Publications by authors named "Alessandro Coppola"

40 Publications

CA19.9 Serum Level Predicts Lymph-Nodes Status in Resectable Pancreatic Ductal Adenocarcinoma: A Retrospective Single-Center Analysis.

Front Oncol 2021 27;11:690580. Epub 2021 May 27.

Department of Surgery, Campus Bio-Medico University, Rome, Italy.

Background: The choice between upfront surgery or neoadjuvant treatments (NAT) for resectable pancreatic ductal adenocarcinoma (R-PDAC) is controversial. R-PDAC with potential nodal involvement could benefit from NT. Ca (Carbohydrate antigen) 19.9 and serum albumin levels, alone or in combination, have proven their efficacy in assessing PDAC prognosis. The objective of this study was to evaluate the role of Ca 19.9 serum levels in predicting nodal status in R-PDAC.

Methods: Preoperative Ca 19.9, as well as serum albumin levels, of 165 patients selected for upfront surgery have been retrospectively collected and correlated to pathological nodal status (N), resection margins status (R) and vascular resections (VR). We further performed ROC curve analysis to identify optimal Ca 19.9 cut-off for pN+, R+ and vascular resection prediction.

Results: Increased Ca 19.9 levels in 114 PDAC patients were significantly associated with pN+ (p <0.001). This ability, confirmed in all the series by ROC curve analysis (Ca 19.9 ≥32 U/ml), was lost in the presence of hypoalbuminemia. Furthermore, Ca 19.9 at the cut off >418 U/ml was significantly associated with R+ (87% specificity, 36% sensitivity, p 0.014). Ca 19.9, at the cut-off >78 U/ml, indicated a significant trend to predict the need for VR (sensitivity 67%, specificity 53%; p = 0.059).

Conclusions: In R-PDAC with normal serum albumin levels, Ca 19.9 predicts pN+ and R+, thus suggesting a crucial role in deciding on NAT.
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http://dx.doi.org/10.3389/fonc.2021.690580DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190389PMC
May 2021

Time to hospitalisation, CT pulmonary involvement and in-hospital death in COVID-19 patients in an Emergency Medicine Unit.

Int J Clin Pract 2021 Jun 2:e14426. Epub 2021 Jun 2.

Emergency Medicine Unit, Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Roma, Italy.

Background: Patients with coronavirus disease 2019 (COVID-19) are often treated at home given the limited healthcare resources. Many patients may have sudden clinical worsening and may be already compromised at hospitalisation. We investigated the burden of lung involvement according to the time to hospitalisation.

Methods: In this observational cohort study, 55 consecutive COVID-19-related pneumonia patients were admitted to the Emergency Medicine Unit. Groups of lung involvement at computed tomography were classified as follows: 0 (<5%), 1 (5%-25%), 2 (26%-50%), 3 (51%-75%) and 4 (>75%). We also investigated in-hospital death and the predictive value of Yan-XGBoost model and PREDI-CO scores for death.

Results: The median age was 74 years and 34 were men. Time to admission increased from 2 days in group 0 to 8.5-9 days in groups 3 and 4. A progressive increase in LDH, CRP and d-dimer was found across groups, while a decrease of lymphocytes paO /FiO ratio and SpO was found. Ten (18.2%) patients died during the in-hospital staying. Patients who died were older, with a trend to lower lymphocytes, a higher d-dimer, creatine phosphokinase and troponin T. The Yan-XGBoost model did not accurately predict in-hospital death with an AUC of 0.57 (95% confidence interval [CI] 0.37-0.76), which improved after the addition of the lung involvement groups (AUC 0.68, 95%CI 0.45-0.90). Conversely, a good predictive value was found for the original PREDI-CO score with an AUC of 0.76 (95% CI 0.58-0.93) which remained similar after the addition of the lung involvement (AUC 0.76, 95% CI 0.57-0.94).

Conclusion: We found that delayed hospital admission is associated with higher lung involvement. Hence, our data suggest that patients at risk for more severe disease, such as those with high LDH, CRP and d-dimer, should be promptly referred to hospital care.
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http://dx.doi.org/10.1111/ijcp.14426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236995PMC
June 2021

Different Biliary Microbial Flora Influence Type of Complications after Pancreaticoduodenectomy: A Single Center Retrospective Analysis.

J Clin Med 2021 May 18;10(10). Epub 2021 May 18.

Department of Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy.

Background: Bacterobilia is associated with postoperative morbidity after pancreaticoduodenectomy (PD), mostly due to infectious complications. The aim of this study was to investigate the prevalence of bacteria species isolated from intraoperative biliary cultures, and related complications after PD.

Methods: An ANOVA test was used to assess the prevalence of isolated bacterial species and postoperative complications. The odds ratio was computed to evaluate the association between biliary cultures and each complication, Endoscopic Retrograde CholangioPancreatography (ERCP) and each complication, ERCP and biliary cultures, Delayed Gastric Emptying (DGE) and Postoperative Pancreatic Fistula (POPF).

Results: Positive biliary cultures were found in 162/244 (66%) PDs. Different prevalences of polymicrobial biliary culture were detected in patients with postoperative complications. In SSIs, a significant prevalence of biliary culture positive for , and ( < 0.001) was detected. Prevalences of polymicrobial biliary cultures with , , and were significantly associated with POPF ( < 0.001). Biliary culture positive for , and showed a higher prevalence of intra-abdominal collection and DGE ( < 0.001). Notably, was significantly associated with DGE as a unique complication (OR = 2.94 (1.30-6.70); < 0.01).

Conclusions: Specific prevalences of polymicrobial bacterobilia are associated with major complications, while monomicrobial bacterobilia is associated with DGE as a unique complication after PD.
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http://dx.doi.org/10.3390/jcm10102180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157867PMC
May 2021

The Role of Pathological Method and Clearance Definition for the Evaluation of Margin Status after Pancreatoduodenectomy for Periampullary Cancer. Results of a Multicenter Prospective Randomized Trial.

Cancers (Basel) 2021 Apr 26;13(9). Epub 2021 Apr 26.

Department of Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy.

Background: There is extreme heterogeneity in the available literature on the determination of R1 resection rate after pancreatoduodenectomy (PD); consequently, its prognostic role is still debated. The aims of this multicenter randomized study were to evaluate the effect of sampling and clearance definition in determining R1 rate after PD for periampullary cancer and to assess the prognostic role of R1 resection.

Methods: PD specimens were randomized to Leeds Pathology Protocol (LEEPP) (group A) or the conventional method adopted before the study (group B). R1 rate was determined by adopting 0- and 1-mm clearance; the association between R1, local recurrence (LR) and overall survival (OS) was also evaluated.

Results: One-hundred-sixty-eight PD specimens were included. With 0 mm clearance, R1 rate was 26.2% and 20.2% for groups A and B, respectively; with 1 mm, R1 rate was 60.7% and 57.1%, respectively ( > 0.05). Only in group A was R1 found to be a significant prognostic factor: at 0 mm, median OS was 36 and 20 months for R0 and R1, respectively, while at 1 mm, median OS was not reached and 30 months. At multivariate analysis, R1 resection was found to be a significant prognostic factor independent of clearance definition only in the case of the adoption of LEEPP.

Conclusions: The 1 mm clearance is the most effective factor in determining the R1 rate after PD. However, the pathological method is crucial to accurately evaluate its prognostic role: only R1 resections obtained with the adoption of LEEPP seem to significantly affect prognosis.
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http://dx.doi.org/10.3390/cancers13092097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8123600PMC
April 2021

Contemporary snapshot of tumor regression grade (TRG) distribution in locally advanced rectal cancer: a cross sectional multicentric experience.

Updates Surg 2021 Apr 5. Epub 2021 Apr 5.

Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia.

Pre-operative chemoradiotherapy (CRT) followed by surgical resection is still the standard treatment for locally advanced low rectal cancer. Nowadays new strategies are emerging to treat patients with a complete response to pre-operative treatment, rendering the optimal management still controversial and under debate. The primary aim of this study was to obtain a snapshot of tumor regression grade (TRG) distribution after standard CRT. Second, we aimed to identify a correlation between clinical tumor stage (cT) and TRG, and to define the accuracy of magnetic resonance imaging (MRI) in the restaging setting. Between January 2017 and June 2019, a cross sectional multicentric study was performed in 22 referral centers of colon-rectal surgery including all patients with cT3-4Nx/cTxN1-2 rectal cancer who underwent pre-operative CRT. Shapiro-Wilk test was used for continuous data. Categorical variables were compared with Chi-squared test or Fisher's exact test, where appropriate. Accuracy of restaging MRI in the identification of pathologic complete response (pCR) was determined evaluating the correspondence with the histopathological examination of surgical specimens.In the present study, 689 patients were enrolled. Complete tumor regression rate was 16.9%. The "watch and wait" strategy was applied in 4.3% of TRG4 patients. A clinical correlation between more advanced tumors and moderate to absent tumor regression was found (p = 0.03). Post-neoadjuvant MRI had low sensibility (55%) and high specificity (83%) with accuracy of 82.8% in identifying TRG4 and pCR.Our data provided a contemporary description of the effects of pre-operative CRT on a large pool of locally advanced low rectal cancer patients treated in different colon-rectal surgical centers.
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http://dx.doi.org/10.1007/s13304-021-01044-0DOI Listing
April 2021

The use of an implemented infection prevention bundle reduces the incidence of surgical site infections after colorectal surgery: a retrospective single center analysis.

Updates Surg 2021 Jan 5. Epub 2021 Jan 5.

Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy.

Background: Surgical-site infections (SSIs) represent the most common complications after colorectal surgery (CS). Role of preoperative administration of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP), alone or in combination, in the prevention of SSIs after CS is debated. Aim of this study was to assess the effect of the introduction of an Implemented Infection Prevention Bundle (IIPB) in preventing SSIs in CS.

Methods: A group of 251 patients (Group 1) who underwent CS receiving only preoperative intravenous antibiotic prophylaxis (IAP) was compared to a Group of 107 patients (Group 2) who also received the IIPB. The IIPB consisted of the combination of oral administrations of three doses of Rifaximin 400 mg and MBP the day before surgery and in the administration of a cleansing enema the day of the surgical procedure.

Results: At the univariate analysis, Group 2 showed significant lower rates of wound infection (WI) (2.8% vs. 9.9%; p = 0.021) and anastomotic leakage (AL) (2.8% vs. 14.7%; p = 0.001) with shorter hospital stay (5 vs. 6 days; p < 0.0001). The probability of postoperative AL was lower in Group 2; patients in this Group resulted protected from AL; a statistically significant Odds ratio of 0.16 (CI 0.05-0.55 p = 0.0034) was found. In diabetic patients, that were at higher risk of WI (OR 3.53, CI 1.49-8.35 p = 0.002), despite having any impact on anastomotic dehiscence, the use of IIPB significantly reduced the rate of WI (0% vs 28.1%; p = 0.01).

Conclusion: The use of an IIPB significantly reduces rates of SSIs and post-operative hospital stay after CS.
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http://dx.doi.org/10.1007/s13304-020-00960-xDOI Listing
January 2021

Long-Term Results of a Prospective Phase 2 Study on Volume De-Escalation in Neoadjuvant Chemoradiotherapy of Rectal Cancer.

Pract Radiat Oncol 2021 Mar-Apr;11(2):e186-e194. Epub 2020 Sep 28.

Radiation Oncology, Campus Bio-Medico University, Rome, Italy.

Purpose: In the current study, we evaluated whether neoadjuvant chemoradiotherapy with reduced treatment volumes due to the exclusion of elective pelvic nodal irradiation is a feasible strategy for selected patients with locally advanced rectal cancer.

Methods And Materials: Patients with T2 low-lying/T3, N0-N1 rectal lesions without evidence of disease in the lateral lymph nodes were prospectively recruited. All patients underwent pretreatment testing, including computed tomography imaging of the chest, abdomen, and pelvis with intravenous contrast, pelvic magnetic resonance imaging with intravenous contrast, and 18-fluorodeoxyglucose positron emission/computed tomography. The clinical target volume included the primary tumor and the mesorectum with vascular supply containing the perirectal and presacral nodes, with the upper border at the S2/S3 interspace. The total radiation dose was 50.4 Gy, and fluoropyrimidine-based chemotherapy was associated concomitantly. The primary endpoint of the study was the reduction of gastrointestinal (GI) toxicity, and the secondary endpoints were pathologic complete response, local control, overall survival, and disease-free survival.

Results: Fifty-two patients (30 men, 22 women) with a median age of 67 years (range, 45-85 years) were enrolled in the study. Acute grade 3 GI toxicity was 7.6%, and there were no cases of grade 4 toxicity. Three patients (5.7%) developed a local recurrence. No relapse occurred in the lateral lymph nodes. The local control rate at 5 years was 96.1%. With a median follow-up time of 72.9 months (range, 2.5-127.6 months), the 3- and 5-year overall survival rates were 89.4% and 87%, respectively. The 3- and 5-year disease-free survival rates were 82.4% and 82.4%, respectively.

Conclusions: De-escalation of radiation therapy target volume reduces GI side effects without compromising efficacy in patients with rectal cancer. These results cannot be clearly extended to high-risk disease and need further evaluation in future randomized trials.
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http://dx.doi.org/10.1016/j.prro.2020.09.009DOI Listing
September 2020

How to do hernioscopy for incarcerated femoral hernia with laparoscopic O-ring retractor system.

ANZ J Surg 2020 11 10;90(11):2353-2354. Epub 2020 Aug 10.

Colorectal Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy.

Incarcerated groin hernia management often required emergency surgery. Hernioscopy is a safe alternative to repair hernia and explore intra-abdominal cavity. Alexis Laparoscope System is a useful device to perform hernioscopy.
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http://dx.doi.org/10.1111/ans.16217DOI Listing
November 2020

A Bio-Imaging Signature as a Predictor of Clinical Outcomes in Locally Advanced Pancreatic Cancer.

Cancers (Basel) 2020 Jul 23;12(8). Epub 2020 Jul 23.

Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy.

: To evaluate the predictive value of F-FDG PET/CT semiquantitative parameters of the primary tumour and CA 19-9 levels assessed before treatment in patients with locally advanced pancreatic cancer (LAPC). : Among one-hundred twenty patients with LAPC treated at our institution with initial chemotherapy followed by curative chemoradiotherapy (CRT) from July 2013 to January 2019, a secondary analysis with baseline F-FDG PET/CT was conducted in fifty-eight patients. Pre-treatment CA 19-9 level and the maximum standardized uptake value (SUVmax), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) of primary tumour were measured. The receiving operating characteristics (ROC) analysis was performed to define the cut-off point of SUVmax, MTV, TLG and CA 19-9 values to use in prediction of early progression (EP), local progression (LP) and overall survival (OS). Areas under the curve (AUCs) were assessed for all variables. Post-test probability was calculated to evaluate the advantage for parameters combination. : For EP, CA 19-9 level > 698 U/mL resulted the best marker to identify patient at higher risk with OR of 5.96 (95% CI, 1.66-19.47; = 0.005) and a Positive Predictive Value (PPV) of 61%. For LP, the most significant parameter was TLG (OR 9.75, 95% CI, 1.64-57.87, = 0.012), with PPV of 83%. For OS, the most significant parameter was MTV (OR 3.12, 95% CI, 0.9-10.83, = 0.07) with PPV of 88%. Adding consecutively each of the other parameters, PPV to identify patients at risk resulted further increased (>90%). : Pre-treatment CA 19-9 level, as well as MTV and TLG values of primary tumour at baseline F-FDG PET/CT and their combination, may represent significant predictors of EP, LP and OS in LAPC patients.
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http://dx.doi.org/10.3390/cancers12082016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7464714PMC
July 2020

Preoperative systemic inflammatory biomarkers and postoperative day 1 drain amylase value predict grade C pancreatic fistula after pancreaticoduodenectomy.

Ann Med Surg (Lond) 2020 Sep 15;57:56-61. Epub 2020 Jul 15.

Department of Surgery, University Campus Bio-Medico of Rome, Rome, Italy.

Background: Postoperative day 1-drains amylase (POD1-DA) values are commonly used to predict the risk of pancreatic fistula (PF) after pancreaticoduodenectomy (PD). Perioperative inflammatory biomarkers have been associated to higher risk of complications in different oncological surgeries. Aim of this study was to investigate the utility of the combination of preoperative inflammatory biomarkers (PIBs) with POD1-DA levels in predicting grade C PF.

Materials And Methods: From a prospective collected database of 317 consecutive pancreaticoduodenectomies, data regarding POD1-DA levels and PIBs as neutrophil-to-lymphocyte ratio (NRL), derived neutrophil-to-lymphocyte ratio (dNRL), platelet-to-lymphocyte ratio (PLR) were analyzed in 227 cases. P-values <0.05 were considered statistically significant. Receiver operating characteristic (ROC) curves defined the optimal thresholds for biomarkers and drains amylase values and their accuracy to predict PF. Furthermore, the Positive Predictive Value (PPV) was computed to evaluate the probability to develop PF combining PIBs and drains amylase values. Combination of drains amylase and different PIBs cut-offs were used to evaluate the risk of grade C PF.

Results: A POD1-DA level of 351 U/L significantly predicted PF (sensitivity 82.7%, specificity 76%, AUC 0.836; p < 0.001) with a PPV of 76.5% and a NPV of 82.6%.POD1-DA levels ≥807 U/L significantly predicted grade C PF (sensitivity 72.7%, specificity 64.4%, AUC 0.676; p = 0.004) with a PPV of 17.8% and a NPV of 95.6%.Notably, this last PPV increased from 17.8% to 89% when PIBs, at different cut-offs, were combined with POD1-DA at the value ≥ 807 U/L.

Conclusion: PIBs significantly improve POD1-DA ability in predicting grade C PF after PD.
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http://dx.doi.org/10.1016/j.amsu.2020.07.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374182PMC
September 2020

Splenic artery dissection: an unusual clinical presentation mimicking a retroperitoneal sarcoma.

ANZ J Surg 2021 03 4;91(3):457-458. Epub 2020 Jul 4.

Department of Surgery, University Campus Bio-Medico of Rome, Rome, Italy.

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http://dx.doi.org/10.1111/ans.16138DOI Listing
March 2021

The impact of multidisciplinary team management on outcome of hepatic resection in liver-limited colorectal metastases.

Sci Rep 2020 07 2;10(1):10871. Epub 2020 Jul 2.

Chirurgia Epatobiliare, Università Cattolica del Sacro Cuore-IRCCS, Rome, Italy.

Hepatic resection is the gold standard treatment for patients affected by liver-limited colorectal metastases. Reports addressing the impact of multidisciplinary team (MDT) evaluation on survival are controversial. The aim of this study was to evaluate the benefit of MDT management in these patients in our Institution experience. The objective of the analysis was to compare survivals of patients managed within our MDT (MDT cohort) to those of patients referred to surgery from other hospitals without MDT discussion (non-MDT cohort). Of the 523 patients, 229 were included in the MDT cohort and 294 in the non-MDT cohort. No difference between the two groups was found in terms of median overall survival (52.5 vs 53.6 months; HR 1.13; 95% CI, 0.88-1.45; p = 0.344). In the MDT cohort there was a higher number of metastases (4.5 vs 2.7; p < 0.0001). The median duration of chemotherapy was lower in MDT patients (8 vs 10 cycles; p < 0.001). Post-operative morbidity was lower in the MDT cohort (6.2 vs 21.5%; p < 0.001). One hundred and ninety-seven patients in each group were matched by propensity score and no significant difference was observed between the two groups in terms of OS and DFS. Our study does not demonstrate a survival benefit from MDT management, but it allows surgery to patients with a more advanced disease. MDT assessment reduces the median duration of chemotherapy and post-operative morbidities.
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http://dx.doi.org/10.1038/s41598-020-67676-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331814PMC
July 2020

An Invited Commentary on: The incidence of right-sided colon cancer in patients aged over 40 years with acute appendicitis: A systematic review and meta-analysis.

Int J Surg 2020 07 22;79:138. Epub 2020 May 22.

Department of Surgery, University Campus Bio-Medico of Rome, Rome, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.ijsu.2020.05.054DOI Listing
July 2020

Role of drain amylase levels assay and routinary postoperative day 3 abdominal CT scan in prevention of complications and management of surgical drains after pancreaticoduodenectomy.

Updates Surg 2020 Sep 14;72(3):727-741. Epub 2020 May 14.

Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy.

To asses drains amylase (DA) cut-offs for the risk of clinically relevant postoperative pancreatic fistula (POPF) and define the optimal timing of drains removal based on daily DA assay and abdominal CT scan finding after pancreatoduodenectomy (PD). Different algorithms able to identify patients at higher risk of POPF and to assess the optimal time for drains removal after PD have been proposed. The most accurate DA cut-offs in the assessment of the risk of clinically relevant POPF were retrospectively identified. Data from a prospective trial for optimal timing of drains removal were analyzed. Then, to validate the cut-offs identified in the first phase, they were applied to the patients enrolled in the prospective trial. Patients with POD1 DA ≥ 666 U/L were at higher risk of clinically relevant POPF (p 0.0001). POD3 DA value ≥ 252 U/L predicted 88% of clinical relevant fistulas. POD3 DA level ≥ 207 U/L was able to predict 68% of biliary fistulas. Patients with abdominal collection ≥ 5 cm, showed a significantly higher rate (60% vs. 23%, p < 0.001) of biliary fistula. Timing of drains removal did not influence complications. Drains amylase levels predict clinically relevant POPF. Drains should be maintained up to POD3; in case of POD1 DA levels < 666 U/L and POD3 DA levels < 252 U/L drains could be removed. In case of POD3 DA levels, ≥ 207 the routine use of abdominal CT scan in the same day could be justified to detect collections ≥ 5 cm and maintain drains beyond the POD3.
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http://dx.doi.org/10.1007/s13304-020-00784-9DOI Listing
September 2020

Invited Commentary to: Enhanced Recovery After Surgery protocols in patients undergoing liver transplantation: A retrospective comparative cohort study.

Int J Surg 2020 06 5;78:168-169. Epub 2020 May 5.

Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro Del Portillo 200, 00128, Rome, Italy.

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http://dx.doi.org/10.1016/j.ijsu.2020.04.081DOI Listing
June 2020

An invited commentary on "Current update in domino liver transplantation".

Int J Surg 2020 06 22;78:73-74. Epub 2020 Apr 22.

Department of Surgery, University Campus Bio-Medico of Rome, Rome, Italy.

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http://dx.doi.org/10.1016/j.ijsu.2020.04.040DOI Listing
June 2020

Delayed surgery after radio-chemotherapy for rectal adenocarcinoma is protective for anastomotic dehiscence: a single-center observational retrospective cohort study.

Updates Surg 2020 Jun 18;72(2):469-475. Epub 2020 Apr 18.

Department of Surgery, University Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 200, 00128, Rome, Italy.

Ideal time interval between end of neoadjuvant radio-chemotherapy (NRCT) and surgery for rectal cancer is debated. Effect that different time intervals have on postoperative complications with particular regard to anastomotic dehiscence (AD) was evaluated on 167 patients who underwent surgery after long-course NRCT. Three different time intervals were considered: (0-42; 43-56; > 57 days). A time interval > 57 days was significantly protective for AD (p = 0.04, Odds ratio = 0.35; 95% CI 0.1254-0.9585) without influence on early oncological outcomes. Optimal time interval after end of NRCT and surgery may help achieving the best pathological response with lowest postoperative morbidity.Trial registration number: Clinical Trial. Gov NCT04013347. https://clinicaltrials.gov/ct2/results?cond=&term=NCT04013347&cntry=&state=&city=&dist= ).
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http://dx.doi.org/10.1007/s13304-020-00770-1DOI Listing
June 2020

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.

Ann Surg 2020 01;271(1):1-14

Department of HPB surgery, Methodist Richardson Medical Center, Richardson, TX.

Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019).

Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking.

Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.

Results: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety.

Conclusion: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.
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http://dx.doi.org/10.1097/SLA.0000000000003590DOI Listing
January 2020

The impact of R1 resection for colorectal liver metastases on local recurrence and overall survival in the era of modern chemotherapy: An analysis of 1,428 resection areas.

Surgery 2019 04 25;165(4):712-720. Epub 2018 Oct 25.

Hepatobiliary Surgery Unit, Fondazione "Policlinico Universitario A. Gemelli," Catholic University of the Sacred Heart, Rome, Italy.

Background: It is still unclear whether a positive surgical margin after resection of colorectal liver metastases remains a poor prognostic factor in the era of modern perioperative chemotherapy. The aim of this study was to evaluate whether preoperative chemotherapy has an impact on reducing local recurrence after R1 resection, and the impact of local recurrence on overall survival.

Methods: Between 2000 and 2014, a total of 421 patients underwent resection for colorectal liver metastases at our unit after preoperative chemotherapy. The overall number of analyzed resection areas was 1,428.

Results: The local recurrence rate was 12.8%, significantly higher after R1 resection than after R0 (24.5% vs 8.7%; P < .001). These results were also confirmed in patients with response to preoperative chemotherapy (23.1% after R1 vs 11.2% after R0; P < .001). At multivariate analysis, R1 resection was the only independent risk factor for local recurrence (P < .001). At the analysis of the 1,428 resection areas, local recurrence significantly decreased according to the increase of the surgical margin width (from 19.1% in 0 mm margin to 2.4% in ≥10 mm). At multivariable logistic regression analysis for overall survival, the presence of local recurrence showed a significant negative impact on 5-year overall survival (P < .001).

Conclusion: Surgical margin recurrence after modern preoperative chemotherapy for colorectal liver metastases was still significantly higher after R1 resection than it was after R0 resection. Local recurrence showed a negative prognostic impact on overall survival. R0 resection should be recommended whenever technically achievable, as well as in patients treated by modern preoperative chemotherapy.
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http://dx.doi.org/10.1016/j.surg.2018.09.005DOI Listing
April 2019

[Stratification of cardiovascular risk in patients with non-traumatic chest pain in the emergency department. Perspectives of the Heart Risk Score in patients with acute coronary syndrome.]

Recenti Prog Med 2018 Oct;109(10):494-508

Unità Operativa Dipartimentale di Pronto Soccorso Medico, Azienda Ospedaliero Universitaria Policlinico Umberto I, Roma.

Introduction: Acute chest pain (CP) is a potentially related both to acute coronary syndrome and to other morbidities; this means that 2%-10% patients with cardiogenic CP are improperly discharged from the Emergency Room (ER). In order to identify risk to develop cardiovascular (CV) events in patients admitted to ER with CP, we used Heart Risk Score (HRS).

Materials And Methods: We included 165 patients referred to the ER for non-traumatic acute CP. We retrospectively analyzed clinical records from ER and Chest Pain Unit (CPU). We calculated HRS, then we analyzed HRS sensitivity and specificity, and correlated raw data of all variables with Spearman's analysis.

Results: Diagnosis of ischemic heart disease was made in 53.9% patients referring CP. The remaining patients were affected by other non-ischemic heart disease (35.5%), gastro-esophageal disease (32.3%), pleuro-pulmonary pathology (15.8%), musculoskeletal disorders (10.5%), and panic attacks (6.6%), respectively. Patients affected by coronaropathy had hypertension (80.9%), history of cardiopathy (61.8%), chronic smoking (49.4%), hypercholesterolemia (37.0%) , diabetes (33.7%) and obesity (24.7%). Low, medium and high HRS patients were 15.7%, 59.4% and 24.8%, respectively. Risk of CV events increased with the increase of the score. The negative predictive value (NPV) in low score was 92.3%. In high score, sensitivity and specificity were 94.7% and 82.7%, respectively. Finally, the following positive Spearman's correlations were found: HRS vs its risk variables, including individual risk variables, ischemic heart disease vs CV risk factors, history of ischemic cardiac disease vs risk factors, number of stenotic vessels vs risk factors (significance values: p <0.05).

Discussion: HRS contains history of all risk factors for coronary artery disease and considers mild ECG and troponin alterations, giving the possibility to undertake the most appropriate path for the patient.

Conclusions: Our work evidences relevance, reliability and ease of use of HRS in CV risk stratification in the emergency department, giving an important contribution in the evaluation of individuals who are likely to experience ischemic heart disease.
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http://dx.doi.org/10.1701/3010.30087DOI Listing
October 2018

Surgical outcomes of oesophagectomy or gastrectomy due to cancer for patients ≥75 years of age: a single-centre cohort study.

ANZ J Surg 2019 03 27;89(3):228-233. Epub 2018 Aug 27.

Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.

Background: The increasing age of the population and prolonged life expectancy result in a widening of age limit criteria for a variety of surgical procedures. Oesophagectomy and total gastrectomy are complex operations associated with significant risks of post-operative complications.

Methods: This is a single-centre cohort study of patients operated with curative intent due to oesophageal or gastric cancer.

Results: From 2007 to 2017, 548 patients underwent surgery with curative intent, with 122 patients (22.3%) classified as elderly (≥75 years). There was no difference in total complication rates between the groups. The adjusted odds ratio for 90-day mortality after oesophageal resection in the elderly group was 3.65 (95% confidence interval (CI): 1.33-10.03) and after gastrectomy was 1.62 (95% CI: 0.55-4.79). The adjusted hazard ratio for 1-year mortality after oesophagectomy was 2.29 (95% CI: 1.25-4.19), and after gastrectomy the adjusted hazard ratio was 1.48 (95% CI: 0.75-2.92). In the event of a complication with Clavien-Dindo score IIIb or higher, there was a statistically significant increase of 90-day mortality to over 50% among elderly patients both after oesophagectomy and gastrectomy (50.0% versus 19.8%; P = 0.005 and 57.1% versus 17.4%; P = 0.012, respectively).

Conclusion: There is a statistically significant increase in 90-day mortality after oesophageal and gastric cancer surgery in elderly compared with younger patients. Post-operative complications with high Clavien-Dindo score in patients undergoing oesophagectomy or gastrectomy, with age ≥75 years, are a dramatic risk factor for post-operative death.
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http://dx.doi.org/10.1111/ans.14761DOI Listing
March 2019

Neutrophil to lymphocyte ratio predicts risk of nodal involvement in T1 colorectal cancer patients.

Minerva Chir 2018 Oct 12;73(5):475-481. Epub 2018 Apr 12.

Department of Surgery, University Campus Bio-Medico of Rome, Rome, Italy.

Background: Risk of nodal involvement in T1 colorectal cancer is assessed by tumor histological features. In several tumors, the ratio between neutrophils and lymphocytes (NLR) or platelets and lymphocytes (PLR) have been applied to lymph-node metastases prediction. The aim of this study was to evaluate the role of NLR, derived NLR (dNLR) and PLR in predicting nodal involvement in T1 colorectal cancers.

Methods: NLR, dNLR and PLR in surgical resected T1 colorectal cancers were retrospectively calculated and analysed in nodal positive and negative cases.

Results: Data regarding 102 patients were considered. Nodal involvement rate was 10.8%. NLR values were higher in node positive patients (P=0.04). A trend toward significance (P=0.05) was found for higher dNLR values and positive nodal status. For NLR, ROC curve analysis allowed to choose a predictive cut-off value of 3.7 (AUC of 0.69; 95% CI: 0.48-0.89). Nodal positivity was reported in 71.5% of high NLR patients; only two N0 cases (28.5%) were registered in high NLR group (P<0.001). The logistic regression analysis aimed to evidence the predictive role of high NLR in node positivity resulted in a significant OR of 37.1 (P<0.0001; 95% CI: 0.48-0.89). NLR allowed to distinguish N0 from N1 patients in 99.4% of cases.

Conclusions: NLR<3.7 was associated with lower risk of lymph-node metastases in T1 colorectal cancer patients. NLR could be used with histopathological data to identify patients at lower risk of nodal metastases.
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http://dx.doi.org/10.23736/S0026-4733.18.07430-8DOI Listing
October 2018

Laparoscopic pancreatoduodenectomy: current status and future directions.

Updates Surg 2016 Sep 4;68(3):217-224. Epub 2016 Nov 4.

Division of General Surgery, Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.

In recent years, laparoscopic pancreatoduodenectomy (LPD) has been gaining a favorable position in the field of pancreatic surgery. However, its role still remains unclear. This review investigates the current status of LPD in high-volume centers. A literature search was conducted in PubMed, and only papers written in English containing more than 30 cases of LPD were selected. Papers with "hybrid" or robotic technique were not included in the analysis. Out of a total of 728 LPD publications, 7 publications matched the review criteria. The total number of patients analyzed was 516, and the largest series included 130 patients. Four of these studies come from the United States, 1 from France, 1 from South Korea, and 1 from India. In 6 reports, LPDs were performed only for malignant disease. The overall pancreatic fistula rate grades B-C were 12.7%. The overall conversion rate was 6.9%. LPD seems to be a valid alternative to the standard open approach with similar technical and oncological results. However, the lack of many large series, multi-institutional data, and randomized trials does not allow the clarification of the exact role of LPD.
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http://dx.doi.org/10.1007/s13304-016-0402-zDOI Listing
September 2016

Neutrophil to Lymphocyte Ratio (NLR) and Derived Neutrophil to Lymphocyte Ratio (d-NLR) Predict Non-Responders and Postoperative Complications in Patients Undergoing Radical Surgery After Neo-Adjuvant Radio-Chemotherapy for Rectal Adenocarcinoma.

Cancer Invest 2016 14;34(9):440-451. Epub 2016 Oct 14.

a Department of General Surgery , University Campus Bio-Medico di Roma , Rome , Italy.

In order to evaluate neutrophil-to-lymphocyte ratio (NLR) and derived neutrophil-to-lymphocyte ratio (d-NLR) in predicting response and complications in rectal cancer patients who underwent surgery after neo-adjuvant radio-chemotherapy, 87 patients were evaluated. Cutoffs before and after radio-chemotherapy were respectively 2.8 and 3.8 for NLR, and 1.4 and 2.3 for d-NLR. They were analyzed in relation to clinical and pathological outcomes. Patients with preoperative NLR and d-NLR higher than cutoffs had significantly higher rates of tumor regression grade response (TRG ≥ 4) and postoperative complications. Elevated NLR and d-NLR after radio-chemotherapy are associated with worse pathological and clinical outcome.
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http://dx.doi.org/10.1080/07357907.2016.1229332DOI Listing
October 2016

Laparoscopic versus open pancreaticoduodenectomy for pancreatic adenocarcinoma: long-term results at a single institution.

Surg Endosc 2017 05 7;31(5):2233-2241. Epub 2016 Sep 7.

Division of General Surgery, Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.

Background: Pancreaticoduodenectomy remains as the only treatment that offers a chance for cure in patients with pancreatic ductal adenocarcinoma (PDAC) of the head of the pancreas. In recent years, laparoscopic pancreaticoduodenectomy (LPD) has been introduced as a feasible alternative to open pancreaticoduodenectomy (OPD) when performed by experienced surgeons. This study reviews and compares perioperative results and long-term survival of patients undergoing LPD versus OPD at a single institution over a 20-year time period.

Methods: From 1995 to 2014, 612 patients underwent PD and 251 patients were found to have PDAC. These latter patients were reviewed and divided into two groups: OPD (n = 193) and LPD (n = 58). LPD was introduced in November 2008 and performed simultaneous to OPD within the remaining time period. Ninety-day perioperative outcomes and long-term survival were analyzed.

Results: Patient demographics were well matched. Operative time was significantly longer with LPD, but blood loss and transfusion rate were lower. Postoperative complications, intensive care unit stay, and overall hospital stay was similar. OPD was associated with larger tumor size; LPD was associated with greater lymph node harvest and lower lymph node ratio. LPD was performed by hand-assist method in 3 (5.2 %) patients and converted to open in 14 (24.1 %). Neoadjuvant therapy was performed in 17 (8.8 %) patients for OPD and 4 (6.9 %) for LPD. The estimated median survival was 20.3 months for OPD and 18.5 months for LPD. Long-term survival was similar for 1-, 2-, 3-, 4-, and 5-year survival for OPD (68, 40, 24, 17 and 15 %) and for LPD (67, 43, 43, 38 and 32 %), respectively.

Conclusion: LPD provides similar short-term outcomes and long-term survival to OPD in the treatment of PDAC.
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http://dx.doi.org/10.1007/s00464-016-5222-1DOI Listing
May 2017

Anatomical liver resection of segment 4a en bloc with the caudate lobe.

J Surg Oncol 2016 May 18;113(6):665-7. Epub 2016 Feb 18.

Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy.

Anatomical segmentectomy is the complete resection of an area supplied by a segmental portal branch. Among segmentectomies, isolated segmentectomy 4 is a technically demanding procedure because there are two transection planes: on the left side along the umbilical fissure and, on the right side, along the middle hepatic vein. Although there are several reports on anatomic segmentectomies, only few regard the anatomic segmentectomy 4a. We report here the case of a 60-year-old man who underwent anatomical segmentectomy 4a en bloc with the caudate lobe to resect a colorectal liver metastasis located in segment 4a and involving the paracaval portion of the caudate lobe. This type of procedure was planned in order to maximize the postoperative functional hepatic reserve, thereby reducing the risk of postoperative liver failure and ultimately allowing the possibility for future repeat hepatectomy in case of recurrence. J. Surg. Oncol. 2016;113:665-667. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/jso.24202DOI Listing
May 2016
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