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1. Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trialResearch in context

Author

Maarten Korrel, Leia R. Jones, Jony van Hilst, Gianpaolo Balzano, Bergthor Björnsson, Ugo Boggi, Svein Olav Bratlie, Olivier R. Busch, Giovanni Butturini, Giovanni Capretti, Riccardo Casadei, Bjørn Edwin, Anouk M.L.H. Emmen, Alessandro Esposito, Massimo Falconi, Bas Groot Koerkamp, Tobias Keck, Ruben H.J. de Kleine, Dyre B. Kleive, Arto Kokkola, Daan J. Lips, Sanne Lof, Misha D.P. Luyer, Alberto Manzoni, Ravi Marudanayagam, Matteo de Pastena, Nicolò Pecorelli, John N. Primrose, Claudio Ricci, Roberto Salvia, Per Sandström, Frederique L.I.M. Vissers, Ulrich F. Wellner, Alessandro Zerbi, Marcel G.W. Dijkgraaf, Marc G. Besselink, Mohammad Abu Hilal, Adnan Alseidi, Constanza Aquilano, Johanna Arola, Denise Bianchi, Rachel Brown, Daniela Campani, Joanne ChinAleong, Jerome Cros, Lyubomira Dimitrova, Claudio Doglioni, Safi Dokmak, Russell Dorer, Michael Doukas, Jean Michel Fabre, Giovanni Ferrari, Viacheslay Grinevich, Stefano Gobbo, Thilo Hackert, Marius van den Heuvel, Clement Huijsentruijt, Mar Iglesias, Casper Jansen, Igor Khatkov, David Kooby, Marco Lena, Claudio Luchini, Krishna Menon, Patrick Michenet, Quintus Molenaar, Anna Nedkova, Andrea Pietrabissa, Mihaela Raicu, Rushda Rajak, Branislava Rankovic, Aniko Rendek, Benjamin Riviere, Antonio Sa Cunha, Olivier Saint Marc, Patricia Sanchez Velazquez, Donatella Santini, Aldo Scarpa, Mylene Sebagh, Donald Sears, Mihir Shah, Zahir Soonawalla, Paola Spaggiari, Lars Tharun, Tore Tholfsen, Ales Tomazic, Alessandro Vanoli, Caroline Verbeke, Joanne Verheij, Moritz Von Winterfeld, Roeland de Wilde, Vincent Yip, and Yoh Zen

Subjects
Distal pancreatectomy, Pancreatic ductal adenocarcinoma, Minimally invasive surgery, Public aspects of medicine, RA1-1270
Abstract

Summary: Background: The oncological safety of minimally invasive surgery has been questioned for several abdominal cancers. Concerns also exist regarding the use of minimally invasive distal pancreatectomy (MIDP) in patients with resectable pancreatic cancer as randomised trials are lacking. Methods: In this international randomised non-inferiority trial, we recruited adults with resectable pancreatic cancer from 35 centres in 12 countries. Patients were randomly assigned to either MIDP (laparoscopic or robotic) or open distal pancreatectomy (ODP). Both patients and pathologists were blinded to the assigned approach. Primary endpoint was radical resection (R0, ≥1 mm free margin) in patients who had ultimately undergone resection. Analyses for the primary endpoint were by modified intention-to-treat, excluding patients with missing data on primary endpoint. The pre-defined non-inferiority margin of −7% was compared with the lower limit of the two-sided 90% confidence interval (CI) of absolute difference in the primary endpoint. This trial is registered with the ISRCTN registry (ISRCTN44897265). Findings: Between May 8, 2018 and May 7, 2021, 258 patients were randomly assigned to MIDP (131 patients) or ODP (127 patients). Modified intention-to-treat analysis included 114 patients in the MIDP group and 110 patients in the ODP group. An R0 resection occurred in 83 (73%) patients in the MIDP group and in 76 (69%) patients in the ODP group (difference 3.7%, 90% CI −6.2 to 13.6%; pnon-inferiority = 0.039). Median lymph node yield was comparable (22.0 [16.0–30.0] vs 23.0 [14.0–32.0] nodes, p = 0.86), as was the rate of intraperitoneal recurrence (41% vs 38%, p = 0.45). Median follow-up was 23.5 (interquartile range 17.0–30.0) months. Other postoperative outcomes were comparable, including median time to functional recovery (5 [95% CI 4.5–5.5] vs 5 [95% CI 4.7–5.3] days; p = 0.22) and overall survival (HR 0.99, 95% CI 0.67–1.46, p = 0.94). Serious adverse events were reported in 23 (18%) of 131 patients in the MIDP group vs 28 (22%) of 127 patients in the ODP group. Interpretation: This trial provides evidence on the non-inferiority of MIDP compared to ODP regarding radical resection rates in patients with resectable pancreatic cancer. The present findings support the applicability of minimally invasive surgery in patients with resectable left-sided pancreatic cancer. Funding: Medtronic Covidien AG, Johnson & Johnson Medical Limited, Dutch Gastroenterology Society.

Published
2023
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2. Clinical nutrition in surgical oncology: Young AIOM-AIRO-SICO multidisciplinary national survey on behalf of NutriOnc research group

Author

Luigi Marano, Federica Marmorino, Isacco Desideri, Ludovico Carbone, Alessandro Rizzo, Viola Salvestrini, Franco Roviello, Saverio Cinieri, Vittorio Donato, Raffaele De Luca, NutriOnc Research Group, Silvia Sofia, Marco Milone, Benedetto Ielpo, Maria Teresa Mita, Silvia Ministrini, Mario Giuffrida, Roberta Tutino, Caterina Baldi, Giampaolo Perri, Anna Stella Lippolis, Chiara Marafante, Giusy Giannandrea, Marco Vito Marino, Letizia Laface, Salomone Di Saverio, Luca Aldrighetti, Nicola de’Angelis, Nick Salimian, Marco Caricato, Gianluca Pellino, Sara Vertaldi, Federica Cipriani, Gabriella Teresa Capolupo, Antonio Costanzo, Letizia Santandrea, Gaetano Gallo, Andrea Belli, Laura Mastrangelo, Fausto Rosa, Nicolò Pecorelli, Graziella Marino, Alessio Giordano, Nicola Cillara, Maria Lemma, Francesco Pata, Federico Cammillini, Gianmario Edoardo Poto, Giulia Grassi, Donato Francesco Altomare, Arcangelo Picciariello, Lorenzo Petagna, Luca Ippolito, Elio Treppiedi, Daniele Delogu, Abdallah Moukachar, Stefano Granieri, Giuseppe Cuticone, Osvaldo Carpineto Samorani, Daniela Rega, Leonardo Solaini, Stefano de Pascale, Francesca Ascari, Michele Manigrasso, Simona Badalucco, Salvatore Paiella, Sara Coppola, Roberta Iadarola, Giovanna Di Meo, Isacco Montroni, Fabio Vistoli, Valentina Ferraro, Edoardo Saladino, Federico Fazio, Roberta Rota, Francesco Orlando, Simone Famularo, Cinzia Bizzoca, Giorgio Dalmonte, Marco Inama, Luigi Verre, Leandro Siragusa, Casoni Pattacini Gianmaria, Michele Benedetti, Nicolò Tamini, Cristian Conti, Giorgio Ammerata, Serena Mantova, Vito Leonardo Pinto, Arianna Corvasce, Giorgio Micheletti, Teresa Perra, Marco Pellicciaro, Marco Materazzo, Michele Zuolo, Emanuele Doria, Antonio Brillantino, Luca Del Prete, Andrea Muratore, Claudio Luciani, Giulia Turri, Fabio Casciani, Giuliani Giuseppe, Graziana Barile, Oldrà Gaia, Valeria Restaino, Simona Deidda, Michele Ammendola, Andrea Fares Bucci, Patrizia Marsanic, Dario Cassetti, Luca Resca, Daniele Fusario, Eleonora Andreucci, Anna Michelotti, Brunella Amoruso, Isabella Franco, Laura Noto, Andrea Spallanzani, Raimondo Calogero Scalia, Teresa Del Giudice, Valeria Merz, Gianmarco Motta, Alessandro Parisi, Mikol Modesti, Antonella Argentiero, Debora Basile, Gianmarco Vannini, Carlotta Ottanelli, Salvatore Corallo, Eufemia Stefania Lutrino, Daniele Rossini, Federica Morano, Luigia Stefania Stucci, Costanza Winchler, Martina Catalano, Andrea Marini, Giuseppe Brisinda, Enrico Sammarco, Martina Carullo, Giandomenico Roviello, Mirko Barone, Maria Grazia Rodriquenz, Giuseppe Tirino, Alessia Amoruso, Anna Russo, Veronica Conca, Laura Orgiano, Sveva Macrini, Giulia Nazzicone, Maria Bensi, Martina Montesano, Emanuela Dell’Aquila, Andrea Sbrana, Beatrice Borelli, Lorenzo Fornaro, Lucrezia Raimondi, Valeria Zurlo, Mattia Garutti, Elena Ongaro, Arianna Pellegrino, Andrea lanese, Laura Bernardini, Alessandra Boccaccino, Patrizia Farina, Federica Buzzacchino, Angelica Petrillo, Ada Taravella, Vittorio Studiale, Paolo Ciracì, Giovanna Lovino, Dora Di Cosmo, Sabrina Montrone, Fabiana Gregucci, Luca Dominici, Alba Fiorentino, Filippo Carannante, Giambattista Siepe, Giampaolo Montesi, Manuele Roghi, Michele Aquilano, Andrea Romei, Ilaria Bonaparte, Roberta Grassi, Emma D’Ippolito, Giulio Frosini, Giuseppina De Marco, Gennaro Giovine, Chiara Mattioli, Ilaria Morelli, Victoria Lorenzetti, Matteo Mariotti, Carolina Orsatti, Vincenzo Troncone, Lorenzo Livi, Antonio Angrisani, Marco Banini, Teresa Di Pietro, Giuseppe Carlo Iorio, Iacopo Cavallo, Cecilia Cerbai, Valerio Nardone, Francesca De Felice, Consuelo Rosa, Giulia Stocchi, Sara Lucidi, Michele Ganovelli, Damiano Dei, Chiara Cascone, Anna Peru, Luisa Caprara, Lucia Angelini, Luca Visani, Giulio Francolini, Beatrice Bettazzi, Francesco Belia, Virginia Boccardi, Simone Serafini, Vincenzo Bottino, Luca Ferrario, Giuseppe Frazzetta, Felice Pirozzi, Gennaro Martines, Francesco Antonio Ciarleglio, Daniele Indiani, Giuliano Barugola, Luca Mazza, and Chiara Guarini

Subjects
clinical nutrition, cancer, malnutrition, nutritional assessment, survey, Nutrition. Foods and food supply, TX341-641
Abstract

Malnutrition is a common condition in cancer patients which is usually associated with functional limitations, as well as increased morbidity and mortality. Based on the support of the young sections of Italian Association of Medical Oncology (AIOM), Italian Association of Radiotherapy and Clinical Oncology (AIRO) and Italian Society of Surgical Oncology (SICO) merged into the NutriOnc Research Group, we performed a multidisciplinary national survey with the aim to define the awareness of nutritional issues among healthcare professionals delivering anticancer care. The questionnaire was organized in four sections, as follows: Knowledge and practices regarding Nutritional Management of cancer patients; Timing of screening and assessment of Nutritional Status; Nutritional Treatment and prescription criteria; Immunonutrition and educational topics. The modules focused on esophagogastric, hepato-bilio-pancreatic and colorectal malignancies. Overall, 215 physicians completed the survey. As regards the management of Nutritional Status of cancer patients, many responders adopted the ERAS program (49.3%), while a consistent number of professionals did not follow a specific validated nutritional care protocol (41.8%), mainly due to lack of educational courses (14.5%) and financial support (15.3%). Nearly all the included institutions had a multidisciplinary team (92%) to finalize the treatment decision-making. Cancer patients routinely underwent nutritional screening according to 57.2% of interviewed physicians. The timing of nutritional assessment was at diagnosis (37.8%), before surgery (25.9%), after surgery (16.7%), before radiochemotherapy (13.5%) and after radiochemotherapy (7%). Most of the responders reported that nutritional status was assessed throughout the duration of cancer treatments (55.6%). An important gap between current delivery and need of nutritional assessment persists. The development of specific and defined care protocols and the adherence to these tools may be the key to improving nutritional support management in clinical practice.

Published
2023
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3. ERAS with or without supplemental artificial nutrition in open pancreatoduodenectomy for cancer. A multicenter, randomized, open labeled trial (RASTA study protocol)

Author

Luca Gianotti, Salvatore Paiella, Isabella Frigerio, Nicolò Pecorelli, Giovanni Capretti, Marta Sandini, and Davide Paolo Bernasconi

Subjects
ERAS, artificial nutrition, outcome, pancreatoduodenectomy, complication, randomized controlled trial, Nutrition. Foods and food supply, TX341-641
Abstract

PurposeThe role of supplemental artificial nutrition in patients perioperatively treated according to enhanced recovery programs (ERAS) on surgery-related morbidity is not known. Therefore, there is a need of a clinical trials specifically designed to explore whether given a full nutritional requirement by parenteral feeding after surgery coupled with oral food “at will” compared to oral food “at will” alone, within an established ERAS program, could achieve a reduction of the morbidity burden.Materials and analysisRASTA will be a multicenter, randomized, parallel-arm, open labeled, superiority trial. The trial will be conducted in five Italian Institutions with proven experience in pancreatic surgery and already applying an established ERAS program. Adult patients (age ≥ 18 and

Published
2023
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4. Prognosis of Upfront Surgery for Pancreatic Cancer: A Systematic Review and Meta-Analysis of Prospective Studies

Author

Nicolò Pecorelli, Alice W. Licinio, Giovanni Guarneri, Francesca Aleotti, Stefano Crippa, Michele Reni, Massimo Falconi, and Gianpaolo Balzano

Subjects
pancreatic neoplasms, upfront surgery, survival, adjuvant chemotherapy, neoadjuvant chemotherapy, pancreatic cancer, Neoplasms. Tumors. Oncology. Including cancer and carcinogens, RC254-282
Abstract

BackgroundThe rate of patients with pancreatic ductal adenocarcinoma (PDAC) receiving neoadjuvant chemotherapy is increasing, but upfront resection is still offered to most patients with resectable or borderline resectable disease. Encouraging data reported in adjuvant chemotherapy trials prompts surgeons towards upfront surgery, but such trials are subject to a significant selection bias. This systematic review aims to summarize available high-quality evidence regarding survival of patients treated with upfront surgery for PDAC.MethodsPubmed, Cochrane, and Web of Science Databases were interrogated for prospective studies published between 2000 and 2021 that included at least a cohort of patients treated with upfront surgery for resectable or borderline resectable PDAC. The Cochrane Collaboration’s risk-of-bias tool for randomized trials (RoB-2) was used to assess risk of bias in all randomized studies. Patient weighted median overall survival (OS) and disease-free survival (DFS) were calculated.ResultsOverall, 8,341 abstracts were screened, 17 reports were reviewed in full text, and finally 5 articles and 1 conference abstract underwent data extraction. Included studies were published between 2014 and 2021. All studies were RCTs comparing different neoadjuvant treatment strategies to upfront surgery. Three studies included only resectable PDAC patients, two studies recruited patients with resectable and borderline resectable disease, and one study selected only borderline resectable patients. A total of 439 patients were included in the upfront resection cohorts of the 6 studies, ranging between 20 to 180 patients per study. The weighted median OS after upfront surgery was 18.8 (95% CI 12.4 – 20.6) months. Median DFS was 9 (95% CI 1.6 – 12.5) months. Resection rate was 74.5% (range 65-90%). Adjuvant treatment was initiated in 68% (range 43-77%) of resected patients.ConclusionsHigh-quality data for PDAC patients undergoing upfront surgery is scarce. Meta-analysis from the included studies showed a significantly shorter OS and DFS compared to recently published studies focusing on adjuvant combination chemotherapy, suggesting that the latter may overestimate survival due to the exclusion of most patients scheduled for upfront surgery.

Published
2022
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5. Postoperative Outcomes and Functional Recovery After Preoperative Combination Chemotherapy for Pancreatic Cancer: A Propensity Score-Matched Study

Author

Nicolò Pecorelli, Michele Pagnanelli, Lorenzo Cinelli, Francesca Di Salvo, Stefano Partelli, Stefano Crippa, Domenico Tamburrino, Renato Castoldi, Giulio Belfiori, Michele Reni, Massimo Falconi, and Gianpaolo Balzano

Subjects
pancreatic cancer, neoadjuvant treatment, pancreaticoduodenectomy, postoperative complications, functional recovery, Neoplasms. Tumors. Oncology. Including cancer and carcinogens, RC254-282
Abstract

Introduction: Previous studies show encouraging oncologic outcomes for neoadjuvant chemotherapy (NACT) in the setting of pancreatic ductal adenocarcinoma (PDAC). However, recent literature reported an increased clinical burden in patients undergoing pancreaticoduodenectomy (PD) following NACT. Therefore, the aim of our study was to assess the impact of NACT on postoperative outcomes and recovery after PD.Methods: A retrospective propensity score-matched study was performed including all patients who underwent PD for PDAC in a single center between 2015 and 2018. Patients treated with NACT for resectable, borderline resectable or locally advanced PDAC were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients who underwent upfront resection. Propensity scores were calculated using 7 perioperative variables, including gender, age, BMI, ASA score, Charlson-Deyo comorbidity score, fistula risk score (FRS), vascular resection. Primary outcome was the number and severity of complications at 90-days after surgery measured by the comprehensive complication index (CCI). Data are reported as median (IQR) or number of patients (%).Results: Of 283 resected patients, 95 (34%) were treated with NACT. Before matching, NACT patients were younger, had less comorbidities (Charlson-Deyo score 0 vs. 1, p = 0.04), similar FRS [2 (0–3) for both groups], and more vascular resections performed [n = 28 (30%) vs. n = 26 (14%), p < 0.01]. After propensity-score matching, preoperative and intraoperative characteristics were comparable. Postoperatively, CCI was similar between groups [8.7 (0–29.6) for both groups, p = 0.59]. NACT patients had a non-statistically significant increase in superficial incisional surgical site infections [n = 12 (13%) vs. 6 (6%), p = 0.14], while no difference was found for overall infectious complications and organ-space SSI. The occurrence of clinically-relevant pancreatic fistula was similar between groups [10 (11%) vs. 13 (14%), p = 0.51]. No difference was found between groups for length of hospital stay [8 (7–15) vs. 8 (7–14) days, p = 0.62], and functional recovery outcomes.Conclusion: After propensity score adjustment for perioperative risk factors, NACT did not worsen postoperative outcomes and functional recovery following PD for PDAC compared to upfront resection.

Published
2019
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7. Effect of preoperative biliary stent on postoperative complications after pancreaticoduodenectomy for cancer: Neoadjuvant versus upfront treatment

Author

Domenico Tamburrino, Giovanni Guarneri, Lorenzo Provinciali, Valentina Riggio, Nicolò Pecorelli, Lorenzo Cinelli, Stefano Partelli, Stefano Crippa, Massimo Falconi, and Gianpaolo Balzano

Subjects
Pancreatic Neoplasms, Postoperative Complications, Preoperative Care, Humans, Surgical Wound Infection, Stents, Surgery, Neoadjuvant Therapy, Pancreaticoduodenectomy, Retrospective Studies
Abstract

Limited data are available regarding the effect of preoperative biliary stent, during long-course neoadjuvant chemotherapy, on postoperative complications. The aim of the study is to analyze whether the association of neoadjuvant chemotherapy and biliary stent increases overall and infectious complications after pancreaticoduodenectomy.Data for 538 consecutive pancreatic ductal adenocarcinoma patients who underwent pancreaticoduodenectomy between 2015 and 2020 were retrospectively analyzed. Four groups of patients were identified: neoadjuvant chemotherapy + biliary stent (171 patients), neoadjuvant chemotherapy-no biliary stent (65 patients), upfront surgery + biliary stent (184 patients), and upfront surgery-no biliary stent (118 patients). Median neoadjuvant chemotherapy duration was 6 months. The main outcome of the study was the occurrence of postoperative infections.No differences among the 4 groups were observed for pancreaticoduodenectomy-specific complications (ie, POPF, DGE, PPH). Infectious complications, in particular surgical site infections, were more frequent in neoadjuvant chemotherapy + biliary stent group (P = 0.001). At multivariate analysis, biliary stent was significantly associated with postoperative infectious complications in the overall cohort (odds ratio 1.996, confidence interval 95% 1.29-3.09, P = .002) and in neoadjuvant chemotherapy patients (odds ratio 5.974, 95% confidence interval 2.52-14.13, P.001). Biliary stent significantly increased the comprehensive complication index by 9.5% (95% confidence interval 0.04-0.64, P = 0.024) in the overall cohort and 18.9% (95% confidence interval 0.22-1.23, P = .005) in the neoadjuvant chemotherapy group. The presence of multidrug-resistant microorganisms in intraoperative bile culture was not influenced by long-course neoadjuvant chemotherapy.In neoadjuvant chemotherapy patients, biliary stent increased the occurrence of postoperative infectious complications and surgical site infections, while the incidence of multidrug-resistant bacteria in intraoperative bile culture was similar between groups.

Published
2022
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9. The impact of preoperative anemia on pancreatic resection outcomes

Author

Giaime G. Arru, Yong H. Lee, Stefano Crippa, Roberto Quattromani, Giovanni Guarneri, Lorenzo Gozzini, Massimo Falconi, Stefano Turi, Alessia Vallorani, Stefano Partelli, Nicolò Pecorelli, Pecorelli, Nicolò, Guarneri, Giovanni, Quattromani, Roberto, Arru, Giaime G, Gozzini, Lorenzo, Lee, Yong H, Vallorani, Alessia, Turi, Stefano, Partelli, Stefano, Crippa, Stefano, and Falconi, Massimo

Subjects
Male, medicine.medical_specialty, Blood transfusion, medicine.medical_treatment, Pancreaticoduodenectomy, Postoperative Complications, Pancreatectomy, Risk Factors, medicine, Humans, Blood Transfusion, Preoperative anemia, Risk factor, Pancreatic resection, Retrospective Studies, Hepatology, business.industry, Gastroenterology, Anemia, Perioperative, Surgery, Treatment Outcome, Female, Hemoglobin, Complication, business
Abstract

Background: Preoperative anemia is a risk factor for blood transfusions and delayed postoperative recovery, but few data are available for pancreatic surgery. Aim of the study was to analyze the impact of preoperative anemia on outcomes after pancreatic resection.Methods: Retrospective review of 1107 patients resected at San Raffaele Hospital (2015-2018). Preoperative anemia was defined as hemoglobin lower than 130 g/L for men and 120 g/L for women. Primary outcome was 90-day comprehensive complication index (CCI). Analysis was stratified according to type of surgery; proximal resections (pancreaticoduodenectomy and total pancreatectomy) versus distal pancreatectomy.Results: In 776 proximal resection patients, preoperative anemia was associated with increased CCI (24 +/- 25 vs. 19 +/- 23, p = 0.018) and perioperative allogenic blood transfusions (n = 124, 46% vs. n = 129, 26%; p < 0.001). Multivariate analysis showed that anemia was associated with a 7% (95%CI 0.02-0.57 p = 0.047) increase in CCI, and was an independent factor associated with perioperative blood transfusion (OR 2.762, 95%CI 1.72-4.49, p < 0.001). In 331 distal pancreatectomies, anemia was not associated to increased morbidity but only to an increased risk of perioperative blood transfusion.Conclusion: Preoperative anemia is an independent risk factor for increased complication severity and blood transfusion in patients undergoing major pancreatic resection.

Published
2022
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10. Clinical and economic validation of grade B postoperative pancreatic fistula subclassification

Author

Valentina Andreasi, Stefano Partelli, Paola M.V. Rancoita, Serena Mele, Michele Mazza, Dario La Fauci, Nicolò Pecorelli, Giovanni Guarneri, Domenico Tamburrino, Stefano Crippa, Massimo Falconi, Andreasi, Valentina, Partelli, Stefano, Rancoita, Paola M V, Mele, Serena, Mazza, Michele, La Fauci, Dario, Pecorelli, Nicolò, Guarneri, Giovanni, Tamburrino, Domenico, Crippa, Stefano, and Falconi, Massimo

Subjects
Pancreatic Fistula, Pancreatectomy, Postoperative Complications, Humans, Surgery, Pancreas, Pancreaticoduodenectomy
Abstract

Background: Grade B postoperative pancreatic fistula represents the largest fraction of postoperative pancreatic fistula. A subclassification of grade B postoperative pancreatic fistula has been recently proposed and seems to better stratify postoperative pancreatic fistula clinical and economic burden. Aim of this study was to validate, from a clinical and economic standpoint, grade B postoperative pancreatic fistula subclassification in patients submitted to pancreaticoduodenectomy.Methods: All consecutive patients who underwent pancreaticoduodenectomy and developed biochemical leak or postoperative pancreatic fistula were included. Grade B postoperative pancreatic fistula was subclassified into 3 categories (B1: persistent drainage >21 days, B2: pharmacological treatments; B3: interventional procedures). Postoperative pancreatic fistula clinical and economic burden was assessed by evaluating postoperative complications, length of hospital stay, and overall hospital costs.Results: Overall, 289 patients developed biochemical leak or postoperative pancreatic fistula. Of these, 34 had biochemical leak (12%), 25 had grade B1 postoperative pancreatic fistula (9%), 91 had grade B2 postoperative pancreatic fistula (31%), 94 had grade B3 postoperative pancreatic fistula (32%), and 45 experienced grade C postoperative pancreatic fistula (16%). The severity of postoperative complications significantly increased across biochemical leak and postoperative pancreatic fistula categories (P

Published
2022
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11. Pain management, fluid therapy and thromboprophylaxis after pancreatoduodenectomy

Author

Bert A. Bonsing, Jesse V. Groen, Essa M. Aleassa, Thilo Hackert, Nicolas Demartines, Alexander L. Vahrmeijer, Takeaki Ishizawa, Timothy E. Miller, Randa G Hanna Sawires, Nicolò Pecorelli, Gareth Morris-Stiff, Jaswinder S. Samra, Christopher Christophi, Chris H. Martini, Rutger B Henrar, J. Sven D. Mieog, Timothy H. Mungroop, Alain Sauvanet, Marc G. Besselink, Mustapha Adham, Surgery, CCA - Cancer Treatment and Quality of Life, and Amsterdam Gastroenterology Endocrinology Metabolism

Subjects
Surgeons, Pain, Postoperative, medicine.medical_specialty, Hepatology, business.industry, General surgery, Gastroenterology, Anticoagulants, Survey research, Venous Thromboembolism, Guideline, Pain management, Pancreaticoduodenectomy, Pancreatic surgery, Analgesics, Opioid, Fluid therapy, Intravenous morphine, Transversus Abdominis Plane Block, medicine, Fluid Therapy, Humans, Pain Management, In patient, business
Abstract

Background The aim of this survey was to assess practices regarding pain management, fluid therapy and thromboprophylaxis in patients undergoing pancreatoduodenectomy on a global basis. Methods This survey study among surgeons from eight (inter)national scientific societies was performed according to the CHERRIES guideline. Results Overall, 236 surgeons completed the survey. ERAS protocols are used by 61% of surgeons and respectively 82%, 93%, 57% believed there is a relationship between pain management, fluid therapy, and thromboprophylaxis and clinical outcomes. Epidural analgesia (50%) was most popular followed by intravenous morphine (24%). A restrictive fluid therapy was used by 58% of surgeons. Chemical thromboprophylaxis was used by 88% of surgeons. Variations were observed between continents, most interesting being the choice for analgesic technique (transversus abdominis plane block was popular in North America), restrictive fluid therapy (little use in Asia and Oceania) and duration of chemical thromboprophylaxis (large variation). Conclusion The results of this international survey showed that only 61% of surgeons practice ERAS protocols. Although the majority of surgeons presume a relationship between pain management, fluid therapy and thromboprophylaxis and clinical outcomes, variations in practices were observed. Additional studies are needed to further optimize, standardize and implement ERAS protocols after pancreatic surgery.

Published
2022

12. The impact of nutritional status on pancreatic cancer therapy

Author

Gabriele Capurso, Nicolò Pecorelli, Alice Burini, Giulia Orsi, Diego Palumbo, Marina Macchini, Roberto Mele, Francesco de Cobelli, Massimo Falconi, Paolo Giorgio Arcidiacono, and Michele Reni

Subjects
Pancreatic Neoplasms, Oncology, Malnutrition, Humans, Nutritional Status, Exocrine Pancreatic Insufficiency, Pharmacology (medical), Pancreas, Carcinoma, Pancreatic Ductal
Abstract

Pancreatic Ductal Adenocarcinoma (PDAC) is an aggressive disease with poor outcomes. One of the reasons for the dismal prognosis resides in its impressive ability to alter the nutritional status of patients who develop malnutrition, cachexia, anorexia, and sarcopenia in most cases. The ideal way to measure such changes in PDAC patients, in order to readily identify them and avoid complications or discontinuations of treatment is a relatively unexplored area. In addition, most PDAC patients experience pancreatic exocrine insufficiency (PEI) that contributes to the complex puzzle of malnutrition and that can be treated with Pancreatic Enzyme Replacement Therapy (PERT).We review current knowledge on the impact of nutritional status on both surgical and medical treatments for PDAC, reporting available data on the causes of malnutrition, characteristics, and advantages of different tools to investigate nutritional status and possible strategies to improve patient outcomes.All PDAC patients should receive a careful nutritional assessment at diagnosis, and this should be repeated alongside their treatment path. Screening tools and biochemical variables or scores are associated with prognosis, but bioimpedance vector analysis (BIVA) and radiological assessment of body composition seem more accurate in predicting clinical outcomes and postoperative complications.

Published
2022
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14. Clinical nutrition in surgical oncology: Young AIOM-AIRO-SICO multidisciplinary national survey on behalf of NutriOnc research group

Author

Marano, Luigi, Marmorino, Federica, Desideri, Isacco, Carbone, Ludovico, Rizzo, Alessandro, Salvestrini, Viola, Roviello, Franco, Cinieri, Saverio, Donato, Vittorio, De Luca, Raffaele, Silvia, Sofia, Marco, Milone, Benedetto, Ielpo, Maria Teresa Mita, Silvia, Ministrini, Mario, Giuffrida, Roberta, Tutino, Caterina, Baldi, Giampaolo, Perri, Anna Stella Lippolis, Chiara, Marafante, Giusy, Giannandrea, Marco Vito Marino, Letizia, Laface, Salomone Di Saverio, Luca, Aldrighetti, Nicola, De'Angelis, Nick, Salimian, Marco, Caricato, Gianluca, Pellino, Sara, Vertaldi, Federica, Cipriani, Gabriella Teresa Capolupo, Antonio, Costanzo, Letizia, Santandrea, Gallo, Gaetano, Andrea, Belli, Laura, Mastrangelo, Fausto, Rosa, Nicolò, Pecorelli, Graziella, Marino, Alessio, Giordano, Nicola, Cillara, Maria, Lemma, Francesco, Pata, Federico, Cammillini, Gianmario Edoardo Poto, Giulia, Grassi, Donato Francesco Altomare, Arcangelo, Picciariello, Lorenzo, Petagna, Luca, Ippolito, Elio, Treppiedi, Daniele, Delogu, Abdallah, Moukachar, Stefano, Granieri, Giuseppe, Cuticone, Osvaldo Carpineto Samorani, Daniela, Rega, Leonardo, Solaini, Stefano de Pascale, Francesca, Ascari, Michele, Manigrasso, Simona, Badalucco, Salvatore, Paiella, Sara, Coppola, Roberta, Iadarola, Giovanna Di Meo, Isacco, Montroni, Fabio, Vistoli, Valentina, Ferraro, Edoardo, Saladino, Federico, Fazio, Roberta, Rota, Francesco, Orlando, Simone, Famularo, Cinzia, Bizzoca, Giorgio, Dalmonte, Marco, Inama, Luigi, Verre, Leandro, Siragusa, Casoni Pattacini Gianmaria, Michele, Benedetti, Nicolò, Tamini, Cristian, Conti, Giorgio, Ammerata, Serena, Mantova, Vito Leonardo Pinto, Arianna, Corvasce, Giorgio, Micheletti, Teresa, Perra, Marco, Pellicciaro, Marco, Materazzo, Michele, Zuolo, Emanuele, Doria, Antonio, Brillantino, Luca Del Prete, Andrea, Muratore, Claudio, Luciani, Giulia, Turri, Fabio, Casciani, Giuliani, Giuseppe, Graziana, Barile, Oldrà, Gaia, Valeria, Restaino, Simona, Deidda, Michele, Ammendola, Andrea Fares Bucci, Patrizia, Marsanic, Dario, Cassetti, Luca, Resca, Daniele, Fusario, Eleonora, Andreucci, Anna, Michelotti, Brunella, Amoruso, Isabella, Franco, Laura, Noto, Andrea, Spallanzani, Raimondo Calogero Scalia, Teresa Del Giudice, Valeria, Merz, Gianmarco, Motta, Alessandro, Parisi, Mikol, Modesti, Antonella, Argentiero, Debora, Basile, Gianmarco, Vannini, Carlotta, Ottanelli, Salvatore, Corallo, Eufemia Stefania Lutrino, Daniele, Rossini, Federica, Morano, Luigia Stefania Stucci, Costanza, Winchler, Martina, Catalano, Andrea, Marini, Giuseppe, Brisinda, Enrico, Sammarco, Martina, Carullo, Giandomenico, Roviello, Mirko, Barone, Maria Grazia Rodriquenz, Giuseppe, Tirino, Alessia, Amoruso, Anna, Russo, Veronica, Conca, Laura, Orgiano, Sveva, Macrini, Giulia, Nazzicone, Maria, Bensi, Martina, Montesano, Emanuela, Dell'Aquila, Andrea, Sbrana, Beatrice, Borelli, Lorenzo, Fornaro, Lucrezia, Raimondi, Valeria, Zurlo, Mattia, Garutti, Elena, Ongaro, Arianna, Pellegrino, Andrea, Lanese, Laura, Bernardini, Alessandra, Boccaccino, Patrizia, Farina, Federica, Buzzacchino, Angelica, Petrillo, Ada, Taravella, Vittorio, Studiale, Paolo, Ciracì, Giovanna, Lovino, Dora Di Cosmo, Sabrina, Montrone, Fabiana, Gregucci, Luca, Dominici, Alba, Fiorentino, Filippo, Carannante, Giambattista, Siepe, Giampaolo, Montesi, Manuele, Roghi, Michele, Aquilano, Andrea, Romei, Ilaria, Bonaparte, Roberta, Grassi, Emma, D'Ippolito, Giulio, Frosini, Giuseppina De Marco, Gennaro, Giovine, Chiara, Mattioli, Ilaria, Morelli, Victoria, Lorenzetti, Matteo, Mariotti, Carolina, Orsatti, Vincenzo, Troncone, Lorenzo, Livi, Antonio, Angrisani, Marco, Banini, Teresa Di Pietro, Giuseppe Carlo Iorio, Iacopo, Cavallo, Cecilia, Cerbai, Valerio, Nardone, Francesca De Felice, Consuelo, Rosa, Giulia, Stocchi, Sara, Lucidi, Michele, Ganovelli, Damiano, Dei, Chiara, Cascone, Anna, Peru, Luisa, Caprara, Lucia, Angelini, Luca, Visani, Giulio, Francolini, Beatrice, Bettazzi, Francesco, Belia, Virginia, Boccardi, Simone, Serafini, Vincenzo, Bottino, Luca, Ferrario, Giuseppe, Frazzetta, Felice, Pirozzi, Gennaro, Martines, Francesco Antonio Ciarleglio, Daniele, Indiani, Giuliano, Barugola, Luca, Mazza, and Chiara, Guarini

Subjects
nutritional assessment, clinical nutrition, cancer, malnutrition, survey
Published
2023

15. Preoperative risk stratification of postoperative pancreatic fistula: A risk-tree predictive model for pancreatoduodenectomy

Author

Giovanni Marchegiani, Claudio Bassi, Roberto Salvia, Stefano Crippa, Lorenzo Cinelli, Giampaolo Perri, Nicolò Pecorelli, Beatrice Bianchi, Alessandro Esposito, Massimo Falconi, Stefano Partelli, Perri, G., Marchegiani, G., Partelli, S., Crippa, S., Bianchi, B., Cinelli, L., Esposito, A., Pecorelli, N., Falconi, M., Bassi, C., and Salvia, R.

Subjects
Male, medicine.medical_specialty, Radiography, Clinical Decision-Making, Preoperative risk, Risk Assessment, Body Mass Index, Pancreaticoduodenectomy, Pancreatic Fistula, Postoperative Complications, Risk Factors, medicine, Humans, Prospective Studies, Aged, Pancreatic duct, business.industry, Regression tree analysis, Decision Trees, Pancreatic Ducts, Patient counseling, Middle Aged, medicine.disease, Surgery, Pancreatic Neoplasms, medicine.anatomical_structure, Pancreatic fistula, Preoperative Period, Female, business, Body mass index, American society of anesthesiologists
Abstract

Background: Existing postoperative pancreatic fistula risk scores rely on intraoperative parameters, which limits their value in the preoperative setting. A preoperative predictive model to stratify the risk of developing postoperative pancreatic fistula before pancreatoduodenectomy was built and externally validated. Methods: A regression risk-tree model for preoperative postoperative pancreatic fistula risk stratification was developed in the Verona University Hospital training cohort using preoperative variables and then tested prospectively in a validation cohort of patients who underwent pancreatoduodenectomy at San Raffaele Hospital of Milan. Results: In the study period 566 (training cohort) and 456 (validation cohort) patients underwent pancreatoduodenectomy. In the multivariable analysis body mass index, radiographic main pancreatic duct diameter and American Society of Anesthesiologists score ≥3 were independently associated with postoperative pancreatic fistula. The regression tree analysis allocated patients into 3 preoperative risk groups with an 8%, 21%, and 32% risk of postoperative pancreatic fistula (all P < .01) based on main pancreatic duct diameter (≥ or

Published
2021
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16. Evaluation of factors predicting loss of benefit provided by laparoscopic distal pancreatectomy compared to open approach

Author

Valentina Andreasi, Domenico Tamburrino, Lorenzo Cinelli, Massimo Falconi, Nicolò Pecorelli, Paola M.V. Rancoita, Stefano Partelli, Stefano Crippa, Partelli, S., Cinelli, L., Andreasi, V., Rancoita, P. M. V., Pecorelli, N., Tamburrino, D., Crippa, S., and Falconi, M.

Subjects
medicine.medical_specialty, Surgical approach, medicine.diagnostic_test, business.industry, Odds ratio, Length of Stay, Surgery, Pancreatic Neoplasms, Pancreatectomy, Postoperative Complications, Treatment Outcome, Blood loss, Propensity score matching, medicine, Humans, Operative time, Laparoscopy, In patient, Distal pancreatectomy, business, Aged, Retrospective Studies
Abstract

Several studies showed safety and feasibility of laparoscopic distal pancreatectomy (LDP) as compared to open distal pancreatectomy (ODP). Patients who underwent LDP or ODP (2015-2019) were included. A 1:1 propensity score matching (PSM) was used to reduce the effect of treatment selection bias. Aim of this study was to identify those factors influencing the loss of benefit (defined as a significantly better outcome compared to ODP) after LDP. Overall, 387 patients underwent DP (n = 250 LDP, n = 137 ODP). After PSM, 274 patients (n = 137 LDP, n = 137 ODP) were selected. LDP was associated with reduced intraoperative blood loss (median: 200 mL vs. 250 mL, p 0.001), decreased wound infection rate (1% vs. 9%, p = 0.044) and shorter time to functional recovery (TFR) (median: 4 days vs. 5 days, p = 0.002). Consequently, TFR 5 days and blood loss 250 mL were defined as loss of benefit after LDP. In the LDP group, age 70 years [Odds Ratio (OR) 2.744, p = 0.022] and duration of surgery 208 min (OR 2.957, p = 0.019) were predictors of TFR 5 days and intraoperative blood loss 250 mL, respectively. No differences in terms of TFR were found between ODP and LDP groups in patients 70 years (p = 0.102). Intraoperative blood loss was significantly higher in the ODP group, also when the analysis was limited to surgical procedures with operative time 208 min (p = 0.003). In conclusion, LDP seems comparable to ODP in terms of TFR in patients aged 70 years. This finding could be helpful in the choice of the best surgical approach in elderly patients undergoing potentially challenging DPs.

Published
2021
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18. Geographical Disparities and Patients’ Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy

Author

Gianpaolo Balzano, Giovanni Guarneri, Nicolò Pecorelli, Stefano Partelli, Stefano Crippa, Augusto Vico, Massimo Falconi, and Giovanni Baglio

Subjects
Cancer Research, Oncology, pancreatic surgery, regionalization, patients’ mobility, hospital volume
Abstract

Patients requiring complex treatments, such as pancreatic surgery, may need to travel long distances and spend extended periods of time away from home, particularly when healthcare provision is geographically dispersed. This raises concerns about equal access to care. Italy is administratively divided into 21 separate territories, which are heterogeneous in terms of healthcare quality, with provision generally decreasing from north to south. This study aimed to evaluate the distribution of adequate facilities for pancreatic surgery, quantify the phenomenon of long-distance mobility for pancreatic resections, and measure its effect on operative mortality. Data refer to patients undergoing pancreatic resections (in the period 2014–2016). The assessment of adequate facilities for pancreatic surgery, based on volume and outcome, confirmed the inhomogeneous distribution throughout Italy. The migration rate from Southern and Central Italy was 40.3% and 14.6%, respectively, with patients mainly directed towards high-volume centers in Northern Italy. Adjusted mortality for non-migrating patients receiving surgery in Southern and Central Italy was significantly higher than that for migrating patients. Adjusted mortality varied greatly among regions, ranging from 3.2% to 16.4%. Overall, this study highlights the urgent need to address the geographical disparities in pancreatic surgery provision in Italy and ensure equal access to care for all patients.

Published
2023
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19. Preoperative predictive factors of laparoscopic distal pancreatectomy difficulty

Author

Carlo Ingaldi, Laura Alberici, Riccardo Casadei, Claudio Ricci, Giaime G. Arru, Stefano Partelli, Valentina Andreasi, Stefano Crippa, Clelia Di Serio, Roberto Maria Montorsi, Nicolò Pecorelli, Paola M.V. Rancoita, Massimo Falconi, Partelli S., Ricci C., Rancoita P.M.V., Montorsi R., Andreasi V., Ingaldi C., Arru G., Pecorelli N., Crippa S., Alberici L., Di Serio C., Casadei R., Falconi M., Partelli, S., Ricci, C., Rancoita, P. M. V., Montorsi, R., Andreasi, V., Ingaldi, C., Arru, G., Pecorelli, N., Crippa, S., Alberici, L., Di Serio, C., Casadei, R., and Falconi, M.

Subjects
Male, medicine.medical_specialty, Preoperative risk, 030230 surgery, Independent predictor, Resection, 03 medical and health sciences, Pancreatectomy, Postoperative Complications, 0302 clinical medicine, Blood loss, medicine, Humans, pancreas, Male gender, Retrospective Studies, Hepatology, business.industry, Gastroenterology, Length of Stay, Surgery, Pancreatic Neoplasms, Treatment Outcome, Quartile, 030220 oncology & carcinogenesis, Laparoscopy, Distal pancreatectomy, business
Abstract

Background: Laparoscopic distal pancreatectomy (LDP) is a challenging operation due to technical complexity and tumor-related factors. Aim of this study was to identify preoperative risk factors affecting LDP difficulty. Methods: Consecutive patients who underwent LDP between 2015 and 2018 at San Raffaele Hospital and Policlinico S.Orsola-Malpighi Hospital were enrolled retrospectively. Three variables were used to define surgical difficulty: conversion to open, duration of surgery >3rd quartile and intraoperative blood loss >3rd quartile. The presence of ≥1 of these 3 variables was considered as another measure of difficulty. Results: Overall, 191 patients were included. Conversion to open was required in 25 patients (13%). At multiple regression analysis, tumor proximity to major vessels was the only independent predictor of conversion from laparoscopic to open (p < 0.001). No variables independently predicted an excessive duration of surgery. Male gender (p = 0.033) and increasing parenchymal thickness at resection line (p = 0.018) were independent predictors of excessive blood loss. Increasing parenchymal thickness at resection line (p = 0.014) and tumor proximity to major vessels (p = 0.002) were significant risk factors for the presence of ≥1 outcome of surgical difficulty. Conclusion: Male gender, increasing parenchymal thickness at resection line and tumor proximity to major vessels represent preoperative risk factors of LDP difficulty.

Published
2020
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20. Impact of Facilitation of Early Mobilization on Postoperative Pulmonary Outcomes After Colorectal Surgery

Author

Julio F. Fiore, Mohsen Alhashemi, Franco Carli, Barry Stein, Saba Balvardi, Petru Niculiseanu, Liane S. Feldman, Patrick Charlebois, Alexander Sender Liberman, Tanya Castelino, Nancy E. Mayo, Nicolò Pecorelli, Balvardi, Saba, Pecorelli, Nicolò, Castelino, Tanya, Niculiseanu, Petru, Alhashemi, Mohsen, Liberman, Alexander Sender, Charlebois, Patrick, Stein, Barry, Carli, Franco, Mayo, Nancy E, Feldman, Liane S, and Fiore, Julio F

Subjects
Lung Diseases, Male, Vital capacity, medicine.medical_specialty, Pulmonary function testing, law.invention, 03 medical and health sciences, Postoperative Complications, 0302 clinical medicine, Randomized controlled trial, law, Humans, Medicine, Colectomy, Early Ambulation, Aged, Retrospective Studies, Mobilization, business.industry, Retrospective cohort study, Odds ratio, Perioperative, Length of Stay, Middle Aged, Colorectal surgery, Respiratory Function Tests, 030220 oncology & carcinogenesis, Anesthesia, Female, Laparoscopy, 030211 gastroenterology & hepatology, Surgery, Colorectal Neoplasms, business, Follow-Up Studies
Abstract

Objective To estimate the extent to which staff-directed facilitation of early mobilization impacts recovery of pulmonary function and 30-day postoperative pulmonary complications (PPCs) after colorectal surgery. Summary background data Early mobilization after surgery is believed to improve pulmonary function and prevent PPCs; however, adherence is low. The value of allocating resources (eg, staff time) to increase early mobilization is unknown. Methods This study involved the analysis of a priori secondary outcomes of a pragmatic, observer-blind, randomized trial. Consecutive patients undergoing colorectal surgery were randomized 1:1 to usual care (preoperative education) or facilitated mobilization (staff dedicated to assist transfers and walking during hospital stay). Forced vital capacity, forced expiratory volume in 1 second (FEV1), and peak cough flow were measured preoperatively and at 1, 2, 3 days and 4 weeks after surgery. PPCs were defined according to the European Perioperative Clinical Outcome Taskforce. Results Ninety-nine patients (57% male, 80% laparoscopic, median age 63, and predicted FEV1 97%) were included in the intention-to-treat analysis (usual care 49, facilitated mobilization 50). There was no between-group difference in recovery of forced vital capacity [adjusted difference in slopes 0.002 L/d (95% CI -0.01 to 0.01)], FEV1 [-0.002 L/d (-0.01 to 0.01)] or peak cough flow [-0.002 L/min/d (-0.02 to 0.02)]. Thirty-day PPCs were also not different between groups [adjusted odds ratio 0.67 (0.23-1.99)]. Conclusions In this randomized controlled trial, staff-directed facilitation of early mobilization did not improve postoperative pulmonary function or reduce PPCs within an enhanced recovery pathway for colorectal surgery. Trial registration ClinicalTrials.gov Identifier: NCT02131844.

Published
2020
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21. Management of clinically relevant postoperative pancreatic fistula-related fluid collections after distal pancreatectomy

Author

Giovanni Guarneri, Giorgia Guazzarotti, Nicolò Pecorelli, Diego Palumbo, Marco Palucci, Lorenzo Provinciali, Chiara Limongi, Stefano Crippa, Stefano Partelli, Francesco De Cobelli, and Massimo Falconi

Subjects
Surgery
Abstract

Distal pancreatectomy is burdened by a high rate of clinically relevant postoperative pancreatic fistula (CR-POPF). The presence of a fistula-related abdominal collection often requires additional treatment such as antibiotics, percutaneous drainage, and endoscopic drainage thus prolonging patient recovery. Aim of this study was to describe the management of abdominal collections related to CR-POPF and identify variables associated with the need for invasive procedures.A retrospective review of clinical data for patients who underwent distal pancreatectomy between 2015 and 2020 was conducted. All postoperative CT-scan imaging performed for clinical signs related to POPF was reviewed. The main outcome of the study was the need for procedural management (percutaneous or endoscopic) of CR-POPF-related fluid collections at 90 days after surgery. A multivariate regression analysis was adopted to analyze factors influencing procedural management of the collection.Five hundred sixteen patients were included in the study. Laparoscopic resection was performed in 290 patients (56%). At 90 days after surgery, CR-POPF occurred in 207 (40.1%) patients. A symptomatic collection related to fistula was observed in 130 patients (25.2%). Factors associated with fluid collections were increased body mass index (BMI) (25.5 versus 24, p = 0.001) and intraoperative blood loss (median of 250 versus 200 ml, p 0.001). Procedural management was required in 70 patients (13.6%); 52 patients required interventional radiology and 18 endoscopic drainage. At multivariate analysis, risk factors for invasive procedures were the following CT-scan parameters: fluid collection diameter greater than 5 cm (OR 6.366, 95%CI 2.29-17.66, p = 0.001), presence of blood in the fluid collection (OR 10.618, 95%CI 1.94-58.09, p = 0.006), and enhancement of its walls (OR 4.073, 95%CI 1.22-13.57, p = 0.022).CR-POPF-related fluid collections affect about a quarter of patients undergoing distal pancreatectomy. CT-scan provides important information which can guide the management of the collection in a "step-up" fashion.

Published
2022

22. Pancreatic resections for benign intraductal papillary mucinous neoplasms: Collateral damages from friendly fire

Author

Francesca Aleotti, Stefano Crippa, Giulio Belfiori, Domenico Tamburrino, Stefano Partelli, Enrico Longo, Diego Palumbo, Nicolò Pecorelli, Marco Schiavo Lena, Gabriele Capurso, Paolo Giorgio Arcidiacono, Massimo Falconi, Aleotti, Francesca, Crippa, Stefano, Belfiori, Giulio, Tamburrino, Domenico, Partelli, Stefano, Longo, Enrico, Palumbo, Diego, Pecorelli, Nicolò, Lena, Marco Schiavo, Capurso, Gabriele, Arcidiacono, Paolo Giorgio, and Falconi, Massimo

Subjects
Pancreatic Neoplasms, Pancreatectomy, Insulins, Humans, Surgery, Female, Aged, Carcinoma, Pancreatic Ductal, Retrospective Studies
Abstract

Surgical resection of intraductal papillary mucinous neoplasms is based on preoperative high-risk stigmata/worrisome features, but the risk of overtreatment remains high. The aim of this study was to evaluate surgical indications and perioperative and long-term complications in patients with low-grade intraductal papillary mucinous neoplasms.Patients who underwent surgical resection between 2009 and 2018 with a final histology of low-grade intraductal papillary mucinous neoplasms were included. Surgical indications, type of surgery, and short- and long-term outcomes were evaluated.A significant decrease in the rate of patients resected for low-grade intraductal papillary mucinous neoplasms was observed (43.6% in 2009-2012 vs 27.8% in 2013-2018; P = .003), and 133 patients were finally included (62 women, median age: 68 years). Of these, 24.1% had 1 worrisome feature, 39.8% had ≥2 worrisome features, 18.8% had ≥1 high-risk stigmata, and 15.8% had ≥1 worrisome features + 1 high-risk stigmata. Overall surgical morbidity was 55.6%, 15.8% had Clavien-Dindo ≥3 complications, reoperation rate was 3.8%, and 90-day postoperative mortality was 1.5%. After a median follow-up of 60 months, 13 patients (11.5%) had a recurrence of benign intraductal papillary mucinous neoplasm in the pancreatic remnant, and 2 patients (1.8%) developed pancreatic ductal adenocarcinoma. After partial pancreatectomy, 51.3% of patients were taking pancreatic enzyme replacement therapy. Among nondiabetics, 26% developed diabetes after partial pancreatectomy, of which 38% were insulin-dependent. Eighteen patients (13.7%) developed incisional hernia.Given the rates of morbidity and long-term complications after pancreatic resections, surgeons should attentively balance the true risks of intraductal papillary mucinous neoplasm degeneration with the risks of surgical resection in each patient.

Published
2022

23. ASO Visual Abstract: The Impact of CT-Assessed Liver Steatosis on Postoperative Complications After Pancreaticoduodenectomy for Cancer

Author

Giovanni Guarneri, Diego Palumbo, Nicolò Pecorelli, Francesco Prato, Chiara Gritti, Raffaele Cerchione, Domenico Tamburrino, Stefano Partelli, Stefano Crippa, Michele Reni, Francesco De Cobelli, Massimo Falconi, Guarneri, Giovanni, Palumbo, Diego, Pecorelli, Nicolò, Prato, Francesco, Gritti, Chiara, Cerchione, Raffaele, Tamburrino, Domenico, Partelli, Stefano, Crippa, Stefano, Reni, Michele, De Cobelli, Francesco, and Falconi, Massimo

Subjects
Fatty Liver, Pancreatic Neoplasms, Postoperative Complications, Oncology, Neoplasms, Humans, Surgery, Tomography, X-Ray Computed, Pancreaticoduodenectomy, Retrospective Studies
Published
2022

24. Total Pancreatectomy with islet Autotransplantation as an Alternative to high-risk Pancreatojejunostomy after Pancreaticoduodenectomy: A Prospective Randomized Trial

Author

Gianpaolo Balzano, Alessandro Zerbi, Francesca Aleotti, Giovanni Capretti, Raffella Melzi, Nicolò Pecorelli, Alessia Mercalli, Rita Nano, Paola Magistretti, Francesca Gavazzi, Francesco De Cobelli, Dario Poretti, Marina Scavini, Chiara Molinari, Stefano Partelli, Stefano Crippa, Paola Maffi, Massimo Falconi, Lorenzo Piemonti, Balzano, Gianpaolo, Zerbi, Alessandro, Aleotti, Francesca, Capretti, Giovanni, Melzi, Raffella, Pecorelli, Nicolò, Mercalli, Alessia, Nano, Rita, Magistretti, Paola, Gavazzi, Francesca, De Cobelli, Francesco, Poretti, Dario, Scavini, Marina, Molinari, Chiara, Partelli, Stefano, Crippa, Stefano, Maffi, Paola, Falconi, Massimo, and Piemonti, Lorenzo

Subjects
Surgery
Abstract

To compare pancreaticoduodenectomy (PD) and Total Pancreatectomy with Islet AutoTransplantation (TP-IAT) in patients at high risk of Post-Operative Pancreatic Fistula (POPF).Criteria to predict the risk of POPF occurrence after PD are available. However, even when a high risk of POPF is predicted, TP is not currently accepted as an alternative to PD, because of its severe consequences on glycaemic control. Combining IAT with TP may mitigate such consequences.Randomized, open-label, controlled, bicentric trial (NCT01346098). Candidates for PD at high-risk pancreatic anastomosis (i.e., soft pancreas and duct diameter ≤3 mm) were randomly assigned (1:1) to undergo either PD or TP-IAT. The primary endpoint was the incidence of complications within 90 days after surgery.Between 2010 and 2019, 61 patients were assigned to PD (n=31) or TP-IAT (n=30). In the intention-to-treat analysis, morbidity rate was 90·3% after PD and 60% after TPIAT (P=0·008). According to complications' severity, PD was associated with an increased risk of grade ≥2 [OR 7·64 (95% CI 1·35-43·3), P=0·022], while the OR for grade ≥3 complications was 2·82 [(95% CI 0·86-9·24), P=0·086]. After TP-IAT, the postoperative stay was shorter [median 10·5 vs. 16·0 days; P0·001). No differences were observed in disease-free survival, site of recurrence, disease-specific survival and overall survival. TP-IAT was associated with a higher risk of diabetes [HR 9·1 (95% CI 3·76-21·9); P0·0001], but most patients maintained good metabolic control and showed sustained C-peptide production over time.TP-IAT may become the standard treatment in candidates for PD, when a high risk of POPF is predicted.

Published
2022

25. Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study (vol 46, pg 2021, 2022)

Author

Pata, Francesco, Di Martino, Marcello, Podda, Mauro, Di Saverio, Salomone, Ielpo, Benedetto, Pellino, ACIE Appy Study Collaborative Abba Julio, Gianluca., Abdullah, Alshamrani, Abdullah, Alturkistani, Abdulrahman, Alghamdi, Abdulrahman, Almalki, Adam, Orengia, Adnan, Kuvvetli, Adolfo, Pisanu, Adrian, Smith, Adriana Michelle Treviño Figueroa, Aeris Jane Nacion, Ahmad, Alhazmi, Ahmad, Bouhuwaish, Ahmad, Khalid, Ahmed, Alsufyani, Ainhoa Valle Rubio, Akshay, Bavikatte, Kumar, Akshay, Al-Radjid, Jamiri, Alberto de San Ildefonso Pereira, Alberto, Porcu, Alberto, Sartori, Aldo, Rocca, Aleksandar, Sretenovic, Anselmo, Alessandro, Alessandro De Luca, Alexandros, Charalabopoulos, Alexios, Tzivanakis, Alfonso, Bandin, Alfonso, Nájar, Alice, Frontali, Alsulaimani, Faisal, Amaia Martínez Roldan, Amal, Hamid, Ana, André, Ana, Minaya-Bravo, Andre, Das, Andrea, Bondurri, Andrea, Costanzi, Lucchi, Andrea, Andrei, Mihailescu, Police, Andrea, Andres Mendoza Zuchini, Angela, Romano, Iossa, Angelo, Antonella, Chessa, Antonella, Tromba, Antonio, Castaldi, Antonio, Brillantino, Antonio, Ferronetti, Giuliani, Antonio, Antonio Ramos-De la Medina, Antonio, Tarasconi, Arcangelo, Picciariello, Argyrios, Ioannidis, Ari, Leppäniemi, Arshad, Rashid, Ashrarur Rahman Mitul, Asif, Mehraj, Asim, Laharwal, Atif, Iqbal, Athanasios, Liarakos, Athanasios, Marinis, Beatriz de Andrés-Asenjo, Belén, Matías-García, DE SIMONE, Belinda, Ben, Creavin, Ben, Stubbs, Brian, Goh, Branislav, Jovanovic, Bruno, Sensi, Carlo, Gazia, Carlos, Cerdán, Carlos Javier Gómez Díaz, Carlos Petrola Chacón, Carlos, Yánez, Carmelo Lo Faro, Caroline, Reinke, Casandra, Dominguez, Charudutt, Paranjape, Charlotte, Thomas, Chia Chi Fung, DE LUCIA, Chiara, Chiu Hiu Fung Jennifer, Christian, Ovalle-Chao, Claudio, Guerci, Cleo, Kenington, Corina, Gica, Cristina, Folliero, Cristopher, Varela, Daniel, Popowich, Daniele, Delogu, Daniele, Zigiotto, Danilo, Vinci, Dario, D'Antonio, David Alessio Merlini, David, Merlini, David, Moro-Valdezate, Deborah, Keller, Diana Cristiana Nicolaescu, Diego, Sasia, Edgar, Rodas, Dimitrios, Linardoutsos, Domenico, Russello, Pedro Alfonso Nájar-Castañeda, Habil Gregor Stavrou, Edoardo, Rosso, Edoardo, Saladino, Edoardo, Ricciardi, Eduardo, Smith-Singares, Efstratia, Baili, Eleftheria, Douka, Guaitoli, Eleonora, Elisa, Francone, Elisa Maria Vaterlini, Elisa Sefora Pierobon, Emilio, Morales, Emilio Peña Ros, Enrico, Benzoni, Enrico, Erdas, Enrico, Pinotti, Enrique, Colás-Ruiz, Ernesto, Laterza, Esteban, Foianini, Eugenia, Cardamone, Eugenio, Licardie, Fabio, Marino, Fahad, Alsofyani, Fahad, Qahtani, Farhan, Khan, Fatlum, Maraska, Fatmir, Saliu, Fausto, Madrid, Fausto, Rosa, Federico, Luvisetto, Felipe, Alconchel, Felipe, Pareja-Ciuro, Fernanda, Neves, Ferdinando, Agresta, Fernando, Cordera, Fernando, Pardo, Fernando, Mendoza-Moreno, Fernando, Munoz-Flores, Francesca Maria Silvestri, Francesca Paola Tropeano, Francesca, Pecchini, Francesca, Serio, Francesco, Colombo, Francesco Di Marzo, Francesco, Ferrara, Francesco, Lancellotti, Francesco, Litta, Francesco, Martini, Francesco, Roscio, Francisco, Blanco-Antona, Francisco Javier Quezada Barcenas, Francisco, Schlottmann, Gabriel, Herrera-Almario, Gabrielle van Ramshorst, Gallo, Gaetano, Gaetano, Luglio, Georgios, Kampouroglou, Georgios, Papadopoulos, Gerardo, Arredondo, Giacomo, Calini, Giampaolo, Formisano, Galiffa, Giampaolo, Gian Marco Palini, Gianluca, Colucci, Gianluca, Pagano, Gianluca, Vanni, Gianmaria Casoni Pattacini, Gianpiero, Gravante, Giorgio, Lisi, Giovanni, Bellanova, Giovanni De Nobili, Giovanni Sammy Necchi, Sinibaldi, Giovanni, Giulia, Bacchiocchi, Giulia, Bagaglini, Maggi, Giulia, Giuliano, Izzo, Giulio, Argenio, Giuseppe, Brisinda, Giuseppe, Esposito, Giuseppe, Frazzetta, Giuseppe Massimiliano De Luca, Nigri, Giuseppe, Giuseppe, Sica, MARTIN DE MERCADO, Gonzalo, Gustavo Armand Ugon, Gustavo, Martinez-Mier, Gustavo Miguel Machain Vega, Gustavo, Nari, Herald, Nikaj, Ignacio, Neri, Igor Alberdi San Roman, Iliya, Fidoshev, Iñaki, Martínez, Ionut, Negoi, Irene, Ortega, Irune Vicente Rodríguez, Isabel, Cornejo, Ismael, Mora-Guzmán, Issam, Al-Najami, Ivan, Romic, Izaskun, Balciscueta, James, Olivier, Jan, Lammel-Lindemann, Jana, Dziakova, Javier, Salinas, Jelena Pejanovic Jovanovic, Jeryl Anne Silvia Reyes, Joanne, Salas, Jose Antonio Diaz-Elizondo, Jose Gustavo Parreira, Juan, Bellido, Juan, Salamea, Juan Carlos Martín Del Olmo, Juliana María Ordoñez, Sofi, Junaid, Justin, Davies, Kapil, Sahnan, Kebebe, Bekele, Kelvin, Voon, Leandro, Siragusa, Lorenzo, Petagna, Ferrario, Luca, Luca, Giordano, Luca, Nespoli, Luca, Pio, Lucia, Moletta, Luciano, Curella, Lucio, Taglietti, Luigi, Bonavina, Luigi, Conti, Luis Eduardo Pérez-Sánchez, Luis Felipe Cabrera Vargas, Luis, Sánchez-Guillén, Luis, Tallon-Aguilar, Mansoor, Khan, Marcello Giuseppe Spampinato, Marcelo, Viola, Marcelo Viola Malet, Angrisani, Marco, Marco, Calussi, Marco, Catarci, Marco, Giordano, Marco, Materazzo, Marco, Milone, Marco, Pellicciaro, Marco Vito Marino, María Daniela Moreno Villamizar, Lolli, MARIA GIULIA, Bellini, MARIA IRENE, Maria, Lemma, Maria Michela Chiarello, Mario, Montes-Manrique, Mario, Rodriguez-Lopez, Mario, Serradilla-Martín, Mark, Peter, Marta, Paniagua-García-Señoráns, Martin, Rutegård, Martin, Salö, Massimiliano, Silveri, Massimiliano, Veroux, Matteo, Nardi, Matteo, Rottoli, Matti, Tolonen, Mauricio Pedraza Ciro, Mauricio, Zuluaga, Maurizio, Iacobone, Mauro, Montuori, Mazin, Ali, Melody García Domínguez, Menna Maria Paola, Micaela, Piccoli, Michela, Campanelli, Michele De Rosa, Manigrasso, Michele, Maruccia, Michele, Michele, Torre, Michele, Zuolo, Miguel, Pera, Mihiri, Weerasekera, Mikel, Prieto, Min Myat Thway, Mohamed, Shaat, Mohammad, Azfar, Mostafa, Shalaby, Muhammad Asif Raza, Muhammad Umar Younis, Muhammed, Elhadi, Mujahid, Ali, Musab, Althomali, Nadiah Al Amri, Nagendra, Dudi-Venkata, Nahar, Alselaim, Neil, Smart, Nelson, Trelles, Nicolò, Falco, Petrucciani, Niccolo', Nicola, Antonacci, Nicola, Cillara, Nicolae, Gica, Nicolò, Pecorelli, Nicolò, Tamini, Nikolaos, Machairas, Nura, Feituri, Nuria Ortega Torrecilla, Octavio Avila Mercado, Ohood, Alaamer, Oktay, Irkorucu, Omar, Alsherif, Oreste Claudio Buonomo, Orestes, Valles-Guerra, Orestis, Ioannidis, Oscar Isaac Hernández Palmas, Oscar Sanz Guadarrama, Osman, Bozbiyik, Pablo, Rodrigues, Pamela, Milito, Paolo, Panaccio, Panagiotis, Dorovinis, Paola, Prieto, Paolo, Baroffio, Patrizia, Marsanic, Pawel, Ajawin, Peng Soon Koh, Pietro, Anoldo, Piotr, Major, Qasem, Alharthi, Rashid, Lui, Riccardo, Caruso, Richard, Brady, Rishi, Rattan, Rishi, Singhal, Roberta, Angelico, Roberta Maria Isernia, Roberta, Tutino, Roberto, Peltrini, Rodrigo, Tejos, Roosevelt, Fajardo, Rossella, Elia, Salvador, Morales-Conde, Sami, Benli, Sara, Fuentes, Sara Gortázar de Las Casas, Sara Ortiz de Guzmán Aragón, Sara, Vertaldi, Selmy, Awad, Sergio, Gentilli, Sergio Alberto Weckmann Lujan, Serkan, Tayar, Shabab, Althobaiti, DI GIOVANNI, Silvia, Soliman, Ghedan, Sonia, Pérez-Bertólez, Sonja, Chiappetta, Spiros, Delis, Stefano, Scaringi, Süleyman, Çetinkünar, Stylianos, Kykalos, Syed Muhammad Ali, Sylvia, Krivan, Tak Lit Derek Fung, Tarik, Delko, Tatiana Nicolás López, Tercio De Campos, Teresa Calderón Duque, Teresa, Perra, Theodore, Liakakos, Theodoros, Daskalakis, Tijmen, Koëter, Tiku, Zalla, Tomás Elosua González, Tommaso, Campagnaro, Toure Alpha Oumar, Ugo, Grossi, Valentina, Sosa, Valentina, Testa, Valentina, Tomajer, Valeria, Andriola, Valeria, Tonini, Valerio, Celentano, Voglino, Valerio, Venkateswara Rao Katta, Víctor Hugo García Orozco, Victor, Turrado-Rodriguez, Victor, Visag-Castillo, Victoria, Graham, Viktor, Rachkov, Vincenzo, Papagni, Vincenzo, Vigorita, Virginia Jiménez Carneros, Bellato, Vittoria, Wolf, Bechstein, Yuksel, Altinel, and Zutoia, Balciscueta

Subjects
appendicitis, COVID19
Published
2022

26. Quantitative assessment of the impact of COVID-19 pandemic on pancreatic surgery: an Italian multicenter analysis of 1423 cases from 10 tertiary referral centers

Author

Sara Nobile, Fausto Rosa, Vito Laterza, Claudio Fiorillo, Giovanni Capretti, Maria Chiara Petrone, Riccardo Casadei, Ugo Boggi, Andrea Coratti, Sergio Alfieri, Roberto Salvia, Vincenzo Mazzaferro, Nicolò Pecorelli, Giovanni Ferrari, Salvatore Paiella, Massimo Falconi, Alessandro Zerbi, Giovanni Butturini, Emanuele Federico Kauffmann, Giuseppe Quero, Quero G., Pecorelli N., Paiella S., Fiorillo C., Petrone M.C., Rosa F., Capretti G., Laterza V., Kauffmann E., Nobile S., Butturini G., Ferrari G., Coratti A., Casadei R., Mazzaferro V., Boggi U., Zerbi A., Salvia R., Falconi M., and Alfieri S.

Subjects
medicine.medical_specialty, Pancreatic disease, Referral, Coronavirus disease 2019 (COVID-19), Settore MED/18 - CHIRURGIA GENERALE, Tertiary Care Center, Pancreatic surgery, Neuroendocrine tumors, law.invention, Tertiary Care Centers, law, Internal medicine, Pandemic, medicine, Humans, Pandemics, COVID, business.industry, SARS-CoV-2, Communicable Disease Control, COVID-19, Perioperative, medicine.disease, Intensive care unit, Surgery, Original Article, business, Human
Abstract

Few evidences are present on the consequences of coronavirus disease 2019 (COVID-19) pandemic on pancreatic surgery. Aim of this study is to evaluate how COVID-19 influenced the diagnostic and therapeutic pathways of surgical pancreatic diseases. A comparative analysis of surgical volumes and clinical, surgical and perioperative outcomes in ten Italian referral centers was conducted between the first semester 2020 and 2019. One thousand four hundred and twenty-three consecutive patients were included in the analysis: 638 from 2020 and 785 from 2019. Surgical volume in 2020 decreased by 18.7% (p

Published
2022

27. The Impact of CT-Assessed Liver Steatosis on Postoperative Complications After Pancreaticoduodenectomy for Cancer

Author

Giovanni Guarneri, Diego Palumbo, Nicolò Pecorelli, Francesco Prato, Chiara Gritti, Raffaele Cerchione, Domenico Tamburrino, Stefano Partelli, Stefano Crippa, Michele Reni, Francesco De Cobelli, Massimo Falconi, Guarneri, Giovanni, Palumbo, Diego, Pecorelli, Nicolò, Prato, Francesco, Gritti, Chiara, Cerchione, Raffaele, Tamburrino, Domenico, Partelli, Stefano, Crippa, Stefano, Reni, Michele, De Cobelli, Francesco, and Falconi, Massimo

Subjects
Male, Fatty Liver, Pancreatic Neoplasms, Postoperative Complications, Oncology, Humans, Surgery, Adenocarcinoma, Tomography, X-Ray Computed, Pancreaticoduodenectomy
Abstract

Introduction Liver steatosis (LS) has been increasingly described in preoperative imaging of patients undergoing pancreaticoduodenectomy (PD). The aim of this study was to assess the impact of preoperative LS on complications after PD and identify possible contributors to LS development in this specific cohort. Methods Pancreatic head adenocarcinoma (PDAC) patients scheduled for PD, with preoperative CT-imaging available were included in the study. LS was defined as mean liver density lower than 45 Hounsfield units. Patients showing preoperative LS were matched for patient age, gender, BMI, ASA score, neoadjuvant treatment, and vascular and multivisceral resections, based on propensity scores in a 1:2 ratio to patients with no LS. The primary outcome was postoperative complication severity at 90 days as measured by the comprehensive complication index (CCI) Results Overall, 247 patients were included in the study. Forty-three (17%) patients presented with LS at preoperative CT-scan. After matching, the LS group included 37 patients, whereas the non-LS group had 74 patients. LS patients had a higher mean (SD) CCI, 29.7 (24.5) versus 19.5 (22.5), p = 0.035, and a longer length of hospital stay, median [IQR] 12 [8-26] versus 8 [7-13] days, p = 0.006 compared with non-LS patients. On multivariate analysis, variables independently associated with CCI were: LS (16% increase, p = 0.048), male sex (19% increase, p = 0.030), ASA score >= 3 (26% increase, p = 0.002), fistula risk score (FRS) (28% increase for each point of FRS, p = 0.001) and vascular resection (20% increase, p = 0.019). Conclusion Preliminary evidence suggests that preoperative LS assessed by CT-scan influences complication severity in patients undergoing PD for PDAC.

Published
2022

29. Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis

Author

Christoph Kuemmerli, Christoph Tschuor, Meidai Kasai, Adnan A Alseidi, Gianpaolo Balzano, Stefan Bouwense, Marco Braga, Mariëlle Coolsen, Sara K Daniel, Christos Dervenis, Massimo Falconi, Dae Wook Hwang, Daniel J Kagedan, Song Cheol Kim, Harish Lavu, Tingbo Liang, Daniel Nussbaum, Stefano Partelli, Michael J Passeri, Nicolò Pecorelli, Sastha Ahanatha Pillai, Venu G Pillarisetty, Michael J Pucci, Wei Su, Robert P Sutcliffe, Bobby Tingstedt, Marion van der Kolk, Dionisios Vrochides, Alice Wei, Caroline Williamsson, Charles J Yeo, Sabino Zani, Efstratios Zouros, Mohammed Abu Hilal, Kuemmerli, Christoph, Tschuor, Christoph, Kasai, Meidai, Alseidi, Adnan A, Balzano, Gianpaolo, Bouwense, Stefan, Braga, Marco, Coolsen, Mariëlle, Daniel, Sara K, Dervenis, Christo, Falconi, Massimo, Hwang, Dae Wook, Kagedan, Daniel J, Kim, Song Cheol, Lavu, Harish, Liang, Tingbo, Nussbaum, Daniel, Partelli, Stefano, Passeri, Michael J, Pecorelli, Nicolò, Pillai, Sastha Ahanatha, Pillarisetty, Venu G, Pucci, Michael J, Su, Wei, Sutcliffe, Robert P, Tingstedt, Bobby, van der Kolk, Marion, Vrochides, Dionisio, Wei, Alice, Williamsson, Caroline, Yeo, Charles J, Zani, Sabino, Zouros, Efstratio, and Abu Hilal, Mohammed

Subjects
COMPLICATIONS, Postoperative Complications/prevention & control, FAST-TRACK SURGERY, LENGTH-OF-STAY, Recovery of Function, Length of Stay, PANCREATIC SURGERY, Patient Readmission, Pancreaticoduodenectomy, PATHWAY, COLORECTAL SURGERY, Postoperative Complications, MANAGEMENT, IMPLEMENTATION, PROGRAM, Humans, Surgery, Pancreaticoduodenectomy/adverse effects, PERIOPERATIVE CARE, Enhanced Recovery After Surgery
Abstract

Background This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy.Methods The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission.Results Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate.Conclusion ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.Lay SummaryEnhanced recovery protocols consist of interdisciplinary interventions aimed at standardizing care and reducing the impact of surgical stress. They often include a short period of preoperative fasting during the night before surgery, early removal of lines and surgical drains, early food intake and mobilization out of bed on the day of surgery. This study gives a summary of reports assessing such care protocols in patients undergoing pancreatic head surgery, and assesses the impact of these protocols on functional recovery in an analysis of individual-patient data. The study revealed the true benefits of enhanced recovery protocols, including shorter time to food intake, earlier bowel activity, fewer complications after surgery, and a shorter hospital stay compared with conventional care.

Published
2021

31. Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein

Author

Nicolò Pecorelli, Giovanni Guarneri, Marco Palucci, Lorenzo Gozzini, Alessia Vallorani, Stefano Crippa, Stefano Partelli, Massimo Falconi, Pecorelli, Nicolò, Guarneri, Giovanni, Palucci, Marco, Gozzini, Lorenzo, Vallorani, Alessia, Crippa, Stefano, Partelli, Stefano, and Falconi, Massimo

Subjects
Male, Pancreatic neoplasms, Distal pancreatectomy, Amylase, C-reactive protein, Pancreaticoduodenectomy, Pancreatic Fistula, C-Reactive Protein, Pancreatectomy, Postoperative Complications, Risk Factors, Amylases, Drainage, Humans, Surgery, Biomarkers
Abstract

Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP.Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed.At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p 0.001), followed by serum amylase on POD 1 (0.651, p 0.001), serum CRP on POD3 (0.644, p 0.001), and CRP change between POD 2 and POD 3 (0.644, p 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p 0.001).Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.

Published
2021

32. Prognostic value of the Duke Activity Status Index (DASI) in patients undergoing colorectal surgery

Author

Charbel, El-Kefraoui, Fateme, Rajabiyazdi, Nicolò, Pecorelli, Franco, Carli, Lawrence, Lee, Liane S, Feldman, and Julio F, Fiore

Subjects
Male, Postoperative Complications, Surveys and Questionnaires, Humans, Female, Self Report, Middle Aged, Prognosis, Colorectal Surgery
Abstract

Complications are common after colorectal surgery and remain a target for quality improvement. Lower preoperative physical functioning is associated with poor postoperative outcomes, but assessment often relies on subjective judgment or resource-intensive tests. Recent literature suggests that self-reported functional capacity, measured using the Duke Activity Status Index (DASI), is a strong predictor of postoperative outcomes. This study aimed to estimate the extent to which DASI predicts 30-day complications after colorectal surgery.In this observational study, 100 patients undergoing colorectal resection [median age 63, 57% men, 81% laparoscopic, 37% rectal surgery] responded to DASI two weeks preoperatively. Complications were classified according to Clavien-Dindo and quantified using the comprehensive complication index (CCI). Our primary analysis targeted the relationship between preoperative DASI and odds of complications. Secondary analyses focused on 30-day severe complications, CCI, readmissions, and length of stay (LOS). We also explored the predictive ability of DASI with scores dichotomized based on a previously validated threshold (≤ 34).Mean preoperative DASI was 48 ± 12. Forty-six patients (46%) experienced 30-day complications (8% severe, CCI 9.6 ± 15). Lower DASI scores were associated with higher odds of complications (OR 1.08, 95%CI 1.03-1.14; p = 0.001). Preoperative DASI was also an independent predictor of severe complications, CCI, and readmissions. The predictive ability was supported when scores were dichotomized at ≤ 34.DASI is a significant predictor of postoperative complications after colorectal surgery. This questionnaire can be easily implemented in clinical practice to identify patients with low preoperative functional capacity and target interventions to those at higher risk.

Published
2021

33. Understanding the Meaning of Recovery to Patients Undergoing Abdominal Surgery

Author

Nancy E. Mayo, Susan Law, Fateme Rajabiyazdi, Liane S. Feldman, Luciana Dias Chiavegato, Aditya Pal, Nicolò Pecorelli, Lawrence Lee, Massimo Falconi, Yusuke Watanabe, Joel Montanez, Julio F. Fiore, Roshni Alam, Satoshi Hirano, Rajabiyazdi, F., Alam, R., Pal, A., Montanez, J., Law, S., Pecorelli, N., Watanabe, Y., Chiavegato, L. D., Falconi, M., Hirano, S., Mayo, N. E., Lee, L., Feldman, L. S., and Fiore, J. F.

Subjects
Laparoscopic surgery, Adult, Male, Pleasure, medicine.medical_specialty, medicine.medical_treatment, Psychological intervention, MEDLINE, Interviews as Topic, Leisure Activities, Patient-Centered Care, Abdomen, medicine, Humans, Meaning (existential), Postoperative Period, Life Style, Qualitative Research, Original Investigation, Aged, business.industry, General surgery, Convalescence, Recovery of Function, Middle Aged, Treatment Outcome, Functional Status, Surgical Procedures, Operative, Quality of Life, Surgery, Female, Laparoscopy, Thematic analysis, Complication, business, Stress, Psychological, Qualitative research, Abdominal surgery
Abstract

Importance Postoperative recovery is difficult to define or measure. Research addressing interventions aimed to improve recovery after abdominal surgery often focuses on measures such as duration of hospital stay and complication rates. Although these clinical parameters are relevant, understanding patients’ perspectives regarding postoperative recovery is fundamental to guiding patient-centered care. Objective To elucidate the meaning of recovery from the perspective of patients undergoing abdominal surgery. Design, Setting, and Participants This international qualitative study involved semistructured interviews with patients recovering from abdominal surgery from October 2016 to November 2018 in tertiary hospitals in 4 countries (Canada, Italy, Brazil, and Japan). A purposive maximal variation sampling method was used to ensure the recruitment of patients with varying demographic, clinical, and surgical characteristics. Data on race were not collected. Each interview lasted between 1 and 2 hours. Interviews were recorded and then transcribed verbatim. Transcripts were then analyzed using an inductive thematic analysis approach. Data analysis was conducted from July 2019 to September 2019. Main Outcomes and Measures The qualitative analysis revealed themes reflecting the meaning of recovery from the perspective of patients undergoing abdominal surgery. Results Thirty patients recovering from abdominal surgery were interviewed (15 [50%] female; mean [SD] age, 57 [18] years; 10 [33%] underwent major surgery; 16 [53%] underwent laparoscopic surgery). The interviews revealed that for patients undergoing abdominal surgery, the meaning of recovery embodied 5 overarching themes: (1) returning to habits and routines, (2) resolution of symptoms, (3) overcoming mental strains, (4) regaining independence, and (5) enjoying life. Themes associating the meaning of recovery to traditional parameters, such as earlier hospital discharge or absence of complications, were not identified in the interviews. Conclusions and Relevance This qualitative study suggests that the meaning of recovery from the perspective of patients undergoing abdominal surgery goes beyond traditional clinical parameters. The elements of recovery identified in this study should be taken into account in patient-surgeon discussions about recovery and when developing patient-centered strategies to improve postoperative outcomes.

Published
2021

34. Perioperative Nutritional Management of Elderly Patients

Author

Nicolò Pecorelli, Giovanni Guarneri, Maria Teresa Salvioni, and Alessia Vallorani

Subjects
medicine.medical_specialty, Surgical stress, business.industry, Perioperative, medicine.disease, Enteral administration, Malnutrition, Parenteral nutrition, Weight loss, Intervention (counseling), Medicine, medicine.symptom, Risk factor, business, Intensive care medicine
Abstract

The nutritional status of patients undergoing surgery is very relevant as it represents a modifiable risk factor for postoperative outcomes. Malnutrition is frequent among elderly patients, which often carry other overlapping conditions such as comorbidities and poor functional status. For this reason, it is very important to screen patients preoperatively for nutritional and functional status and tailor perioperative strategies accordingly. Malnourished patients can be identified through simple screening tools that include questions focused on BMI, weight loss, and dietary intake. Surgery may also be delayed to implement a nutritional intervention to potentially reduce postoperative morbidity. Preoperative nutritional interventions to enhance patient nutritional status aim at meeting an adequate protein target by improving diet or adding high-protein oral nutritional supplements, since proteins are the most used substrate in surgical stress situations. If the oral route is not effective, nutritional interventions include enteral feeding and parenteral nutrition.

Published
2021
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35. Prognostic value of the Duke Activity Status Index (DASI) in patients undergoing colorectal surgery

Author

Nicolò Pecorelli, Julio F. Fiore, Fateme Rajabiyazdi, Liane S. Feldman, Charbel El-Kefraoui, Lawrence Lee, Franco Carli, El-Kefraoui, C., Rajabiyazdi, F., Pecorelli, N., Carli, F., Lee, L., Feldman, L. S., and Fiore, J. F.

Subjects
medicine.medical_specialty, business.industry, Vascular surgery, Colorectal surgery, Cardiac surgery, Activity Status, Cardiothoracic surgery, Internal medicine, medicine, Surgery, Observational study, business, Complication, Abdominal surgery
Abstract

Background: Complications are common after colorectal surgery and remain a target for quality improvement. Lower preoperative physical functioning is associated with poor postoperative outcomes, but assessment often relies on subjective judgment or resource-intensive tests. Recent literature suggests that self-reported functional capacity, measured using the Duke Activity Status Index (DASI), is a strong predictor of postoperative outcomes. This study aimed to estimate the extent to which DASI predicts 30-day complications after colorectal surgery. Methods: In this observational study, 100 patients undergoing colorectal resection [median age 63, 57% men, 81% laparoscopic, 37% rectal surgery] responded to DASI two weeks preoperatively. Complications were classified according to Clavien–Dindo and quantified using the comprehensive complication index (CCI). Our primary analysis targeted the relationship between preoperative DASI and odds of complications. Secondary analyses focused on 30-day severe complications, CCI, readmissions, and length of stay (LOS). We also explored the predictive ability of DASI with scores dichotomized based on a previously validated threshold (≤ 34). Results: Mean preoperative DASI was 48 ± 12. Forty-six patients (46%) experienced 30-day complications (8% severe, CCI 9.6 ± 15). Lower DASI scores were associated with higher odds of complications (OR 1.08, 95%CI 1.03–1.14; p = 0.001). Preoperative DASI was also an independent predictor of severe complications, CCI, and readmissions. The predictive ability was supported when scores were dichotomized at ≤ 34. Conclusion: DASI is a significant predictor of postoperative complications after colorectal surgery. This questionnaire can be easily implemented in clinical practice to identify patients with low preoperative functional capacity and target interventions to those at higher risk.

Published
2021

36. Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Author

Benedetto, Ielpo, Mauro, Podda, Gianluca, Pellino, Pata, Francesco, Gianpiero, Gravante, Salomone Di Saverio, Gallo, Gaetano, Rashid, Lui, Adam, Orengia, Aditya, Chowdary, Aditya, Kulkarni, Adnan, Kuvvetli, Adolfo, Navarro, Adolfo, Pisanu, Adrian, Smith, Adriana Cavero Ibiricu, Aeris Jane, D Nacion, Ahmad, Alsaleh, Ahmad, Alhazmi, Ahmad, Elmabri, Ajaz, Wani, Ahmet, Rencuzogullari, Aingeru Sarriugarte Lasarte, Ainhoa Valle Rubio, Akshay, Bavikatte, Akshay, Kumar, Al-Radjid, Jamiri, Alain Michel Alvarado Padilla, Alban, Cacurri, Alberto de San Ildefonso, Alberto, Porcu, Alberto, Sartori, Aldo, Rocca, Alejandro Paz Yáñez, Alejandro, Becaria, Alejandro, Solís-Peña, Aleksandar, Sretenović, Alex, Urbistondo, Alfonso, Bandin, Alfonso, Najar, Alessandro De Luca, Alex, Boddy, Alexandros, Charalabopoulos, Alexios, Tzivanakis, Alfonso, Amendola, Alfredo Ramirez-Gutierrez de Velasco, Ali Cihat Yildirim, Alice, Frontali, Alpha Oumar Toure, Alvaro, García-Granero, Amaia Martínez Roldan, Amaia Sanz Larrainzar, Amila Sanjiva Ratnayake, Ana María Gonzalez-Ganso, Ana, M Minaya-Bravo, Andre, Das, Andrea, Bondurri, Andrea, Costanzi, Andrea, Lucchi, Andrea, Mazzari, Andrea, Musig, Andrea, Peloso, Andrea, Piano, Andrea, Police, Andrei, Mihailescu, Andrés, Pouy, Angela, Romano, Iossa, Angelo, Anna Carmen Leonetti, Anna, Guariniello, Anna, Isaac, Anna Pia Delli Bovi, Antonella, Chessa, Antonella, Tromba, Antonio Álvarez Martínez, Antonio, Brillantino, Antonio, Caira, Antonio, Castaldi, Antonio, Ferronetti, Antonio, Giuliani, Antonio, Prestera, Antonio Ramos-De la Medina, Antonio, Tarasconi, Antonino, Tornambè, Arcangelo, Picciariello, Argyrios, Ioannidis, Ari, Leppäniemi, Arshad, Khan, Arshad, Rashid, Arteaga Luis Eduardo Pérez-Sánchez, Ashok, Mittal, Ashrarur Rahman Mitul, Asif, Mehraj, Asim, Laharwal, Asnel, Dorismé, Athanasios, Marinis, Atif, Iqbal, Augusto, Moncada, Bartolomeo, Braccio, Basim, Alkhafaji, Beatriz de Andrés Asenjo, Beatriz, Martin-Perez, Belinda Sánchez Pérez, Ben, Creavin, Benedetto, Calì, Beniamino, Pascotto, Benjamin, Stubbs, Benjamin Zavala Retes, Branislav, Jovanovic, Brian Kp Goh, Bruno, Sensi, Carlo, Biddau, Carlo, Gazia, Carlo, Vallicelli, Carlos Alberto Fagundes, Carlos Cerdán Santacruz, Carlos, Chirico, Carlos Javier Gómez, Carlos, Petrola, Carlos Sánchez Rodriguez, Carlos Yánez Benítez, Carmelisa, Dammaro, Carmelo Lo Faro, Caroline, Reinke, Casandra Dominguez Paez, Catalina, Oliva, Charudutt, Paranjape, Charlotte, Thomas, Chi Fung Chia, Chi Kwan Kong, Chiara De Lucia, Christian Ovalle Chao, Claudio, Arcudi, Claudio, Guerci, Clement, Chia, Cristiano, Parise, Cristina, Folliero, Cristopher, Varela, Dalya, M Ferguson, Daniel, Camacho, Daniel, Popowich, Daniel Souza Lima, Daniela, Rega, Daniele, Delogu, Daniele, Zigiotto, Danilo, Vinci, Dario, D'Antonio, Dario, Parini, David Alessio Merlini, David DE Zimmerman, David, Moro-Valdezate, Davide, Pertile, Deborah Maria Giusti, Deborah, S Keller, Delko, Tarik, Denis, Kalivaçi, Dennis, Mazingi, Diana Gabriela Maldonado-Pintado, Diego, Sasia, Dimitrios, Linardoutsos, Dixon, Osilli, Domenico, Murrone, Domenico, Russello, Edgar, Rodas, Edisson Alberto Acuña Roa, Edoardo, Ricciardi, Edoardo, Rosso, Edoardo, Saladino, Eduardo, Flores-Villalba, Eduardo Ruiz Ajs, Eduardo, Smith-Singares, Efstratia, Baili, Efstratios, Kouroumpas, Eirini, Bourmpouteli, Eleftheria, Douka, Elena, Martin-Perez, Eleonora, Guaitoli, Elgun, Samadov, Elisa, Francone, Elisa, Vaterlini, Emilio, Morales, Emilio, Peña, Enhao, Zhao, Eneko Del Pozo Andres, Enrico, Benzoni, Enrico, Erdas, Enrico, Pinotti, Enrique, Colás-Ruiz, Erman, Aytac, Ernesto, Laterza, Ervis, Agastra, Esteban, Foianini, Esteban, Moscoso, Estefania, Laviano, Ester, Marra, Eugenia, Cardamone, Eugenio, Licardie, Eustratia, Mpaili, Eva, Pinna, Evaristo, Varo, Fabian Martín Navarro, Fabio, Marino, Fabio, Medas, Fabio, Romano, Fatlum, Maraska, Fatmir, Saliu, Fausto, Madrid, Fausto, Rosa, Federica, Mastella, Federico, Gheza, Federico, Luvisetto, Felipe, Alconchel, Felipe Monge Vieira, Felipe, Pareja, Ferdinando, Agresta, Fernanda, Luna, Fernando, Bonilla, Fernando, Cordera, Fernando, Burdió, Fernando, Mendoza-Moreno, Fernando Muñoz Flores, Fernando Pardo Aranda, Fiona, Taylor, Flavia, L Ramos, Flavio, Fernandes, Francesca Paola Tropeano, Francesco, Balestra, Francesco, Bianco, Francesco, Ceci, Francesco, Colombo, Francesco Di Marzo, Francesco, Ferrara, Francesco, Lancellotti, Francesco, Lazzarin, Francesco, Litta, Francesco, Martini, Francesco, Pizza, Francesco, Roscio, Francesco, Virdis, Francisco Blanco Antona, Francisco Cervantes Ramírez, Francisco Miguel Fernandez, Francisco Oliver Llinares, Francisco, Quezada, Francisco, Schlottmann, Gabriel, Herrera-Almario, Gabriel, Massaferro, Gabriele, Bislenghi, Gabrielle van Ramshorst, Gaetano, Gallo, Gaetano, Luglio, Georgios, Bointas, Georgios, Kampouroglou, Georgios, Papadopoulos, Gerardo Arredondo Manrique, Giacomo, Calini, Giacomo, Nastri, Giampaolo, Formisano, Giampaolo, Galiffa, Gian Marco Palini, Gianluca, Colucci, Gianluca, Pagano, Gianluca, Vanni, Gianmaria Casoni Pattacini, Gilda De Paola, Giorgio, Lisi, Giovanna, Partida, Giovanni, Bellanova, Giovanni De Nobili, Giovanni Sammy Necchi, Giovanni, Sinibaldi, Giovanni, Tebala, Giulia, Bagaglini, Giuliano, Izzo, Giulio, Argenio, Giuseppe, Brisinda, Giuseppe, Candilio, Giuseppe Di Grezia, Giuseppe, Esposito, Giuseppe, Faillace, Giuseppe, Frazzetta, Giuseppe La Gumina, Giuseppe, Nigri, Giuseppe, Romeo, Gloria Chocarro Amatriaín, Gloria, Ortega, Gonzalo, Martin-Martin, Gregor, A Stavrou, Gunadi, Gustavo Armand Ugon, Gustavo, Machain, Gustavo, Marcucci, Gustavo, Martínez-Mier, Gustavo Miguel Machain, Gustavo, Nari, Haydée, Calvo, Hamada, Fathy, Hamilto, Hazem, Ahmed, Hazem, Faraj, Hector, Nava, Hector Ordas Macias, Herald, Nikaj, Heriberto, Solano, Huma Ahmed Khan, Humberto Sánchez Alarcón, Husam, Ebied, Iacopo, Giani, Ibabe Villalabeitia Ateca, Ignacio, Neri, Igor Alberdi San Roman, Iliya, Fidoshev, Iñaki Martinez Rodriguez, Ionut, Negoi, Irene, Ortega, Irina, Bernescu, Iris Shari Russo, Irune Vincente Rodríguez, Irving, Palomares, Isaac, Baltazar, Isabel Jaén Torrejimeno, Isabel María Cornejo Jurado, Isabella, Reccia, Ishtiyaq, Hussain, Ismael Brito Toledo, Ismael, Mora-Guzmán, Iulia, Dogaru, Ivan, Romic, Izaskun, Balciscueta, J Cleo Kenington, Jackison, Sagolsem, Jae, Y Jang, James, Olivier, Jan, Lammel-Lindemann, Jana, Dziakova, Javier Ismael Roldán Villavicencio, Javier, Salinas, Jelena, Pejanovic, Jose Gustavo Parreira, Jovanovic, Jeny Rincón Pérez, Jeryl, Asreyes, Jesus Antonio Medina Luque, Joanna, Mak, Joanne Salas Rodriguez, Johnn Henry Herrera Kok, Jon, Krook, Jose Antonio Diaz-Elizondo, Jose, Castell, José Eduardo García-Flores, José María Jover Navalón, Jose Mauro Silva Rodrigues, José, Pereira, José Tomas Castell Gómez, Juan Bellido Luque, Juan Carlos Martín Del Olmo, Juan Carlos Salamea, Juan Francisco Coronel Olivier, Juan Luis Blas Laina, Juliana Maria Ordoñez, Julieta, Gutierrez, Julio, Abba, Junaid Ahmad Sofi, Kashaf, Sherafgan, Kapil, Sahnan, Katsuhiko, Yanaga, Kevin, Beatson, Laharwal, Asim, Laura, Alvarez, Leandro, Siragusa, Lee, Farber, Lester, Ong, Liarakos, Athanasios, Lorena, García-Bruña, Luca De Martino, Luca, Ferrario, Luca, Giordano, Luca, Gordini, Luca, Pio, Luca, Ponchietti, Lucia, Moletta, Luciano, Curella, Luciano, Poggi, Lucio, Taglietti, Luigi, Bonavina, Luigi, Conti, Luigi, Goffredi, Luis Angel Garcia Ruiz, Luis, Barrionuevo, Luis Enrique Fregoso, Luis, F Cabrera, Luis, G Rodriguez, Luis, Grande, Luis Gregorio Osoria, Luis Javier Kantun Gonzalez, Luis, Sánchez-Guillén, Luis, Tallon-Aguilar, Luis, Tresierra, Luisa, Giavarini, Mahmoud, Hasabelnabi, Maja, Odovic, Mamoru, Uemura, Mansoor, Khan, Manuel, Artiles-Armas, Mara, David, Marcello Di Martino, Marcello Giuseppe Spampinato, Marcelo A, F Ribeiro, Marcelo, Viola, Marco, Angrisani, Marco, Calussi, Marco, Cannistrà, Marco, Catarci, Marco, Cereda, Marco, Conte, Marco, Giordano, Marco, Pellicciaro, Marco Vito Marino, Maria, E Vaterlini, María, F Jiménez, María Giulia Lolli, Bellini, MARIA IRENE, Maria, Lemma, Maria Michela Chiarello, Maria, Nicola, Mario, Arrigo, Mario Caneda Mejia, Mario Montes Manrique, Mario, Rodriguez-Lopez, Mario, Serradilla-Martín, Mario Zambrano Lara, Marisa, Martínez, Mark, Bagnall, Mark, Peter, Marta Cañón Lara, Marta Jimenez Gomez, Marta, Paniagua-Garcia-Señorans, Marta Perez Gonzalez, Martin, Rutegård, Martin, Salö, Marzia, Franceschilli, Massimiliano, Silveri, Massimiliano, Veroux, Massimo, Pezzulo, Matteo, Nardi, Matteo, Rottoli, Matti, Tolonen, Mauricio Pedraza Ciro, Mauricio, Zuluagua, Maurizio, Cannavò, Maurizio, Cervellera, Maurizio, Iacobone, Mauro, Montuori, Melody García Domínguez, Meltem, Bingol-Kologlu, Mian, Tahir, Michael, Lim, Michael Sj Wilson, Michael, Wilson, Michela, Campanelli, Michele, Bisaccia, Michele De Rosa, Michele, Maruccia, Michele, Paterno, Michele, Pisano, Michele, Torre, Michele, Treviño, Michele, Zuolo, Miguel, A Hernandez Bartolome, Miguel, Farina, Miguel, Pera, Miguel Prieto Calvo, Milagros, Sotelo, Min Myat Thway, Mohamed, Hassan, Mohamed Salah Eldin Hassan, Mohammad, Azfar, Mohammad, Bouhuwaish, Mohammad, Taha, Mohammad, Zaieem, Mohammed, Korkoman, Montserrat, Guraieb, Mostafa, Shalaby, Muhammad Asif Raza, Muhammad Umar Younis, Muhammed, Elhadi, Mujahid Zulfiqar Ali, Nadeem, Quazi, Nagendra, N Dudi-Venkata, Nahar, Alselaim, Natasha, Loria, Nathalie Villan Ramírez, Nay Win Than, Neil, Smart, Nelson, Trelles, Nicanor, Pinto, Niccolò, Allievi, Niccolo, Petrucciani, Nicola, Antonacci, Nicola, Cillara, Nicolae, Gica, Nicolaescu Diana Cristiana, Nicolás, Nicolás, Nicolò, Falco, Nicolò, Pecorelli, Nicolò, Tamini, Nikolaos Andreas Dallas, Nikolaos, Machairas, Noelia, Brito, Nura Ahmed Fieturi, Nuria, Ortega, Octavio, Avilamercado, Oktay, Irkorucu, Omar, Alsherif, Orestes, Valles, Orestis, Ioannidis, Oscar Hernández Palmas, Oscar Isaac Hernandez Palmas, Oscar Sanz Guadarrama, Osman, Bozbiyik, Pablo, Omelanczuk, Pablo, Ottolino, Pablo, Rodrigues, Pablo, Ruiz, Paola, Campenni, Paola, Chiarade, Paola Prieto Olivares, Paolo, Baroffio, Pascal, Wintringer, Pasquale Di Fronzo, Pasquale, Talento, Pasqualino, Favoriti, Patricia, Sendino, Patrizia, Marsanic, Patricia, Mifsut, Paúl, Andrade, Pawel, Ajawin, Valentina, Ferri, Giuseppe Massimiliano de Luca, Sara, Ingallinella, Eva, Pueyo, Francesco, Palmieri, Jesus, Silva, Ken Min Chin, Nicholas, Syn, Brian K, P Goh, Ye Xin Koh, Valeria, Tonini, Ana, Gonzales-Ganso, Vicente, Simó, Maria Victoria Diago, Pedro, Abadía-Barnó, Pedro Alfonso Najar Castañeda, Pedro Omar Sillas Arevalos, Pedro Palazón Bellver, Peng Soon Koh, Petry, Souza, Piotr, Major, Rajandeep Singh Bali, Rakesh Mohan Khattar, Renato Bessa Melo, Reza, Ebrahiminia, Ricardo, Azar, Ricardo López Murga, Riccardo, Caruso, Riccardo, Pirolo, Richard, Brady, Richard Justin Davies, Rishi, Dholakia, Rishi, Rattan, Rishi, Singhal, Robert, Lim, Roberta, Angelico, Roberta Maria Isernia, Roberta, Tutino, Roberto, Faccincani, Roberto, Peltrini, Rocío, Carrera-Ceron, Rodrigo, Tejos, Rohit, Kashyap, Roosevelt, Fajardo, Rosa, Lozito, Royer Madariaga Pareja, Sabrina, Garbarino, Salvador, Morales-Conde, Sami, Benli, Sami, Mansour, Samir, Flores, Samuel Limon Suarez, Santiago Lopez Ben, Sara, Fuentes, Sara, Napetti, Sara Ortiz de Guzmán, Selmy, Awad, Sergio, A Weckmann Luján, Sergio, Gentilli, Sergio, Grimaldi, Sergio Olivares Pizarro, Serkan, Tayar, Shakeeb, Nabi, Shannon, M Chan, Sheikh, Junaid, Sidney, Rojas, Silvana, Monetti, Silvia, García, Silvia, Salvans, Silvia, Tenconi, Simon, Shaw, Simone, Santoni, Sofia Andrea Parra, Sofía, Cárdenas, Sonia, Pérez-Bertólez, Sonja, Chiappetta, Sophie, Dessureault, Spiros, Delis, Stefano Amore Bonapasta, Stefano, Rausei, Stefano, Scaringi, Sundeep, Keswani, Syed Muhammad Ali, Süleyman, Cetinkunar, Tak Lit Derek Fung, Tariq, Rawashdeh, Tatiana Nicolás López, Tercio De Campos, Teresa Calderon Duque, Teresa, Perra, Theodore, Liakakos, Theodoros, Daskalakis, Theodoros, Liakakos, Thomas, Barnes, Tijmen, Koëter, Tiku, Zalla, Tomás, E González, Tomás, Elosua, Tommaso, Campagnaro, Tommy, Brown, Topi, Luoto, Touré Alpha Oumar, Ugo, Giustizieri, Ugo, Grossi, Umberto, Bracale, Uriel, Rivas, Valentina, Sosa, Valentina, Testa, Valeria, Andriola, Valerio, Balassone, Valerio, Celentano, Valerio, Progno, Varun, Raju, Vanessa, Carroni, Venera, Cavallaro, Venkateswara Rao Katta, Veronica De Simone, Vicent Primo Romaguera, Victor Hugo García Orozco, Victor, Luraschi, Victor, Rachkov, Victor, Turrado-L, Victor, Visag-Castillo, Victoria, Dowling, Victoria, Graham, Vincenzo, Papagni, Vincenzo, Vigorita, Vinicius Cordeiro Fonseca, Virginia Jimenez Carneros, Vittoria, Bellato, Walyson, Gonçalves, William, F Powers, William, Grigg, Wolf, O Bechstein, Yu Bing Lim, Yuksel, Altinel, Zoran, Golubović, Zutoia, Balciscueta, Ielpo B., Podda M., Pellino G., Pata F., Caruso R., Gravante G., Di Saverio S., Gallo G., Lui R., Orengia A., Chowdary A., Kulkarni A., Kuvvetli A., Navarro A., Pisanu A., Smith A., Ibiricu A.C., Nacion A.J.D., Alsaleh A., Alhazmi A., Elmabri A., Wani A., Rencuzogullari A., Lasarte A.S., Rubio A.V., Bavikatte A., Kumar A., Jamiri A.-R., Padilla A.M.A., Cacurri A., de San Ildefonso A., Porcu A., Sartori A., Rocca A., Yanez A.P., Becaria A., Solis-Pena A., Sretenovic A., Urbistondo A., Bandin A., Najar A., De Luca A., Boddy A., Charalabopoulos A., Tzivanakis A., Amendola A., de Velasco A.R.-G., Yildirim A.C., Frontali A., Toure A.O., Garcia-Granero A., Roldan A.M., Larrainzar A.S., Ratnayake A.S., Gonzalez-Ganso A.M., Minaya-Bravo A.M., Das A., Bondurri A., Costanzi A., Lucchi A., Mazzari A., Musig A., Peloso A., Piano A., Police A., Mihailescu A., Pouy A., Romano A., Iossa A., Leonetti A.C., Guariniello A., Isaac A., Bovi A.P.D., Chessa A., Tromba A., Martinez A.A., Brillantino A., Caira A., Castaldi A., Ferronetti A., Giuliani A., Prestera A., la Medina A.R.-D., Tarasconi A., Tornambe A., Picciariello A., Ioannidis A., Leppaniemi A., Khan A., Rashid A., Perez-Sanchez A.L.E., Mittal A., Mitul A.R., Mehraj A., Laharwal A., Dorisme A., Marinis A., Iqbal A., Moncada A., Braccio B., Alkhafaji B., de Andres Asenjo B., Martin-Perez B., Perez B.S., Creavin B., Cali B., Pascotto B., Stubbs B., Retes B.Z., Jovanovic B., Goh B.K.P., Sensi B., Biddau C., Gazia C., Vallicelli C., Fagundes C.A., Santacruz C.C., Chirico C., Diaz C.J.G., Petrola C., Rodriguez C.S., Benitez C.Y., Dammaro C., Faro C.L., Reinke C., Paez C.D., Oliva C., Paranjape C., Thomas C., Chia C.F., Kong C.K., De Lucia C., Chao C.O., Arcudi C., Guerci C., Chia C., Parise C., Folliero C., Varela C., Ferguson D.M., Camacho D., Popowich D., Lima D.S., Rega D., Delogu D., Zigiotto D., Vinci D., D'Antonio D., Parini D., Merlini D.A., Zimmerman D.D.E., Moro-Valdezate D., Pertile D., Giusti D.M., Keller D.S., Tarik D., Kalivaci D., Mazingi D., Maldonado-Pintado D.G., Sasia D., Linardoutsos D., Osilli D., Murrone D., Russello D., Rodas E., Roa E.A.A., Ricciardi E., Rosso E., Saladino E., Flores-Villalba E., Ajs E.R., Smith-Singares E., Baili E., Kouroumpas E., Bourmpouteli E., Douka E., Martin-Perez E., Guaitoli E., Samadov E., Francone E., Vaterlini E., Morales E., Pena E., Zhao E., Andres E.D.P., Benzoni E., Erdas E., Pinotti E., Colas-Ruiz E., Aytac E., Laterza E., Agastra E., Foianini E., Moscoso E., Laviano E., Marra E., Cardamone E., Licardie E., Mpaili E., Pinna E., Varo E., Navarro F.M., Marino F., Medas F., Romano F., Maraska F., Saliu F., Madrid F., Rosa F., Mastella F., Gheza F., Luvisetto F., Alconchel F., Vieira F.M., Pareja F., Agresta F., Luna F., Bonilla F., Cordera F., Burdio F., Mendoza-Moreno F., Flores F.M., Aranda F.P., Taylor F., Ramos F.L., Fernandes F., Tropeano F.P., Balestra F., Bianco F., Ceci F., Colombo F., Di Marzo F., Ferrara F., Lancellotti F., Lazzarin F., Litta F., Martini F., Pizza F., Roscio F., Virdis F., Antona F.B., Ramirez F.C., Fernandez F.M., Llinares F.O., Quezada F., Schlottmann F., Herrera-Almario G., Massaferro G., Bislenghi G., van Ramshorst G., Luglio G., Bointas G., Kampouroglou G., Papadopoulos G., Manrique G.A., Calini G., Nastri G., Formisano G., Galiffa G., Palini G.M., Colucci G., Pagano G., Vanni G., Pattacini G.C., De Paola G., Lisi G., Partida G., Bellanova G., De Nobili G., Necchi G.S., Sinibaldi G., Tebala G., Bagaglini G., Izzo G., Argenio G., Brisinda G., Candilio G., Di Grezia G., Esposito G., Faillace G., Frazzetta G., La Gumina G., Nigri G., Romeo G., Amatriain G.C., Ortega G., Martin-Martin G., Stavrou G.A., Gunadi, Ugon G.A., Machain G., Marcucci G., Martinez-Mier G., Machain G.M., Nari G., Calvo H., Fathy H., Hamilto, Ahmed H., Faraj H., Nava H., Macias H.O., Nikaj H., Solano H., Khan H.A., Alarcon H.S., Ebied H., Giani I., Ateca I.V., Neri I., Roman I.A.S., Fidoshev I., Rodriguez I.M., Negoi I., Ortega I., Bernescu I., Russo I.S., Rodriguez I.V., Palomares I., Baltazar I., Torrejimeno I.J., Jurado I.M.C., Reccia I., Hussain I., Toledo I.B., Mora-Guzman I., Dogaru I., Romic I., Balciscueta I., Kenington J.C., Sagolsem J., Jang J.Y., Olivier J., Lammel-Lindemann J., Dziakova J., Villavicencio J.I.R., Salinas J., Parreira J.P.J.G., Jovanovic, Perez J.R., Reyes J.A.S., Luque J.A.M., Mak J., Rodriguez J.S., Kok J.H.H., Krook J., Diaz-Elizondo J.A., Castell J., Garcia-Flores J.E., Navalon J.M.J., Rodrigues J.M.S., Pereira J., Gomez J.T.C., Luque J.B., del Olmo J.C.M., Salamea J.C., Olivier J.F.C., Laina J.L.B., Ordonez J.M., Gutierrez J., Abba J., Sofi J.A., Sherafgan K., Sahnan K., Yanaga K., Beatson K., Asim L., Alvarez L., Siragusa L., Farber L., Ong L., Athanasios L., Garcia-Bruna L., De Martino L., Ferrario L., Giordano L., Gordini L., Pio L., Ponchietti L., Moletta L., Curella L., Poggi L., Taglietti L., Bonavina L., Conti L., Goffredi L., Ruiz L.A.G., Barrionuevo L., Fregoso L.E., Cabrera L.F., Rodriguez L.G., Grande L., Osoria L.G., Gonzalez L.J.K., Sanchez-Guillen L., Tallon-Aguilar L., Tresierra L., Giavarini L., Hasabelnabi M., Odovic M., Uemura M., Khan M., Artiles-Armas M., David M., Di Martino M., Spampinato M.G., Ribeiro M.A.F., Viola M., Angrisani M., Calussi M., Cannistra M., Catarci M., Cereda M., Conte M., Giordano M., Pellicciaro M., Marino M.V., Vaterlini M.E., Jimenez M.F., Lolli M.G., Bellini M.I., Lemma M., Chiarello M.M., Nicola M., Arrigo M., Mejia M.C., Manrique M.M., Rodriguez-Lopez M., Serradilla-Martin M., Lara M.Z., Martinez M., Bagnall M., Peter M., Lara M.C., Gomez M.J., Paniagua-Garcia-Senorans M., Gonzalez M.P., Rutegard M., Salo M., Franceschilli M., Silveri M., Veroux M., Pezzulo M., Nardi M., Rottoli M., Tolonen M., Ciro M.P., Zuluagua M., Cannavo M., Cervellera M., Iacobone M., Montuori M., Dominguez M.G., Bingol-Kologlu M., Tahir M., Lim M., Wilson M.S., Wilson M., Campanelli M., Bisaccia M., De Rosa M., Maruccia M., Paterno M., Pisano M., Torre M., Trevino M., Zuolo M., Hernandez Bartolome M.A., Farina M., Pera M., Calvo M.P., Sotelo M., Thway M.M., Hassan M., Hassan M.S.E., Azfar M., Bouhuwaish M., Taha M., Zaieem M., Korkoman M., Guraieb M., Shalaby M., Raza M.A., Younis M.U., Elhadi M., Ali M.Z., Quazi N., Dudi-Venkata N.N., Alselaim N., Loria N., Ramirez N.V., Than N.W., Smart N., Trelles N., Pinto N., Allievi N., Petrucciani N., Antonacci N., Cillara N., Gica N., Cristiana N.D., Krystek N., Falco N., Pecorelli N., Tamini N., Dallas N.A., Machairas N., Brito N., Fieturi N.A., Ortega N., Mercado O.A., Irkorucu O., Alsherif O., Valles O., Ioannidis O., Palmas O.H., Palmas O.I.H., Guadarrama O.S., Bozbiyik O., Omelanczuk P., Ottolino P., Rodrigues P., Ruiz P., Campenni P., Chiarade P., Olivares P.P., Baroffio P., Panaccio P., Wintringer P., Di Fronzo P., Talento P., Favoriti P., Sendino P., Marsanic P., Mifsut P., Andrade P., Ajawin P., Abadia-Barno P., Castaneda P.A.N., Arevalos P.O.S., Bellver P.P., Koh P.S., Souza P., Major P., Bali R.S., Khattar R.M., Melo R.B., Ebrahiminia R., Azar R., Murga R.L., Pirolo R., Brady R., Davies R.J., Dholakia R., Rattan R., Singhal R., Lim R., Angelico R., Isernia R.M., Tutino R., Faccincani R., Peltrini R., Carrera-Ceron R., Tejos R., Kashyap R., Fajardo R., Lozito R., Pareja R.M., Garbarino S., Morales-Conde S., Benli S., Mansour S., Flores S., Suarez S.L., Ben S.L., Fuentes S., Napetti S., de Guzman S.O., Awad S., Weckmann Lujan S.A., Gentilli S., Grimaldi S., Pizarro S.O., Tayar S., Nabi S., Chan S.M., Junaid S., Rojas S., Monetti S., Garcia S., Salvans S., Tenconi S., Shaw S., Santoni S., Parra S.A., Cardenas S., Perez-Bertolez S., Chiappetta S., Dessureault S., Delis S., Bonapasta S.A., Rausei S., Scaringi S., Keswani S., Ali S.M., Cetinkunar S., Fung T.L.D., Rawashdeh T., Lopez T.N., De Campos T., Duque T.C., Perra T., Liakakos T., Daskalakis T., Barnes T., Koeter T., Zalla T., Gonzalez T.E., Elosua T., Campagnaro T., Brown T., Luoto T., Oumar T.A., Giustizieri U., Grossi U., Bracale U., Rivas U., Sosa V., Testa V., Andriola V., Tonini V., Balassone V., Celentano V., Progno V., Raju V., Carroni V., Cavallaro V., Katta V.R., De Simone V., Romaguera V.P., Orozco V.H.G., Luraschi V., Rachkov V., Turrado-L V., Visag-Castillo V., Dowling V., Graham V., Papagni V., Vigorita V., Fonseca V.C., Carneros V.J., Bellato V., Goncalves W., Powers W.F., Grigg W., Bechstein W.O., Lim Y.B., Altinel Y., Golubovic Z., Balciscueta Z., Ielpo, B., Podda, M., Pellino, G., Pata, F., Caruso, R., Gravante, G., Di Saverio, S., Gallo, G., Lui, R., Orengia, A., Chowdary, A., Kulkarni, A., Kuvvetli, A., Navarro, A., Pisanu, A., Smith, A., Ibiricu, A. C., Nacion, A. J. D., Alsaleh, A., Alhazmi, A., Elmabri, A., Wani, A., Rencuzogullari, A., Lasarte, A. S., Rubio, A. V., Bavikatte, A., Kumar, A., Jamiri, A. -R., Padilla, A. M. A., Cacurri, A., de San Ildefonso, A., Porcu, A., Sartori, A., Rocca, A., Yanez, A. P., Becaria, A., Solis-Pena, A., Sretenovic, A., Urbistondo, A., Bandin, A., Najar, A., De Luca, A., Boddy, A., Charalabopoulos, A., Tzivanakis, A., Amendola, A., de Velasco, A. R. -G., Yildirim, A. C., Frontali, A., Toure, A. O., Garcia-Granero, A., Roldan, A. M., Larrainzar, A. S., Ratnayake, A. S., Gonzalez-Ganso, A. M., Minaya-Bravo, A. M., Das, A., Bondurri, A., Costanzi, A., Lucchi, A., Mazzari, A., Musig, A., Peloso, A., Piano, A., Police, A., Mihailescu, A., Pouy, A., Romano, A., Iossa, A., Leonetti, A. C., Guariniello, A., Isaac, A., Bovi, A. P. D., Chessa, A., Tromba, A., Martinez, A. A., Brillantino, A., Caira, A., Castaldi, A., Ferronetti, A., Giuliani, A., Prestera, A., la Medina, A. R. -D., Tarasconi, A., Tornambe, A., Picciariello, A., Ioannidis, A., Leppaniemi, A., Khan, A., Rashid, A., Perez-Sanchez, A. L. E., Mittal, A., Mitul, A. R., Mehraj, A., Laharwal, A., Dorisme, A., Marinis, A., Iqbal, A., Moncada, A., Braccio, B., Alkhafaji, B., de Andres Asenjo, B., Martin-Perez, B., Perez, B. S., Creavin, B., Cali, B., Pascotto, B., Stubbs, B., Retes, B. Z., Jovanovic, B., Goh, B. K. P., Sensi, B., Biddau, C., Gazia, C., Vallicelli, C., Fagundes, C. A., Santacruz, C. C., Chirico, C., Diaz, C. J. G., Petrola, C., Rodriguez, C. S., Benitez, C. Y., Dammaro, C., Faro, C. L., Reinke, C., Paez, C. D., Oliva, C., Paranjape, C., Thomas, C., Chia, C. F., Kong, C. K., De Lucia, C., Chao, C. O., Arcudi, C., Guerci, C., Chia, C., Parise, C., Folliero, C., Varela, C., Ferguson, D. M., Camacho, D., Popowich, D., Lima, D. S., Rega, D., Delogu, D., Zigiotto, D., Vinci, D., D'Antonio, D., Parini, D., Merlini, D. A., Zimmerman, D. D. E., Moro-Valdezate, D., Pertile, D., Giusti, D. M., Keller, D. S., Tarik, D., Kalivaci, D., Mazingi, D., Maldonado-Pintado, D. G., Sasia, D., Linardoutsos, D., Osilli, D., Murrone, D., Russello, D., Rodas, E., Roa, E. A. A., Ricciardi, E., Rosso, E., Saladino, E., Flores-Villalba, E., Ajs, E. R., Smith-Singares, E., Baili, E., Kouroumpas, E., Bourmpouteli, E., Douka, E., Martin-Perez, E., Guaitoli, E., Samadov, E., Francone, E., Vaterlini, E., Morales, E., Pena, E., Zhao, E., Andres, E. D. P., Benzoni, E., Erdas, E., Pinotti, E., Colas-Ruiz, E., Aytac, E., Laterza, E., Agastra, E., Foianini, E., Moscoso, E., Laviano, E., Marra, E., Cardamone, E., Licardie, E., Mpaili, E., Pinna, E., Varo, E., Navarro, F. M., Marino, F., Medas, F., Romano, F., Maraska, F., Saliu, F., Madrid, F., Rosa, F., Mastella, F., Gheza, F., Luvisetto, F., Alconchel, F., Vieira, F. M., Pareja, F., Agresta, F., Luna, F., Bonilla, F., Cordera, F., Burdio, F., Mendoza-Moreno, F., Flores, F. M., Aranda, F. P., Taylor, F., Ramos, F. L., Fernandes, F., Tropeano, F. P., Balestra, F., Bianco, F., Ceci, F., Colombo, F., Di Marzo, F., Ferrara, F., Lancellotti, F., Lazzarin, F., Litta, F., Martini, F., Pizza, F., Roscio, F., Virdis, F., Antona, F. B., Ramirez, F. C., Fernandez, F. M., Llinares, F. O., Quezada, F., Schlottmann, F., Herrera-Almario, G., Massaferro, G., Bislenghi, G., van Ramshorst, G., Luglio, G., Bointas, G., Kampouroglou, G., Papadopoulos, G., Manrique, G. A., Calini, G., Nastri, G., Formisano, G., Galiffa, G., Palini, G. M., Colucci, G., Pagano, G., Vanni, G., Pattacini, G. C., De Paola, G., Lisi, G., Partida, G., Bellanova, G., De Nobili, G., Necchi, G. S., Sinibaldi, G., Tebala, G., Bagaglini, G., Izzo, G., Argenio, G., Brisinda, G., Candilio, G., Di Grezia, G., Esposito, G., Faillace, G., Frazzetta, G., La Gumina, G., Nigri, G., Romeo, G., Amatriain, G. C., Ortega, G., Martin-Martin, G., Stavrou, G. A., Ugon, G. A., Machain, G., Marcucci, G., Martinez-Mier, G., Machain, G. M., Nari, G., Calvo, H., Fathy, H., Ahmed, H., Faraj, H., Nava, H., Macias, H. O., Nikaj, H., Solano, H., Khan, H. A., Alarcon, H. S., Ebied, H., Giani, I., Ateca, I. V., Neri, I., Roman, I. A. S., Fidoshev, I., Rodriguez, I. M., Negoi, I., Ortega, I., Bernescu, I., Russo, I. S., Rodriguez, I. V., Palomares, I., Baltazar, I., Torrejimeno, I. J., Jurado, I. M. C., Reccia, I., Hussain, I., Toledo, I. B., Mora-Guzman, I., Dogaru, I., Romic, I., Balciscueta, I., Kenington, J. C., Sagolsem, J., Jang, J. Y., Olivier, J., Lammel-Lindemann, J., Dziakova, J., Villavicencio, J. I. R., Salinas, J., Parreira, J. P. J. G., Perez, J. R., Reyes, J. A. S., Luque, J. A. M., Mak, J., Rodriguez, J. S., Kok, J. H. H., Krook, J., Diaz-Elizondo, J. A., Castell, J., Garcia-Flores, J. E., Navalon, J. M. J., Rodrigues, J. M. S., Pereira, J., Gomez, J. T. C., Luque, J. B., del Olmo, J. C. M., Salamea, J. C., Olivier, J. F. C., Laina, J. L. B., Ordonez, J. M., Gutierrez, J., Abba, J., Sofi, J. A., Sherafgan, K., Sahnan, K., Yanaga, K., Beatson, K., Asim, L., Alvarez, L., Siragusa, L., Farber, L., Ong, L., Athanasios, L., Garcia-Bruna, L., De Martino, L., Ferrario, L., Giordano, L., Gordini, L., Pio, L., Ponchietti, L., Moletta, L., Curella, L., Poggi, L., Taglietti, L., Bonavina, L., Conti, L., Goffredi, L., Ruiz, L. A. G., Barrionuevo, L., Fregoso, L. E., Cabrera, L. F., Rodriguez, L. G., Grande, L., Osoria, L. G., Gonzalez, L. J. K., Sanchez-Guillen, L., Tallon-Aguilar, L., Tresierra, L., Giavarini, L., Hasabelnabi, M., Odovic, M., Uemura, M., Khan, M., Artiles-Armas, M., David, M., Di Martino, M., Spampinato, M. G., Ribeiro, M. A. F., Viola, M., Angrisani, M., Calussi, M., Cannistra, M., Catarci, M., Cereda, M., Conte, M., Giordano, M., Pellicciaro, M., Marino, M. V., Vaterlini, M. E., Jimenez, M. F., Lolli, M. G., Bellini, M. I., Lemma, M., Chiarello, M. M., Nicola, M., Arrigo, M., Mejia, M. C., Manrique, M. M., Rodriguez-Lopez, M., Serradilla-Martin, M., Lara, M. Z., Martinez, M., Bagnall, M., Peter, M., Lara, M. C., Gomez, M. J., Paniagua-Garcia-Senorans, M., Gonzalez, M. P., Rutegard, M., Salo, M., Franceschilli, M., Silveri, M., Veroux, M., Pezzulo, M., Nardi, M., Rottoli, M., Tolonen, M., Ciro, M. P., Zuluagua, M., Cannavo, M., Cervellera, M., Iacobone, M., Montuori, M., Dominguez, M. G., Bingol-Kologlu, M., Tahir, M., Lim, M., Wilson, M. S., Wilson, M., Campanelli, M., Bisaccia, M., De Rosa, M., Maruccia, M., Paterno, M., Pisano, M., Torre, M., Trevino, M., Zuolo, M., Hernandez Bartolome, M. A., Farina, M., Pera, M., Calvo, M. P., Sotelo, M., Thway, M. M., Hassan, M., Hassan, M. S. E., Azfar, M., Bouhuwaish, M., Taha, M., Zaieem, M., Korkoman, M., Guraieb, M., Shalaby, M., Raza, M. A., Younis, M. U., Elhadi, M., Ali, M. Z., Quazi, N., Dudi-Venkata, N. N., Alselaim, N., Loria, N., Ramirez, N. V., Than, N. W., Smart, N., Trelles, N., Pinto, N., Allievi, N., Petrucciani, N., Antonacci, N., Cillara, N., Gica, N., Cristiana, N. D., Krystek, N., Falco, N., Pecorelli, N., Tamini, N., Dallas, N. A., Machairas, N., Brito, N., Fieturi, N. A., Ortega, N., Mercado, O. A., Irkorucu, O., Alsherif, O., Valles, O., Ioannidis, O., Palmas, O. H., Palmas, O. I. H., Guadarrama, O. S., Bozbiyik, O., Omelanczuk, P., Ottolino, P., Rodrigues, P., Ruiz, P., Campenni, P., Chiarade, P., Olivares, P. P., Baroffio, P., Panaccio, P., Wintringer, P., Di Fronzo, P., Talento, P., Favoriti, P., Sendino, P., Marsanic, P., Mifsut, P., Andrade, P., Ajawin, P., Abadia-Barno, P., Castaneda, P. A. N., Arevalos, P. O. S., Bellver, P. P., Koh, P. S., Souza, P., Major, P., Bali, R. S., Khattar, R. M., Melo, R. B., Ebrahiminia, R., Azar, R., Murga, R. L., Pirolo, R., Brady, R., Davies, R. J., Dholakia, R., Rattan, R., Singhal, R., Lim, R., Angelico, R., Isernia, R. M., Tutino, R., Faccincani, R., Peltrini, R., Carrera-Ceron, R., Tejos, R., Kashyap, R., Fajardo, R., Lozito, R., Pareja, R. M., Garbarino, S., Morales-Conde, S., Benli, S., Mansour, S., Flores, S., Suarez, S. L., Ben, S. L., Fuentes, S., Napetti, S., de Guzman, S. O., Awad, S., Weckmann Lujan, S. A., Gentilli, S., Grimaldi, S., Pizarro, S. O., Tayar, S., Nabi, S., Chan, S. M., Junaid, S., Rojas, S., Monetti, S., Garcia, S., Salvans, S., Tenconi, S., Shaw, S., Santoni, S., Parra, S. A., Cardenas, S., Perez-Bertolez, S., Chiappetta, S., Dessureault, S., Delis, S., Bonapasta, S. A., Rausei, S., Scaringi, S., Keswani, S., Ali, S. M., Cetinkunar, S., Fung, T. L. D., Rawashdeh, T., Lopez, T. N., De Campos, T., Duque, T. C., Perra, T., Liakakos, T., Daskalakis, T., Barnes, T., Koeter, T., Zalla, T., Gonzalez, T. E., Elosua, T., Campagnaro, T., Brown, T., Luoto, T., Oumar, T. A., Giustizieri, U., Grossi, U., Bracale, U., Rivas, U., Sosa, V., Testa, V., Andriola, V., Tonini, V., Balassone, V., Celentano, V., Progno, V., Raju, V., Carroni, V., Cavallaro, V., Katta, V. R., De Simone, V., Romaguera, V. P., Orozco, V. H. G., Luraschi, V., Rachkov, V., Turrado-L, V., Visag-Castillo, V., Dowling, V., Graham, V., Papagni, V., Vigorita, V., Fonseca, V. C., Carneros, V. J., Bellato, V., Goncalves, W., Powers, W. F., Grigg, W., Bechstein, W. O., Lim, Y. B., Altinel, Y., Golubovic, Z., Balciscueta, Z., Ielpo, B, Podda, M, Pellino, G, Pata, F, Caruso, R, Gravante, G, Di Saverio, S, and Luglio, G

Subjects
medicine.medical_specialty, Anti-Bacterial Agents, Appendectomy, Appendicitis, COVID-19 Testing, Hospital Administration, Humans, Pandemics, Personal Protective Equipment, Practice Patterns, Physicians', Surveys and Questionnaires, Attitude of Health Personnel, COVID-19, Surgeons, Coronavirus disease 2019 (COVID-19), Settore MED/18 - CHIRURGIA GENERALE, COVID-19 pandemic. Acute appendicitis, MEDLINE, Practice Patterns, 030230 surgery, Health administration, 03 medical and health sciences, 0302 clinical medicine, Anti-Bacterial Agent, Pandemic, medicine, Surveys and Questionnaire, Appendiciti, General, Laparoscopy, Personal protective equipment, Physicians', medicine.diagnostic_test, business.industry, General surgery, Original Articles, medicine.disease, Anti-bacterial agents, appendectomy, appendicitis, COVID-19 testing, hospital administration, humans, pandemics, personal protective equipment, practice patterns physicians', surveys and questionnaires, attitude of health personnel, surgeons, appendicitis - COVI-19 - ACIE study - management, Acute appendicitis, Original Article, Surgery, Covid-19, business, Human
Abstract

Background Surgical strategies are being adapted to face the COVID‐19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X‐ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P, The COVID‐19 pandemic required reorganization of surgical services, affecting patients with common surgical diseases including acute appendicitis. No evidence is available on the topic. This study found global variation in screening policies, use of personal protective equipment and intraoperative directives. There has been increased adoption of non‐operative management and open appendicectomy. Hands off

Published
2021

37. Impact of care pathway adherence on recovery following distal pancreatectomy within an enhanced recovery program

Author

Michele Mazza, Nicolò Pecorelli, Luigi Beretta, Giovanni Guarneri, Stefano Partelli, Renato Meani, Massimo Falconi, Gianpaolo Balzano, Stefano Turi, Roberto Delpini, Pecorelli, N., Mazza, M., Guarneri, G., Delpini, R., Partelli, S., Balzano, G., Turi, S., Meani, R., Beretta, L., and Falconi, M.

Subjects
medicine.medical_specialty, 030230 surgery, Perioperative Care, 03 medical and health sciences, 0302 clinical medicine, Pancreatectomy, Postoperative Complications, Enhanced recovery, Internal medicine, medicine, Clinical endpoint, Care pathway, Humans, Digestive System Surgical Procedures, Hepatology, business.industry, Gastroenterology, Postoperative complication, Perioperative, Length of Stay, Bowel surgery, 030220 oncology & carcinogenesis, Critical Pathways, Distal pancreatectomy, business, Complication
Abstract

Background: In bowel surgery, adherence to enhanced recovery program (ERP) has been associated with improved recovery. The objective of this study was to evaluate the impact of adherence to ERP elements on outcomes, and identify factors associated with successful recovery following distal pancreatectomy (DP). Methods: Data for 376 patients who underwent DP managed within an ERP including 16 perioperative elements were reviewed. Primary endpoint was successful recovery, a composite outcome defined as length of hospital stay≤7 days, no severe complications nor readmissions. Results: Patients had a mean (SD) overall adherence of 76 (14)%. Overall, 166 (44%) patients had a successful recovery. There was a positive association between overall adherence and successful recovery (OR 1.19, 95%CI 1.08–1.31 for every additional element, p = 0.001), while an inverse relationship was found with comprehensive complication index (8% reduction, 95%CI -15 to −2%, p = 0.011). Adherence to postoperative phase interventions had the greatest impact on recovery (OR 1.29, 95%CI 1.13–1.47 for every additional postoperative element; p < 0.001). At multivariable regression, early termination of IV fluids was the only ERP element associated with successful recovery (OR 2.80, 95%CI 1.73–4.54; p < 0.001). Conclusion: Increased adherence to ERP elements was associated with successful early recovery and reduction of postoperative complication severity.

Published
2020

38. R Status is a Relevant Prognostic Factor for Recurrence and Survival After Pancreatic Head Resection for Ductal Adenocarcinoma

Author

Massimo Falconi, Roberto Delpini, Domenico Tamburrino, G. Belfiori, Claudio Doglioni, Marco Schiavo Lena, Stefano Crippa, Michele Pagnanelli, Stefano Partelli, Nicolò Pecorelli, Fabio Giannone, Gianpaolo Balzano, Crippa, S., Giannone, F., Schiavo Lena, M., Belfiori, G., Partelli, S., Tamburrino, D., Delpini, R., Pagnanelli, M., Pecorelli, N., Balzano, G., Doglioni, C., and Falconi, M.

Subjects
Surgical margin, medicine.medical_specialty, medicine.medical_treatment, Breast Neoplasms, 030230 surgery, Pancreaticoduodenectomy, 03 medical and health sciences, 0302 clinical medicine, Surgical oncology, medicine.artery, Medicine, Humans, Superior mesenteric artery, Superior mesenteric vein, Retrospective Studies, business.industry, Hazard ratio, Histology, Prognosis, Pancreatic Neoplasms, Oncology, 030220 oncology & carcinogenesis, Resection margin, Surgery, Female, Radiology, Neoplasm Recurrence, Local, business, Carcinoma, Pancreatic Ductal
Abstract

Background: The prognostic role of resection margins in pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to investigate the impact that global and individual resection margin status after pancreatic head resection for PDAC has on disease-free survival (DFS) and disease-specific survival (DSS). Methods: Surgical specimens of pancreaticoduodenectomy/total pancreatectomy performed for PDAC were examined with a standardized protocol. Surgical margin status (biliary, pancreatic neck, duodenal, anterior and posterior pancreatic, superior mesenteric vein groove and superior mesenteric artery margins) was classified as the presence of malignant cells (1) directly at the inked surface (R1 direct), (2) within less than 1 mm (R1 ≤ 1 mm), or (3) with a distance greater than 1 mm (R0). Patients with a positive neck margin at the final histology were excluded from the study. Results: Of the 362 patients included in the study, 179 patients (49.4 %) had an R0 resection, 123 patients (34 %) had an R1 ≤ 1 mm resection, and 60 patients (16.6 %) had an R1 direct resection. The independent predictors of DFS were R1 direct resection (hazard ratio [HR], 1.49), R1 ≤ 1 mm resection (HR, 1.38), involvement of one margin (HR, 1.36), and involvement of two margins or more (HR, 1.55). When surgical margins were analyzed separately, only R1 ≤ 1 mm superior mesenteric vein margin (HR, 1.58) and R1 direct posterior margin (HR, 1.69) were independently associated with DFS. Conclusions: Positive R status is an independent predictor of DFS (R1 direct and R1 ≤ 1 mm definitions) and of DSS (R1 direct). The presence of multiple positive margins is a risk factor for cancer recurrence and poor survival. Different surgical margins could have different prognostic roles.

Published
2020

39. The impact of minimally invasive surgery on hospital readmissions, emergency department visits and functional recovery after distal pancreatectomy

Author

Michele Mazza, Stefano Crippa, Giovanni Guarneri, Kemal Alagol, Stefano Partelli, Massimo Falconi, Nicolò Pecorelli, Renato Castoldi, Gianpaolo Balzano, Roberto Quattromani, Pecorelli, N., Guarneri, G., Alagol, K., Mazza, M., Quattromani, R., Partelli, S., Crippa, S., Castoldi, R., Balzano, G., and Falconi, M.

Subjects
medicine.medical_specialty, Multivariate analysis, Pancreatic neoplasms, Distal pancreatectomy, Aftercare, 030230 surgery, Patient Readmission, law.invention, 03 medical and health sciences, 0302 clinical medicine, Pancreatectomy, Postoperative Complications, Randomized controlled trial, law, Internal medicine, medicine, Humans, Minimally Invasive Surgical Procedures, Laparoscopy, Retrospective Studies, medicine.diagnostic_test, business.industry, Emergency department, Postoperative recovery, Perioperative, Hepatology, medicine.disease, Patient Discharge, Surgery, Pancreatic Neoplasms, Readmissions, Treatment Outcome, Pancreatic fistula, 030211 gastroenterology & hepatology, business, Emergency Service, Hospital, Abdominal surgery
Abstract

Background: A recent RCT showed similar postoperative outcomes and a reduced time to functional recovery in patients undergoing minimally invasive distal pancreatectomy (DP) compared to open approach. However, it reported very-high post-discharge readmission rates, calling for further investigation. The aim of our study was to evaluate the extent to which minimally invasive surgery impacts on postoperative readmissions following DP. Methods: Clinical data for patients undergoing DP between 2011 and 2018 were reviewed. Primary outcome was hospital readmission at 90 days after surgery. Secondary outcomes included post-discharge emergency department (ED) visits and time to functional recovery. Regression analyses were performed to evaluate the impact of the laparoscopic approach and other perioperative factors. Results: Overall, 376 consecutive patients underwent DP during the study period. Laparoscopy was successfully performed in 219 (58%) patients. Overall, 62 patients (16.5%) returned to the ED after discharge, 41 (18.7%) of laparoscopically operated patients, and21 (13.4%) of those undergoing open surgery (p = 0.162). Forty-six (12.2%) of them required readmission, 31 (14.2%) after laparoscopic, and 15 (9.6%) after open procedures (p = 0.179). At multivariate regression, a low preoperative physical status (OR 2.3, 95% CI 1.2–4.7; p = 0.017), occurrence of pancreatic fistula (OR 6.8, 95% CI 2.9–15.9; p < 0.001), and post-pancreatectomy hemorrhage (OR 3.9, 95% CI 1.2–13.1; p = 0.025) were significantly associated with 90-day readmission, while laparoscopy had no impact. Median time to reach functional recovery was 5 (IQR 4–6) days. At multivariate analysis, laparoscopy reduced time to functional recovery by 13% (95% CI −19 to −6%; p < 0.001), time to adequate oral intake by 19% (95% CI −27 to −10%; p < 0.001), and time to adequate pain control by 12% (95% CI −18 to −5%; p < 0.001). Conclusion: Hospital readmissions and ED visits following DP were not influenced by the surgical approach. A low preoperative physical status, occurrence of postoperative pancreatic fistula and hemorrhage were significantly associated with post-discharge readmission within 90days.Laparoscopy reducedtimetofunctional recovery.

Published
2020

40. A four-step method to centralize pancreatic surgery, accounting for volume, performance and access to care

Author

Massimo Falconi, Nicolò Pecorelli, Gianpaolo Balzano, Gabriele Capurso, Michele Reni, Giovanni Guarneri, Balzano, G., Guarneri, G., Pecorelli, N., Reni, M., Capurso, G., and Falconi, M.

Subjects
Hospitals, Low-Volume, Population, MEDLINE, Accounting, Hospital performance, Health Services Accessibility, Health data, Pancreatic surgery, 03 medical and health sciences, 0302 clinical medicine, Humans, Medicine, Hospital Mortality, education, Digestive System Surgical Procedures, Retrospective Studies, education.field_of_study, Hepatology, business.industry, Gastroenterology, Retrospective cohort study, 030220 oncology & carcinogenesis, 030211 gastroenterology & hepatology, Christian ministry, business, Hospitals, High-Volume, Step method
Abstract

Background: Adequate criteria for pancreatic surgery centralization are debated. This retrospective study aimed to define a reproducible method for complex care centralization, accounting for hospital performance and access to care. Methods: The method consisted in: 1. Analysis of overall outcome and mortality-related factors. 2. Assessment of volume and adjusted mortality of each hospital. 3. Definition of different centralization models. 4. Final adjustments to guarantee access to care, evaluating travel times and waiting lists. This method was tested on Lombardy, the most populous Italian region (about 10 million inhabitants, 24 000 km2). Results: According to Ministry of Health data, 79 hospitals performed 3037 resections in 2014–2016. Mean overall mortality was 5.0%, increasing from 2.3%, of seven high-volume facilities (>30 resections/year) to 10.7% of 56 low-volume facilities (90% of the population), and limited impact on waiting list (1.1 extra-resection/hospital/week). Conclusion: The four-step method appears as a flexible tool to centralize pancreatic surgery, allowing regulatory institutions to estimate the effect of different models.

Published
2020

41. Pancreatic metastasis of papillary thyroid carcinoma with an intraductal growth pattern

Author

Massimo Falconi, Maria Chiara Petrone, Marco Schiavo Lena, Paolo Giorgio Arcidiacono, Nicolò Pecorelli, Claudio Doglioni, Gemma Rossi, Rossi, Gemma, Petrone, Maria Chiara, Schiavo Lena, Marco, Doglioni, Claudio, Pecorelli, Nicolò, Falconi, Massimo, and Arcidiacono, Paolo Giorgio

Subjects
Pancreatic Neoplasms, Thyroid carcinoma, Pancreatic metastasis, Thyroid Cancer, Papillary, business.industry, Gastroenterology, Cancer research, Humans, Medicine, Thyroid Neoplasms, business, Carcinoma, Pancreatic Ductal
Published
2020

42. Modelling centralization of pancreatic surgery in a nationwide analysis

Author

Salvatore Paiella, Gianpaolo Balzano, Giovanni Guarneri, Nicolò Pecorelli, Paola M.V. Rancoita, Massimo Falconi, Claudio Bassi, Balzano, G., Guarneri, G., Pecorelli, N., Paiella, S., Rancoita, P. M. V., Bassi, C., and Falconi, M.

Subjects
business.industry, Mortality rate, 030230 surgery, Pancreatic surgery, 03 medical and health sciences, 0302 clinical medicine, Hospital volume, 030220 oncology & carcinogenesis, Cohort, Medicine, Surgery, Christian ministry, NA, Pancreatic resection, business, Performance model, Demography
Abstract

Background The benefits of centralization of pancreatic surgery have been documented, but policy differs between countries. This study aimed to model various centralization criteria for their effect on a nationwide cohort. Methods Data on all pancreatic resections performed between 2014 and 2016 were obtained from the Italian Ministry of Health. Mortality was assessed for different hospital volume categories and for each individual facility. Observed mortality and risk-standardized mortality rate (RSMR) were calculated. Various models of centralization were tested by applying volume criteria alone or in combination with mortality thresholds. Results A total of 395 hospitals performed 12 662 resections; 305 hospitals were in the very low-volume category (mean 2·6 resections per year). The nationwide mortality rate was 6·2 per cent, increasing progressively from 3·1 per cent in very high-volume to 10·6 per cent in very low-volume hospitals. For the purposes of centralization, applying a minimum volume threshold of at least ten resections per year would lead to selection of 92 facilities, with an overall mortality rate of 5·3 per cent. However, the mortality rate would exceed 5 per cent in 48 hospitals and be greater than 10 per cent in 17. If the minimum volume were 25 resections per year, the overall mortality rate would be 4·7 per cent in 38 facilities, but still over 5 per cent in 17 centres and more than 10 per cent in five. The combination of a volume requirement (at least 10 resections per year) with a mortality threshold (maximum RSMR 5 or 10 per cent) would allow exclusion of facilities with unacceptable results, yielding a lower overall mortality rate (2·7 per cent in 45 hospitals or 4·2 per cent in 76 respectively). Conclusion The best performance model for centralization involved a threshold for volume combined with a mortality threshold.

Published
2020

43. Pancreaticoduodenectomy in octogenarians: The importance of 'biological age' on clinical outcomes

Author

Alessandro Zerbi, Riccardo Casadei, Andrea Coratti, Sara Nobile, Giovanni Butturini, Ugo Boggi, Claudio Fiorillo, Maria Chiara Petrone, Vincenzo Mazzaferro, Fausto Rosa, Giovanni Capretti, Giovanni Ferrari, Emanuele Federico Kauffmann, Roberta Menghi, Sergio Alfieri, Roberto Salvia, Nicolò Pecorelli, Massimo Falconi, Giuseppe Quero, Salvatore Paiella, Vito Laterza, Davide De Sio, Quero G., Pecorelli N., Paiella S., Fiorillo C., Petrone M.C., Capretti G., Laterza V., De Sio D., Menghi R., Kauffmann E., Nobile S., Butturini G., Ferrari G., Rosa F., Coratti A., Casadei R., Mazzaferro V., Boggi U., Zerbi A., Salvia R., Falconi M., and Alfieri S.

Subjects
Male, Aging, medicine.medical_specialty, Multivariate analysis, Settore MED/18 - CHIRURGIA GENERALE, Biological age, medicine.medical_treatment, Pancreatic surgery, Pancreaticoduodenectomy, Elderly, Pancreatic cancer, Age Factors, Aged, Aged, 80 and over, Carcinoma, Female, Humans, Italy, Logistic Models, Pancreatic Neoplasms, Postoperative Complications, Propensity Score, Treatment Outcome, Internal medicine, 80 and over, medicine, business.industry, Perioperative, medicine.disease, Oncology, Cohort, Propensity score matching, Surgery, business
Abstract

Introduction With the prolongation of life expectancy, an increasing number of elderly patients are evaluated for pancreatic surgery. However, the influence of increasing age on outcomes after pancreaticoduodenectomy (PD) is still unclear, especially in octogenarians. Aim of this study is to evaluate the perioperative characteristics and outcomes of octogenarians undergoing PD. Methods Data for 812 patients undergoing PD between 2019 and 2020 in 10 referral centers in Italy were reviewed. Patients aged 80 years or older were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients younger than 80 years. Propensity scores were calculated using 7 perioperative variables including gender, ASA score, neoadjuvant treatment (NAT), biliary stent positioning, type of surgical approach (open, laparoscopic, robot-assisted), associated vascular resections, type of lesion. Perioperative characteristics and short-term postoperative outcomes were compared before and after matching. Results Overall, 81 (10%) patients had 80 years or more. Before matching, octogenarians had a higher rate of ASA score≥ 3 (n = 35, 43.2% vs. n = 207, 28.3%; p = 0.005) and less frequently underwent NAT (n = 11, 13.6% vs. n = 213, 29.1%; p = 0.003). Matching was successfully performed for 70 octogenarians. After matching, no differences in preoperative and intraoperative characteristics were found. Postoperatively, ICU admission was more frequent in octogenarians (50% vs 30%; p = 0.01). Although in-hospital mortality was higher in octogenarians before matching (7.4% vs 2.9% in the younger cohort; p = 0.03), no difference was noted between the matched cohorts (p = 0.36). Postoperative morbidity was comparable between groups in the whole and selected populations. At the multivariate analysis, chronological age was not recognized as a prognostic factor for cumulative major complications, while ASA ≥3 was the only confirmed influencing feature (OR 2.98; 95%CI: 1.6–6.8; p = 0.009). Conclusio In high-volume centers, PD in octogenarians shows similar outcomes than younger patients. Age itself should not be considered an exclusion criterion for PD, but a focused preoperative assessment is essential for adequate patient selection.

Published
2022
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44. A Pancreatic Cystic Neoplasms Drama. Accuracy of Diagnostic Presumption and Surgical Indication on a Ten-year Experience

Author

P.G. Arcidiacono, S. Partelli, E. Longo, Fabio Giannone, Domenico Tamburrino, M. Schiavo Lena, Nicolò Pecorelli, Massimo Falconi, G. Belfiori, Stefano Crippa, and D. Palumbo

Subjects
medicine.medical_specialty, Hepatology, business.industry, Endocrinology, Diabetes and Metabolism, Presumption, General surgery, Gastroenterology, Medicine, business, Drama
Published
2021
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45. An app for patient education and self-audit within an enhanced recovery program for bowel surgery: a pilot study assessing validity and usability

Author

Julio F. Fiore, Barry Stein, Nicolò Pecorelli, Liane S. Feldman, Abarna Somasundram, Patrick Charlebois, Franco Carli, A. Sender Liberman, Pepa Kaneva, Pecorelli, N., Fiore, J. F., Kaneva, P., Somasundram, A., Charlebois, P., Liberman, A. S., Stein, B. L., Carli, F., and Feldman, L. S.

Subjects
Adult, Male, Clinical audit, medicine.medical_specialty, Intraclass correlation, Pilot Projects, Audit, 030230 surgery, Perioperative Care, 03 medical and health sciences, 0302 clinical medicine, Patient satisfaction, Cohen's kappa, Physical medicine and rehabilitation, Patient Education as Topic, Colorectal surgery, Outcome Assessment, Health Care, Humans, Medicine, Prospective Studies, Outcome and process assessment (health care), Enhanced recovery, Digestive System Surgical Procedures, Aged, Aged, 80 and over, Clinical Audit, business.industry, System usability scale, Reproducibility of Results, Usability, Middle Aged, Mobile Applications, Health education, Patient Satisfaction, 030220 oncology & carcinogenesis, Physical therapy, Patient Compliance, Female, Surgery, Self Report, business, Patient education
Abstract

Introduction: While patient engagement and clinical audit are key components of successful enhanced recovery programs (ERPs), they require substantial resource allocation. The objective of this study was to assess the validity and usability of a novel mobile device application for education and self-reporting of adherence for patients undergoing bowel surgery within an established ERP. Methods: Prospectively recruited patients undergoing bowel surgery within an ERP used a novel app specifically designed to provide daily recovery milestones and record adherence to 15 different ERP processes and six patient-reported outcomes (PROs). Validity was measured by the agreement index (Cohen’s kappa coefficient for categorical, and interclass correlation coefficient (ICC) for continuous variables) between patient-reported data through the app and data recorded by a clinical auditor. Acceptability and usability of the app were measured by the System Usability Scale (SUS). Results: Forty-five patients participated in the study (mean age 61, 64% male). Overall, patients completed 159 of 179 (89%) of the available questionnaires through the app. Median time to complete a questionnaire was 2min 49s (i.q.r. 2′32″–4′36″). Substantial (kappa > 0.6) or almost perfect agreement (kappa > 0.8) and strong correlation (ICC > 0.7) between data collected through the app and by the clinical auditor was found for 14 ERP processes and four PROs. Patient-reported usability was high; mean SUS score was 87 (95% CI 83–91). Only 6 (13%) patients needed technical support to use the app. Forty (89%) patients found the app was helpful to achieve their daily goals, and 34 (76%) thought it increased their motivation to recover after surgery. Conclusions: This novel application provides a tool to record patient adherence to care processes and PROs, with high agreement with traditional clinical audit, high usability, and patient satisfaction. Future studies should investigate the use of mobile device apps as strategies to increase adherence to perioperative interventions.

Published
2017
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46. Predictors of adherence to enhanced recovery pathway elements after laparoscopic colorectal surgery

Author

Juan Mata, Barry Stein, Julio F. Fiore, Nicolò Pecorelli, Liane S. Feldman, Sender Liberman, Patrick Charlebois, Mata, J., Fiore, J. F., Pecorelli, N., Stein, B. L., Liberman, S., Charlebois, P., and Feldman, L. S.

Subjects
Male, medicine.medical_specialty, Nausea, 030230 surgery, Perioperative Care, 03 medical and health sciences, 0302 clinical medicine, Clinical Protocols, Colorectal surgery, Internal medicine, medicine, Humans, Prospective Studies, Patient participation, Laparoscopy, Enhanced recovery, medicine.diagnostic_test, Postoperative recovery, business.industry, Middle Aged, Hepatology, Surgery, Adherence, 030220 oncology & carcinogenesis, Vomiting, Female, Guideline Adherence, medicine.symptom, business, Colorectal Surgery, Postoperative nausea and vomiting, Abdominal surgery
Abstract

Introduction: Enhanced recovery pathways (ERP) include a bundle of evidence-based preoperative, intraoperative, and postoperative interventions that together reduce morbidity and length of stay after colorectal surgery. Increased adherence with the bundle is associated with better postoperative outcomes, but adherence is lowest in the postoperative period. Identifying risk factors for lower adherence may help design quality improvement strategies. The aim of this study was to estimate the extent to which patient, procedural, and organizational factors predict adherence to postoperative ERP elements in laparoscopic colorectal surgery. Methods: Patients in an institutional ERP registry undergoing elective laparoscopic colorectal surgery between 2012 and 2014 were analyzed. The ERP included 10 postoperative ERP elements classified into 2 groups: those requiring patient participation (PP, 5 elements, including nutritional intake and mobilization) and those provided by the clinical team (CT, 5 elements, including removal of catheters and type of analgesia). The impact of baseline and intraoperative factors on adherence was estimated using stepwise linear regression. Results: A total of 223 patients were included (mean age 60, 48% male). Mean adherence was 79% to the PP bundle (range 65–93% for individual elements), and 82% for the CT bundle (range 68–98% for individual elements). The occurrence of nausea/vomiting in the first 24h was associated with lower adherence to both bundles. In the PP bundle, patients who arrived at the ward after 6p.m. had lower adherence. In the CT bundle, patients who had rectal resection had lower adherence while thoracic epidural was associated with higher adherence. Conclusions: With the exception of postoperative nausea and vomiting, predictors of adherence to ERP elements after colorectal surgery differed for elements requiring patient participation and those provided by the clinical team. Strategies to improve ERP adherence should target staff education and engagement of patients at risk for lower adherence.

Published
2017
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47. Ensuring Early Mobilization Within an Enhanced Recovery Program for Colorectal Surgery

Author

Petru Niculiseanu, Olivia Hershorn, Nicolò Pecorelli, Barry Stein, Tanya Castelino, Saba Balvardi, Patrick Charlebois, Julio F. Fiore, Liane S. Feldman, Franco Carli, Sender Liberman, and Nancy E. Mayo

Subjects
Male, medicine.medical_specialty, genetic structures, Colon, 030230 surgery, behavioral disciplines and activities, law.invention, 03 medical and health sciences, Postoperative Complications, 0302 clinical medicine, Randomized controlled trial, Enhanced recovery, law, Colon surgery, Early ambulation, Humans, Medicine, Digestive System Surgical Procedures, Early Ambulation, business.industry, Background data, Rectum, Middle Aged, Colorectal surgery, Treatment Outcome, 030220 oncology & carcinogenesis, Emergency medicine, Facilitation, Physical therapy, Early mobilization, Female, Surgery, business
Abstract

To estimate the extent to which the addition of staff-directed facilitation of early mobilization to an Enhanced Recovery Program (ERP) impacts recovery after colorectal surgery, compared with usual care.Early mobilization is considered an important component of ERPs but, despite guidelines recommendations, adherence remains quite low. The value of dedicating specific resources (eg, staff time) to increase early mobilization is unknown.This randomized trial involved 99 colorectal surgery patients in an established ERP (median age 63, 57% male, 80% laparoscopic) randomized 1:1 to usual care (including preoperative education about early mobilization with postoperative daily targets) or facilitated mobilization [staff dedicated to assist transfers and walking from postoperative days (PODs) 0-3]. Primary outcome was the proportion of patients returning to preoperative functional walking capacity (6-min walk test) at 4 weeks after surgery. We also explored the association of the intervention with in-hospital mobilization, time to achieve discharge criteria, time to recover gastrointestinal function, 30-day comprehensive complication index, and patient-reported outcome measures.In the facilitated mobilization group, adherence to mobilization targets was greater on POD0 [OR 4.7 (95% CI 1.8-11.9)], POD1 [OR 6.5 (95% CI 2.3-18.3)], and POD2 [OR 3.7 (95% CI 1.2-11.3)]. Step count was at least 2-fold greater on POD1 [mean difference 843.3 steps (95% CI 219.5-1467.1)] and POD2 [mean difference 1099.4 steps (95% CI 282.7-1916.1)] There was no between-group difference in recovery of walking capacity at 4 weeks after surgery [OR 0.77 (95% CI 0.30-1.97)]. Other outcome measures were also not different between groups.In an ERP for colorectal surgery, staff-directed facilitation of early mobilization increased out-of-bed activities during hospital stay but did not improve outcomes. This study does not support the value of allocating additional resources to ensure early mobilization in ERPs.ClinicalTrials.gov Identifier: NCT02131844.

Published
2017
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48. Goal-directed Fluid Therapy Does Not Reduce Primary Postoperative Ileus after Elective Laparoscopic Colorectal Surgery

Author

Barry Stein, Liane S. Feldman, Patrick Charlebois, Nicolò Pecorelli, David Mirzakandov, Alessandro Trainito, Gabriele Baldini, Franco Carli, Sender Liberman, and Juan C. Gómez-Izquierdo

Subjects
medicine.medical_specialty, medicine.diagnostic_test, Postoperative ileus, business.industry, 030208 emergency & critical care medicine, Perioperative, Colorectal surgery, Surgery, law.invention, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, Randomized controlled trial, Fluid therapy, 030202 anesthesiology, law, Anesthesia, medicine, Gastrointestinal function, Laparoscopy, business, Elective Surgical Procedure
Abstract

Background Inadequate perioperative fluid therapy impairs gastrointestinal function. Studies primarily evaluating the impact of goal-directed fluid therapy on primary postoperative ileus are missing. The objective of this study was to determine whether goal-directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Methods Randomized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Patients were assigned randomly to receive intraoperative goal-directed fluid therapy (goal-directed fluid therapy group) or fluid therapy based on traditional principles (control group). Primary postoperative ileus was the primary outcome. Results One hundred twenty-eight patients were included and analyzed (goal-directed fluid therapy group: n = 64; control group: n = 64). The incidence of primary postoperative ileus was 22% in the goal-directed fluid therapy and 22% in the control group (relative risk, 1; 95% CI, 0.5 to 1.9; P = 1.00). Intraoperatively, patients in the goal-directed fluid therapy group received less intravenous fluids (mainly less crystalloids) but a greater volume of colloids. The increase of stroke volume and cardiac output was more pronounced and sustained in the goal-directed fluid therapy group. Length of hospital stay, 30-day postoperative morbidity, and mortality were not different. Conclusions Intraoperative goal-directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program. Its previously demonstrated benefits might have been offset by advancements in perioperative care.

Published
2017
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49. Does Pancreatic Fat Really Really Matter In Determining Post-Operative Pancreatic Fistula?

Author

Michele Mazza, Stefano Partelli, Domenico Tamburrino, S. Mele, Massimo Falconi, Claudio Doglioni, Nicolò Pecorelli, M. Schiavolena, and Stefano Crippa

Subjects
medicine.medical_specialty, Hepatology, business.industry, Pancreatic fistula, Endocrinology, Diabetes and Metabolism, Gastroenterology, Medicine, Post operative, business, medicine.disease, Surgery
Published
2020
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50. Tumor size but not margin status is an indipendent prognostic factor for body/tail ductal adenocarcinoma after distal pancreatectomy

Author

G. Balzano, S. Partelli, Domenico Tamburrino, Giulia Gasparini, Nicolò Pecorelli, Claudio Doglioni, Fabio Giannone, Massimo Falconi, M. Schiavo Lena, Stefano Crippa, and G. Belfiori

Subjects
medicine.medical_specialty, Prognostic factor, Hepatology, Tumor size, business.industry, Endocrinology, Diabetes and Metabolism, Gastroenterology, medicine, Radiology, Ductal adenocarcinoma, Distal pancreatectomy, business, Margin status
Published
2020
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