the other conditions., Conclusions: Insulin bolus adjustment methods are effective for negative ROCs, but they generally appear to overdose for positive ROCs, calling for safer strategies in such a scenario. These results can be useful in outlining guidelines to identify which adjustment to apply based on the mealtime condition.

People with type 1 diabetes (T1D) need exogenous insulin administrations several times a day. The amount of injected insulin is key for maintaining the concentration of blood glucose (BG) within a physiological safe range. According to well-established clinical guidelines, insulin dosing at mealtime is calculated through an empirical formula which, however, does not take advantage of the knowledge of BG trend provided in real-time by continuous glucose monitoring (CGM) sensors. To overcome suboptimal insulin dosage, we recently used machine learning techniques to build two new models, one linear and one nonlinear, which incorporate BG trend information.In this work, we propose an ensemble learning method for mealtime insulin bolus estimation based on dynamic voting, which combines the two models by taking advantage of where each alternative performs better. Being the resulting model black-box, a tool that enables its interpretability was applied to evaluate the contribution of each feature. The proposed model was trained using a synthetic dataset having information on 100 virtual subjects with different mealtime conditions, and its performance was evaluated within a simulated environment.The benefit given by the ensemble method compared to the single models was confirmed by the high time within the target glycemic range, and the trade-off reached in terms of time spent below and above this range. Moreover, the model interpretation pointed out the key role played by the information on BG dynamics in the estimation of insulin dosage.

Type 1 diabetes (T1D) is a chronic life-threatening metabolic condition which needs to be accurately and continuously managed with care by multiple daily exogenous insulin injections, frequent blood glucose concentration monitoring, ad-hoc diet, and physical activity. In the last decades, new technologies, such as continuous glucose monitoring sensors, eased the burden for T1D patients and opened new therapy perspectives by fostering the development of decision support systems (DSS). A DSS for T1D should be able to provide patients with advice aimed at improving metabolic control and reducing the number of actions related to therapy handling. Major challenges are the vast intra-/inter-subject physiological variability and the many factors that impact glucose metabolism. The present work illustrates a new DSS for T1D management. The algorithmic core includes a module for optimal, personalized, insulin dose calculation and a module that triggers the assumption of rescue carbohydrates to avoid/mitigate impending hypoglycemic events. The algorithms are integrated within a prototype communication platform that comprises a mobile app, a real-time telemonitoring interface, and a cloud server to safely store patients' data. Tests made in silico show that the use of the new algorithms lead to metabolic control indices significantly better than those obtained by the standard care for T1D. The preliminary test of the prototype platform suggests that it is robust, performant, and well-accepted by both patients and clinicians. Future work will focus on the refinement of the communication platform and the design of a clinical trial to assess the system effectiveness in real-life conditions.Clinical Relevance- The presented DSS is a promising tool to facilitate T1D daily management and improve therapy efficacy.

Introduction: In persons with type 1 diabetes (T1D) insulin dosing can be adjusted based on trend arrows derived from continuous glucose monitoring (CGM). We propose a slide rule with narrower blood glucose intervals and more classes of insulin sensitivity than are available in current models., Methods: The slide rule was tested in silico, in which a meal was simulated in 100 virtual subjects and the insulin bolus was calculated either in the standard way based on the insulin-to-carbohydrate ratio and the correction factor or according to the slide rule, following which the percentage time spent in range (70-180 mg/dl; %T IR ), hypoglycemia (< 70 mg/dl; %T HYPO ), and hyperglycemia (> 180 mg/dl; %T HYPER ) was compared between the methods during the 4 h after the meal. Slide rule performance was also tested in real life by analyzing the same variables at during the 4 h postprandial period in 27 individuals with T1D. Only meals starting while the rate of change was at least 1 mg/dl per minute (increasing or decreasing) were considered for analysis., Results: In silico, when the preprandial trend arrow was increasing, our slide rule reduced %T HYPER and increased %T IR (p < 0.05), whereas when the preprandial trend arrow was decreasing, it reduced %T HYPO and slightly increased %T HYPER (p < 0.05). In real life, our slide rule kept subjects on target for 70.8 and 91.6% of postprandial time when preprandial trend arrows were increasing or decreasing, respectively., Conclusion: The proposed slide rule performed well both in silico and in real life, suggesting that it could be safely adopted by individuals with T1D to improve glucose control.

Since the beginning of the pandemic due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), several articles reported negative outcomes in surgery of infected patients. Aim of this study is to report results of patients with COVID-19-positive swab, in the perioperative period after surgery. Data of COVID-19-positive patients undergoing emergent or oncological surgery, were collected in a retrospective, multicenter study, which involved 20 Italian institutions. Collected parameters were age, sex, body mass index, COVID-19-related symptoms, patients' comorbidities, surgical procedure, personal protection equipment (PPE) used in operating rooms, rate of postoperative infection among healthcare staff and complications, within 30-postoperative days. 68 patients, who underwent surgery, resulted COVID-19-positive in the perioperative period. Symptomatic patients were 63 (92.5%). Fever was the main symptom in 36 (52.9%) patients, followed by dyspnoea (26.5%) and cough (13.2%). We recorded 22 (32%) intensive care unit admissions, 23 (33.8%) postoperative pulmonary complications and 15 (22%) acute respiratory distress syndromes. As regards the ten postoperative deaths (14.7%), 6 cases were related to surgical complications. One surgeon, one scrub nurse and two circulating nurses were infected after surgery due to the lack of specific PPE. We reported less surgery-related pulmonary complications and mortality in Sars-CoV-2-infected patients, than in literature. Emergent and oncological surgery should not be postponed, but it is mandatory to use full PPE, and to adopt preoperative screenings and strategies that mitigate the detrimental effect of pulmonary complications, mostly responsible for mortality.

Background: Inguinal hernioplasty is the most frequently performed operation in the Western world today. Although the laparoscopic approach for inguinal hernia repair has shown excellent results in terms of complications and recurrences, the anterior approach is still the most used. Postoperative pain and recurrences are the most widely studied complications in both approaches, but there is little information about the often more troublesome rare complications of laparoscopic surgery and their treatment. Methods: In the period from January 1, 2014 to December 31, 2019, 1874 hernioplasty operations were performed with the transabdominal approach and recorded prospectively in the Wall Hernia Group database. The mean follow-up was 47 months (range 3-64 months). All less frequent complications were analyzed and a literature review was carried out to assess the presence of similar cases and their treatment in other series. Results: Eight cases of rare complications were identified and subdivided according to the Clavien-Dindo classification. They included a bowel perforation, 4 cases of bleeding, 2 bowel obstructions, and an injury to the motor branch of the obturator nerve. The postoperative course in these patients was significantly longer than in patients with a regular postoperative course. In 2 cases the complication occurred during the first admission, while the remaining 6 patients had to be readmitted within 30 days after discharge. Conclusions: Although serious postoperative complications in laparoscopic inguinal hernioplasty are rare, all surgeons, also those who have completed the learning curve, should be aware of their possible occurrence.

Objective: This paper aims at proposing a new machine-learning based model to improve the calculation of mealtime insulin boluses (MIB) in type 1 diabetes (T1D) therapy using continuous glucose monitoring (CGM) data. Indeed, MIB is still often computed through the standard formula (SF), which does not account for glucose rate-of-change ( ∆G), causing critical hypo/hyperglycemic episodes., Methods: Four candidate models for MIB calculation, based on multiple linear regression (MLR) and least absolute shrinkage and selection operator (LASSO) are developed. The proposed models are assessed in silico, using the UVa/Padova T1D simulator, in different mealtime scenarios and compared to the SF and three ∆G-accounting variants proposed in the literature. An assessment on real data, by retrospectively analyzing 218 glycemic traces, is also performed., Results: All four tested models performed better than the existing techniques. LASSO regression with extended feature-set including quadratic terms (LASSO Q ) produced the best results. In silico, LASSO Q reduced the error in estimating the optimal bolus to only 0.86 U (1.45 U of SF and 1.36-1.44 U of literature methods), as well as hypoglycemia incidence (from 44.41% of SF and 44.60-45.01% of literature methods, to 35.93%). Results are confirmed by the retrospective application to real data., Conclusion: New models to improve MIB calculation accounting for CGM- ∆G and easy-to-measure features can be developed within a machine learning framework. Particularly, in this paper, a new LASSO Q model was developed, which ensures better glycemic control than SF and other literature methods., Significance: MIB dosage with the proposed LASSO Q model can potentially reduce the risk of adverse events in T1D therapy.

Type 1 diabetes (T1D) therapy requires multiple daily insulin injections to compensate the lack of endogenous insulin production due to β-cells destruction. An empirical standard formula (SF) is commonly used for such a task. Unfortunately, SF does not include information on glucose dynamics, e.g. the glucose rate-of-change (ROC) provided by continuous glucose monitoring (CGM) sensor. Hence, SF can sometimes lead to under/overestimations that can cause critical hypo/hyperglycemic episodes during/after the meal. Recently, to overcome this limitation, we proposed new linear regression models, integrating ROC information and personalized features. Despite the first encouraging results, the nonlinear nature of the problem calls for the application of nonlinear models. In this work, random forest (RF) and gradient boosting tree (GBT), nonlinear machine learning methodologies, were investigated. A dataset of 100 virtual subjects, opportunely divided into training and testing sets, was used. For each individual, a single-meal scenario with different meal conditions (preprandial ROC, BG and meal amounts) was simulated. The assessment was performed both in terms of accuracy in estimating the optimal bolus and glycemic control. Results were compared to the best performing linear model previously developed. The two tree-based models proposed lead to a statistically significant improvement of glycemic control compared to the linear approach, reducing the time spent in hypoglycemia (from 32.49% to 27.57-25.20% for RF and GBT, respectively). These results represent a preliminary step to prove that nonlinear machine learning techniques can improve the estimation of insulin bolus in T1D therapy. Particularly, RF and GBT were shown to outperform the previously linear models proposed.Clinical Relevance- Insulin bolus estimation with nonlinear machine learning techniques reduces the risk of adverse events in T1D therapy.

Background: Many eponyms have been used to classify some rare conditions of incarceration of a hernia at the level of the groin and femoral canal. The incarceration of the appendix at the level of the groin canal was first described by Claudius Amyand, while the incarceration of the appendix inside the femoral canal is a condition known as De Garengeot hernia. The incidence of such an event is very low and surgical treatment is usually performed via inguinal approach., Case Presentation: We describe the case of a 63-year-old woman who presented upon arrival at the Emergency Room a sore tumefaction in the femoral region with skin erythema. The patient had never undergone surgery for groin or femoral hernias. After performing ultrasound reporting the presence of an incarcerated intestinal loop, the patient underwent surgery. Laparoscopic exploration highlighted the presence of a De Garengeot hernia. After exploration, it was decided to continue the laparoscopic operation: at first, the hernia sac was reduced, then a self-gripping mesh was put in place. Finally, after the closure of the peritoneum, the operation was completed by performing a laparoscopic appendectomy. The patient was discharged from hospital three days from surgery with an antibiotic therapy for further two days after discharge. After three months, upon clinical examination, no recurrences of hernia were evident., Conclusions: We describe a rare case of De Garengeot hernia treated laparoscopically. The treatment of such a condition is not standardized because of the few cases described. The laparoscopic approach should always be considered to perform at least an exploration of the abdominal cavity and evaluate the contents of the hernia sac. Laparoscopic hernia treatment should be carried out by experienced surgeons who are familiar with the technique and apply it routinely., Key Words: Appendicitis, De Garengeot, Hernia, Laparoscopy.

Background: Groin hernioplasty is the most performed intervention in the adults worldwide. Small bowel occlusion after hernioplasty with anterior approach is an unusual complication because the peritoneum is not opened during this procedure. However during TAPP the closure of the peritoneal flap is mandatory. In literature some cases of small bowel occlusion related to the barbed suture for the closure the peritoneum are reported., Methods: Here we describe a case of a 64-year old male with small bowel obstruction after TAPP caused by the barbed suture used for peritoneal closure., Results: Intrabdominal use of self-anchoring suture is controversial. Some studies reported good results by using this device, while others from gynecologists describe bowel occlusion and volvulus caused by barbed suture., Conclusions: Self-anchoring device is innovative and reduces operation time. It is most important to know the correct use of this device to reduce some possible troubles.

Prognostic assessment of patients with hepatocellular carcinoma (HCC) at the time of diagnosis remains controversial and becomes even more complex at the time of restaging when new variables need to be considered. The aim of the current study was to evaluate the prognostic utility of restaging patients before proceeding with additional therapies for HCC. Two independent Italian prospective databases were used to identify 1,196 (training cohort) and 648 (validation cohort) consecutive patients with HCC treated over the same study period (2008-2015) who had complete restaging before decisions about additional therapies. The performance of the Italian Liver Cancer (ITA.LI.CA) prognostic score at restaging was compared with that of the Barcelona Clinic Liver Cancer, Hong Kong Liver Cancer, and Cancer of the Liver Italian Program systems. A multivariable Cox survival analysis was performed to identify baseline, restaging, or dynamic variables that were able to improve the predictive performance of the prognostic systems. At restaging, 35.3% of patients maintained stable disease; most patients were either down-staged by treatment (27.2%) or had disease progression (37.5%). The ITA.LI.CA scoring system at restaging demonstrated the best prognostic performance in both the training and validation cohorts (c-index 0.707 and 0.722, respectively) among all systems examined. On multivariable analysis, several variables improved the prognostic ability of the ITA.LI.CA score at restaging, including progressive disease after the first treatment, Model for End-Stage Liver Disease at restaging, and choice of nonsurgical treatment as additional therapy. A new ITA.LI.CA restaging model was created that demonstrated high discriminative power in both the training and validation cohorts (c-index 0.753 and 0.745, respectively)., Conclusion: Although the ITA.LI.CA score demonstrated the best prognostic performance at restaging, other variables should be considered to improve the prognostic assessment of patients at the time of deciding additional therapies for HCC., (© 2018 by the American Association for the Study of Liver Diseases.)

Background: Esophagectomy is contraindicated in case of advanced cancer (i.e., carcinomatosis, distant metastasis, and invasion of other organs). In some cases, preoperative imaging may fail to identify advanced neoplasm and esophagectomy is inappropriately planned. The aim of the study was to identify preoperative biomarkers of occult advanced disease that force surgeons to abort the planned esophagectomy., Methods: From 2008 to 2014, 244 consecutive patients were taken to the operative room to have esophagectomy for cancer in our department. All of them had blood test at admission and their preoperative biomarker data were retrieved. Their medical history was collected and the intraoperative findings and outcome were recorded. Non parametric tests, multiple regression analysis, and ROC curves analysis were performed., Results: In our study group, 14 (5.7 %) patients, scheduled for esophagectomy, were discovered to have occult advanced disease at laparotomy/laparoscopy or at thoracotomy. Six of them had peritoneal carcinomatosis, three had advanced tumor invading other organs, three had small liver metastasis, and two pleural carcinomatosis. In all these cases, esophagectomy was aborted and a feeding jejunostomy was placed. In patients with unresectable esophageal cancer, CA19.9 and CEA serum levels were significantly higher than patients who could have esophagectomy (p < 0.001 and p = 0.003, respectively). CA19.9 and CEA resulted to be accurate biomarkers of occult advanced disease (AUC = 85 %, p < 0.001 and AUC = 73 %, p = 0.002, respectively)., Conclusions: Preoperative CEA and CA19.9 serum levels should be taken in consideration when evaluating patients candidate to esophagectomy for esophageal cancer to prevent inappropriate laparotomy or thoracotomy. If any doubt arises minimally invasive exploration is warranted.

Background: The aim of this study was to evaluate the impact of jejunostomy during esophagectomy for cancer on postoperative health-related quality of life (HRQL)., Methods: We evaluate all consecutive patients who underwent esophagectomy for cancer at the surgical oncology unit of the Veneto Institute of Oncology (IOV-IRCCS) between January 2008 and March 2014. The primary outcome was HRQL, which was assessed using nine scales of EORTC C30 and OES18 questionnaires. General linear models were estimated to evaluate mean score difference (MD) of each selected scale in patients with and without jejunostomy, adjusting for clinically relevant confounders. The secondary outcomes were morbidity, hospital stay, postoperative weight loss and postoperative albumin impairment., Results: Jejunostomy was performed in 40 on 109 patients (41.3%) who participated in quality of life investigation. A clinically and statistically significantly worse eating at admission (P=0.009) became not clinically significant at 3 months after surgery (MD =9.1). Jejunostomy was associated to clinically and statistically significantly poorer emotional function (EF) at 3 months after surgery (MD =-15.6; P=0.04). Hospital stay was longer in jejunostomy group (median, 20 vs. 17 days, P=0.02)., Conclusions: In our series patients who had a jejunostomy during esophagectomy had been selected for their risk for postoperative complication. However, their postoperative outcome was actually similar compared to those without jejunostomy. Nevertheless, jejunostomy was associated to clinically and statistically significantly poorer EF at 3 months after surgery. Therefore, patient candidate to esophagectomy and feeding jejunostomy should receive additional psychological support.

Objectives: There are no prospective studies of laparoscopic microwave (MW) ablation in patients with hepatocellular carcinoma (HCC). The aim of this study was to demonstrate the safety and efficacy of laparoscopic MW ablation., Methods: A prospective study group of consecutive HCC patients considered ineligible for liver resection and/or percutaneous ablation was conducted from December 2009 to December 2010. Short-term (3-month) outcomes included a centralized revision of radiological response, mortality and morbidity. Mid-term (24-month) outcomes included time to recurrence in the study group compared with that in a cohort of consecutive patients treated with laparoscopic radiofrequency (RF) ablation using propensity score analysis., Results: A total of 42 patients were enrolled. Their median age was 64 years; 67% were positive for hepatitis C virus; 33% were of Child-Pugh class B status; the median tumour diameter was 2.5 cm, and 48% of patients had multinodular HCC. In 47 of 50 (94%) nodules treated with MW ablation, a complete radiological response was observed at 3 months. There was no perioperative mortality. The overall morbidity rate was 24%. The 2-year survival rate was 79% and the 2-year recurrence rate was 55%. Using propensity score analysis (in 28 MW ablation patients and 28 RF ablation controls), 2-year recurrence rates were 55% in the MW ablation group and 77% in the control group (P = 0.03)., Conclusions: Laparoscopic MW ablation is a safe and effective therapeutic option for selected HCC patients who are ineligible for liver resection and/or percutaneous ablation., (© 2014 International Hepato-Pancreato-Biliary Association.)