Authenticity assessment of ground black pepper by combining headspace gas-chromatography ion mobility spectrometry and machine learning

Currently, the authentication of ground black pepper is a major concern, creating a need for a rapid, highly sensitive and specific detection tool to prevent the introduction of adulterated batches into the food chain. To this aim, head space gas-chromatography ion mobility spectrometry (HS-GC-IMS), combined with machine learning, is tested in this initial, proof-of-concept study. A broad variety of authentic samples originating from eight countries and three continents were collected and spiked with a range of adulterants, both endogenous sub-products and an assortment of exogenous materials. The method is characterized by no sample preparation and requires 20 min for chromatographic separation and ion mobility data acquisition. After an explorative analysis of the data, those were submitted to two different machine learning algorithms (partial least squared discriminant analysis-PLS-DA and support vector machine-SVM). While the PLS-DA model did not provide fully satisfactory performances, the combination of HS-GC-IMS and SVM successfully classified the samples as authentic, exogenously-adulterated or endogenously-adulterated with an overall accuracy of 90 % and 96 % on withheld test set 1 and withheld test set 2, respectively (at a 95 % confidence level). Some limitations, expected to be mitigated by further research, were encountered in the correct classification of endogenously adulterated ground black pepper. Correct categorization of the ground black pepper samples was not adversely affected by the operator or the time span of data collection (the method development and model challenge were carried out by two operators over 6 months of the study, using ground black pepper harvested between 2015 and 2019). Therefore, HS-GC-IMS, coupled to an intelligent tool, is proposed to: (i) aid in industrial decision-making before utilization of a new batch of ground black pepper in the production chain; (ii) reduce the use of time-consuming conventional analyses and; (iii) increase the number of ground black pepper samples analyzed within an industrial quality control frame.

Untargeted metabolomics liquid chromatography-high resolution mass spectrometry approach for the geographical origin assessment of Italian dehydrated apples

Geographical provenience is nowadays a relevant aspect of the authenticity and the quality of many food commodities. Dehydrated apple cubes/slices represent an ingredient commonly used by food companies for bakery products. However, this apple-based matrix is not so known and studied from an analytical point of view. In the present work, seven compounds were identified as key molecules to distinguish between Italian and non-Italian samples, through an untargeted ultrahigh-pressure liquid chromatography-high-resolution mass spectrometry (UHPLC-HRMS) approach. This methodology was merged with multivariate statistical analysis, and the principal features were studied and identified considering several identification steps. Samples from 2020 and 2021 harvesting campaigns, with partial and total dehydration rates, with or without peel, and from different apple varieties were considered for the study, for a total of 91 samples. Afterward, the same analysis protocol was applied to an external set (n = 12 samples), included in the statistical models, searching for the key compounds identified in the training set. Interesting and significant results underlined the potentiality of the UHPLC-HRMS technology as a confirmatory strategy for the geographical origin assessment of dehydrated apple commodities.

A geographical origin assessment of Italian hazelnuts: Gas chromatography-ion mobility spectrometry coupled with multivariate statistical analysis and data fusion approach

Hazelnut is a commodity that has gained interest in the food science community concerning its authenticity. The quality of the Italian hazelnuts is guaranteed by Protected Designation of Origin and Protected Geographical Indication certificates. However, due to their modest availability and the high price, fraudulent producers/suppliers blend, or even substitute, Italian hazelnuts with others from different countries, having a lower price, and often a lower quality. To contrast or prevent these illegal activities, the present work investigated the application of the Gas Chromatography-Ion mobility spectrometry (GC-IMS) technique on the hazelnut chain (fresh, roasted, and paste of hazelnuts). The raw data obtained were handled and elaborated using two different ways, software for statistical analysis, and a programming language. In both cases, Principal Component Analysis and Partial Least Squares-Discriminant Analysis models were exploited, to study how the Volatile Organic Profiles of Italian, Turkish, Georgian, and Azerbaijani products differ. A prediction set was extrapolated from the training set, for a preliminary models' evaluation, then an external validation set, containing blended samples, was analysed. Both approaches highlighted an interesting class separation and good model parameters (accuracy, precision, sensitivity, specificity, F1-score). Moreover, a data fusion approach with a complementary methodology, sensory analysis, was achieved, to estimate the performance enhancement of the statistical models, considering more discriminant variables and integrating at the same time further information correlated to quality aspects. GC-IMS could be a key player as a rapid, direct, cost-effective strategy to face authenticity issues regarding the hazelnut chain.

301 ACUTE ACALCULOUS CHOLECYSTITIS AND CARDIOVASCULAR DISEASE, WHICH CAME FIRST?

Background

The existence of a close association between disease of the biliary tract and heart's disease is known from the mists of time. Acute acalculous cholecystitis (AAC) can be defined as an acute necro-inflammatory disease of the gallbladder in the absence of cholelithiasis. AAC is a challenging diagnosis. The atypical clinical onset associated to a paucity and similarity of symptoms and to laboratory data mimicking cardiovascular disease (CVD) often results in under and misdiagnosed cases. Moreover, AAC has commonly a fulminant course compared to calculous cholecystitis and it is often associated with gangrene, perforation and empyema as well as considerable morbidity and mortality(up 50%). Early diagnosis is crucial to a prompt treatment in order to avoid complications and to increase survivability. Even today, although scientific evidence has shown a close association between AAC and CVD, due to the lack of RCT, there is still a lot of confusion regarding the relationship and consequently the clinical management AAC and CVD. In addition, emergency physicians are not always familiar with transient ECG changes with AAC.

Aim

the aim of this review was to provide evidence regarding epidemiology, pathophysiology, clinical presentation and treatment of the complex association between AAC and CVD.

Methods

we searched for publications addressing Acalculous cholecystitis and cardiovascular disease, consulting Medline and Scopus databases. Any retrospective or prospective study design or systematic review focusing on the aforementioned topic was accepted. This study was conducted in accordance with the PRISMA and AMSTAR Guidelines. Our search rendered 1422 hits (995 from Medline and 427 from Scopus). After removing the duplicates, there were 114 studies. After progressive screening, 268 full texts were assessed for eligibility and 135 studies were included in qualitative synthesis.

Results

According to the literature, 11 cases of AAC were reported after cardiopulmonary bypass surgery. Besides, in patients recovering from open-heart surgery with extracorporeal circulation, prolonged bypass time and depressed cardiac output were identified 22 cases of AAC. Similarly, in 6 of 7 patients following aortic reconstruction. Small vessel occlusion has shown to be the predominant phenomenon in AAC, concluding that the common cause was visceral hypoperfusion. Histological analysis of AAC resulted in leukocyte margination of blood vessels, suggesting involvement of ischaemia and reperfusion mediated injury. These types of histopathological alterations are typical of myocardium after reperfusion injury. Moreover, bile infiltration into the bladder mucosa demonstrated by many authors, validates the abnormal epithelial permeability in AAC. Data suggest that AAC is a manifestation of systemic critical illness. The most common ECG alterations noted in AAC are changes in T waves in significant leads, slurring and notching of the QRS complex and elevation or depression of the S-T segment, hypothesizing a vagally reflex mechanism, due to the distention of the common bile duct, with a reduced coronary blood flow. Finally it was reported a resolution of ECG changes due to AAC after cholecystectomy or antibiotic treatment within a few days.

Conclusion

AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases and major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA could be related to a misdiagnosed AAC. Ultrasonography plays a key role in the early diagnosis and also in the follow up of AAC. Cholecystostomy and cholecystectomy represent the two prevailing treatment options for AAC.

Acute acalculous cholecystitis and cardiovascular disease, which came first? After two hundred years still the classic chicken and eggs debate: A review of literature

The existence of a close association between disease of the biliary tract and disease of the heart is known from the mists of time.

Acute acalculous cholecystitis (AAC) can be defined as an acute necro inflammatory disease of the gallbladder in the absence of cholelithiasis.

AAC is a challenging diagnosis. The atypical clinical onset associated to a paucity and similarity of symptoms and to laboratory data mimicking cardiovascular disease (CVD) often results in under and misdiagnosed cases. Moreover, AAC has commonly a fulminant course compared to calculous cholecystitis and it is often associated with gangrene, perforation and empyema as well as considerable morbidity and mortality (up 50%). Early diagnosis is crucial to a prompt treatment in order to avoid complications and to increase survivability.

Even today, although scientific evidence dating two hundred years has shown a close association between AAC and CVD, due to the lack of RCT, there is still a lot of confusion regarding the relationship and consequently the clinical management AAC and CVD.

In addition, emergency physicians are not always familiar with transient ECG changes with AAC.

The aim of this review was to provide evidence regarding epidemiology, pathophysiology, clinical presentation and treatment of the complex association between AAC and CVD.

Our main findings indicate that AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA (Acute myocardial infarction) could be related to a misdiagnosed AAC.

US – Ultrasonography-plays a key role in the early diagnosis and also in the follow up of AAC.

Cholecystostomy and cholecystectomy as unique or sequential represent the two prevailing treatment options for AAC.

•

AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery.

•

ECG changes in absence of significant laboratory data for IMA could be related to a misdiagnosed AAC.

•

Cholecystectomy is an only definitive treatment for AAC.

•

The first report on this theme after 20 years.

Changes in hospital admissions and complications of acute appendicitis during the COVID-19 pandemic: A systematic review and meta-analysis

Background

Acute appendicitis (AA) is one of the most common emergencies in general surgery worldwide. During the pandemic, a significant decrease in the number of accesses to the emergency department for AA has been recorded in different countries. A systematic review of the current literature sought to determine the impact of Coronavirus Disease 2019 (COVID-19) on hospital admissions and complications of AA.

Method

A systematic search was undertaken to identify repeated cross-sectional studies reporting the management of AA during the COVID-19 pandemic (index period) as compared to the previous year, or at the turn of lockdown (reference period). Data were abstracted on article (country of origin) and patients characteristics (adults, children [i.e. non adults, <18-year-old]), or mixed population) within the two given timeframes, including demographics, number of admissions for AA, number of appendectomies, and complicated appendectomies.

Results

Of 201 full-text articles assessed for eligibility, 54 studies from 22 world countries were included. In total, 27 (50%) were conducted on adults, 12 (22%) on children, and 15 (28%) on a mixed patients population. The overall rate ratio of admissions for AA between the two periods was 0.94 (95%CI, 0.75-1.17), with significant differences between studies on adults (0.90 [0.74-1.09]), mixed population (0.50 [0.27-0.90]), and children (1.50 [1.01-2.22]). The overall risk ratio of complicated AA was 1.65 (1.32-2.07), ranging from 1.32 in studies on children, to 2.45 in mixed population.

Conclusion

The pandemic has altered the rate of admissions for AA and appendectomy, with parallel increased incidence of complicated cases in all age groups.

A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLEROFOAM)

Background

The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids.

Methods

A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year.

Results

There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18–75) years]. Complete resolution of bleeding was reached in 125/183 patients (68.3%) at 1 week and the recurrence rate was 12% (15/125).

Thirteen patients (7.4%) underwent a second sclerotherapy session, while only 1 patient (1.8%) had to undergo a third session. The overall 1-year success rate was 95.6% (175/183). The HDSS and the SHS score significantly improved from a median preoperative value of 11 and 18 to 0 and 0, respectively (p < 0.001). There were 3 episodes of external thrombosis. No serious adverse events occurred.

Conclusions

Sclerotherapy with 3% polidocanol foam is a safe, effective, painless, repeatable and low-cost procedure in patients with bleeding haemorrhoids.

High complication rate in Crohn's disease surgery following percutaneous drainage of intra-abdominal abscess: a multicentre study

INTRODUCTION

Intra-abdominal abscesses complicating Crohn's disease (CD) present an additional challenge as their presence can contraindicate immunosuppressive treatment whilst emergency surgery is associated with high stoma rate and complications. Treatment options include a conservative approach, percutaneous drainage, and surgical intervention. The current multicentre study audited the short-term outcomes of patients who underwent preoperative radiological drainage of intra-abdominal abscesses up to 6 weeks prior to surgery for ileocolonic CD.

METHODS

This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing ileocolic resection for primary or recurrent CD from June 2018 to May 2019. The outcomes of patients who underwent radiological guided drainage prior to ileocolonic resection were compared to the patients who did not require preoperative drainage. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes.

RESULTS

Amongst a group of 575 included patients who had an ileocolic resection for CD, there were 36 patients (6.2%) who underwent abscess drainage prior to surgery. Postoperative morbidity (44.4%) and anastomotic leak (11.1%) were significantly higher in the group of patients who underwent preoperative drainage.

CONCLUSIONS

Patients with Crohn's disease who require preoperative radiological guided drainage of intra-abdominal abscesses are at increased risk of postoperative morbidity and septic complications following ileocaecal or re-do ileocolic resection.

Non-targeted high-resolution mass spectrometry study for evaluation of milk freshness

Milk freshness is an important parameter for both consumers' health and quality of milk-based products. Up to now there have been neither analytical methods nor specific parameters to uniquely define milk freshness from a complete and univocal chemical perspective. In this study, 8 molecules were selected and identified as responsible for milk aging, using a liquid chromatography-high-resolution mass spectrometry approach followed by chemometric data elaboration. For model setup and marker selection, 30 high-quality pasteurized fresh milk samples were collected directly from the production site and analyzed immediately and after storage at 2 to 8°C for 7 d. The markers were then validated by challenging the model with a set of 10 milk samples, not previously analyzed. Our results demonstrated that the markers identified within this study can be successfully used for the correct classification of non-fresh milk samples, complementing and successfully enhancing parallel evaluations obtainable through sensory measures.

Association of Delayed Surgery With Oncologic Long-term Outcomes in Patients With Locally Advanced Rectal Cancer Not Responding to Preoperative Chemoradiation

Importance

Extending the interval between the end of neoadjuvant chemoradiotherapy (CRT) and surgery may enhance tumor response in patients with locally advanced rectal cancer. However, data on the association of delaying surgery with long-term outcome in patients who had a minor or poor response are lacking.

Objective

To assess a large series of patients who had minor or no tumor response to CRT and the association of shorter or longer waiting times between CRT and surgery with short- and long-term outcomes.

Design, Setting, and Participants

This is a multicenter retrospective cohort study. Data from 1701 consecutive patients with rectal cancer treated in 12 Italian referral centers were analyzed for colorectal surgery between January 2000 and December 2014. Patients with a minor or null tumor response (ypT stage of 2 to 3 or ypN positive) stage greater than 0 to neoadjuvant CRT were selected for the study. The data were analyzed between March and July 2020.

Exposures

Patients who had a minor or null tumor response were divided into 2 groups according to the wait time between neoadjuvant therapy end and surgery. Differences in surgical and oncological outcomes between these 2 groups were explored.

Main Outcomes and Measures

The primary outcomes were overall and disease-free survival between the 2 groups.

Results

Of a total of 1064 patients, 654 (61.5%) were male, and the median (IQR) age was 64 (55-71) years. A total of 579 patients (54.4%) had a shorter wait time (8 weeks or less) 485 patients (45.6%) had a longer wait time (greater than 8 weeks). A longer waiting time before surgery was associated with worse 5- and 10-year overall survival rates (67.6% [95% CI, 63.1%-71.7%] vs 80.3% [95% CI, 76.5%-83.6%] at 5 years; 40.1% [95% CI, 33.5%-46.5%] vs 57.8% [95% CI, 52.1%-63.0%] at 10 years; P < .001). Also, delayed surgery was associated with worse 5- and 10-year disease-free survival (59.6% [95% CI, 54.9%-63.9%] vs 72.0% [95% CI, 67.9%-75.7%] at 5 years; 36.2% [95% CI, 29.9%-42.4%] vs 53.9% [95% CI, 48.5%-59.1%] at 10 years; P < .001). At multivariate analysis, a longer waiting time was associated with an augmented risk of death (hazard ratio, 1.84; 95% CI, 1.50-2.26; P < .001) and death/recurrence (hazard ratio, 1.69; 95% CI, 1.39-2.04; P < .001).

Conclusions and Relevance

In this cohort study, a longer interval before surgery after completing neoadjuvant CRT was associated with worse overall and disease-free survival in tumors with a poor pathological response to preoperative CRT. Based on these findings, patients who do not respond well to CRT should be identified early after the end of CRT and undergo surgery without delay.

Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview

Hemorrhoidal disease (HD) is the symptomatic enlargement and/or distal displacement of the normal hemorrhoidal cushions and is one of the most frequent diseases in colorectal surgery. Several surgical or office-based therapies are currently available, with the aim of being a more tailored approach. This article aimed to elucidate the historical evolution of surgical therapy for HD from ancient times, highlighting the crucial steps, controversies, and pioneers in the field. In contrast with the previous literature on the topic that is often updated to the 1990s, with the introduction of stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization, this article describes all new surgical and office-based treatments introduced in the first 20 years of the 2000s.

Endoscopic Pilonidal Sinus Treatment: A Tertiary Care Academic Center Experience

Background: Pilonidal disease (PD) represents one of the most common proctological diseases in young adults. Although several approaches to treating PD have been described, there is still a lack of agreement on which is the best. The aim of this study was to evaluate the long-term efficacy of endoscopic pilonidal sinus treatment (EPSiT) at a tertiary care academic center. Methods: Between June 2017 and January 2021, a total of 32 patients [12 women (37.5%) and 20 men (62.5%)] with a mean age of 29.22 ± 12.98 years were treated with EPSiT. Pre- and post-operative symptoms were assessed with a score of 0-5. Success was defined as the absence of any subjective symptoms, as well as by complete post-operative wound healing. Results: Most of the patients had a midline external opening (17/32; 53.1%), with a mean number of external openings of 2.41 (1-4) ± 1.04. The median post-operative pain score was 0, and the mean follow-up period was 22 (4-42) ± 11.49 months. The time to wound healing was reduced in patients with one opening (28.14 ± 4.06 days) compared to patients with two or more openings (33.64 ± 7.3 days) (p = 0.067). The mean operative time was longer in patients who subsequently had a recurrence (41.75 ± 6.24 vs. 34.18 ± 6.24 min; p = 0.031). The overall success rate was 87.5% (28/32), and the mean time to recurrence was 3.25 (2-5) ± 1.26 months. Conclusions: EPSiT represents a viable option for the treatment of PD. More evidence and a longer follow-up period are needed to validate the results.

What paradigm shifts occurred in the management of acute diverticulitis during the COVID-19 pandemic? A scoping review

BACKGROUND

Acute colonic diverticulitis (ACD) is common in Western countries, with its prevalence increasing throughout the world. As a result of the coronavirus disease 2019 (COVID-19), elective surgery and in-patients’ visits have been cancelled or postponed worldwide.

AIM

To systematically explore the impact of the pandemic in the management of ACD.

METHODS

MEDLINE, Embase, Scopus, MedxRiv, and the Cochrane Library databases were searched to 22 December 2020. Studies which reported on the management of patients with ACD during the COVID-19 pandemic were eligible. For cross sectional studies, outcomes of interest included the number of hospital admission for ACD, as well as key features of disease severity (complicated or not) across two time periods (pre- and during lockdown).

RESULTS

A total of 69 papers were inspected, and 21 were eligible for inclusion. Ten papers were cross sectional studies from seven world countries; six were case reports; three were qualitative studies, and two review articles. A 56% overall decrease in admissions for ACD was observed during lockdown, peaking 67% in the largest series. A 4%-8% decrease in the rate of uncomplicated diverticulitis was also noted during the lockdown phase. An initial non-operative management was recommended for complicated diverticulitis, and encouraged to an out-of-hospital regimen. Despite initial concerns on the use of laparoscopy for Hinchey 3 and 4 patients to avoid aerosolized contamination, societal bodies have progressively mitigated their initial recommendations as actual risks are yet to be ascertained.

CONCLUSION

During the COVID-19 pandemic, fewer patients presented and were diagnosed with ACD. Such decline may have likely affected the spectrum of uncomplicated disease. Established outpatient management and follow up for selected cases may unburden healthcare resources in time of crisis.

Therapeutic Targets and Tumor Microenvironment in Colorectal Cancer

Colorectal cancer (CRC) is a genetically, anatomically, and transcriptionally heterogeneous disease. The prognosis for a CRC patient depends on the stage of the tumor at diagnosis and widely differs accordingly. The tumor microenvironment (TME) in CRC is an important factor affecting targeted cancer therapy. The TME has a dynamic composition including various cell types, such as cancer-associated fibroblasts, tumor-associated macrophages, regulatory T cells, and myeloid-derived suppressor cells, as well as extracellular factors that surround cancer cells and have functional and structural roles under physiological and pathological conditions. Moreover, the TME can limit the efficacy of therapeutic agents through high interstitial pressure, fibrosis, and the degradation of the therapeutic agents by enzymatic activity. For this reason, the TME is a fertile ground for the discovery of new drugs. The aim of this narrative review is to present current knowledge and future perspectives regarding the TME composition based on strategies for patients with CRC.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Anastomosis configuration and technique following ileocaecal resection for Crohn's disease: a multicentre study

A limited ileocaecal resection is the most frequently performed procedure for ileocaecal CD and different anastomotic configurations and techniques have been described. This manuscript audited the different anastomotic techniques used in a national study and evaluated their influence on postoperative outcomes following ileocaecal resection for primary CD. This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing elective ileocaecal resection for primary CD from June 2018 May 2019. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. 427 patients were included. The side to side anastomosis was the chosen configuration in 380 patients (89%). The stapled anastomotic (n = 286; 67%), techniques were preferred to hand-sewn (n = 141; 33%). Postoperative morbidity was 20.3% and anastomotic leak 3.7%. Anastomotic leak was independent of the type of anastomosis performed, while was associated with an ASA grade ≥ 3, presence of perianal disease and ileocolonic localization of disease. Four predictors of LOS were identified after multivariate analysis. The laparoscopic approach was the only associated with a reduced LOS (p = 0.017), while age, ASA grade ≥ 3 or administration of preoperative TPN were associated with increased LOS. The side to side was the most commonly used anastomotic configuration for ileocolic reconstruction following primary CD resection. There was no difference in postoperative morbidity according to anastomotic technique and configuration. Anastomotic leak was associated with ASA grade ≥ 3, a penetrating phenotype of disease and ileo-colonic distribution of CD.

Short-Term Outcomes of Polycarbophil and Propionibacterium acnes Lysate Gel after Open Hemorrhoidectomy: A Prospective Cohort Study

Background: Pain is the most common complication after open excisional hemorrhoidectomy (OEH). We assessed the effectiveness of polycarbophil and Propionibacterium acnes lysate gel (Emorsan^®Gel) on pain control after OEH. Research design and methods: Fifty consecutive patients undergoing OEH were included. All patients received stool softeners and oral analgesia in the post-operative period. Emorsan^®Gel was also used topically by the last 25 patients (Emorsan^®Gel group (EG)) until Post-Operative Day 20 (POD 20). The primary outcome was the effectiveness of Emorsan^®Gel on pain relief using an 11-point visual analogue scale (VAS). Morbidity, wound healing (WH), and time to work were documented at POD 1, POD 10, POD 20, and POD 40. Results: Of the 50 patients enrolled, twenty-eight (56%) were males; median age, 49 (range, 28–73) years. The VAS score decreased over time in all patients, with significantly lower scores at POD 20 in the EG (1.44 (SD, 1.16) vs. 2.12 (0.93) in the control group (CG); p = 0.045). All patients in the EG achieved complete WH at last follow-up, compared to only 17 (68%) in the CG (p = 0.004). The likelihood of WH was 66% higher in the EG (OR, 1.66 [95%CI, 0.80–3.44; p = 0.172). Conclusions: Emorsan^®Gel is safe and effective at reducing pain after EOH, promoting earlier WH compared to standard care treatment.

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume–pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference.

Correction to: Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR)

An amendment to this paper has been published and can be accessed via the original article.

Practical approach to develop a multi-group screening method for detection of mycotoxins, pesticides and veterinary drugs in food

A multi-group screening method to detect residues of veterinary drugs in meat and environmental contaminants in wheat flour has been developed using liquid chromatography coupled to quadrupole-Orbitrap high-resolution mass spectrometry (LC-HRMS). The procedure was tested for over 300 representative compounds (173 veterinary drugs, 122 pesticides and 9 mycotoxins) analysing in parallel negative and positive (spiked) samples according to European validation rules. The Screening Target Concentrations (STCs) were chosen conservatively with respect to the method purposes. Interpretation of results was based on retention time, mass accuracy of precursor and MS² spectral library. Evaluating the percentage of false negative results, 280 out of the 304 analytes were detectable at the STCs (false compliant rate ≤ 5%). In wheat flours, incurred levels of mycotoxins, deoxynivalenol and 3-acetyldeoxynivalenol, higher than STCs, were frequently found, whereas in meat, the most detected veterinary drugs were antibiotics generally at negligible concentrations (<10 μg kg^-1 ). Finally, seven test materials from proficiency test schemes were successfully tested.

Mesenchymal Stromal Cell Therapy in the Management of Perianal Fistulas in Crohn's Disease: An Up-To-Date Review

Crohn’s Disease (CD) is a chronic inflammatory disorder that potentially involves the entire gastrointestinal tract. Perianal fistulizing CD (pCD) is a serious and frequent complication associated with significant morbidities and a heavy negative impact on quality of life. The aim of CD treatment is to induce and maintain disease remission and to promote mucosal repair. Unfortunately, even the best therapeutic regimens in pCD do not have long-term efficacy and cause a significant number of side effects. Therefore, it is mandatory to study new therapeutical options such as the use of mesenchymal stromal cells (MSCs). These cells promote tissue repair via the induction of immunomodulation. The present review aims to analyze the existing updated scientific literature on MSCs adoption in the treatment of pCD to evaluate its efficacy and safety and to compare the use of bone marrow and adipose tissue derived MSCs, type of administration, and dose required for recovery.

Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR)

Background

Excisional haemorrhoidectomy is the gold standard technique in patients with III and IV degree haemorrhoidal disease (HD). However, it is associated with a significant rate of post-operative pain. The aim of our study was to evaluate the efficacy of mesoglycan in the post-operative period of patients who underwent open excisional diathermy haemorrhoidectomy (OEH).

Methods

This was a retrospective multicentre observational study. Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled. All patients were followed-up on the first post-operative day (T1) and after 1 week (T2), 3 weeks (T3) and 6 weeks (T4). BMI, habits, SF-12 questionnaire, VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated.

Results

In the mesoglycan group, post-operative thrombosis was significantly reduced at T2 (p < 0.05) and T3 (p < 0.005), and all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003). There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding. There was an early recovery of autonomy in the mesoglycan group in all three follow-up periods (T2 p = 0.016; T3 p = 0.002; T4 p = 0.007).

Conclusions

The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain with consequent early resumption of autonomy.

Trial registration NCT04481698—Mesoglycan for Pain Control After Open Excisional HAEMOrrhoidectomy (MeHAEMO) https://clinicaltrials.gov/ct2/show/NCT04481698?term=Mesoglycan+for+Pain+Control+After+Open+Excisional+HAEMOrrhoidectomy+%28MeHAEMO%29&draw=2&rank=1

Mast Cells, microRNAs and Others: The Role of Translational Research on Colorectal Cancer in the Forthcoming Era of Precision Medicine

Colorectal cancer (CRC) is a heterogeneous disease, molecularly and anatomically, that develops in a multi-step process requiring the accumulation of several genetic or epigenetic mutations that lead to the gradual transformation of normal mucosa into cancer. In fact, tumorigenesis is extremely complex, with many immunologic and non-immunologic factors present in the tumor microenvironment that can influence tumorigenesis. In the last few years, a role for mast cells (MCs), microRNAs (miRNAs), Kirsten rat sarcoma (KRAS) and v-raf murine sarcoma viral oncogene homologue B (BRAF) in cancer development and progression has been suggested, and numerous efforts have been made to thoroughly assess their correlation with CRC to improve patient survival and quality of life. The identification of easily measurable, non-invasive and cost-effective biomarkers, the so-called "ideal biomarkers", for CRC screening and treatment remains a high priority. The aim of this review is to discuss the emerging role of mast cells (MCs), microRNAs (miRNAs), KRAS and BRAF as diagnostic and prognostic biomarkers for CRC, evaluating their influence as potential therapy targets in the forthcoming era of precision medicine.

Deadlock of proctologic practice in Italy during COVID-19 pandemic: a national report from ProctoLock2020

Proctology is one of the surgical specialties that suffered the most during COVID-19 pandemic. Using data from a cross-sectional worldwide web survey, we aimed to snapshot the current status of proctologic practice in Italy with differences between three macro areas (North, Centre, South). Specialists affiliated to renowned scientific societies with an interest in coloproctology were invited to join a 27-item survey. Predictive power of respondents' and hospitals' demographics on the change of status of surgical activities was calculated. The study was registered at ClinicalTrials.gov (NCT04392245). Of 299 respondents from Italy, 94 (40%) practiced in the North, 60 (25%) in the Centrer and 82 (35%) in the South and Islands. The majority were men (79%), at consultant level (70%), with a mean age of 46.5 years, practicing in academic hospitals (39%), where a dedicated proctologist was readily available (68%). Southern respondents were more at risk of infection compared to those from the Center (OR, 3.30; 95%CI 1.46; 7.47, P = 0.004), as were males (OR, 2.64; 95%CI 1.09; 6.37, P = 0.031) and those who routinely tested patients prior to surgery (OR, 3.02; 95%CI 1.39; 6.53, P = 0.005). The likelihood of ongoing surgical practice was higher in the South (OR 1.36, 95%CI 0.75; 2.46, P = 0.304) and in centers that were not fully dedicated to COVID-19 care (OR 4.00, 95%CI 1.88; 8.50, P < 0.001). The results of this survey highlight important factors contributing to the deadlock of proctologic practice in Italy and may inform the development of future management strategies.

Thrombosed External Haemorrhoids: A Clinician's Dilemma

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Excisional Haemorrhoidectomy: Where Are We?

Haemorrhoidal disease (HD) is defined as the symptomatic enlargement and/or distal displacement of anal cushions and is one of the most frequent and ancient anorectal conditions. Bleeding, during or after defecation, is the most common symptom. The color of the blood is typically bright red covering the outer surface of the stools. The severity of HD is based on the degree of the prolapse. There are several excisional surgery treatments. In this review, we describe the most common techniques such as Milligan and Morgan, Parks, Ferguson and Whitehead technique. Despite significant improvements in conservative treatments, excisional haemorrhoidectomy techniques are the most effective treatment for III- and IV degree.

P275 Feasibility and accuracy of the automated quantification of two- and three-dimensional left ventricular ejection fraction and its role in the arrhythmic risk stratification of organic heart disease

BACKGROUND

New automated approaches for left heart chamber quantification based on adaptive analytics algorithms have been introduced for both two- (2DE) and three-dimensional (3DE) echocardiography. These algorithms measure a left ventricular ejection fraction (LVEF) and reduce the intra- and inter-observer variability associated with the conventional manual tracing of LV endocardial borders. However, the clinical utility of these algorithms in the sudden cardiac death (SCD) risk stratification of patients with organic heart disease remains to be clarified.

PURPOSE

We sought to test the feasibility and the accuracy of two automated algorithms that measure 2DE and 3DE LVEF in patients with impaired LV systolic function and to define the cut-off values for fully automated 2DE and 3DE LVEF that could predict major arrhythmic events (MAE). We wanted also to assess the feasibility of replacing manual 2DE and semi-automated (SA) 3DE LVEF with fully-automated (FA) 2DE and 3DE LVEF respectively, in the stratification of high arrhythmic risk patients.

METHODS

We prospectively enrolled 240 patients (63 ± 13 years, 81% men) with both ischemic and non-ischemic cardiomyopathy with 2DE LVEF &lt; 50%, no previous MAE or coronary artery revascularization &lt; 90 days, after at least 3 months of optimal medical therapy for heart failure. MAE were defined as SCD, resuscitated cardiac arrest (CA), ventricular fibrillation, sustained ventricular tachycardia and appropriate ICD shocks. The risk detection cut-off values for 2DE and 3DE FA LVEF were computed using the maximally selected rank statistics method. In order to predict the risk of MAE we created four different risk models, including both clinical characteristics (age, NYHA class, aetiology of the LV dysfunction) and imaging-derived data (2DE manual LVEF, 2DE FA LVEF, 3DE SA LVEF and 3DE FA LVEF), analyzed by a ROC curve.

RESULTS

During a 27 ± 25months follow-up period, 31 patients (13%) presented MAE including SCD (n= 22; 9%), resuscitated CA (n = 3; 1%) and appropriate ICD shocks (n = 6; 2%). Both 2DE and 3DE FA LVEF showed high feasibility (92% and 95%, respectively), and good agreement with conventional LVEF (2DE mean difference 4 ± 7%, and 3DE mean difference 4 ± 7%). We identified two FA LVEF cut-offs for the MAE detection: 2DE &lt;39% (p = 0.006) and 3DE &lt;37% (p = 0.005). The model including the 2DE FA LVEF showed an area under the curve (AUC) larger than the one including conventional 2DE LVEF (0.83 vs 0.80). Conversely, the AUC obtained with FA 3DE LVEF model was slightly lower than the one obtained using SA 3DE LVEF model (0.80 vs 0.84).

CONCLUSIONS

Both 2DE and 3DE FA LVEF are feasible and accurate alternative to the conventional (manual) or SA endocardial border tracing. The use of specific FA 2DE LVEF cut-off values showed a comparable predictive power in the MAE risk stratification compared to the conventional one with the advantage of very low intra- and inter-observer variability.

P1581 The global myocardial work index is a powerful predictor of major arrhythmic events in patients with organic heart disease and reduced left ventricular ejection fraction

Background

Current guidelines recommend implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular ejection fraction (2DE LVEF) by two-dimensional echocardiography≤ 35%. However, new echocardiography parameters of LV function such as the mechanical dispersion (MD), the LVEF by three-dimensional echocardiography (3DE) and the global myocardial work index (GWI) have been reported to provide a more accurate stratification of the arrhythmic risk, and potentially improve ICD patient selection.

Purpose

We wanted to compare the arrhythmic risk predictive power of the new parameters of LV function with the conventional 2DLVEF.

Material and Methods

we prospectively enrolled 216 patients (63 ± 12 years, 88% men) with organic heart diseases and 2DE LVEF &lt;50%, in whom we re-measured LVEF using 3DE, and obtained MD and GWI using 2DE speckle tracking. Major arrhythmic events were defined as sudden cardiac death, sustained ventricular tachycardia, ventricular fibrillation and appropriate ICD shocks. We assessed the predictive power of 4 different parameters: 2DE LVEF&lt; 35%; 3DE LVEF&lt; 35%; MD &gt; 80 ms; and GWI&lt; 672 mmHg% to identify patients at risk of major arrhythmic events.

Results

During a mean follow-up of 27 ± 24 months, 24 patients (10%) experienced sudden cardiac death, whereas 28 patients (13%) presented major arrhythmic events. The predictive power in terms of major arrhythmic events prediction (Harrel C statistics) improved from 0.67 (95%CI 0.57-0.76) for 2DE LVEF&lt; 35%, to 0.73 (95%CI 0.64-0.82) for 3DE LVEF&lt; 35%, and 0.77 (95%CI 0.68-0.86) for GWI &lt; 672 mm Hg%. Whereas, MD &gt; 80 ms showed a limited predictive power (HCS= 0.53, 95%CI 0.41-0.76)).

Conclusions

GWI&lt; 672 mm Hg% was the most accurate predictor of major arrhythmic events among echocardiography parameters in patients with organic heart disease and LVEF &lt; 50%.

Mast Cells, Angiogenesis and Lymphangiogenesis in Human Gastric Cancer

Gastric cancer is diagnosed in nearly one million new patients each year and it remains the second leading cause of cancer-related deaths worldwide. Although gastric cancer represents a heterogeneous group of diseases, chronic inflammation has been shown to play a role in tumorigenesis. Cancer development is a multistep process characterized by genetic and epigenetic alterations during tumour initiation and progression. The stromal microenvironment is important in maintaining normal tissue homeostasis or promoting tumour development. A plethora of immune cells (i.e., lymphocytes, macrophages, mast cells, monocytes, myeloid-derived suppressor cells, Treg cells, dendritic cells, neutrophils, eosinophils, natural killer (NK) and natural killer T (NKT) cells) are components of gastric cancer microenvironment. Mast cell density is increased in gastric cancer and there is a correlation with angiogenesis, the number of metastatic lymph nodes and the survival of these patients. Mast cells exert a protumorigenic role in gastric cancer through the release of angiogenic (VEGF-A, CXCL8, MMP-9) and lymphangiogenic factors (VEGF-C and VEGF-F). Gastric mast cells express the programmed death ligands (PD-L1 and PD-L2) which are relevant as immune checkpoints in cancer. Several clinical undergoing trials targeting immune checkpoints could be an innovative therapeutic strategy in gastric cancer. Elucidation of the role of subsets of mast cells in different human gastric cancers will demand studies of increasing complexity beyond those assessing merely mast cell density and microlocalization.

The prognostic value of KRAS and BRAF in stage I-III colorectal cancer. A systematic review

BACKGROUND

Colorectal cancer (CRC) is one of the leading cause of cancer deaths worldwide. The aetiology of CRC is complex and involves interaction on environmental and genetic factors. The two most important pathways are the EGFR (Epidermal Grow Factor Receptor) signaling pathway, with the involvement of KRAS and BRAF, and the DNA mismatch repair (MMR). Generally, KRAS and BRAF mutations are mutually exclusive. They are both able to cause RAS/RAF/MAPK signaling pathway upregulation and are necessary for CRC development. BRAF mutations confers a poor prognosis in Western CRC patients, particularly in metastatic CRC (mCRC) and its mutations occur in approximately 4-20% CRC, with the vast majority being the V600E hotspot mutation. KRAS mutations are observed in 30- 40% CRC patients and act as predictive markers of resistance to epidermal growth factor receptor (EGFR)-targeted antibodies in metastatic CRC. Initial patient management is defined by TNM stage at diagnosis but in patient with stage II and III CRC, TNM staging alone does not predict outcome in CRC patients who may be eligible for adjuvant chemotherapy. Furthermore, for stage II and III, non-metastatic CRC patients, the prognostic role of BRAF and KRAS mutations is still controversial, particularly comparing microsatellite-unstable (MSI) and - stable tumors (MSS). The aim of this study was to clarify the impact of KRAS/BRAF mutations on prognosis in patients with stage I-III CRC.

MATERIALS AND METHODS

A systematic review of literature was undertaken to evaluate the prognostic value of KRAS and BRAF mutations in stage I-III colorectal cancer. Four major databases (PUBMED, EMBASE, WEB OF SCIENCE and COCHRANE LIBRARY) were searched.

RESULTS

Ninety-two studies were identified. After screening of titles, abstract and inclusion criteria sixteen articles were included. Of the selected articles, five were prospective, ten were retrospectives studies, and one was a combined retrospective/ prospective study.

CONCLUSION

In our opinion, a combination of molecular markers, tumor location with the other clinical-pathological variables and microsatellite status is essential to have a correct prognosis. Nevertheless, this combination could be useful as a predictive factor in stage I-III CRC.

KEY WORDS

BRAF, Colorectal Cancer, KRAS, Stage I-III CRC, Translational research.

Bariatric Surgery and Rheumatic Diseases: A Literature Review

BACKGROUND

Obesity is a debilitating growing condition and represents a challenge for every surgeon. It is associated with the activation of the inflammatory pathway and this may have a negative impact on the natural history of some rheumatic diseases. Bariatric surgery, reducing obesity, could bring to a minor activation of the well-known inflammatory pathway with improvement of these diseases. The aim of this review is to investigate the role of weight loss, achieved through bariatric surgery, in rheumatic diseases.

MATERIALS AND METHODS

A systematic review of literature was undertaken to evaluate weight loss subsequent to bariatric surgery in obese patients suffering from some rheumatic diseases (Rheumatoid Arthritis, Psoriasis, Psoriatic Arthritis, Fibromyalgia, Osteoarthritis, Systemic Lupus Erythematous). Three major databases (PUBMED, EMBASE and WEB OF SCIENCE) were searched.

RESULTS

Three-hundred studies were identified. After screening of titles, abstracts and inclusion criteria sixteen articles were included. Of the selected articles, seven were reviews, five were case reports, one was a clinical report, one was a retrospective study, one was a cohort study and one was an author manuscript.

CONCLUSION

Weight loss, obtained through bariatric surgery, seems to reduce serum inflammatory markers as a consequence of the inflammatory pathway reduction and this is connected with both the improvement of some rheumatic diseases as well as with the reduction in the use of medicaments (steroids and immunosuppressors).

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

Sphincter-saving proctectomy for rectal cancer with NO COIL® transanal tube and without ostoma. Clinical outcomes, cost effectiveness and quality of life in the elderly

BACKGROUND

Colorectal cancer is one of the most common invasive cancers, and it is responsible for considerable physical and psychosocial morbidity specially in older patients. However, only few reports focused on quality of life, cost-effectiveness and clinical outcomes of rectal cancer patients undergone to surgery. This retrospective study compares short-term and long-term outcomes in rectal cancer patients with more and less than 75 years of age.

METHODS

Four hundred consecutive patients underwent radical surgery for rectal adenocarcinoma and they were collected in a prospective institutional database and divided into two groups: group 1 (≥75 years, N.=98); group 2 (<75 years, N.=302). Rectal anterior resection (RAR) with sphincter-saving restorative proctectomy and with application of silicone transanal tube NO COIL® 60-80 mm long, was the only procedure considered. Main clinical and pathological data were assessed and compared.

RESULTS

Statistically significant differences between the two groups were detected regard to comorbidities and the emergency presentation. Overall survival is lower in patients over 75 age, but cancer-related survival is not different between the two groups.

CONCLUSIONS

Although advanced age is associated with higher morbidity and mortality, in our experience, itself is not a contraindication for surgical sphincter-saving proctetomy in rectal cancer patients. The absence of a stoma also improved the cost effectiveness and patients' quality of life in both groups: psychological morbidity, sexuality, levels of anxiety and depression, body image.

The density of mast cells c-Kit+ and tryptase+ correlates with each other and with angiogenesis in pancreatic cancer patients

Literature data suggest that inflammatory cells such as mast cells (MCs) are involved in angiogenesis. MCs can stimulate angiogenesis by releasing of well identified pro-angiogenic cytokines stored in their cytoplasm. In particular, MCs can release tryptase, a potent in vivo and in vitro pro-angiogenic factor. Nevertheless, few data are available concerning the role of MCs positive to tryptase in primary pancreatic cancer angiogenesis. This study analyzed the correlation between mast cells positive to c-Kit receptor (c-Kit⁺ MCs), the density of MCs expressing tryptase (MCD-T) and microvascular density (MVD) in primary tumor tissue from patients affected by pancreatic ductal adenocarcinoma (PDAC). A series of 35 PDAC patients with stage T_2-3N_0-1M₀ (by AJCC for Pancreas Cancer Staging 7^th Edition) were selected and then undergone to surgery. Tumor tissue samples were evaluated by mean of immunohistochemistry and image analysis methods in terms of number of c-Kit⁺ MCs, MCD-T and MVD. The above parameters were related each other and with the most important main clinico-pathological features. A significant correlation between c-Kit⁺ MCs, MCD-T and MVD groups each other was found by Pearson t-test analysis (r ranged from 0.75 to 0.87; p-value ranged from 0.01 to 0.04). No other significant correlation was found. Our in vivo preliminary data, suggest that tumor microenvironmental MCs evaluated in terms of c-Kit⁺ MCs and MCD-T may play a role in PDAC angiogenesis and they could be further evaluated as a novel tumor biomarker and as a target of anti-angiogenic therapy.

Tryptase mast cell density, protease-activated receptor-2 microvascular density, and classical microvascular density evaluation in gastric cancer patients undergoing surgery: possible translational relevance

BACKGROUND

Mast cells (MCs) can stimulate angiogenesis, releasing several proangiogenic cytokines stored in their cytoplasm. In particular, MCs can release tryptase, a potent in vivo and in vitro proangiogenic factor via protease-activated receptor-2 (PAR-2) activation and mitogen-activated protein kinase (MAPK) phosphorylation. Nevertheless, no data are available concerning the relationship among tryptase MC density (TMCD), endothelial cells (ECs) positive to PAR-2 microvascular density (PAR-2-MVD) and classical MVD (C-MVD) in gastric cancer (GC) angiogenesis.

METHODS

In this study, we analyzed the correlation of TMCD, PAR-2-MVD, C-MVD with each other and with the main clinicopathological features in GC patients who underwent surgery. A series of 77 GC patients with stage T_2-3N_2-3M₀ (classified by the American Joint Committee on Cancer for Gastric Cancer, 7th edition) were selected and then underwent surgery.

RESULTS

Tumour tissue samples were evaluated by mean of immunohistochemistry and image analysis methods in terms of numbers of TMCD, PAR-2-MVD and C-MVD. A significant correlation between the TMCD, PAR-2-MVD and C-MVD groups with each other was found by Pearson t-test analysis (r ranged from 0.64 to 0.76; p value ranged from 0.02 to 0.03). There was no other significant correlation between the above parameters and clinicopathological features.

CONCLUSIONS

Our in vivo preliminary data suggest that TMCD and PAR-2-MVD may play a role in GC angiogenesis and they could be further evaluated as a target of antiangiogenic therapy.

Frequency of "Pocket" Hematoma in Patients Receiving Vitamin K Antagonist and Antiplatelet Therapy at the Time of Pacemaker or Cardioverter Defibrillator Implantation (from the POCKET Study)

In patients undergoing cardiac device implantation, anticoagulant and antiplatelet therapy are associated with an increased risk of pocket hematoma. In case of vitamin K antagonist therapy, a strategy of continued warfarin with no heparin bridge showed a reduction of pocket hematoma. Evidence regarding antiplatelet therapy management is limited. This is a single-center observational study which reflects our systematic approach to the problem. In 2012, we proposed an improved management protocol for anticoagulant and antiplatelet therapy (no-bridge protocol) based on individual thromboembolic risk stratification, noninterruption of oral anticoagulation, no bridge with heparin and elastic adherence compression bandage. The primary end point was the incidence of clinically significant pocket hematoma in the first 30 days after implantation. A total of 1,035 patients were enrolled, of whom 522 received the standard management and 513 the new protocol. The primary end point occurred in 34 patients of the standard management group and 8 patients of the no-bridge protocol group (6.5% vs 1.6%, p <0.001). Patients in the standard management group had a higher incidence of pocket infections (2.3% vs 0.6%, p = 0.02), lead dislodgements (4.8% vs 2.1%, p = 0.02), and thromboembolic events (1.3% vs 0.0%, p <0.01). On a multivariate analysis, heparin and coronary artery disease were independent predictors of pocket hematoma (relative risk [RR] 3.48, 95% confidence interval [CI] 1.55 to 7.83 and RR 2.43, 95% CI 1.25 to 4.76, respectively), whereas the no-bridge protocol was associated with a reduction of pocket hematoma (RR 0.33, 95% CI 0.14 to 0.76). New anticoagulant and antiplatelet therapy management protocol was associated with a reduced incidence of clinically significant pocket hematomas, thromboembolic events, pocket infections, and lead dislodgements.

Skin grafting for the treatment of chronic leg ulcers - a systematic review in evidence-based medicine

Skin grafting is one of the most common surgical procedures in the area of non-healing wounds by which skin or a skin substitute is placed over a wound to replace and regenerate the damaged skin. Chronic leg ulcers are an important problem and a major source of expense for Western countries and for which many different forms of treatment have been used. Skin grafting is a method of treatment that decreases the area of chronic leg ulcers or heals them completely, thus improving a patient's quality of life. Skin grafting is an old technique, rediscovered during the first and second world wars as the main treatment for wound closure. Nowadays, skin grafting has a pivotal role in the context of modern wound healing and tissue regeneration. The aim of this review was to track and to analyse the specific outcomes this technique achieved, especially in the last decade, in relation to venous, arterial, diabetic, rheumatoid and traumatic leg ulcers. Our main findings indicate that autologous split-thickness skin grafting still remains the gold standard in terms of safety and efficacy for chronic leg ulcers; skin grafting procedures have greater success rates in chronic venous leg ulcers compared to other types of chronic leg ulcers; skin tissue engineering, also supported by genetic manipulation, is quickly expanding and, in the near future, may provide even better outcomes in the area of treatments for long-lasting chronic wounds.

A pilot observational study on magnesium and calcium imbalance in elderly patients with acute aortic dissection

Background

Magnesium (Mg) and calcium (Ca) are the principal essential elements involved in endothelial cell homeostasis. Extracellular changes in the levels of either alter endothelial contraction and dilatation. Consequently Mg and Ca imbalance is associated with a high risk of endothelial dysfunction, the main process observed during acute aortic dissection (AAD); in this clinical condition, which mainly affects elderly men, smooth muscle cell alterations lead to intimal tears, creating a false new lumen in the media of the aorta. AAD patients have a high risk of mortality as a result of late diagnosis because often it is not distinguished from other cardiovascular diseases.

We investigated Mg and Ca total circulating levels and the associated pro-inflammatory mediators in elderly AAD patients, to gain further information on the pathophysiology of this disorder, with a view to suggesting newer and earlier potential biomarkers of AAD.

Results

Total circulating Mg and Ca levels were both lower in AAD patients than controls (p < 0.0001). Using Ca as cut-off, 90% of AAD patients with low Ca (<8.4 mg/dL) came into the type A classification of AAD. Stratifying AAD according to this cut-off, Mg was lower in patients with lower total Ca.

Compared to controls, both type A and B AAD patients had higher levels of all the pro-coagulant and pro-inflammatory mediators analyzed, including sP-sel, D-dimer, TNF-α, IL-6, and CRP (p < 0.05). Dividing types A and B using the Stanford classification, no significant differences were found (p > 0.05) The levels of both ICAM-1 and EN-1 were lower in AAD than in a control group (p < 0.0001 and p < 0.05 respectively).

Conclusions

These findings suggest that low Mg and Ca in AAD elderly patients may contribute to altering normal endothelial physiology and also concur in changing the normal concentrations of different mediators involved in vasodilatation and constriction, associated with AAD onset and severity.

Bridge to surgery in patients with obstructive colorectal cancer Comparison of covered and uncovered stents

AIM

Placement of self-expandable metallic stent has been used for bridge to surgery in the treatment of colorectal obstruction. Our aim was to compare technical success and complication rates of covered and uncovered inserted stents in colorectal malignant obstruction patients.

MATERIAL OF STUDY

A series of 24 obstruction colorectal cancer patients were selected and included in the study for endoscopic stenting as a bridge to surgery: group 1 (patients with covered stents, n =12); group 2 (patients with uncovered stents, n=12). Technical success and complication rates of all procedures were compared between covered and uncovered stents.

RESULTS

Stent placement was technically successful in all patients with no procedure-related complications. No significant differences between the two groups were found (p-value > 0.05). Complications were observed after the technical success.

CONCLUSIONS

Our preliminary data suggest that self-expandable metallic stent is a safe and efficacy approach in patients with malignant colorectal obstruction for bridge to surgery and there are not differences in the use of covered or uncovered stents due to low complication rates and positive outcomes in both groups.

KEY WORDS

Bridge to Surgery, Colorectal Cancer, Emergency Obstruction, Stents.

The role of self-expandable metallic stents as "bridge to surgery" for the treatment of acute malignant colorectal obstruction. Our experience

INTRODUCTION

Despite the widespread use of screening programs, the colorectal cancer occurs in 7-29% of cases with a bowel obstruction, needing an immediate decompression treatment by emergency surgery; unfortunately, the emergency surgery is characterized by high morbidity and mortality rates. The endoscopic placement of self-expandable metallic stents can be a useful alternative, allowing to decompress the acute obstruction in a short time, in order to correct dehydration, electrolytic imbalance and to improve the overall clinical conditions prior to adequately plan the intervention of elective surgery.

AIM

The objective of our study was to evaluate the clinical success and potential complications related to the stent placement as "bridge to surgery".

MATERIALS AND METHODS

Twenty-four patients with acute intestinal obstruction due to colorectal cancer were retrospectively observed in our Surgery Unit. They were selected only patients in whom technical success, defined as the correct placement of the stent, was recorded. All patients underwent a preoperative abdominal X-rays and whole body contrast- enhanced Computed Tomography (ceCT). Furthermore, an intraoperative fluoroscopy was also performed to obtain a better anatomical depiction of the lesions. The sites of obstruction were in the left colon (n=13) and in the proximal rectal tract (n=11). Covered and uncovered stents were placed respectively in 12 and 12 patients. The Over The Wire (OTW) technique has been used in 11 patients while the Through The Scope (TTS) technique in 13 subjects. All patients were brought to elective surgery in 5-10 days. The clinical success was defined as the resumption of normal bowel function within 48-72 hours and the absence of complications.

RESULTS

Technical success was documented in 24 patients (100%). Clinical success was recorded in 17 patients (70.8%) while, in 7 patients, as treatment complications were recorded: 2 stent migrations (8.3%), 2 cases with tenesmus (8.3%), 2 bleeding (8.3%), 2 cases of abdominal pain (8.3%) and 1 case of perforation (4.2%), were recorded.

CONCLUSION

In our series we found that placing self-expandable metallic stents, considered as "bridge to surgery", was a useful technique in the resolution of acute malignant colorectal obstructions, with high success rate and low rate of complications.

KEY WORDS

Colorectal cancer, Clinical success, Large bowel obstruction, Radiology, Self-expanding metallic stent, Stenting, Surgery.

Mast Cells Density Positive to Tryptase Correlate with Microvascular Density in both Primary Gastric Cancer Tissue and Loco-Regional Lymph Node Metastases from Patients That Have Undergone Radical Surgery

Mast Cells (MCs) play a role in immune responses and more recently MCs have been involved in tumoral angiogenesis. In particular MCs can release tryptase, a potent in vivo and in vitro pro-angiogenic factor via proteinase-activated receptor-2 (PAR-2) activation and mitogen-activated protein kinase (MAPK) phosphorylation. MCs can release tryptase following c-Kit receptor activation. Nevertheless, no data are available concerning the relationship among MCs Density Positive to Tryptase (MCDPT) and Microvascular Density (MVD) in both primary gastric cancer tissue and loco-regional lymph node metastases. A series of 75 GC patients with stage T_2-3N_2-3M₀ (by AJCC for Gastric Cancer Seventh Edition) undergone to radical surgery were selected for the study. MCDPT and MVD were evaluated by immunohistochemistry and by image analysis system and results were correlated each to other in primary tumor tissue and in metastatic lymph nodes harvested. Furthermore, tissue parameters were correlated with important clinico-pathological features. A significant correlation between MCDPT and MVD was found in primary gastric cancer tissue and lymph node metastases. Pearson t-test analysis (r ranged from 0.74 to 0.79; p-value ranged from 0.001 to 0.003). These preliminary data suggest that MCDPT play a role in angiogenesis in both primary tumor and in lymph node metastases from GC. We suggest that MCs and tryptase could be further evaluated as novel targets for anti-angiogenic therapies.