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BackgroundTransanal total mesorectal excision (TaTME) was introduced in 2009 as a dedicated approach for the treatment of mid-low rectal cancer. We aimed to describe and discuss the learning curve for 121 consecutive TaTME procedures performed by the same team.MethodsThe primary outcome was the number of operations required to decrease the mean operative time (mOT). The secondary outcomes were the number of operations required to decrease the major complication (MC) rate, the anastomotic leakage (AL) rate, the clinical anastomotic failure rate, and the reoperation rate. A cumulative sum (CUSUM) curve analysis was used to identify the inflection points. As an integrative analysis, Bernoulli CUSUM curves, risk-adjusted CUSUM curves based on the observed-expected outcomes, and CUSUM curves targeting results reported in the literature were created.ResultsSeventy-one cases were needed to overcome the OT learning curve sufficiently to reach mastery. The MC and reoperation rates started to decrease after the 54th case and further decreased after the 69th case. The AL rate started to decrease after the 27th case and remained stable at 5–5.1%. The comparison between the different phases of the learning curves confirmed these turning points.ConclusionsTaTME had a learning curve of 71 cases for the mOT, 55–69 cases for MCs and reoperation, and 27 cases for AL. According to our results, attention should be paid during the first part of the learning curve to avoid an increased rate of MCs and AL.

Background The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the “missing factor” that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery. Methods We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics. Results According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection. Conclusions The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.

Introduction The aim of this study is to compare short- and long-term outcomes of totally laparoscopic right colectomy (TLRC) and laparoscopically assisted right colectomy (LARC), using propensity score matching (PSM) analysis. Materials and methods A retrospective analysis of patients who underwent laparoscopic right colectomy between January 2006 and July 2016 was conducted. PSM analysis was performed to overcome patient selection bias between the two surgical techniques. Results A total of 116 patients were reviewed. After PSM, 54 patients for the TLRC group and 54 patients for the LARC group were compared. TLRC was associated with shorter post-operative hospital stay (6.81 vs. 4.79 days; p  < 0.001) with no difference in 30-day morbidity and mortality. A lower incidence of long-term incisional hernia was observed in the TLRC group (1.9 vs. 21.2%; p  = 0.002). TLRC showed better oncological accuracy as demonstrated by a greater number of lymph node achieved (19.21 vs. 15.19; p  = 0.001) and higher vascular pedicle length (131.81 vs. 114.76 mm; p  = 0.014). Discussion TLRC is a safe and feasible technique with similar results of LARC in terms of short-term morbidity and mortality. Major advantages related to TLRC are represented by shorter post-operative hospital stay and lower incidence of long-term incisional hernias. Further investigations are needed to assess the oncological outcomes for this technique.

Background Neoadjuvant chemoradiation therapy (nCRT) is the standard treatment modality in locally advanced rectal cancer (LARC). Since response to radiotherapy (RT) is dose dependent in rectal cancer, dose escalation may lead to higher complete response rates. The possibility to predict patients who will achieve complete response (CR) is fundamental. Recently, an early tumour regression index (ERI) was introduced to predict pathological CR (pCR) after nCRT in LARC patients. The primary endpoints will be the increase of CR rate and the evaluation of feasibility of delta radiomics-based predictive MRI guided Radiotherapy (MRgRT) model. Methods Patients affected by LARC cT2-3, N0-2 or cT4 for anal sphincter involvement N0-2a, M0 without high risk features will be enrolled in the trial. Neoadjuvant CRT will be administered using MRgRT. The initial RT treatment will consist in delivering 55 Gy in 25 fractions on Gross Tumor Volume (GTV) plus the corresponding mesorectum and 45 Gy in 25 fractions on the drainage nodes. Chemotherapy with 5-fluoracil (5-FU) or oral capecitabine will be administered continuously. A 0.35 Tesla MRI will be acquired at simulation and every day during MRgRT. At fraction 10, ERI will be calculated: if ERI will be inferior than 13.1, the patient will continue the original treatment; if ERI will be higher than 13.1 the treatment plan will be reoptimized, intensifying the dose to the residual tumor at the 11 th fraction to reach 60.1 Gy. At the end of nCRT instrumental examinations are to be performed in order to restage patients. In case of stable disease or progression, the patient will undergo surgery. In case of major or complete clinical response, conservative approaches may be chosen. Patients will be followed up to evaluate toxicity and quality of life. The number of cases to be enrolled will be 63: all the patients will be treated at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. Discussion This clinical trial investigates the impact of RT dose escalation in poor responder LARC patients identified using ERI, with the aim of increasing the probability of CR and consequently an organ preservation benefit in this group of patients. Trial registration ClinicalTrials.gov Identifier: NCT04815694 (25/03/2021).

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.

•Postoperative complications and length of hospital stay are major problems in surgery.•The ERAS program aims to ameliorate postoperative recovery, reducing complications, hospital stay, and consequently hospital costs.•A Nutritional Support in ERAS Program on Colorectal Cancer is proposed.•Clinical outcomes (postoperative complications and length of hospital stay) and cost effectiveness are improved.•If applied in large-volume centers adopting ERAS protocols, it may become a model to ameliorate care, further reducing hospital costs. Postoperative complications and length of hospital stay (LOS) are major issues and affect hospital costs. Enhanced Recovery After Surgery (ERAS) protocols are effective in reducing morbidity and LOS after major surgery. We propose a nutritional protocol within ERAS programs in colorectal surgery, starting from preadmission. We compared the ERAS + NutriCatt approach versus the ERAS standard program adopted in our center in the previous months. Complications, LOS, hospital readmission at 30 days, and late complications (at 90 days) were assessed and compared. A cost-effectiveness analysis was performed. A total of 114 patients were treated according to the ERAS program between April 2015 and January 2016; 105 were enrolled in the ERAS + NutriCatt protocol from February to September 2016; Patients' characteristics were similar in the two groups, except for American Society of Anesthesiologists score, which was significantly worse in the ERAS + NutriCatt cohort; preoperative diagnoses and surgical approaches were similar in the two periods. LOS was significantly inferior in the ERAS + NutriCatt protocol (4.9 ± 1.7 d; 95% confidence interval [CI] 4.60–5.28) compared with the standard ERAS program (6.1 ± 3.9 d, 95% CI 5.36–6.81) (P = 0.006), as were postoperative complications (36, 34.3% versus 55, 48.2%; P = 0.03). Complications within 90 d were 0 in ERAS + NutriCatt and 4 in the ERAS standard cohort. Cost-effectiveness analyses indicated savings in the ERAS + NutriCatt protocol. Nutritional care, starting from the preadmission visit, is able to reduce LOS, postoperative and late complications, and costs, in addition to ERAS standard items in colorectal surgery.

Background There is a clinical need to identify early predictors for response to neoadjuvant chemotherapy (NAC) in patients with gastric and gastroesophageal junction cancer (GC and GEJC). Radiomics involves extracting quantitative features from medical images. This study aimed to apply radiomics to build prediction models for the response to NAC. Methods All consecutive patients with non-metastatic GC and GEJC undergoing NAC and surgical resection in an Italian high-volume referral center between 2005 and 2021 were considered eligible. In patients selected, the CT scans performed upon staging were reviewed to segment the tumor and extract radiomic features using MODDICOM. The primary endpoint was to develop and validate radiomic-based predictive models to identify major responders (MR: tumor regression grade TRG 1–2) and non-responders (NR: TRG 4–5) to NAC. Following an initial feature selection, radiomic and combined radiomic-clinicopathologic prediction models were built for the MR or NR status based on logistic regressions. Internal validation was performed for each model. Radiomic models (in the entire case series and according to NAC regimens) were evaluated using the receiver operating characteristic area under the curve (AUC), sensitivity, and negative predictive value (NPV). Results The study included 77 patients undergoing NAC and subsequent tumor resection. The MR prediction model after all types of NAC (AUC of 0.876, CI 95% 0.786 − 0.966, sensitivity 83%, and NPV 96%) was based on a statistical feature. The models predicting NR among patients undergoing epirubicin with cisplatin and fluorouracil (ECF), epirubicin with oxaliplatin and capecitabin (EOX), or fluorouracil with oxaliplatin and docetaxel (FLOT) (AUC 0.760, CI 95% 0.639–0.882), oxaliplatin-based chemotherapy (AUC 0.810, CI 95% 0.692–0.928), and FLOT (AUC 0.907, CI 95% 0.818 − 0.995) were based on statistical, morphological and textural features. Conclusions The developed radiomic models resulted promising in predicting the response to different neoadjuvant chemotherapy strategies. Once further implemented on larger datasets, they could be valuable and cost-effective instruments to target multimodal treatment in patients with GC.

Purpose Male sex, high BMI, narrow pelvis, and bulky mesorectum were acknowledged as clinical variables correlated with a difficult pelvic dissection in colorectal surgery. This paper aimed at comparing pelvic biometric measurements in female and male patients and at providing a perspective on how pelvimetry segmentation may help in visualizing mesorectal distribution. Methods A 3D software was used for segmentation of DICOM data of consecutive patients aged 60 years, who underwent elective abdominal CT scan. The following measurements were estimated: pelvic inlet, outlet, and depth; pubic tubercle height; distances from the promontory to the coccyx and to S3/S4; distance from S3/S4 to coccyx’s tip; ischial spines distance; pelvic tilt; offset angle; pelvic inlet angle; angle between the inlet/sacral promontory/coccyx; angle between the promontory/coccyx/pelvic outlet; S3 angle; and pelvic inlet to pelvic depth ratio. The measurements were compared in males and females using statistical analyses. Results Two-hundred patients (M/F 1:1) were analyzed. Out of 21 pelvimetry measurements, 19 of them documented a significant mean difference between groups. Specifically, female patients had a significantly wider pelvic inlet and outlet but a shorter pelvic depth, and promontory/sacral/coccyx distances, resulting in an augmented inlet/depth ratio when comparing with males ( p  < 0.0001). The sole exceptions were the straight conjugate ( p  = 0.06) and S3 angle ( p =  0.17). 3D segmentation provided a perspective of the mesorectum distribution according to the pelvic shape. Conclusion Significant differences in the structure of pelvis exist in males and females. Surgeons must be aware of the pelvic shape when approaching the rectum.

Background Apolipoprotein E (ApoE) is a multifunctional protein playing both a key role in the metabolism of cholesterol and triglycerides, and in tissue repair and inflammation. The ApoE gene (19q13.2) has three major isoforms encoded by ε2, ε3 and ε4 alleles with the ε4 allele associated with hypercholesterolemia and the ε2 allele with the opposite effect. An inverse relationship between cholesterol levels and gastric cancer (GC) has been previously reported, although the relationship between a poE genotypes and GC has not been explored so far. Methods One hundred and fifty-six gastric cancer cases and 444 hospital controls were genotyped for apoE polymorphism (ε2, ε3, ε4 alleles). The relationship between GC and putative risk factors was measured using the adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) from logistic regression analysis. A gene-environment interaction analysis was performed. The effect of the apoE genotypes on survival from GC was explored by a Kaplan–Meier analysis and Cox proportional hazard regression model. Results Subjects carrying at least one apoE ε2 allele have a significant 60% decrease of GC risk (OR=0.40, 95% CI: 0.19 – 0.84) compared with ε3 homozygotes. No significant interaction emerged between the ε4 or ε2 allele and environmental exposures, nor ε2 or ε4 alleles affected the median survival times, even after correcting for age, gender and stadium. Conclusions Our study reports for the first time a protective effect of the ε2 allele against GC, that might be partly attributed to the higher antioxidant properties of ε2 compared with the ε3 or ε4 alleles. Given the study’s sample size, further studies are required to confirm our findings.

The aim of this study was to identify stage II colon cancer patients with a high risk of recurrence. All patients who underwent surgery for stage II colon cancer (CC) were retrospectively enrolled and sub-grouped according to TNM staging (IIa-b-c) and stage IIa in high (IIaHR) and low risk (IIaLR) according to pathologic features. The primary outcomes measured were the 5-year overall survival (OS) and disease-free survival (DFS). A total of 214 patients were reviewed. Only a maximum tumor diameter<4 cm in the IIaLR group was associated with a higher recurrence rate than a large tumor size (5-year DFS 71.7%vs.87.6%, p = 0.028). The DFS in the large IIaLR CC group was better than that in the IIaHR and IIb-c groups (5-year DFS: 92.7%vs.79.3%, p = 0.023). In contrast, the recurrence rate in the small IIaLR CC group was similar to that in the IIaHR, IIb-c stage CC group. In stage IIa CC evaluation of the tumor size as a prognostic factor may help identify patients who could benefit from additional postoperative therapy.