Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

The MIS-COVID-AGICT Study: Trend of Minimally Invasive Surgery for Gastrointestinal Cancer Treatment During the First Waves of the COVID-19 Pandemic in Italy. Subgroup Analysis from the COVID-AGICT Study: COVID-19 and Advanced Gastrointestinal Cancer Surgical Treatment

Background: A preliminary analysis from the COVID-Advanced Gastrointestinal Cancer Surgical Treatment (AGICT) study showed that the rate of minimally invasive surgery (MIS) for elective and urgent procedures did not decrease during the pandemic year. In this article, we aimed to perform a subgroup analysis using data from the COVID-AGICT study to evaluate the trend of MIS during the COVID-19 pandemic period in Italy. Methods: This study was conducted collecting data of MIS patients from the COVID-AGICT database. The primary endpoint was to demonstrate whether the SARS-CoV-2 pandemic scenario reduced MIS for elective treatment of gastrointestinal cancer (GIC) in Italy in 2020. The secondary endpoint was to evaluate the impact of the pandemic period on perioperative outcomes in the MIS group. Results: In the pandemic year, 62% of patients underwent surgery with a minimally invasive approach, compared to 63% in 2019 (P = .23). In 2020, the proportion of patients undergoing elective MIS decreased compared to the previous year (80% versus 82%, P = .04), and the rate of urgent MIS did not differ between the 2 years (31% and 33% in 2019 and 2020 - P = .66). Colorectal cancer was less likely to be treated with MIS approach during 2020 (78% versus 75%, P < .001). Conversely, the rate of MIS pancreatic resection was higher in 2020 (28% versus 22%, P < .002). Conversion to an open approach was lower in 2020 (7.2% versus 9.2% - P = .01). Major postoperative complications were similar in both years (11% versus 11%, P = .9). Conclusion: In conclusion, although MIS for elective treatment of GIC in Italy was reduced during the COVID-19 pandemic period, our study revealed that the overall proportion of MIS (elective and urgent) and postoperative outcomes were comparable to the prepandemic period. ClinicalTrial.gov (NCT04686747).

The COVID - AGICT study: COVID-19 and advanced gastro-intestinal cancer surgical treatment. A multicentric Italian study on the SARS-CoV-2 pandemic impact on gastro-intestinal cancers surgical treatment during the 2020. Analysis of perioperative and short-term oncological outcomes

BACKGROUND

This Italian multicentric retrospective study aimed to investigate the possible changes in outcomes of patients undergoing surgery for gastrointestinal cancers during the COVID-19 pandemic.

METHOD

Our primary endpoint was to determine whether the pandemic scenario increased the rate of patients with colorectal, gastroesophageal, and pancreatic cancers resected at an advanced stage in 2020 compared to 2019. Considering different cancer staging systems, we divided tumors into early stages and advanced stages, using pathological outcomes. Furthermore, to assess the impact of the COVID-19 pandemic on surgical outcomes, perioperative data of both 2020 and 2019 were also examined.

RESULTS

Overall, a total of 8250 patients, 4370 (53%) and 3880 (47%) were surgically treated during 2019 and 2020 respectively, in 62 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (P = 0.25). Nevertheless, the analysis of quarters revealed that in the second half of 2020 the rate of advanced cancer resected, tented to be higher compared with the same months of 2019 (P = 0.05). During the pandemic year 'Charlson Comorbidity Index score of cancer patients (5.38 ± 2.08 vs 5.28 ± 2.22, P = 0.036), neoadjuvant treatments (23.9% vs. 19.5%, P < 0.001), rate of urgent diagnosis (24.2% vs 20.3%, P < 0.001), colorectal cancer urgent resection (9.4% vs. 7.37, P < 0.001), and the rate of positive nodes on the total nodes resected per surgery increased significantly (7 vs 9% - 2.02 ± 4.21 vs 2.39 ± 5.23, P < 0.001).

CONCLUSIONS

Although the SARS-CoV-2 pandemic did not influence the pathological stage of colorectal, gastroesophageal, and pancreatic cancers at the time of surgery, our study revealed that the pandemic scenario negatively impacted on several perioperative and post-operative outcomes.

Validation of a Lumped Parameter Model of the Battery Thermal Management System of a Hybrid Train by Means of Ultrasonic Clamp-On Flow Sensor Measurements and Hydronic Optimization

Electrification of the field of transport is one of the key elements needed to reach the targets of greenhouse gas emissions reduction and carbon neutrality planned by the European Green Deal. In the railway sector, the hybrid powertrain solution (diesel-electric) is emerging, especially for non-electrified lines. Electric components, especially battery power systems, need an efficient thermal management system that guarantees the batteries will work within specific temperature ranges and a thermal uniformity between the modules. Therefore, a hydronic balancing needs to be realized between the parallel branches that supply the battery modules, which is often realized by introducing pressure losses in the system. In this paper, a thermal management system for battery modules (BTMS) of a hybrid train has been studied experimentally, to analyze the flow rates in each branch and the pressure losses. Since many branches of this system are built inside the battery box of the hybrid train, flow rate measurements have been conducted by means of an ultrasonic clamp-on flow sensor because of its minimal invasiveness and its ability to be quickly installed without modifying the system layout. Experimental data of flow rate and pressure drop have then been used to validate a lumped parameter model of the system, realized in the Simcenter AMESim^® environment. This tool has then been used to find the hydronic balancing condition among all the battery modules; two solutions have been proposed, and a comparison in terms of overall power saved due to the reduction in pressure losses has been performed.

Impact of operation duration on postoperative outcomes of minimally-invasive right colectomy

AIM

Operation time (OT) is a key operational factor influencing surgical outcomes. The present study aimed to analyse whether OT impacts on short-term outcomes of minimally-invasive right colectomies by assessing the role of surgical approach (robotic [RRC] or laparoscopic right colectomy [LRC]), and type of ileocolic anastomosis (i.e., intracorporal [IA] or extra-corporal anastomosis [EA]).

METHODS

This was a retrospective analysis of the Minimally-invasivE surgery for oncological Right ColectomY (MERCY) Study Group database, which included adult patients with nonmetastatic right colon adenocarcinoma operated on by oncological RRC or LRC between January 2014 and December 2020. Univariate and multivariate analyses were used.

RESULTS

The study sample was composed of 1549 patients who were divided into three groups according to the OT quartiles: (1) First quartile, <135 min (n = 386); (2) Second and third quartiles, 135-199 min (n = 731); and (3) Fourth quartile ≥200 min (n = 432). The majority (62.7%) were LRC-EA, followed by LRC-IA (24.3%), RRC-IA (11.1%), and RRC-EA (1.9%). Independent predictors of an OT ≥ 200 min included male gender, age, obesity, diabetes, use of indocyanine green fluorescence, and IA confection. An OT ≥ 200 min was significantly associated with an increased risk of postoperative noninfective complications (AOR: 1.56; 95% CI: 1.15-2.13; p = 0.004), whereas the surgical approach and the type of anastomosis had no impact on postoperative morbidity.

CONCLUSION

Prolonged OT is independently associated with increased odds of postoperative noninfective complications in oncological minimally-invasive right colectomy.

Surgical management of acute diverticulitis. An update based on our experience and literature data

BACKGROUND

The treatment of acute diverticulitis is a matter of debate and has undergone significant changes. Currently the main focus of surgical treatment is a more conservative and less invasive management.

AIMS AND METHODS

To focus the role of surgery in the treatment of acute diverticulitis, the Authors have conducted a review of the literature of the last two decades and have revised critically their own experience.

RESULTS

The indications for elective surgery based on the number of episodes, the young age at diagnosis and the presence of risk factors such as immunosuppression, have to be overcome in favour of a more individual approach based on the severity of the disease. Similarly the presence of pneumoperitoneum is no longer a compelling indication for urgent surgery just as it was in the past. In the treatment of complicated diverticulitis with abscess (Hinchey I-II) is used more and more conservative treatments consisting of guided percutaneous drainage combined with antibiotics. Resection with primary anastomosis with or without diverting ileostomy is preferable to Hartmann's procedure in case of perforated diverticulitis with peritonitis (Hinchey III-IV), using the latter only in the case of comorbidities, severe sepsis, hemodynamic instability or longtime feculent peritonitis (Hinchey IV). Recently, laparoscopic peritoneal lavage was introduced in the treatment of diverticulitis.

CONCLUSIONS

Thanks to the progress made in conservative and interventional treatment and laparoscopic surgery, an increasingly less invasive treatment is proposed in the management of acute diverticulitis.

KEY WORDS

Acute diverticulitis, Laparoscopic surgery, Surgical treatment.

Molecular characterization of an inhibitor of NF-κB in the scallop Argopecten purpuratus: First insights into its role on antimicrobial peptide regulation in a mollusk

Inhibitors of nuclear factor kappa B (IκBs) are major control components of the Rel/NF-κB signaling pathway, a key regulator in the modulation of the expression of immune-related genes in vertebrates and invertebrates. The activation of the Rel/NF-κB signaling pathway depends largely in the degradation of IκB proteins and thus, IκBs are a main target for the identification of genes whose expression is controlled by Rel/NF-κB pathway. In order to identify such regulation in bivalve mollusks, the cDNA sequence encoding an IκB protein was characterized in the scallop Argopecten purpuratus, ApIκB. The cDNA sequence of ApIκB is comprised of 1480 nucleotides with a 1086 bp open reading frame encoding for 362 amino acids. Bioinformatics analysis showed that ApIκB displays the conserved features of IκB proteins. The deduced amino acid sequence consists of a 39.7 kDa protein, which has an N-terminal degradation motif, six ankyrin repeats and a C-terminal phosphorylation site motif. Phylogenetic analysis revealed a high degree of identity between ApIκB and other IκBs from mollusks, but also to arthropod cactus proteins and vertebrate IκBs. Tissue expression analysis indicated that ApIκB is expressed in all examined tissues and it is upregulated in circulating hemocytes from scallops challenged with the pathogenic Gram-negative bacterium Vibrio splendidus. After inhibiting ApIκB gene expression using the RNA interference technology, the gene expression of the antimicrobial peptide big defensin was upregulated in hemocytes from non-challenged scallops. Results suggest that ApIκB may control the expression of antimicrobial effectors such as big defensin via a putative Rel/NF-κB signaling pathway. This first evidence will help to deepen the knowledge of the Rel/NF-κB conserved pathway in scallops.

Real-time digital control of optical interferometers by the mechanical-modulation technique

We discuss the application of digital systems to the automatic control of dual-wave optical interferometers. We show that, if the mechanical-modulation technique is used for error-signal extraction, digital techniques can be used both for error-signal extraction and for control-signal generation. Therefore, apart from two front/end amplifiers that are necessary to match the dynamics of the detectors and actuators to the dynamics of the analog-to-digital converters and digital-to-analog converters, no other analog devices are required. In particular, the mechanical-modulation technique requires the synchronous demodulation of the photodiode output signal. Hence we need to implement a digital lock-in amplifier whose algorithm is described here. Finally, we describe one of the possible applications of this digital control procedure, such as the control of a classic Mach-Zehnder interferometer in air.

Fringe-counting technique used to lock a suspended interferometer

We implement a digital fringe-counting technique to measure in real time the relative mirror displacement of a suspended Michelson interferometer with modulated optical path length for oscillations much larger than the laser wavelength (λ). This provides the proper error signal for a servo mechanism that reduces the relative displacement within λ/2. The implemented technique does not require extra optics or polarizers and thus can be used for interferometric gravitational wave detectors as a starting procedure to get the system locked.