Search

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

Elective diverting ileostomy may reduce consequences of anastomotic leakage after laparoscopic total mesorectal excision (L-TME); however, its safety is debated because of morbidity related to stoma creation and closure. We aimed to investigate the impact of diverting ileostomy on clinical behavior of anastomotic leakage and complications related to stoma itself.We retrospectively evaluated 150 L-TMEs with (Group 1, 100 patients) or without (Group 2, 50 patients) elective ileostomy for rectal cancer.Overall anastomotic fistula rate was 26% without significant differences between the two groups (28% in the Group 1 and 22% in the Group 2, respectively). In all the series, NAD was significantly associated with higher risk of postoperative complications (OR=2.14, p=0.02). In Group 2, NAD particularly increased the risk of anastomotic fistula (OR=6.6, p=0.014). Instead, patients of Group 1 showed higher odd of post-operative complications (OR: 3.8; CI 95%: 1.8483-8.0492; p = 0.0003) and notably 79 (79%) developed complications related to the ileostomy itself (hydroelectrolytic, metabolic and peristomal skin disorders). Moreover, thirty-two (32%) ileostomies were never reversed; among the reversed patients, 27 (39.7%) developed at least one postoperative complication and in 9 (33.3%) cases an urgent re-intervention was needed.Diverting ileostomy may mitigate clinical behavior of anastomotic leakage after L-TME. However, there is non-negligible morbidity of stoma creation and closure.Diverting ileostomy should be selectively considered in higher risk patients as those who received NAD.Anastomotic leakage, Ileostomy, Rectal cancer.Il reale ruolo protettivo della ileostomia derivativa in chirurgia laparoscopica del retto è ancora controverso. L’ileostomia derivativa può mitigare le manifestazioni cliniche della deiscenza anastomotiche ma non ne riduce l’incidenza. Inoltre, la non trascurabile incidenza di complicanze legate alla presenza della stessa ileostomia ed alla procedura di ricanalizzazione comportano la necessità di una attenta selezione dei pazienti per i quali il confezionamento di una stomia di protezione è realmente vantaggioso. Obiettivo di questo studio è quello di investigare l’impatto dell’ileostomia derivativa sugli effetti della deiscenza anastomotica e sulla morbilità legata alla stomia stessa. Sono stati analizzati retrospettivamente 150 pazienti con cancro del retto che sottoposti a TOTAL MESORECTAL EXCISION LAPAROSCOPICA (TME-L) con (Gruppo 1, 100 pazienti) o senza (Gruppo 2, 50 pazienti) ileostomia elettiva per cancro del retto dal 2012 al 2017 presso l’Università Campus Bio-Medico di Roma. Di questi due gruppi sono state analizzate le caratteristiche demografiche (età, sesso, punteggio dell’American Society of Anesthesiologists (ASA), indice di massa corporea (BMI)), le dimensione e la localizzazione del tumore, i trattamenti neoadiuvanti (NAD), la tecnica operatoria, complicanze della chirurgia primaria, durata della degenza, e complicanze correlate all’ileostomia. La percentuale complessiva di fistole anastomotiche è stata del 26% senza differenze significative tra i due gruppi (28% nel Gruppo 1 e 22% nel Gruppo 2). In entrambi i gruppi, il trattamento neoadiuvante era significativamente associato a un rischio più elevato di complicanze postoperatorie (OR = 2,14, p = 0,02). Nel Gruppo 2, la NAD ha aumentato in modo particolare il rischio di fistole anastomotiche (OR = 6,6, p = 0,014). Invece, i pazienti del Gruppo 1 hanno mostrato una maggiore probabilità di complicanze post-operatorie dopo resezione anteriore del retto laparoscopica (OR: 3,8; CI 95%: 1,8483-8,0492; p = 0,0003) e in particolare 79 (79%) hanno sviluppato complicanze correlate a l’ileostomia stessa (disturbi della cute peristomale, squilibri idroelettrolitici e metabolici). Inoltre, trentadue (32%) ileostomie non sono mai state ri-canalizzate; tra i pazienti ri-canalizzati, 27 (39,7%) hanno sviluppato almeno una complicanza postoperatoria e in 9 (33,3%) casi è stato necessario un re-intervento urgente. Il confezionamento dell’ileostomia può mitigare il comportamento clinico della deiscenza anastomotica dopo TME-L. Tuttavia, a causa della morbilità non trascurabile relativa alla presenza stessa della stomia ed alla sua ricanalizzazione, il confezionamento di una ileostomia derivativa dovrebbe essere considerato selettivamente nei pazienti a rischio più elevato come ad esempio coloro i quali hanno ricevuto una radio-chemioterapia neoadiuvante.

Introduction: Postoperative pancreatic fistula (POPF) is the most dreaded complication after distal pancreatectomy (DP). This multicenter randomized trial evaluated the efficacy, safety, and tolerance of Hemopatch in preventing clinically relevant (grades B/C according to the ISGPS classification) POPF after DP. Material and methods: After stump closure, patients were randomized to affix Hemopatch to the stump or not. Statistical significance was set at 0.025. Clinical significance was defined as the number of patients needed to treat (NNT) to avoid 1 B/C POPF. Results: Of 631 eligible patients, 360 were randomized and 315 analyzed per protocol (155 in the standard closure group; 160 in the Hemopatch group). The rates of B/C POPF (the primary endpoint) were 23.2% and 16.3% (P = 0.120), while the number of patients with 1 or more complications (including patients with B/C POPF) was 34.8% and 24.4% (P = 0.049) in the standard and Hemopatch groups, respectively. In patients with hand-sewn stump and main duct closure, the rates were 26.2% versus 10.0% (P = 0.014) and 23.3% versus 7.7% (P = 0.015) in the standard and Hemopatch groups, respectively. The NNT in these 2 subgroups was 6 and 6.4, respectively. Conclusion: The results of the first randomized trial evaluating Hemopatch-reinforced pancreatic stump after DP to prevent type B/C POPF do not allow us to conclude that the risk of B/C POPF was lower. Based on the NNT, however, routine use of Hemopatch after DP may result in fewer complications (including POPF) overall, especially in cases with hand-sewn closure of the pancreatic stump or main pancreatic duct. © 2021 BMJ Publishing Group. All rights reserved.

To understand constellations of subversion in art, it is essential to differentiate central terms and concepts on the fields of the political, the media, and the public. What is our concept of the political, of power, of critique, and of change? What are media and what is their importance? How does the public react to art and to specific works in different contexts? (2) Then, we have to conceptualize subversion and to make this term operational. To do so, we will develop a complex system of what the subversive is, based on a discourse-analytical approach (3). Ideally, both steps will help us to get a notion of what subversion studies could be and of how specific case studies could be analyzed productively (4).