A randomized double-blind trial on perioperative administration of probiotics in colorectal cancer patients

AIM:To investigate whether probiotic bacteria,given perioperatively,might adhere to the colonic mucosa, reduce concentration of pathogens in stools,and modulate the local immune function. METHODS:A randomized,double-blind clinical trial was carried out in 31 subjects undergoing elective colorectal resection for cancer.Patients were allocated to receive either a placebo(group A,n=10),or a dose of 10 7 of a mixture of Bifidobacterium longum(BB536) and Lactobacillus johnsonii(La1)(group B,n=11),or the same mixture at a concentration of 10 9 (group C,n=10).Probiotics,or a placebo,were given orally 2 doses/d for 3 d before operation.The same treatment continued postoperatively from day two to day four. Stools were collected before treatment,during surgery (day 0)and 5 d after operation.During the operation, colonic mucosa samples were harvested to evaluate bacterial adherence and to assess the phenotype of dendritic cells(DCs)and lymphocyte subsets by surface antigen expression(flow cytometry).The presence of BB536 and La1 was evaluated by the random amplified polymorphism DNA method with specific polymerase chain reaction probes. RESULTS:The three groups were balanced for baseline and surgical parameters.BB536 was never found at any time-points studied.At day 0,La1 was present in 6/10(60%)patients in either stools or by biopsy in group C,in 3/11(27.2%)in group B,and none in the placebo group(P=0.02,C vs A).There was a linear correlation between dose given and number of adher- ent La1(P=0.01).The rate of mucosal colonization by enterobacteriacae was 30%(3/10)in C,81.8%(9/11) in B and 70%(7/10)in A(P=0.03,C vs B).The Enterobacteriacae count in stools was 2.4(log10 scale) in C,4.6 in B,and 4.5 in A(P=0.07,C vs A and B). The same trend was observed for colonizing enterococ- ci.La1 was not found at day+5.We observed greater expression of CD3,CD4,CD8,and naive and memory lymphocyte subsets in group C than in group A with a dose response trend(C>B>A).Treatment didnot affect DC phenotype or activation,but after ex vivo stimulation with lipopolysaccharides,groups C and B had a lower proliferation rate compared to group A (P=0.04).Moreover,dendritic phenotypes CD83-123, CD83-HLADR,and CD83-11c(markers of activation) were significantly less expressed in patients colonized with La1(P=0.03 vs not colonized). CONCLUSION:La1,but not BB536,adheres to the colonic mucosa,and affects intestinal microbiota byreducing the concentration of pathogens and modulates local immunity.

Long-term outcomes after laparoscopic colectomy

AIM:To evaluate long-term outcomes in a large series of patients who randomly received laparoscopic or open colorectal resection.METHODS:From February 2000 to December 2004,six hundred sixty-two patients with colorectal disease were randomly assigned to laparoscopic(LPS,n = 330) or open(n = 332) colorectal resection.All patients were analyzed on an intention-to-treat basis.Long-term follow-up was carried out every 6 mo by office visits.In 526 cancer patients five-year overall and disease-free survival were evaluated.Median oncologic follow-up was 96 mo.RESULTS:Eight(4.2%) LPS group patients needed conversion to open surgery.Overall long-term morbidity rate was 7.6%(25/330) in the LPS vs 11.1%(37/332) in the open group(P = 0.17).In cancer patients,fiveyear overall survival was 68.6% in the LPS group and 64.0% in the Open group(P = 0.27).Excluding stage Ⅳ patients,five-year local and distant recurrence rates were 32.5% in the LPS group and 36.8% in the Open group(P = 0.36).Further,no difference in recurrence rate was found when patients were stratified according to cancer stage.CONCLUSION:LPS colorectal resection was associated with a slightly lower incidence of long-term complications than open surgery.No difference between groups was found in overall and disease-free survival rates.

Combined laparoscopic spleen-preserving distal pancreatectomy and islet autotransplantation for benign pancreatic neoplasm

AIM:To evaluate the safety and feasibility of laparoscopic spleen-preserving distal pancreatectomy(LSPDP)with autologous islet transplantation(AIT)for benign tumors of the pancreatic body-neck.METHODS:Three non-diabetic,female patients(age37,44 and 35 years,respectively)were declared candidates for surgery,between May and September 2011,because of pancreatic body/neck cystic lesions.The planned operation was an LSPDP associated with AIT from the normal pancreas distal to the neoplasm.Islets isolation was performed on the residual pancreatic parenchyma after frozen section examination of the margin.Purified autologous islets were infused into the portal vein by a percutaneous transhepatic approach the day after surgery.RESULTS:The procedure was performed successfully in all the three cases,and the spleen was preserved along with its vessels.Mean operation time was 283±52 min and average blood loss was 133±57 mL.Residual pancreas weights were 33,22 and 30 g,and105.200,40.390 and 94.790 islet equivalents were isolated,respectively.Surgical complications occurred in one patient(grade A pancreatic fistula).Postoperative stays were 6,6 and 7 d,respectively.Histopathological evaluation revealed mucinous cystic neoplasm in cases1 and 3,and serous cystic neoplasm in patient 2.No postoperative insulin administration was required.One patient developed a transient partial portal thrombosis2 mo after islet infusion.Patients are insulin independent at a mean follow up of 8±2 mo.CONCLUSION:Combination of LSPDP and AIT is feasible and could be effective to minimize the surgical impact for benign neoplasm of pancreatic body-neck.

Is there a role for treatment-oriented surgery in liver metastases from gastric cancer?

BACKGROUND Distant metastases are found in approximately 35%of patients with gastric cancer at their first clinical observation,and of these,4%-14%involves the liver.Unfortunately,only 0.4%-2.3%of patients with metastatic gastric cancer are eligible for radical surgery.Although surgical resection for gastric cancer metastases is still debated,there have been changes in recent years,although several clinical issues remain to be defined and that must be taken into account before surgery is proposed.AIM To analyze the clinicopathological factors related to primary gastric tumor and metastases that impact the survival of patients with liver metastatic gastric cancer.METHODS We performed a systematic review of the literature from 2000 to 2018 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.The study protocol was based on identifying studies with clearly defined purpose,eligibility criteria,methodological analysis,and patient outcome.RESULTS We selected 47 studies pertaining to the purpose of the review,which involved a total of 2304 patients.Median survival was 7-52.3 mo,median disease-free survival was 4.7-18 mo.The 1-,2-,3-,and 5-year overall survival(OS)was 33%-90.1%,10%-60%,6%-70.4%,and 0%-40.1%,respectively.Only five papers reported the 10-year OS,which was 5.5%–31.5%.The general recurrence rate was between 55.5%and 96%,and that for hepatic recurrence was between 15%and 94%.CONCLUSION Serous infiltration and lymph node involvement of the primary cancer indicate an unfavorable prognosis,while the presence of single metastasis or≤3 metastases associated with a size of<5 cm may be considered data that do not contraindicate liver resection.

Muscle Loss in Cancer Patients: Pathophysiology and Impact on the Outcome

A generalized loss of skeletal muscle can be associated with malnutrition, cancer, inflammation or neurodegenerative processes. Most cancer patients undergoing surgery are sarcopenic although only a minority of them suffer from severe weight loss. The cancer stage is a major determinant of sarcopenia, while nutritional factors seem to be less important. In cancer patients sarcopenia has been associated with a worse physical performance, a reduced response to chemotherapy and radiotherapy, a higher postoperative morbidity rate, and a reduced life expectancy.

Relation between skeletal muscle volume and prognosis in rectal cancer patients undergoing neoadjuvant therapy

The prognostic role of body composition indexes,and specifically sarcopenia,has recently been explored in different cancer types.However,conflicting results have been reported.Heterogeneity in cancer type,cancer stage or oncological treatments,as well as different methodology and definition of sarcopenia,could be accounted for different conclusions retrieved from literature.When focusing on colorectal cancer,it clearly appears that colon and rectal cancers are often treated as a single entity though they have different behaviors and treatments.Particularly,patients with advanced rectal cancer represent a peculiar group of patients that according to current guidelines are treated with neoadjuvant chemotherapy and radiotherapy followed by radical surgery.This review was restricted to a homogeneous group of patients with advanced lower rectal cancer and the aim of exploring whether there is a correlation between skeletal muscle depletion and prognosis.Literature was searched for articles related to patients with advanced rectal cancer undergoing neoadjuvant chemo-radiotherapy(NCRT)followed by radical surgery,in whom muscle mass and/or change in muscle mass during neoadjuvant treatment were measured.Eight full-text articles were selected and included in the present review.The main findings of our review were:(1)The majority of the studies defined sarcopenia as muscle mass alone over muscle strength or physical performance;(2)There was a great deal of heterogeneity in the definition and measures of sarcopenia,in the definition of cut-off values,and in the method to measure change in muscle mass;(3)There was not full agreement on the association between sarcopenia at baseline and/or after chemoradiotherapy and prognosis,and only few studies found a significance in the multivariate analysis;and(4)It seems that a loss in skeletal muscle mass during NCRT is associated with the worst outcomes in terms of disease-free survival.In conclusion,analysis of muscle mass might provide prognostic information on patients with rectal cancer,however more robust evidence is needed to define the role of muscle depletion and/or muscle change during neoadjuvant treatments,related to this specific group of patients.If a prognostic role would be confirmed by future studies,the role of preoperative intervention aimed at modifying muscle mass could be explored in order to improve outcomes.

Branching patterns of the left portal vein and consequent implications in liver surgery:The left anterior sector

To the Editor: There are still some open issues about the systematization of the knowledge of the branching of the left portal vein(LPV) and the division in anatomo-functional units within the left liver. The first controversial topic concerns the division of S4 in subsegments. The Brisbane 20 0 0 system of Nomenclature of Hepatic Anatomy and Resections(B20 0 0) [1] does not mention such subdivision, but in literature this is still a matter of discussion.

胃肠道肿瘤患者身体成分对预后的影响(详见光盘)

胃肠道肿瘤手术患者常出现肌肉减少症和内脏脂肪肥胖,研究表明:胰腺癌手术患者的肌肉减少症高达64%,且25%的患者存在体重丢失。身体体成分检测应添加到传统的营养评估中,肌肉减少症和内脏脂肪肥胖严重影响术后患者临床结局,总体死亡率增加、术后并发症增加以及长期生存降低。在各研究因素中,肿瘤所处的阶段是决定肌肉减少症的主要因素,患者本身的营养因素则并不是很重要。研究证明:肌肉减少性内脏脂肪肥胖是术后并发症及死亡率的重要预测因子。

加速康复和预康复在消化道肿瘤患者中的应用(详见光盘)

加速康复外科是采用有循证医学证据的围术期处理的一系列优化措施,以减少手术患者生理及心理的创伤应激,达到快速康复的目的。在胃肠肿瘤手术患者中的研究发现,采用加速康复外科有助于改善患者临床结局,包括降低严重并发症的发生率(12%vs.20%)、降低平均住院日(7vs.10days)、降低医疗费用(1,651欧元/人)。

Nutritional and Metabolic Support in Cancer Patients Undergoing Surgery

Substantial advances have been made in preoperative patient assessment,the reduction of postsurgical stress,and oral feeding recovery after surgery during the past few years.The use of“prehabilitation”protocols can improve the preoperative nutritional status of patients,optimizing their body composition and increasing their physical performance.Within enhanced recovery protocols,early oral feeding is possible following the majority of surgical procedures.When oral intake is not adequate,the enteral route is the first choice to nourish surgical patients,since the gut has been identified as a major regulator of the postoperative inflammatory response.The perioperative supplementation of nutrients with specific metabolic effects and the early recovery of oral feeding following surgery reduce the postoperative morbidity and shorten the hospital stay.

Nutrition Care and Minimally Invasive Pathway in Surgical Cancer Patients

Nutritional status is often neglected or under evaluated in patients with cancer,despite international guidelines suggest that nutritional deterioration negatively affects patients’survival.Preoperative malnutrition increases postoperative complications and mortality and prolongs hospital stay.Nutritional support must be given to undernourished cancer patients,as it can bring many clinical and economic advantages.Today,an inadequate nutritional support for cancer patients should be considered ethically unacceptable.Minimally invasive surgical techniques result in less operative blood loss,decreased surgical stress response,and less postoperative pain and discomfort.When associated to enhanced recovery pathway(ERP),a quicker recovery and a shorter hospital stay are obtained.Thus far,routine nutritional care and ERP have only been incorporated into the clinical practice in a minority of hospitals.Possible reasons are an insufficient awareness of the clinical relevance of undernutrition and a lack of structured collaboration between surgeons and clinical nutrition specialists.This review suggests that a better cooperation among healthcare providers,patients,and families would bring tremendous clinical benefits to patients with cancer,especially those undergoing surgery,radiotherapy,and chemotherapy.

Impact of Neoadjuvant Therapy on Body Composition and Prognosis in Rectal Cancer Patients

Objectives The aim of this study was to assess the impact of neoadjuvant chemo-radiotherapy (nCRT) on body composition in patients who subsequently underwent curative surgery for low rectal cancer. Methods Thirty-eight consecutive patients who underwent nCRT and subsequent laparoscopic proctectomy for locally advanced low rectal cancer have been studied. In all patients body composition was measured by computed tomography before and after nCRT. Pathology response on CRT, postoperative short-term outcome, overall and disease-free long-term survival were assessed. Results Twelve patients (31.5%) had skeletal muscle loss 2% after nCRT. No correlation was found between changes in body composition and postoperative complications. Skeletal muscle loss after nCRT significantly correlated with a shorter 5-year disease-free survival. Conclusion Preliminary data suggests that skeletal muscle loss after nCRT negatively impacted on disease-free survival in patients with locally advanced rectal cancer.