Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort

BACKGROUND

Current evidence concerning bowel preparation before elective colorectal surgery is still controversial. This study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation.

METHODS

A prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). Twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. The primary endpoints were AL, SSIs, and OM. All the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI).

RESULTS

Compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23-2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10-1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25-0.79; p = .008).

CONCLUSIONS

MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP.

Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort

BACKGROUND

In Italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. The aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery.

METHODS

A database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. The primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. The results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i.

RESULTS

A total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). Group A versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). A mean postoperative duration of stay difference of 0.86 days was detected between groups. No difference was recorded between the two groups for all the other endpoints.

CONCLUSION

This study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery.

Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts

Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.

Outcomes and Complications of Duodenopancreatectomy in Octogenarian Patients: a Review

Background: Duodenopancreatectomy is a surgical procedure that involves the removal of part of the pancreas, duodenum, and bile ducts. This procedure is commonly performed in patients with pancreatic cancer or other gastrointestinal disorders. However, the safety and efficacy of duodenopancreatectomy in older adults (octogenarians) remain unclear. Objectives:The goal of this review is to assess the outcomes and complications of duodenopancreatectomy in octogenarian patients. Methods:A systematic search of relevant literature was conducted using PubMed, Embase and the Cochrane Library databases. Studies reporting the outcomes and complications of duodenopancreatectomy in octogenarian patients were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Egger's test was used to evaluate publication bias. Results:A total of 14 studies were included in this review. The outcomes of duodenopancreatectomy in octogenarian patients were generally favorable, with a median 30-day mortality rate of 3.5% (range 0-16.7%). The most common complications were pancreatic fistula (12.2%), delayed gastric emptying (6.3%) and wound infection (5.5%). The overall long-term survival rate of octogenarian patients after duodenopancreatectomy was 21.2%. Conclusions:Duodenopancreatectomy can be safely performed in carefully selected octogenarian patients with good outcomes. However, this procedure is associated with a high risk of complications, particularly pancreatic fistula, in this age group.

Image-guided techniques for localization of pulmonary nodules during video-assisted thoracoscopic surgery lobectomy

In the modern era when screening and early surveillance of pulmonary nodules are increasing in importance, the management of the pulmonary nodule represents a different challenge to thoracic surgeons. The difficulty lies in the merging of sound surgical and oncological principles with more minimally invasive and appropriate lung-sparing surgery. The success rates of video-assisted thoracoscopic surgery (VATS) resection for smaller as well as subsolid nodules have increased as a result of radiologists' preoperative localization tools. Fast tracking in thoracic surgery is promoted by proper postoperative care for patients having lobectomies in combination with the VATS technique. Image-guided surgery refers to the application of a real-time correlation of the surgical field to preoperative imaging data collection that reflects the precise placement of a chosen surgical instrument in the adjacent anatomic structures. Among the cross-sectional digital imaging techniques the most widely utilized imaging modalities for image-guided therapy are computed tomography and magnetic resonance imaging. Additionally, surgical navigation devices, tracking tools, integration software, ultrasound, and angiography are used to support these procedures. For people who are thinking about implementing or optimizing a nodule localization program in view of workflow patterns, surgeon preferences, and institutional resources in a certain facility, this review provides in-depth, unbiased evaluation and offers useful information.

Inframesocolic main pancreatic vessels-first approach for minimally invasive radical antegrade modular pancreaticosplenectomy (RAMPS): technical description and first experience

Radical modular antegrade pancreaticosplenectomy (RAMPS) improves posterior tumor-free margins during resections of pancreatic neoplasia involving the body or tail. However, minimally invasive RAMPS is technically challenging and has been reported seldom. We present for the first time a minimally invasive RAMPS technique with an innovative approach providing early dissection and control of the main peripancreatic vessels from an inframesocolic embryonal window, suitable for laparoscopy and robotics. Minimally invasive RAMPS with inframesocolic main pancreatic vessels-first approach was performed at the Tricase Hospital (Italy) from May 2017 to April 2022 in 11 consecutive patients with neoplastic lesions of the pancreas (8 laparoscopic RAMPS and 3 robotic RAMPS). Among the laparoscopic cases, 1 included a portal vein tangential resection and 1 a celiac artery resection (modified Appleby procedure). There were no conversions, no Clavien-Dindo complications > 2, all resections' margins were tumor free, and no 90-day mortality.

End-to-end invaginated pancreaticojejunostomy during minimally invasive pancreatoduodenectomy: technical description and single center experience

BACKGROUND

Remarkable progress has been made in pancreatic surgery over the last decades with the introduction of minimally invasive techniques. Minimally invasive pancreatoduodenectomy (MIPD) remains one of the most challenging operations in abdominal surgery and it is performed in a few centers worldwide. The treatment of the pancreatic stump is a crucial step of this operation; however, the best strategy to perform pancreatic anastomosis is still debated. In this article, we describe the technical details of our original technique of modified minimally invasive end-to-end invaginated pancreaticojejunostomy (EIPJ) using video footage.

METHODS

In the current study, we retrospectively analyzed a pilot series of 67 consecutive cases of minimally invasive (7 robotic/60 fully laparoscopic) MIPD operated on at the General Surgery Department of the Panico Hospital, Tricase (Italy) between March 2017 and October 2022.The reconstruction phase involved an EIPJ, tailored using an intra-ductal anastomotic plastic stent. The aim of this study was to describe the technique and evaluate the short-term outcomes of patients undergoing MIPD with EIPJ.

RESULTS

The mean operative time to perform the EIPJ was 21.57 ± 3.32 min. Seven patients (10.5%) developed biochemical leaks and 13 (19.4%) developed clinically relevant pancreatic fistulas (grade B or C according to the definition of the International Study Group on Pancreatic Surgery).

CONCLUSION

The early results confirm that this anastomosis is safe, easy to perform, and effective in the hands of hepatobiliopancreatic (HBP) surgeons with experience in minimally invasive surgery.

Impact of Oocyte Extract Supplement on Quality of Life after Hepatectomy for Liver Tumours: A Prospective, Multicentre, Double-Blind Randomized Clinical Trial

BACKGROUND

Previous studies on oocyte extract supplementation showed benefits in patients with liver tumours. In this trial, we hypothesized that the oocyte extract supplement impacted the QoL after hepatectomy for hepatocellular carcinoma and intrahepatic cholangiocarcinoma.

METHODS

This was a multicentre, double-blind, randomized clinical trial designed to assess the QoL of patients receiving a supplement of oocyte extract or placebo postoperatively. QoL was assessed using the Short Form-36 questionnaire in participants randomly assigned to treatment (Synchrolevels) or placebo. All study personnel and participants were masked to treatment assignment. The endpoint was the change in the QoL score.

RESULTS

Between June 2018 and September 2022, 66 of 128 expected patients were considered as per interim analysis, of which 33 were assigned to the treatment and 33 to the placebo group. Baseline and clinicopathological characteristics were similar between the two groups. In the treatment group, the health, mental and psychological status improved for many of the items considered, reaching statistical significance, while in the placebo group, those items either did not change or were impaired in comparison with the corresponding baseline.

CONCLUSIONS

Supplementation with oocyte extract modifies QoL after liver surgery by enhancing functional recovery. Further in-depth studies are required to confirm this evidence.

One-stage approach to cholecystocholedocholithiasis treatment: a feasible surgical strategy for emergency settings and frail patients

BACKGROUND

Cholecystocholedocholithiasis (CCL) occurs in up to 18% of patients undergoing laparoscopic cholecystectomy (LC). The two-stage treatment using endoscopic retrograde cholangiopancreatography (ERCP) followed by LC is the treatment of choice for CCL. However, only 10 to 60% of patients have common bile duct (CBD) stones at the time of ERCP, thus exposing patients to unnecessary ERCPs, causing 3 to 15% of post-interventional pancreatitis. One-stage laparoscopic-endoscopic rendezvous (LERV) is an alternative for the treatment of CCL. Given the selective top-to-bottom CBD cannulation, LERV reduces the risk of pancreatitis and failed CBD cannulation. Additionally, LERV is performed exclusively in patients presenting CBD stones at intraoperative cholangiography, avoiding unnecessary ERCPs. Despite its advantages, considering the logistical burden of coordinating different specialties, LERV is performed in few centers. Here, we present the largest retrospective series of LERVs performed at our department, analyzing elective and emergency procedures.

METHODS

All consecutive patients undergoing LERV for CCL between January 2014 and December 2021 were included. LERV success rate, operative time, biliary outflow restoration rate, postoperative complications (POC), length of hospital stay (LOS), and recurrences were analyzed.

RESULTS

181 patients were included (61 elective LERVs, 120 emergency LERVs). We reported a 100% LERV success rate, a 97.79% biliary outflow restoration rate, a 0% conversion rate, a mean intraoperative time of 120.17 ± 31.35 min, and LOS of 4.00 ± 2.82 days. POC included 7 Clavien-Dindo type 1, 11 type 2, and 3 type 3 cases. Seven patients presented with CBD stone recurrence: 2 within 30 days after discharge, 3 within 6 months after discharge, and 2 patients at 1 year. No statistically significant difference was found between elective and emergency patients.

CONCLUSION

LERV is safe, representing a valid option even in emergency settings, thus enabling the management of CCL within a single procedure, consequently sparing additional anesthesia and decreasing post-ERCP complications.

Intraoperative bowel perfusion quantification with hyperspectral imaging: a guidance tool for precision colorectal surgery

BACKGROUND

Poor anastomotic perfusion can cause anastomotic leaks (AL). Hyperspectral imaging (HSI), previously validated experimentally, provides accurate, real-time, contrast-free intestinal perfusion quantification. Clinical experience with HSI is limited. In this study, HSI was used to evaluate bowel perfusion intraoperatively.

METHODS

Fifty-two patients undergoing elective colorectal surgeries for neoplasia (n = 40) or diverticular disease (n = 12), were enrolled. Intestinal perfusion was assessed with HSI (TIVITA®, Diaspective Vision, Am Salzhaff, Germany). This device generates a perfusion heat map reflecting the tissue oxygen saturation (StO2) amount. Prior to anastomose creation, the clinical transection line (CTL) was highlighted on the proximal bowel and imaged with HSI. Upon StO2 heat map evaluation, the hyperspectral transection line (HTL) was identified. In case of CTL/HTL discrepancy > 5 mm, the bowel was always resected at the HTL. HSI outcomes were compared to the clinical ones.

RESULTS

AL occurred in one patient who underwent neoadjuvant radiochemotherapy and ultralow anterior resection for rectal cancer. HSI assessment was feasible in all patients, and StO2-values were significantly higher at proximal segments than distal ones. Twenty-six patients showed CTL/HTL discrepancy, and these patients had a lower mean StO2 (54.55 ± 21.30%) than patients without discrepancy (65.10 ± 21.30%, p = 0.000). Patients undergoing neoadjuvant radiochemotherapy showed a lower StO2 (51.41 ± 23.41%) than non-neoadjuvated patients (60.51 ± 24.98%, p = 0.010).

CONCLUSION

HSI is useful in detecting intraoperatively marginally perfused segments, for which the clinical appreciation is unreliable. Intestinal vascular supply is lower in patients undergoing neoadjuvant radiochemotherapy, and this novel finding together with the clinical impact of HSI perfusion quantification deserves further investigation in larger trials.

Automatic optical biopsy for colorectal cancer using hyperspectral imaging and artificial neural networks

BACKGROUND

Intraoperative identification of cancerous tissue is fundamental during oncological surgical or endoscopic procedures. This relies on visual assessment supported by histopathological evaluation, implying a longer operative time. Hyperspectral imaging (HSI), a contrast-free and contactless imaging technology, provides spatially resolved spectroscopic analysis, with the potential to differentiate tissue at a cellular level. However, HSI produces "big data", which is impossible to directly interpret by clinicians. We hypothesize that advanced machine learning algorithms (convolutional neural networks-CNNs) can accurately detect colorectal cancer in HSI data.

METHODS

In 34 patients undergoing colorectal resections for cancer, immediately after extraction, the specimen was opened, the tumor-bearing section was exposed and imaged using HSI. Cancer and normal mucosa were categorized from histopathology. A state-of-the-art CNN was developed to automatically detect regions of colorectal cancer in a hyperspectral image. Accuracy was validated with three levels of cross-validation (twofold, fivefold, and 15-fold).

RESULTS

32 patients had colorectal adenocarcinomas confirmed by histopathology (9 left, 11 right, 4 transverse colon, and 9 rectum). 6 patients had a local initial stage (T1-2) and 26 had a local advanced stage (T3-4). The cancer detection performance of the CNN using 15-fold cross-validation showed high sensitivity and specificity (87% and 90%, respectively) and a ROC-AUC score of 0.95 (considered outstanding). In the T1-2 group, the sensitivity and specificity were 89% and 90%, respectively, and in the T3-4 group, the sensitivity and specificity were 81% and 93%, respectively.

CONCLUSIONS

Automatic colorectal cancer detection on fresh specimens using HSI, using a properly trained CNN is feasible and accurate, even with small datasets, regardless of the local tumor extension. In the near future, this approach may become a useful intraoperative tool during oncological endoscopic and surgical procedures, and may result in precise and non-destructive optical biopsies to support objective and consistent tumor-free resection margins.

Modified FOLFOXIRI plus panitumumab (mFOLFOXIRI/PAN) versus mFOLFOX6/PAN as initial treatment of patients with unresectable RAS and BRAF wild-type metastatic colorectal cancer (mCRC): Results of the phase III randomized TRIPLETE study by GONO

LBA3505

Background: The association of a chemotherapy doublet (FOLFOX/FOLFIRI) with an anti-EGFR monoclonal antibody (cetuximab or panitumumab) is an upfront option for the treatment of RAS and BRAF wt mCRC patients. Phase II studies investigating the combination of the triplet FOLFOXIRI with an anti-EGFR reported promising activity results and an acceptable safety profile when lower doses of 5FU and irinotecan were adopted. The added value of intensifying the upfront chemotherapy when combined with a targeted agent in a molecularly selected population is not established. Methods: TRIPLETE is a prospective, open label, phase III trial in which previously untreated patients with unresectable RAS and BRAF wt mCRC were randomized to receive mFOLFOX6/pan (arm A) or mFOLFOXIRI (irinotecan 150 mg/sqm, oxaliplatin 85 mg/sqm, L-leucovorin 200 mg/sqm, 5-fluoruracil 2400 mg/sqm 48 h infusion)/pan (arm B) up to 12 cycles, followed by 5FU/LV/pan until disease progression. The primary endpoint is overall response rate (ORR) according to RECIST 1.1 criteria. Secondary endpoints include safety profile, R0 resection rate, PFS and OS. Under the assumption of an ORR of 60% in arm A, to detect an increase of at least 15% in arm B, a sample size of 432 cases provided approximately 90% power to a two-sided chi square test for heterogeneity at the 0.05 significance level. Results: From September 2017 to September 2021, 435 pts were enrolled (arm A/B: 217/218) in 67 Italian sites. Main pts’ characteristics were (arm A/B): median age 59/59, ECOG PS 0 80%/84%, left-sided 88%/88%, synchronous metastases 88%/87%, prior adjuvant 2%/6%, resected primary 43%/51%, liver-only 37%/39%. Main grade > 2 adverse events were diarrhoea 7%/23%, stomatitis 7%/7%, neutropenia 20%/32%, febrile neutropenia 3%/6%, fatigue 2%/7%, skin rash 29%/19%. 160 (73%) out of 218 patients in arm B and 165 (76%) out of 217 patients in arm A achieved RECIST response (OR 0.87, 95%CI 0.56-1.34, p=0.526). No interaction effect between treatment arm and disease spread (liver-limited vs not-liver limited) was evident. No differences in early tumor shrinkage (arm A/B 58%/57%, p=0.878) and deepness of response (median arm A/B: 47%/48%, p=0.845) were reported, nor in R0 resection rate (arm A/B 29%/25%, p=0.317). At a median follow up of 26.5 mos, 305 (arm A/B: 157/148) PFS events were collected, with no significant difference between arms (median PFS: 12.7 vs 12.3 months, HR: 0.88, 95%CI 0.70-1.11, p=0.277). Conclusions: The intensification of the upfront chemotherapy backbone in combination with panitumumab in molecularly selected and mostly (88%) left-sided mCRC patients does not provide any benefit in terms of treatment activity at the price of a non-negligible increase in gastrointestinal toxicity. Clinical trial information: NCT03231722.

ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study

BACKGROUND

Enhanced recovery after surgery (ERAS) programs influence morbidity rates and length of stay after colorectal surgery (CRS), and may also impact major complications and anastomotic leakage rates. A prospective multicenter observational study to investigate the interactions between ERAS program adherence and early outcomes after elective CRS was carried out.

METHODS

Prospective enrolment of patients submitted to elective CRS with anastomosis in 18 months. Adherence to 21 items of ERAS program was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints [major morbidity (MM) and anastomotic leakage (AL) rates] were identified through logistic regression analyses including all significant variables, presenting odds ratios (OR).

RESULTS

Institutional ERAS protocol was declared by 27 out of 38 (71.0%) participating centers. Median overall adherence to ERAS program items was 71.4%. Among 3830 patients included in the study, MM and AL rates were 4.7% and 4.2%, respectively. MM rates were independently influenced by intra- and/or postoperative blood transfusions (OR 7.79, 95% CI 5.46-11.10; p < 0.0001) and standard anesthesia protocol (OR 0.68, 95% CI 0.48-0.96; p = 0.028). AL rates were independently influenced by male gender (OR 1.48, 95% CI 1.06-2.07; p = 0.021), intra- and/or postoperative blood transfusions (OR 4.29, 95% CI 2.93-6.50; p < 0.0001) and non-standard resections (OR 1.49, 95% CI 1.01-2.22; p = 0.049).

CONCLUSIONS

This study disclosed wide room for improvement in compliance to several ERAS program items. It failed to detect any significant association between institutionalization and/or adherence rates to ERAS program with primary endpoints. These outcomes were independently influenced by gender, intra- and postoperative blood transfusions, non-standard resections, and standard anesthesia protocol.

Real-Life Clinical Data of Lenvatinib versus Sorafenib for Unresectable Hepatocellular Carcinoma in Italy

Background

Lenvatinib has been approved in Italy since October 2019 as a first-line therapy for advanced hepatocellular carcinoma (HCC) and to date data on effectiveness and safety of lenvatinib are not available in our region. To fill this gap, we performed a multicentric analysis of the real-world treatment outcomes with the propensity score matching in a cohort of Italian patients with unresectable HCC who were treated with either sorafenib or lenvatinib.

Aims and Methods

To evaluate the effectiveness of sorafenib and lenvatinib as primary treatment of advanced HCC in clinical practice we performed a multicentric analysis of the treatment outcomes of 288 such patients recruited in 11 centers in Italy. A propensity score was used to mitigate confounding due to referral biases in the assessment of mortality and progression-free survival.

Results

Over a follow-up period of 11 months the Cox regression model showed 48% reduction of death risk for patients treated with lenvatinib (95% CI: 0.34-0.81; p = 0.0034), compared with those treated with sorafenib. The median PFS was 9.0 and 4.9 months for lenvatinib and sorafenib arm, respectively. Patients treated with lenvatinib showed a higher percentage of response rate (29.4% vs 2.8%; p < 0.00001) compared with patients treated with sorafenib. Sorafenib was shown to be correlated with more HFSR, diarrhea and fatigue, while lenvatinib with more hypertension and fatigue.

Conclusion

Our study highlighted for the first time the efficacy and safety of lenvatinib in an Italian cohort of patients.

Intraoperative Guidance Using Hyperspectral Imaging: A Review for Surgeons

Hyperspectral imaging (HSI) is a novel optical imaging modality, which has recently found diverse applications in the medical field. HSI is a hybrid imaging modality, combining a digital photographic camera with a spectrographic unit, and it allows for a contactless and non-destructive biochemical analysis of living tissue. HSI provides quantitative and qualitative information of the tissue composition at molecular level in a contrast-free manner, hence making it possible to objectively discriminate between different tissue types and between healthy and pathological tissue. Over the last two decades, HSI has been increasingly used in the medical field, and only recently it has found an application in the operating room. In the last few years, several research groups have used this imaging modality as an intraoperative guidance tool within different surgical disciplines. Despite its great potential, HSI still remains far from being routinely used in the daily surgical practice, since it is still largely unknown to most of the surgical community. The aim of this study is to provide clinical surgeons with an overview of the capabilities, current limitations, and future directions of HSI for intraoperative guidance.

Deep Learning Analysis of In Vivo Hyperspectral Images for Automated Intraoperative Nerve Detection

Nerves are critical structures that may be difficult to recognize during surgery. Inadvertent nerve injuries can have catastrophic consequences for the patient and lead to life-long pain and a reduced quality of life. Hyperspectral imaging (HSI) is a non-invasive technique combining photography with spectroscopy, allowing non-invasive intraoperative biological tissue property quantification. We show, for the first time, that HSI combined with deep learning allows nerves and other tissue types to be automatically recognized in in vivo hyperspectral images. An animal model was used, and eight anesthetized pigs underwent neck midline incisions, exposing several structures (nerve, artery, vein, muscle, fat, skin). State-of-the-art machine learning models were trained to recognize these tissue types in HSI data. The best model was a convolutional neural network (CNN), achieving an overall average sensitivity of 0.91 and a specificity of 1.0, validated with leave-one-patient-out cross-validation. For the nerve, the CNN achieved an average sensitivity of 0.76 and a specificity of 0.99. In conclusion, HSI combined with a CNN model is suitable for in vivo nerve recognition.

Identification of lenvatinib prognostic index via recursive partitioning analysis in advanced hepatocellular carcinoma

BACKGROUND

After the advent of new treatment options for advanced hepatocellular carcinoma (HCC), the identification of prognostic factors is crucial for the selection of the most appropriate therapy for each patient.

PATIENTS AND METHODS

With the aim to fill this gap, we applied recursive partitioning analysis (RPA) to a cohort of 404 patients treated with lenvatinib.

RESULTS

The application of RPA resulted in a classification based on five variables that originated a new prognostic score, the lenvatinib prognostic index (LEP) index, identifying three groups: low risk [patients with prognostic nutritional index (PNI) >43.3 and previous trans-arterial chemoembolization (TACE)]; medium risk [patients with PNI >43.3 but without previous TACE and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage B (BCLC-B)]; high risk [patients with PNI <43.3 and ALBI grade 2 and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage C (BCLC-C)]. Median overall survival was 29.8 months [95% confidence interval (CI) 22.8-29.8 months] in low risk patients (n = 128), 17.0 months (95% CI 15.0-24.0 months) in medium risk (n = 162) and 8.9 months (95% CI 8.0-10.7 months) in high risk (n = 114); low risk hazard ratio (HR) 1 (reference group), medium risk HR 1.95 (95% CI 1.38-2.74), high risk HR 4.84 (95% CI 3.16-7.43); P < 0.0001. The LEP index was validated in a cohort of 127 Italian patients treated with lenvatinib. While the same classification did not show a prognostic value in a cohort of 311 patients treated with sorafenib, we also show a possible predictive role in favor of lenvatinib in the low risk group.

CONCLUSIONS

LEP index is a promising, easy-to-use tool that may be used to stratify patients undergoing systemic treatment of advanced HCC.

Phase II study of preoperative (PREOP) chemoradiotherapy (CTRT) plus avelumab (AVE) in patients (PTS) with locally advanced rectal cancer (LARC): The AVANA study

3511

Background: Preop CTRT is considered the standard of care in the management of LARC. RT can induce antigen release from a low neoantigen-burden tumor (such as a mismatch repair proficient colorectal cancer) and activate dendritic cells leading to a CD8+ T lymphocyte-mediated anticancer immune response. In LARC patients, neoadjuvant CTRT increases PD-L1 expression in tumor cells, strongly suggesting a neoadjuvant combinatory strategy with RT and PD-1/PD-L1 pathway blockade. Based on such considerations, we have designed the AVANA study to investigate the role of Ave in combination with preop CTRT in LARC. Methods: This is an Italian multi-center, phase II study. Pts with resectable LARC, defined by the presence of at least one of the following features: cN+, cT4, high risk cT3, received standard preop CTRT (capecitabine 825 mg/sqm/bid 5 days/week+ 50.4 Gy in 28 fractions over 5.5 weeks) plus 6 cycles of Ave 10 mg/Kg every 2 weeks. Surgery with total mesorectal excision was performed at 8-10 weeks after the end of CTRT. The primary end-point was the pCR rate, defined as complete histological regression with no available tumor cells ypT0N0. Secondary end-points were R0 resection rate, tumor downstaging, local recurrence, sphincter preservation rate, progression-free survival, overall survival, safety profile, and the evaluation of exploratory predictive and/or prognostic biomarkers. Assuming as null hypothesis p0 a pCR rate of 15%, a significance level of 5% (one-side), and a power of 80%, a sample size of 101 pts was needed to detect an absolute increment of 10% in pCR rate (from 15% to 25%). The experimental regimen is considered for further studies if, in at least 22 pts, we observe a pCR. Results: From April 2019 to November 2020, a total of 101 resectable LARC pts were enrolled in 10 Italian Centers. The median age was 63 years (23-82), 62 (61.4%) pts were male, 93 (92%) had ECOG PS 0. At baseline, 94 (93%) and 16 (16%) pts had cN+ and cT4 LARC, respectively. All pts completed the induction phase. Out of 96 pts evaluable for pathological response, 22 (23%) pts achieved a pCR and 59 (61.5%) pts a major pathological response (a central review is ongoing). At this time, microsatellite status is available only in 39 pts, of which only one was instable. The rate of grade 3-4 non-immune and immune-related adverse events was 8% and 4%, respectively. Avelumab was early interrupted in 9 pts out 101, mainly due to toxicity. Conclusions: The combination of preop CTRT plus Ave showed a promising activity and a feasible safety profile. According to our statistical considerations, the experimental regimen will be considered for further studies. Updated results will be presented during the Congress. Sponsored by GONO and partially supported by Merck. EUDRACT 2017-003582-10. Clinical trial information: NCT03854799.