A Glimpse into the Role and Effectiveness of Splenectomy for Isolated Metachronous Spleen Metastasis of Colorectal Cancer Origin: Long-Term Survivals Can Be Achieved

Background: Many papers exploring the role of resectioning metastases in colorectal cancer (CRC) have focused mainly on liver and lung sites, showing improved survival compared with non-resectional therapies. However, data about exceptional metastatic sites such as splenic metastases (SMs) are scarce. This paper aims to assess the role and effectiveness of splenectomy in the case of isolated metachronous SM of CRC origin. Methods: The patients' data were extracted after a comprehensive literature search through public databases for articles reporting patients with splenectomies for isolated metachronous SM of CRC origin. Potential predictors of survival were explored, along with demographic, diagnostic, pathology, and treatment data for each patient. Results: A total of 83 patients with splenectomies for isolated metachronous SM of CRC origin were identified. The primary CRC was at an advanced stage (Duke's C-70.3%) and on the left colon (45.5%) for most patients, while the median interval between CRC resection and SM was 24 months. The median overall survival after splenectomy was 84 months, and patients younger than 62 years presented statistically significantly worse overall survival rates than those ≥62 years old (p = 0.011). There was no significant impact on the long-term outcomes for factors including primary tumor location or adjuvant chemotherapy (p values ≥ 0.070, ns). Laparoscopic splenectomy was increasingly used in the last 20 years from 2002 (33.3% vs. 0%, p < 0.001). Conclusions: Splenectomy is the optimal treatment for patients with isolated metachronous SM of CRC, with the laparoscopic approach being increasingly used and having the potential to become a standard of care. Encouraging long-term survival rates were reported in the context of a multidisciplinary approach. Younger ages are associated with worse survival. Perioperative chemotherapy in the context of a patient diagnosed with SM of CRC origin appears to be a reasonable option, although the present study failed to show any significant impact on long-term survival.

Robotic or laparoscopic pelvic exenteration for gynecological malignancies: feasible options to open surgery

OBJECTIVE

To acknowledge that minimally invasive pelvic exenteration is a feasible alternative to open surgery and potentially identify prediction factors for patient outcome.

METHODS

The study was designed as a retrospective single team analysis of 12 consecutive cases, set between January 2008 and January 2022.

RESULTS

Six anterior and 6 total pelvic exenterations were performed. A 75% of cases were treated using a robotic approach. In 4 cases, an ileal conduit was used for urinary reconstruction. Mean operative time was 360±30.7 minutes. for anterior pelvic exenterations and 440±40.7 minutes. for total pelvic exenterations and mean blood loss was 350±35 mL. An R0 resection was performed in 9 cases (75%) and peri-operative morbidity was 16.6%, with no deaths recorded. Median disease-free survival was 12 months (10-14) and overall survival (OS) was 20 months (1-127). In terms of OS, 50% of patients were still alive 24 months after surgery. Taking into consideration the follow up period,16.6% of females under 50 or above 70 years old did not reach the cut off and 4 out of 6 patients that failed to reach it were diagnosed with distant metastases or local recurrence (p=0.169).

CONCLUSION

Our experience is very much consistent with literature in regard to primary site of cancer, post-operative complications, R0 resection and survival rates. On the other hand, minimally invasive approach and urinary reconstruction type were in contrast with cited publications. Minimally invasive pelvic exenteration is indeed a safe and feasible procedure, providing patients selection is appropriately performed.

Short-term Outcome of Robotic and Laparoscopic Surgery for Gynecological Malignancies: A Single-center Experience

Objectives

Minimally invasive surgery (MIS) has become the preferred option for many gynecologic pathologies since complication rate and postoperative recovery time have decreased considerably. Postoperative complications remain an important aspect when using the MIS approach, if they are not timely or accurately diagnosed and treated. The main aim of the study is to first assess their incidence, followed by identifying possible risk factors. Furthermore, the secondary aim is to identify if the type of MIS approach used, robotic or laparoscopic, may render some additional benefits.

Materials and Methods

The database of the General Surgery Department was queried between 2008 and 2019 for patients with gynecologic pathology: 2907 cases were identified. An additional selection was performed using the following filters: MIS and neoplasia. All emergency surgeries were excluded. One hundred and ninety-eight cases were obtained.

Results

The majority of complications were urological (11.6%) with only 7.07% requiring a specific urological procedure. The second most common was lymphorrhea 4.5%. Dindo-Clavien classification correlates positively with the postoperative hospital stay (PHS) (P = 0.000), the type of surgery (P = 0.046), the primary tumor location (P = 0.011), conversion rate (P = 0.049), the expertise of the lead surgeon (P = 0.012), and the operative time (P = 0.002). The urological complications correlate positively with the type of surgery (P = 0.002), the tumor location (P = 0.001), early reintervention (P = 0.000), operative time (P = 0.006), postoperative hemorrhage (P = 0.000), pelvic abscess (P = 0.000), venous thrombosis (P = 0.011), and postoperative cardiac complications (P = 0.002). Laparoscopic and robotic approaches were comparatively assessed. The PHS (P = 0.025), the type of surgery performed (P = 0.000), and primary tumor location (P = 0.011) were statistically significantly different.

Conclusion

Postoperative complications reported after MIS for gynecological malignancies show similar incidence as in the current literature, also taking into consideration those for the open approach. The robotic approach seems to be able to perform more complex surgeries with no difference in the postoperative complication rates. The expertise of the lead surgeon in gynecology correlates with lower postoperative complications. Further prospective studies are needed to confirm these results.

Propensity Score-Matched Analysis of Minimal Invasive Surgery versus Open Surgery for Colorectal Cancer in Older Patients

Introduction: Currently, surgeons deal with an older patient cohort, confronting new challenges brought by the raised life expectancy. This population is unrepresented in surgical trials; therefore, the optimal therapy is still a matter of debate. The efficacy of open versus minimal invasive management of colorectal cancer (CRC) in an elderly cohort is not clearly established. The current study assesses the minimal invasive approach in elderly patients undergoing colorectal surgery. Material and Methods: The General Surgery Department database was inquired between 2012 and 2015 using the following filters: age â?¥ 65 and rectal or colon adenocarcinoma. After applying the exclusion criteria, 975 cases were obtained: 842 underwent open surgery (OS) and 133 underwent minimal invasive surgery (MIS). A propensity score matching was performed to reduce patient selection bias. Results: After the propensity score matching, the MIS group had a shorter postoperative hospital stay than the OS group (p = 0.025). From the preoperative variables, the presence of chronic lung disease was significantly higher in the OS group (p = 0.039). The presence of chronic lung disease positively associates with the Clavien-Dindo classification (p 0.001) and with the number of days from surgery to discharge (p = 0.028). Conclusion: The chronological age alone should not be a limit to MIS granting that it showed no inferiority to the OS in terms of postoperative morbidity, correlating with lower postoperative stay in the elderly. Further prospective studies are needed to assess the outcome of MIS in elderly population.

Achalasia Treatment. Robotic Approach or Laparoscopy?

Background: Nowadays the question persists whether to choose the endoscopic or surgical method as the first treatment of choice for achalasia. Another debate topic is about the differences between the outcomes of the two approaches of minimally invasive surgical treatment and their feasibility. Material and Methods: This retrospective observational study included 193 patients with achalasia treated between 2008 and 2021. The patients were divided into 2 groups (A and B): 152 with minimally invasive heller myotomy (HM), and 41 with pneumatic dilation (PD). Patients surgically treated were then subdivided into robotic group (RG) and laparoscopic group (LG). Results: The recurrence rate was significantly higher in PD group (Ã?2 = 16.81, DF = 1, p 0.0001), with a success rate of 63,4%, comparing with 92,7% in HM group. No significant difference was obtained between the 2 groups concerning symptom relief on patients successfully treated. The success rate was comparable between the robotic and laparoscopic groups (p = 1). Significant difference was obtained in length of hospital stay between the 2 groups, with a mean of 4.78 +-1.59 days in the RG and, respectively, 5.52 +-2.1 days in the LG (t = 2.40, DF = 124.34, p = 0.0177). Postprocedural esophagitis rates were higher in patients with no fundoplication (6 out of 37 - 16.2%) and in patients treated with pneumatic dilation (4 out of 26 - 15.4%) than in patients with fundoplication (4 out of 46 - 8.5%). Conclusion: The present study indicates that surgery may be a better choice in fit patients for the treatment of achalasia. The procedure has a better success rate, even if the long-term outcomes are comparable in patients successfully treated. The success rate and long-term results were comparable between laparoscopy and robotic surgery.

Anti-miR-93-5p therapy prolongs sepsis survival by restoring the peripheral immune response

Sepsis remains a leading cause of human death and currently has no pathogenesis-specific therapy. Hampered progress is partly due to a lack of insight into deep mechanistic processes. In the last decade, deciphering the functions of small non-coding microRNAs (miRNAs) in sepsis pathogenesis became a dynamic research topic. To screen for new miRNA targets for sepsis therapeutics, we used human samples for miRNA array from peripheral blood mononuclear cells from sepsis patients and controls, blood samples from two cohorts of sepsis patients, and multiple animal models: mouse cecum ligation-puncture (CLP)-induced sepsis, mouse viral miRNA challenge, and baboon Gram-positive and Gram-negative sepsis models. miR-93-5p met the criteria for a therapeutic target, being overexpressed in baboons that died early after induction of sepsis, downregulated in humans who survived after sepsis, and correlated with negative clinical prognosticators for sepsis. Therapeutically, inhibiting miR-93-5p prolonged the overall survival of mice with CLP-induced sepsis, with a stronger effect in older mice. Mechanistically, anti-miR-93-5p therapy reduced inflammatory monocytes and increased circulating effector memory T cells, especially the CD4+ subset. AGO2-immunoprecipitation in miR-93-knockout T cells identified important regulatory receptors, such as CD28, as direct miR-93-5p target genes. In conclusion, miR-93-5p is a potential therapeutic target in sepsis through regulating both innate and adaptive immunity with possibly more benefit for the elderly than the young patients.

Safety and Efficacy of Simultaneous Resection of Gastric Carcinoma and Synchronous Liver Metastasis-A Western Center Experience

Background and objectives: Gastric cancer (GC) is often diagnosed in the metastatic stage. Palliative systemic therapy is still considered the gold standard, even for patients with resectable oligometastatic disease. The aim of the current study is to assess the potential benefit of up-front gastric and liver resection in patients with synchronous resectable liver-only metastases from GC (LMGC) in a Western population. Materials and Methods: All patients with GC and synchronous LMGC who underwent gastric resection with or without simultaneous resection of LMs between January 1997 and December 2016 were selected from the institutional records. Those with T4b primary tumors or with unresectable or more than three LMs were excluded from the analysis. All patients who underwent emergency surgery for hemorrhagic shock or gastric perforation were also excluded. Results: Out of 28 patients fulfilling the inclusion criteria, 16 underwent simultaneous gastric and liver resection (SR group), while 12 underwent palliative gastric resection (GR group). The median overall survival (OS) of the entire cohort was of 18.81 months, with 1-, 3- and 5-year OS rates of 71.4%, 17.9% and 14.3%, respectively. The 1-, 3- and 5-year OS rates in SR group (75%, 31.3% and 25%, respectively) were significantly higher than those achieved in GR group (66.7%, 0% and 0%, respectively; p = 0.004). Multivariate analysis of the entire cohort revealed that the only independent prognostic factor associated with better OS was liver resection (HR = 3.954, 95% CI: 1.542-10.139; p = 0.004). Conclusions: In a Western cohort, simultaneous resection of GC and LMGC significantly improved OS compared to patients who underwent palliative gastric resection.

Molecular profile of the NF-κB signalling pathway in human colorectal cancer

The development and progression of colorectal cancer (CRC) have been associated with inflammation processes that involve the overactivation of the NF-κB signalling pathway. The characterization of the NF-κB expression profile in CRC is an important topic since the suppression of NF-κB represents a potential therapeutic approach. In this study, we assessed the expression levels of 84 NF-κB-related genes in paired tumoral (T) and peritumoral (PT) tissues from 18 CRC patients and 18 normal colonic mucosae, and the expression levels of three miRNAs targeting the most dysregulated genes revealed by the case-control analysis. Comparing the gene expression profile of T and controls, 60 genes were dysregulated. The comparison of T and PT revealed 17 dysregulated genes in the tumoral tissues, with IL1B, CXCL8, IL1A, and CSF2 being the most upregulated. Notably, through a bioinformatics analysis, the differential gene expression of 11 out of the 17 genes was validated on a larger cohort of 308 CRC patients compared with 41 controls. Moreover, a decrease in the levels of RELA, NOD1, CASP8, BCL2L1, ELK1, and IKBKB was identified in poorly differentiated tumours compared to moderately differentiated tumours. The analysis of the three miRNAs targeting IL1B, CXCL8, IL1A, and CSF2 showed that miR-182-5p was upregulated in T compared with PT, whereas miR-10b-5p was downregulated in T compared with PT and control tissues. Our results may contribute to the design of new experimental therapeutic strategies based on endogenous molecules, such as miRNAs, to target the genetic key players of the NF- κB pathway.

Endoscopic Retrograde Cholangiopancreatography in Acute Biliary Pancreatitis: Urgent vs. Delayed and the Outcome of Same-Admission Cholecystectomy

Introduction: Acute pancreatitis (AP) represents a major burden for the medical system, associating important morbidity and mortality rates. This paper is focused on debatable aspects of the management of biliary AP, namely indications, timing and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) on the hand and, on the other hand, same-admission cholecystectomy as a preventive measure for recurrent disease. Material and methods: This is a retrospective study including 108 patients with biliary AP in whom ERCP was performed, treated in the Clinical Emergency Hospital of Bucharest between 2016 and 2020. According to the urgency of the ERCP, we divided the patients into two groups: urgent versus delayed ERCP. Results: Urgent ERCP was performed in 52 patients, while delayed ERCP was performed in 56 patients; the hospital stay was higher in the urgent group than in the delayed group (10 days vs 8 days, p = 0.299) with no difference in morbidity rates. The mean time between ERCP and surgery was 5 days, without significant difference between the groups. The laparoscopic approach was the preferred method, with a conversion rate of 7%. Conclusion: ERCP with stone extraction followed by same-admission laparoscopic cholecystectomy is a safe therapeutic option, that prevents recurrent pancreatitis. The timing of the procedures remains debatable, further prospective studies being needed to achieve statistical significance.

COVID-19 Pandemic Was Associated with Lower Activity but Not Higher Perioperative Mortality in a Large Eastern European Center

Background

Surges of critically ill patients can overwhelm hospitals during pandemic waves and disrupt essential surgical activity. This study aimed to determine whether hospital mortality increased during the COVID-19 pandemic and during pandemic waves.

Material/Methods

This was a retrospective analysis of a prospective, observational, epidemiological database. All patients who underwent surgery from January 1 to December 31, 2020, were included in the analysis. The setting was a large Eastern European Surgical Center referral center of liver transplant and liver surgery, a major center of abdominal surgery.

Results

A total of 1078 patients were analyzed, and this number corresponded to a reduction of surgical activity by 30% during the year 2020 compared with 2019. Despite an increase in surgery complexity during the pandemic, perioperative mortality was not different, and this was maintained during the pandemic wave. The pandemic (OR 1.45 [0.65–3.22], P=0.365) and the wave period (OR 0.897 [0.4–2], P=0.79) were not associated with hospital mortality in univariate analysis. In the multivariate model analysis, only the American Society of Anesthesiology (ASA) score (OR 5.815 [2.9–11.67], P<0.0001), emergency surgery (OR 5.066 [2.24–11.48], P<0.0001), and need for surgical reintervention (OR 5.195 [1.78–15.16], P=0.003) were associated with hospital mortality.

Conclusions

Despite considerable challenges, in this large retrospective cohort, perioperative mortality was similar to that of pre-pandemic practice. Efforts should be made to optimize personnel issues, while maintaining COVID-19-free surgical pathways, to adequately address patients’ surgical needs during the following waves of the pandemic.

The seen and the unseen: Molecular classification and image based-analysis of gastrointestinal cancers

Gastrointestinal cancers account for 22.5% of cancer related deaths worldwide and represent circa 20% of all cancers. In the last decades, we have witnessed a shift from histology-based to molecular-based classifications using genomic, epigenomic, and transcriptomic data. The molecular based classification revealed new prognostic markers and may aid the therapy selection. Because of the high-costs to perform a molecular classification, in recent years immunohistochemistry-based surrogate classification were developed which permit the stratification of patients, and in parallel multiple groups developed hematoxylin and eosin whole slide image analysis for sub-classifying these entities. Hence, we are witnessing a return to an image-based classification with the purpose to infer hidden information from routine histology images that would permit to detect the patients that respond to specific therapies and would be able to predict their outcome. In this review paper, we will discuss the current histological, molecular, and immunohistochemical classifications of the most common gastrointestinal cancers, gastric adenocarcinoma, and colorectal adenocarcinoma, and will present key aspects for developing a new artificial intelligence aided image-based classification of these malignancies.

Long-term Metabolic Morbidity and Steatohepatosis Following Standard Pancreatic Resections and Parenchyma-sparing, Local Extirpations for Benign Tumor: A Systematic Review and Meta-analysis

OBJECTIVE

To assess metabolic dysfunctions and steatohepatosis after standard and local pancreatic resections for benign and premalignant neoplasms.

SUMMARY OF BACKGROUND DATA

Duodenopancreatectomy, hemipancreatectomy, and parenchyma-sparing, limited pancreatic resections are currently in use for nonmalignant tumors.

METHODS

Medline, Embase, and Cochrane libraries were searched for studies reporting measured data of metabolic functions following PD, pancreatic left resection (PLR), duodenum-sparing pancreatic head resection (DPPHR), pancreatic middle segment resection (PMSR), and tumor enucleation (TEN). Forty cohort studies comprising data of 2729 patients were eligible.

RESULTS

PD for benign tumor was associated in 46 of 327 patients (14.1%) with postoperative new onset of diabetes mellitus (pNODM) and in 109 of 243 patients (44.9%) with postoperative new onset of pancreatic exocrine insufficiency measured after a mean follow-up of 32 months. The meta-analysis displayed pNODM following PD in 32 of 204 patients (15.7%) and in 10 of 200 patients (5%) after DPPHR [P < 0.01; OR: 0.33; (95%-CI: 0.15-0.22)]. PEI was found in 77 of 174 patients following PD (44.3%) and in 7 of 104 patients (6.7%) following DPPHR (P < 0.01;OR: 0.15; 95%-CI: 0.07-0.32). pNODM following PLR was reported in 107 of 459 patients (23.3%) and following PMSR 23 of 412 patients (5.6%) (P < 0.01; OR: 0.20; 95%-CI: 0.12-0.32). Postoperative new onset of pancreatic exocrine insufficiency was found in 17% following PLR and in 8% following PMSR (P < 0.01). pNODM following PPPD and tumor enucleation was observed in 19.7% and 5.7% (P < 0.03) of patients, respectively. Following PD/PPPD, 145 of 608 patients (23.8%) developed a nonalcoholic fatty liver disease after a mean follow-up of 30.4 months. Steatohepatosis following DPPHR developed in 2 of 66 (3%) significantly lower than following PPPD (P < 0.01).

CONCLUSION

Standard pancreatic resections for benign tumor carry a considerable high risk for a new onset of diabetes, pancreatic exocrine insufficiency and following PD for steatohepatosis. Parenchyma-sparing, local resections are associated with low grade metabolic dysfunctions.

Abdominoperineal Resection for Rectal Cancer: Open, Laparoscopic or Robotic Approach

OBJECTIVES

The present study compares abdominoperineal resection (APR) performed by minimally invasive and open approach, regarding preoperative selection criteria, intraoperative and early postoperative aspects, in choosing the suitable technique performed by surgical teams with experience in both open and minimally invasive surgery (MIS). Methods: This is a retrospective study, conducted between 2008-2020. Two hundred thirty-three patients with APR performed for low rectal or anal cancer were included. The cohort was divided into two groups, depending on the surgical approach used: Minimally Invasive Surgery (laparoscopic and robotic procedures) and Open Surgery (OS). The perioperative characteristics were analyzed in order to identify the optimal approach and a possible selection criteria. Results: We identified a high percentage of patients with a history of abdominal surgery in the open group (p = .0002). Intraoperative blood loss was significantly higher in the open group (p= .02), with an increased number of simultaneous resections (p = .041). The early postoperative outcome was marked by significantly lower morbidity in the MIS group (p = .005), with mortality recorded only in the open group (3 cases), in patients that associated severe comorbidities. The hystopathological results identified a significant number of patients with stage T2 in the MIS group (p= .037). Conclusions: Minimally invasive surgery provides a major advantage to APR, by avoiding an additional incision, the specimen being extracted through the perineal wound. The success of MIS APR seems to be assured by a good preoperative selection of the patients, alongside with experienced surgical teams in both open and minimally invasive rectal resections. The lack of conversion identified in robotic APR confirm the technical superiority over laparoscopic approach.

TNF-alpha releasing capacity of the whole blood drops after open total splenectomy, but increases after partial/subtotal or minimally invasive splenectomy

BACKGROUND

The mechanisms that induce immunodeficiency after splenectomy remain unknown. The aim of this study was to measure the cytokine releasing capacity of the whole blood as an expression of the innate immunity after total (TS) and subtotal/partial splenectomy (S/PS) in order to assess the impact of splenectomy on the individual cytokine reactivity.

METHODS

We prospectively collected blood before (D0) and at multiple time points after splenectomy (7 days - D7, 30 days - D30, 90 days - D90, 180 days - D180, and 360 days - D360) and measured the cytokines releasing capacity of IL-6, TNF-alpha and IL-10 from whole blood under LPS stimulation which we normalized to the monocytes number.

RESULTS

When analyzing all splenectomies at D0, D7 and D30, normalized ΔTNF-alpha significantly dropped after splenectomy (p = .0038) and normalized ΔIL-6 and ΔIL-10 did not significantly change. More specifically, normalized ΔTNF-alpha dropped after TS (p = .0568) and significantly increased after S/PS (p = .0388). Open surgery induced a decrease in normalized ΔTNF-alpha (p = .0970), whereas minimally invasive (MI) surgery significantly increased the normalized ΔTNF-alpha releasing capacity (p = .0178). The cytokine levels were heterogenous between pathologies at D0, and ΔIL-6 dropped mainly in cirrhotic patients after splenectomy (all underwent TS), ΔTNF-alpha dropped in immune thrombocytopenic purpura patients (all underwent TS), but increased in spherocytosis (91% underwent S/PS) after splenectomy.

CONCLUSIONS

Splenectomy induces a decrease of the pro-inflammatory cytokine TNF-alpha and if splenic parenchyma is spared and the surgery is performed MI, this change is hindered.

An hiv infection - a problem of quality of life!?

Introduction

The quality of life is a multidiimensional and subjective construct, based on the patient’s experience.

Objectives

The objective of this study is to observe if at the HIV - positive patient the quality of life in relation to health is a consequence of disease and treatment and if his perception about the disease changes his ability to have a full and useful life.

Methods

We centralized the data coming from a number of 600 patients registered in the Iasi Regional Center, for a period of 12 months. The side effects reported by the patients emerged from discussions with the infectious diseases specialist and the psychologist.

Results

From 600 pacients, 59% of them were male with mean age of 21.1 years old. Approximately 14% of the patiens had stable jobs, the rest were unemployed or had part-time jobs. 38% came from foster care units of from broken homes. The average number of days of hospitalization was 4 days, 25% of them were at their first scheme, 10% in the seventh-eighth scheme. Among the antiretroviral side effects patients complained nausea and vomiting in 85% of cases, lipodystrophy symptoms in 25% of cases, diarrhea in 15% of the cases; regarding the psychological aspects, 65% of patients showed an above level of anxiety, 40% had depressive manifestations, 10% had specific obsessions-compulsions and 10% neurotic and hysterical tendencies.

Conclusions

We need a close collaboration between the infectious diseases specialist and the psychologists in order to enhance the quality of life of the HIV patient.

The failure of adherence of the antiretroviral therapy is a field of work for the psychologist to HIV possitive patients in intensive care units

Introduction

HIV infection is currently considered a worldwide pandemic.

Objectives

The objective of this paper is to outline the profile of HIV – positive patients in intensive care units, regarding the psycho-emotional and viral parameters.

Methods

We realized a retrospective study for a period of 36 months, evaluating HIV positive patients in intensive care unit in the “Sf. Parascheva” Infectious Diseases Clincal Hospital Iasi, Romania.

Results

From 1^st of Janury 2011 to 31^st of December 2013, the HIV/AIDS Regional Centre of Iasi recorded 2649 hospitalizations, of which 18 cases required intensive medical care, 10 males and 8 females. The number of days of hospital admission varied between 4.5 and 32 days in the Intensive Care Unit. Initialy the psychological interview was conducted for 16 of the 18^th patients, 2 cases were with severely deteriorated health status that didn’t allowed communication. From them, 7 survived and they were evaluated at discharge from IIntensive Care Unit and also monitored long term, that revealed an increase in adherence to Antiretroviral Therapy and a change in lifestyle.

Conclusions

HIV positive patients that requires intensive care showed a marked immunological collapse due to abandonment of the therapy or late detection. In order to fully accomplish the needs of the HIV positive patient, the infectious diseases specialist must collaborate with the psychologist.

Pancreatic Fistula after D1+/D2 Radical Gastrectomy according to the Updated International Study Group of Pancreatic Surgery Criteria: Risk Factors and Clinical Consequences. Experience of Surgeons with High Caseloads in a Single Surgical Center in Eastern Europe

Purpose

Incidence, risk factors, and clinical consequences of pancreatic fistula (POPF) after D1+/D2 radical gastrectomy have not been well investigated in Western patients, particularly those from Eastern Europe.

Materials and Methods

A total of 358 D1+/D2 radical gastrectomies were performed by surgeons with high caseloads in a single surgical center from 2002 to 2017. A retrospective analysis of data that were prospectively gathered in an electronic database was performed. POPF was defined and graded according to the International Study Group for Pancreatic Surgery (ISGPS) criteria. Uni- and multivariate analyses were performed to identify potential predictors of POPF. Additionally, the impact of POPF on early complications and long-term outcomes were investigated.

Results

POPF was observed in 20 patients (5.6%), according to the updated ISGPS grading system. Cardiovascular comorbidities emerged as the single independent predictor of POPF formation (risk ratio, 3.051; 95% confidence interval, 1.161–8.019; P=0.024). POPF occurrence was associated with statistically significant increased rates of postoperative hemorrhage requiring re-laparotomy (P=0.029), anastomotic leak (P=0.002), 90-day mortality (P=0.036), and prolonged hospital stay (P<0.001). The long-term survival of patients with gastric adenocarcinoma was not affected by POPF (P=0.661).

Conclusions

In this large series of Eastern European patients, the clinically relevant rate of POPF after D1+/D2 radical gastrectomy was low. The presence of co-existing cardiovascular disease favored the occurrence of POPF and was associated with an increased risk of postoperative bleeding, anastomotic leak, 90-day mortality, and prolonged hospital stay. POPF was not found to affect the long-term survival of patients with gastric adenocarcinoma.

Minimal Access Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumours - A Single Centre Experience

Introduction: Laparoscopic techniques have been increasingly adopted in the field of General Surgery in the last decades. The main disadvantages of laparoscopy are related to limited degrees of freedom of instruments and poor ergonomics, which are associated with a steep learning curve. Robotic surgery overcomes most of the technical limitations of laparoscopic surgery and has the potential to expand the indications of minimal access surgery (MAS) in procedures that are difficult to perform using laparoscopy. Methods: Patients who underwent MAS resections of gastric gastrointestinal stromal tumours (GIST) between January 2002 and October 2018 in a single Surgical Department were retrospectively analysed. Demographic data as well as the following characteristics were recorded for each patient: age, sex, symptoms, tumour location and size, type of surgical procedure, intraoperative blood loss, operative time, length of hospital stay, histopathological assessment of resection margins, and incidence of perioperative complications. Results: The mean patient age was 58 (range, 27-81 years). Most lesions were found on the great curvature (7) and in the distal stomach or antrum (7), respectively. Twenty patients underwent laparoscopic resection, while five patients had robotic resection of gastric GISTs. Surgical laparoscopic treatment consisted of antrectomy (n=4) and wedge gastrectomy (n=16). In all robotic cases a wedge gastrectomy was performed. One patient was converted to open surgery due to adhesions from previous operation. The mean operative time was 130 minutes (range, 70-210 minutes).The mean tumour size was 3.8 cm (range, 2-7 cm). There were no complications except one case that required reoperation for postoperative bleeding. There were no mortalities. Conclusion: The MAS approach of gastric GISTs is safe and effective and it is associated with low morbidity. Therefore, it should constitute the first option in patients with small tumours and favourable locations. The only limiting factor for the widespread use of MAS resections for gastric GISTs is surgeon expertise in this challenging technique.

The Long Noncoding RNA CCAT2 Induces Chromosomal Instability Through BOP1-AURKB Signaling

BACKGROUND & AIMS

Chromosomal instability (CIN) is a carcinogenesis event that promotes metastasis and resistance to therapy by unclear mechanisms. Expression of the colon cancer-associated transcript 2 gene (CCAT2), which encodes a long noncoding RNA (lncRNA), associates with CIN, but little is known about how CCAT2 lncRNA regulates this cancer enabling characteristic.

METHODS

We performed cytogenetic analysis of colorectal cancer (CRC) cell lines (HCT116, KM12C/SM, and HT29) overexpressing CCAT2 and colon organoids from C57BL/6N mice with the CCAT2 transgene and without (controls). CRC cells were also analyzed by immunofluorescence microscopy, γ-H2AX, and senescence assays. CCAT2 transgene and control mice were given azoxymethane and dextran sulfate sodium to induce colon tumors. We performed gene expression array and mass spectrometry to detect downstream targets of CCAT2 lncRNA. We characterized interactions between CCAT2 with downstream proteins using MS2 pull-down, RNA immunoprecipitation, and selective 2'-hydroxyl acylation analyzed by primer extension analyses. Downstream proteins were overexpressed in CRC cells and analyzed for CIN. Gene expression levels were measured in CRC and non-tumor tissues from 5 cohorts, comprising more than 900 patients.

RESULTS

High expression of CCAT2 induced CIN in CRC cell lines and increased resistance to 5-fluorouracil and oxaliplatin. Mice that expressed the CCAT2 transgene developed chromosome abnormalities, and colon organoids derived from crypt cells of these mice had a higher percentage of chromosome abnormalities compared with organoids from control mice. The transgenic mice given azoxymethane and dextran sulfate sodium developed more and larger colon polyps than control mice given these agents. Microarray analysis and mass spectrometry indicated that expression of CCAT2 increased expression of genes involved in ribosome biogenesis and protein synthesis. CCAT2 lncRNA interacted directly with and stabilized BOP1 ribosomal biogenesis factor (BOP1). CCAT2 also increased expression of MYC, which activated expression of BOP1. Overexpression of BOP1 in CRC cell lines resulted in chromosomal missegregation errors, and increased colony formation, and invasiveness, whereas BOP1 knockdown reduced viability. BOP1 promoted CIN by increasing the active form of aurora kinase B, which regulates chromosomal segregation. BOP1 was overexpressed in polyp tissues from CCAT2 transgenic mice compared with healthy tissue. CCAT2 lncRNA and BOP1 mRNA or protein were all increased in microsatellite stable tumors (characterized by CIN), but not in tumors with microsatellite instability compared with nontumor tissues. Increased levels of CCAT2 lncRNA and BOP1 mRNA correlated with each other and with shorter survival times of patients.

CONCLUSIONS

We found that overexpression of CCAT2 in colon cells promotes CIN and carcinogenesis by stabilizing and inducing expression of BOP1 an activator of aurora kinase B. Strategies to target this pathway might be developed for treatment of patients with microsatellite stable colorectal tumors.

The non-coding RNome after splenectomy

Splenectomy is a common surgical procedure performed in millions of people worldwide. Epidemiologic data show that splenectomy is followed by infectious (sepsis) and non-infectious complications, with unknown mechanisms. In order to explore the role of the non-coding transcripts involved in these complications, we analysed a panel of circulating microRNAs (miRNAs), which were previously reported to be deregulated in sepsis, in the plasma of splenectomized patients. MiR-223 was overexpressed immediately and late after splenectomy, while miR-146a was overexpressed immediately after splenectomy, returning latter to basal levels; and miR-16, miR-93, miR-26a and miR-26b were overexpressed only late after splenectomy, suggesting similarities with sepsis. We also explored the non-coding (nc)RNome of circulating peripheral blood leucocytes by performing a ncRNA full genome profiling. We observed a reorganization of the ncRNoma after splenectomy, characterized by up-regulation of miRNAs and down-regulation of transcribed pyknons (T-PYKs). Pathway analysis revealed that deregulated miRNAs control pathways involved in immunity, cancer and endothelial growth. We checked the expression of the ncRNAs in 15 immune cell types from healthy donors and observed that plasma miRNAs, cellular miRNAs and T-PYKs have a cell-specific expression pattern and are abundant in different types of immune cells. These findings suggest that the ncRNAs potentially regulate the immune changes observed after splenectomy.

Laparoscopic Hartmann s Reversal: A Single Center Experience

Minimally invasive colorectal surgery showed multiple advantages in terms of morbidity, surgeons applied this approach to Hartmann reversal considering improving the reversal rate and postoperative outcome. The database from Fundeni Clinical Institute, General Surgery Department, was analyzed, selecting the laparoscopic Hartmann reversals. Nine cases were reported with a median age of 63 years, mean BMI 29 and three of them with prior open Hartmann surgery. The average operative time was 223 minutes, without any case necessitating ileostomy diversion. No anastomotic leakage was reported. The laparoscopic approach seems to be an attainable alternative in the reversal of Hartmann procedure, considering the experience of the surgical team and the patient's characteristics. Further studies are needed in order to confirm its superiority on larger case series.

D2 Lymphadenectomy for Gastric Adenocarcinoma: Long-term Results and the Impact of Surgeon Experience on the Survival Rates

Background: Surgery is the main component of the multimodality treatment of gastric cancer (GC). The present study aims to comparatively assess the early and long-term outcomes after D1 and D2 lymph node dissection. Furthermore, the impact of surgeon case-load on the long-term survival after D2 gastrectomies is also explored. Methods: A number of 773 patients with curative-intent surgery for GC adenocarcinoma (1997 - 2010: 325 patients with D1 lymphadenectomy, 448 patients with D2 lymphadenectomy) were included. Results: No statistically significant differences of overall morbidity rates were observed between the D1 and D2 groups of patients (16.3%for D1 group vs. 18.8% for D2 group, p = 0.39). However, statistically significant higher rates of post operative pancreatic fistulae rates were observed in the D2 group of patients (3.2% for D1 group vs. 7.9% for D2 group, p 0.001). Interestingly, statistically significant higher rates of mortality were observed for the D1 group of patients (8.9% for D1 group vs. 2.9% for D2 group, p 0.001). The 5-year survival rate was statistically significant higher in the D2 group of patients (median overall survival time of 18 months for D1 group vs. 60 months for D2 group, p 0.001). A statistically significant correlation (p=0.005, r=0.571) was observed between the overall survival time and the number of D2 lymphadenectomies performed by each surgeon. Conclusions: D2 lymph node dissection is associated with statistically significant improved longterm survivals at the expense of higher postoperative pancreatic fistulae rates, compared to D1 surgery. However, no increased mortality rates were observed in the D2 group of patients. D2 radical gastrectomies should be performed in high-volume centers by high case-load surgeons.

Recurrence rate of hepatocellular carcinoma in patients with treated hepatocellular carcinoma and hepatitis C virus-associated cirrhosis after ombitasvir/paritaprevir/ritonavir+dasabuvir+ribavirin therapy

Introduction

Recent studies have suggested a higher recurrence rate of hepatocellular carcinoma (HCC) in patients with a history of HCC and hepatitis C virus (HCV)-associated cirrhosis treated with direct-acting antiviral (DAA) agents.

Material and methods

We conducted a prospective analysis of 24 patients with HCV-associated cirrhosis and treated HCC who received ombitasvir/paritaprevir/ritonavir+dasabuvir+ribavirin for 12 weeks. Prior therapies for HCC included resection (9/24 patients), radiofrequency ablation (RFA) (7/24) and trans-arterial chemoembolization (TACE) (8/24). All patients were eligible for treatment if they had no HCC recurrence 6 months after their last procedure. A control group was defined. All patients were followed every 6 months, with dynamic computed tomography and/or magnetic resonance imaging.

Results

The sustained virological response rate per protocol was 21/24 (87.5%). The study group included 14 (59%) males, median age 64 years (51-77), 50% with associated non-alcoholic steatohepatitis and 24% with Child-Pugh A6 points. HCC recurrence rate/100 patient-years was lower in the DAA-HCC group versus control: 5.5 versus 24.6% patient-years for the resection+RFA group (p = 0.044), respectively, and 18.6 versus 72.7% patient-years for TACE group (p = 0.002). Survival without recurrence was higher in the resection+RFA group (45 compared to 18 months (p < 0.001)) and also in the TACE group (44 compared to 11.5 months (p = 0.002)).

Conclusions

DAA therapy significantly reduced the recurrence rate of HCC and improved survival without recurrence in patients with treated HCV-associated HCC.

Splenic Cysts: A Strong Indication for a Minimally Invasive Partial Splenectomy. Could the Splenic Hilar Vasculature Type Hold a Defining Role?

BACKGROUND

The aim of the study is to assess the impact of the splenic hilar vasculature configuration on the amount of remnant splenic parenchyma volume after partial splenectomy for splenic cysts.

METHODS

The data of all patients receiving a splenectomy for a splenic cyst from 2002 to 2016 at the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute were retrospectively reviewed. The size and location in the splenic parenchyma of the cyst and the splenic hilar vasculature type were assessed for each patient with a splenectomy.

RESULTS

Thirty-one patients with non-parasitic and 32 patients with hydatid cysts were recorded. In cases of centrally located cysts, a total splenectomy was performed for the majority of cases, while in peripheral cysts a spleen-preserving surgery was feasible for most of the patients (p = 0.001). The size of the cyst was significantly higher in the group of patients with a total splenectomy, compared with the group with a partial splenectomy (p = 0.003). In the subgroup with a distributed arterial pattern, preservation of more than 50% of the initial parenchyma was achieved in a significantly higher proportion of patients, compared with the subgroup of patients with a magistral pattern (p = 0.012).

CONCLUSION

Besides cyst size or peripheral location in the splenic parenchyma, the vascular pattern is also considered another decisive factor that associates with successful conservative or minimally invasive approach.

Smoking and Risk Factors in Deep Vein Thrombosis

The incidence of deep vein thrombosis (DVT) as diagnosed by the 125I fibrinogen test (125IFT) was determined in a series of 300 newly admitted medical and 201 surgical patients. 6 medical patients died before 125IFT screening could be completed. The incidence of DVT was l4% in medical patients and 18% in surgical patients. Increasing age, a malignant condition and a past history of thromboembolism all increased the risk of DVT. Increasing levels of cigarette smoking were found to be associated with a reduced incidence of DVT. Although statistical significance was achieved at only the 10% level for this finding it is in agreement with the results from studies on patients with myocardial infarction. The protective effect of cigarette smoking was observed at all ages, and in both medical and surgical patients.

An Attempt to Build a National Prospective Electronic Database for Pancreaticoduodenectomies in Romania - Preliminary Results of the First Year Enrollment

Introduction: National databases for pancreaticoduodenectomies (PD) have contributed to better postoperative outcomes after such complex surgical procedure because the multicentre collection of data allowed more reliable analyses with quality assessment and further improvement of technical issues and perioperative management. The current practice and outcomes after PD are poorly known in Romania because there was no national database for these patients. Thus, in 2016 a national-intent electronic registry for PD was proposed for all Romanian surgical centers. The study aims to present the preliminary results of this national-intent registry for PD after one-year enrollment. Patients Methods: The database was started on October 1st, 2016. Data were prospectively collected with an electronic online form including 102 items for each patient. The registry was opened to all the Departments of Surgery from Romania performing PD, with no restriction. Results: During the first year of enrollment were collected the data of 181 patients with PD performed by 24 surgeons from four surgical centers. The age of patients was 64 years (28 - 81 years), with slightly male predominance (61.3%). Computed tomography was the main preoperative imaging investigation (84.5%). All the PDs were performed by an open approach. The Whipple technique was used in 53% of patients, and a venous resection was required in 14.3% of cases. A posterior approach PD was considered in 16.6% of patients. The stomach was used to treat the distal remnant pancreas in 50.1% of patients. The operative time was 285 min (110 - 615 min), and the estimated blood loss was 400 ml (80 - 3000 ml). The overall morbidity rate was 55.8%, with severe (i.e., grade III-IV Dindo-Clavien) morbidity rate of 10%, and 3.9% in-hospital mortality rate. The overall pancreatic fistula, delayed gastric emptying and hemorrhage rates were 19.9%, 39.8% and 15.5%. Periampullary malignancies were the main indications for PD (78.9%), with pancreatic cancer on the top (48%). Conclusions: To build a prospective electronic online database for PD in Romania appears to be a feasible project and a useful tool to know the current practice and outcomes after PD in our country. However, improvements are still required to encourage a larger number of surgical centers to introduce the data of patients with PD.

Using microRNA Networks to Understand Cancer

Human cancers are characterized by deregulated expression of multiple microRNAs (miRNAs), involved in essential pathways that confer the malignant cells their tumorigenic potential. Each miRNA can regulate hundreds of messenger RNAs (mRNAs), while various miRNAs can control the same mRNA. Additionally, many miRNAs regulate and are regulated by other species of non-coding RNAs, such as circular RNAs (circRNAs) and long non-coding RNAs (lncRNAs). For this reason, it is extremely difficult to predict, study, and analyze the precise role of a single miRNA involved in human cancer, considering the complexity of its connections. Focusing on a single miRNA molecule represents a limited approach. Additional information could come from network analysis, which has become a common tool in the biological field to better understand molecular interactions. In this review, we focus on the main types of networks (monopartite, association networks and bipartite) used for analyzing biological data related to miRNA function. We briefly present the important steps to take when generating networks, illustrating the theory with published examples and with future perspectives of how this approach can help to better select miRNAs that can be therapeutically targeted in cancer.

Circulating miRNAs in sepsis-A network under attack: An in-silico prediction of the potential existence of miRNA sponges in sepsis

Biomarkers based on the molecular mechanism of sepsis are important for timely diagnosis and treatment. A large panel of small non-coding microRNAs was reported to modulate the immune response in sepsis but have not been tested in clinical practice. Large-scale identification of microRNA networks in sepsis might reveal a new biological mechanism that can be also targeted by gene therapy. Therefore, the main objective of this study is to perform a comparison of the miRNA network between septic patients and healthy controls. We used the previously measured levels of expression of 16 different circulating human and viral microRNAs in plasma from 99 septic patients and 53 healthy controls. We used three different computational methods to find correlations between the expressions of microRNAs and to build microRNA networks for the two categories, septic patients and healthy controls. We found that the microRNA network of the septic patients is significantly less connected when compared to miRNA network of the healthy controls (21 edges vs 52 edges, P < 0.0001). We hypothesize that several microRNAs (miR-16, miR-29a, miR-146, miR-155, and miR-182) are being sponged in sepsis explaining the loss of connection in the septic patient miRNA network. This was specific for sepsis, as it did not occur in other conditions characterized by an increased inflammatory response such as in post-surgery patients. Using several target prediction instruments, we predicted potential common sponges for the miRNA network in sepsis from several signaling pathways. Understanding the dynamics of miRNA network in sepsis is useful to explain the molecular pathophysiology of sepsis and for designing therapeutic strategies that target essential components of the immune response pathways.

From mobility to crosstalk. A model of intracellular miRNAs motion may explain the RNAs interaction mechanism on the basis of target subcellular localization

MicroRNAs (miRNAs), 22 nucleotides long molecules with the function to reduce gene expression by inhibiting mRNA translation through partial complementary to one or more messenger RNA (mRNA) molecules. A single miRNA can reduce the expression levels of hundreds of genes and one mRNA can be a target for many miRNAs. Despite the study models used so far, miRNAs and mRNAs cannot be seen as acting in an isolated manner or even "in pairs". They most likely exert their complex actions through numerous overlapping interrelations. One of the models depicting interdependence of intracytoplasmic RNAs is the crosstalk model. It is based on a competition between several target mRNAs which are regulated by the same miRNA. In this paper, we will discuss the mobility mechanism of miRNAs, recently suggested by data from "single particle tracking" experiments. These data suggests that miRNA intracellular mobility may be of "intermittent active transport"(IAT) type. IAT is a mobility model composed by alternation of active transport (AT) and Brownian motion (BM). Based on a mathematical model, we concluded that, AT phase may explain the efficiency in reaching far targets and the BM phase may explain the competition. Furthermore, we suggest that the interaction between miRNAs and their targets depends on the concentration of the molecules, the affinity between the molecules and also on the intracellular localization of the molecules. Hence, the probability that a miRNA interacts with its target depends also on the distance to the target and the macromolecular crowding. Taken together, our data proposes an intracytoplasmic mobility mechanism for miRNA and shows that this model can partially explain the RNA crosstalk.

Robotically performed total mesorectal excision for rectal cancer

BACKGROUND

Rectal cancer is an important health problem, due to the increasing number of new cases and the quality of life issues brought forth by surgical treatment in these patients.

AIM

The aim of the study was to analyse the results of robotic surgery in the treatment of lower and middle rectal cancer,locations in which TME is performed.

MATERIAL AND METHOD

Patients diagnosed with and operated on for rectal cancer by the means of robotic surgery between 2008-2012 at the Fundeni Clinical Institute were retrospectively analysed.

RESULTS

A number of 117 patients with rectal cancer were operated on by robotic surgery, of which 79 (67.52%) were submitted to total mesorectal excision (TME). The most frequently performed surgery was low anterior resection, followed by rectal amputation through abdominoperineal approach.Anastomosis fistula was observed in 9 (11.39%) patients. Local recurrence was encountered in 2 (2.53%) of the robotically performed surgeries.

CONCLUSIONS

1. Robotically assisted total mesorectal excision is feasible, safe and can be performed with a small number of complications and a low local recurrence rate; 2. The main advantages are oncological safety and quality of life; 3.Conversion to open surgery is rarely encountered; 4. Protection loop ileostomy existence allows avoiding reintervention in case anastomotic fistula occurs in patients with low anterior resection. 5. Robotic surgery may become gold standard in the surgical treatment of rectal cancer.

Key principles of miRNA involvement in human diseases

Although rapid progress in our understanding of the functions of miRNA has been made by experimentation and computational approach, a considerable effort still has to be done in determining the general principles that govern the miRNA's mode of action in human diseases. We will further discuss how these principles are being progressively approached by molecular studies, as well as the importance of miRNA in regulating different target genes and functions in specific biological contexts. There is a great demand to understand the principles of context - specific miRNA target recognition in order to design future experiments and models of normal developmental and disease states.

Potentiality of the "Gum Metal" titanium-based alloy for biomedical applications

In this study, the "Gum Metal" titanium-based alloy (Ti-23Nb-0.7Ta-2Zr-1.2O) was synthesized by melting and then characterized in order to evaluate its potential for biomedical applications. Thus, the mechanical properties, the corrosion resistance in simulated body fluid and the in vitro cell response were investigated. It was shown that this alloy presents a very high strength, a low Young's modulus and a high recoverable strain by comparison with the titanium alloys currently used in medicine. On the other hand, all electrochemical and corrosion parameters exhibited more favorable values showing a nobler behavior and negligible toxicity in comparison with the commercially pure Ti taken as reference. Furthermore, the biocompatibility tests showed that this alloy induced an excellent response of MC3T3-E1 pre-osteoblasts in terms of attachment, spreading, viability, proliferation and differentiation. Consequently, the "Gum Metal" titanium-based alloy processes useful characteristics for the manufacturing of highly biocompatible medical devices.

MicroRNAs and ceRNAs: therapeutic implications of RNA networks

INTRODUCTION

A new concept of gene regulation, in which competitive endogenous RNAs (ceRNAs) compete for common microRNAs (miRNAs), suggests that mRNA targets have an active role as key elements in the regulation of miRNA availability within cells. ceRNAs are considered to be natural decoys of miRNA activity and can influence the expression of multiple miRNAs.

AREAS COVERED

A new complex network of indirect interaction among the RNA transcripts competing for the same pool of miRNAs has been described; in this network, the nodes are the targets, and the links between the nodes are the miRNAs the targets have in common, which form smaller subnetworks. The incidence, state and severity of cancer can be evaluated on the basis of this network signature. The study of these new genome-scale regulatory networks involving miRNAs and ceRNAs may provide information that researchers can use to fine-tune these networks to improve responses to cancer therapy and/or develop new therapeutic interventions.

EXPERT OPINION

Combinational approaches based on complex regulatory ceRNA networks (ceRNETs) may be one of the most promising strategies for silencing important mediators of cancer-promoting pathways. Targeting a single miRNA may in fact represent a combined intervention that acts on the feedback and compensatory pathways that can impair treatment response or cause treatment resistance.

Benign cystic neoplasm and endocrine tumours of the pancreas--when and how to operate--an overview

BACKGROUND

The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard.

OBJECTIVES

To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate.

RESULTS

Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2-3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20% of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11%, pancreatic fistula in 33%. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33% pancreatic fistula and severe post-operative complications of 18% is related to management of proximal pancreatic stump. DPPHRt/s is used in 70% for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10% for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy.

CONCLUSION

The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.

Fractal-like kinetics of intracellular enzymatic reactions: a chemical framework of endotoxin tolerance and a possible non-specific contribution of macromolecular crowding to cross-tolerance

BACKGROUND

The response to endotoxin (LPS), and subsequent signal transduction lead to the production of cytokines such as tumor necrosis factor-α (TNF-α) by innate immune cells. Cells or organisms pretreated with endotoxin enter into a transient state of hyporesponsiveness, referred to as endotoxin tolerance (ET) which represents a particular case of negative preconditioning. Despite recent progress in understanding the molecular basis of ET, there is no consensus yet on the primary mechanism responsible for ET and for the more complex cases of cross tolerance. In this study, we examined the consequences of the macromolecular crowding (MMC) and of fractal-like kinetics (FLK) of intracellular enzymatic reactions on the LPS signaling machinery. We hypothesized that this particular type of enzyme kinetics may explain the development of ET phenomenon.

METHOD

Our aim in the present study was to characterize the chemical kinetics framework in ET and determine whether fractal-like kinetics explains, at least in part, ET. We developed an ordinary differential equations (ODE) mathematical model that took into account the links between the MMC and the LPS signaling machinery leading to ET. We proposed that the intracellular fractal environment (MMC) contributes to ET and developed two mathematical models of enzyme kinetics: one based on Kopelman's fractal-like kinetics framework and the other based on Savageau's power law model.

RESULTS

Kopelman's model provides a good image of the potential influence of a fractal intracellular environment (MMC) on ET. The Savageau power law model also partially explains ET. The computer simulations supported the hypothesis that MMC and FLK may play a role in ET.

CONCLUSION

The model highlights the links between the organization of the intracellular environment, MMC and the LPS signaling machinery leading to ET. Our FLK-based model does not minimize the role of the numerous negative regulatory factors. It simply draws attention to the fact that macromolecular crowding can contribute significantly to the induction of ET by imposing geometric constrains and a particular chemical kinetic for the intracellular reactions.

Robotic surgery for rectal cancer: a single center experience of 100 consecutive cases

BACKGROUND

Minimally invasive techniques have revolutionized the field of general surgery over the few last decades. Despite its advantages, in complex procedures such as rectal surgery, laparoscopy has not achieved a high penetration rate because of its steep learning curve, its relatively high conversion rate and technical challenges. The aim of this study was to present a single center experience with robotic surgery for rectal cancer focusing mainly on early and mid-term postoperative outcome.

METHODS

A series of 100 consecutive patients who underwent robotic rectal surgery between January 2008 and June 2012 was analyzed retrospectively in terms of demographics, pathological data, surgical and oncological outcomes.

RESULTS

Seventy-seven patients underwent robotic sphincter-saving resection, and 23 patients underwent robotic abdominoperineal resection. There were 4 conversions. The median operative time for sphincter-saving procedures was 180 min. The median time for robotic abdominoperineal resection was 160 min. The median distal resection margin of the operative specimen was 3 cm. The median number of retrieved lymph nodes was 14. The median hospital stay was 10 days. In-hospital mortality was nil. The overall morbidity was 30%. Four patients presented transitory postoperative urinary dysfunction. Severe erectile dysfunction was reported by 3 patients. The median length of follow-up was 24 months. The 3-year overall survival rate was 90%.

CONCLUSIONS

Robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). In rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field.

Surface characterization and biocompatibility of titanium alloys implanted with nitrogen by Hardion+ technology

In this study, the new Hardion+ micro-implanter technology was used to modify surface properties of biomedical pure titanium (CP-Ti) and Ti-6Al-4V ELI alloy by implantation of nitrogen ions. This process is based on the use of an electron cyclotron resonance ion source to produce a multienergetic ion beam from multicharged ions. After implantation, surface analysis methods revealed the formation of titanium nitride (TiN) on the substrate surfaces. An increase in superficial hardness and a significant reduction of friction coefficient were observed for both materials when compared to non-implanted samples. Better corrosion resistance and a significant decrease in ion release rates were observed for N-implanted biomaterials due to the formation of the protective TiN layer on their surfaces. In vitro tests performed on human fetal osteoblasts indicated that the cytocompatibility of N-implanted CP-Ti and Ti-6Al-4V alloy was enhanced in comparison to that of the corresponding non treated samples. Consequently, Hardion+ implantation technique can provide titanium alloys with better qualities in terms of corrosion resistance, cell proliferation, adhesion and viability.

A clinical case of Fournier gangrene

OBJECTIVE

To present a case of Fournier gangrene and the specific surgical therapy

CASE PRESENTATION

A 71-year old patient with a two days history of pain in the perineal region, swelling, developing necrosis and foul-smelling lesions was examined in emergency settings. The swelling of subcutaneous plane involved the flank regions, mainly on the left side. The investigations were performed (full blood count, blood urea, electrolytes, coagulation profile). A Fournier gangrene was diagnosed and surgery performed under general anesthesia. Broad spectrum antibiotics were given concomitantly. The first surgical procedure consisted in surgical debridement and excision of all the necrotic tissue. Cultures were taken. We performed counter incisions bilaterally on both flanks. The communication through the fascial planes was clearly demonstrated, especially on the left side. A loop colostomy was also performed. Multiple re-excisions were further employed. Due to a precarious evolution, the patient were on mechanical ventilation for 13 days. Inotrope medication was given for a total of 19 days and, the antibiotherapy adapted to the antibiogram (Bacterioides eggerthii was identified). The reconstruction of the perineum was later performed and, after 3 months, the colostomy was closed in good conditions without further complications.

CONCLUSION

Early recognition and aggressive surgical excision are mandatory for success in patients with Fournier gangrene. Colonic diversion can be very useful if employed from the beginning.

Robotic surgery of locally advanced gastric cancer: a single-surgeon experience of 41 cases

The mainstay of curative gastric cancer treatment is open gastric resection with regional lymph node dissection. Minimally invasive surgery is yet to become an established technique with a well defined role. Robotic surgery has by-passed some of the limitations of conventional laparoscopy and has proven both safe and feasible. We present our initial experience with robotic surgery based on 41 gastric cancer patients. We especially wish to underline the advantages of the robotic system when performing the digestive tract anastomoses. We present the techniques of end-to-side eso-jejunoanastomoses (using a circular stapler or manual suture) and side-to-side eso-jejunoanastomoses. In our hands, the results with circular stapled anastomoses were good and we advocate against manual suturing when performing anastomoses in robotic surgery. Moreover, we recommend performing totally intracorporeal anastomoses which have a better post-operative outcome, especially in obese patients. We present three methods of realising the total intracorporeal eso-jejuno-anastomosis with a circular stapler: manual purse-string suture, using the OrVil and the double stapling technique. The eso-jejunoanastomosis is one of the most difficult steps in performing the total gastrectomy, but these techniques allow the surgeon to choose the best option for each case. We consider that surgeons who undertake total gastrectomies must have a special training in performing these anastomoses.