Endoscopic ultrasound and magnetic resonance imaging for re-staging rectal cancer after radiotherapy

AIM： To compare the sensitivity and specificity of two imaging techniques, endoscopic ultrasound （EUS） and magnetic resonance imaging （MRI）, in patients with rectal cancer after neoadjuvant chemoradiation therapy. And we compared EUS and MRI data with histological findings from surgical specimens. METHODS： Thirty-nine consecutive patients （51.3% Male; mean age： 68.2 ＋ 8.9 years） with histologically confirmed distal rectal cancer were examined for staging. All patients underwent EUS and MRI imaging before and after neoadjuvant chemoradiation therapy. RESULTS： After neoadjuvant chemoradiation, EUS and MRI correctly classified 46% （18/39） and 44% （17/39） of patients, respectively, in line with their histological T stage （P 〉 0.05）. These proportions were higher for both techniques when nodal involvement was considered： 69% （27/39） and 62% （24/39）. When patients were sorted into T and N subgroups, the diagnostic accuracy of EUS was better than MRI for patients with T0-T2 （44% vs 33%, P 〉 0.05） and NO disease （87% vs 52%, P = 0.013）. However, MRI was more accurate than EUS in T and N staging for patients with more advanced disease after radiotherapy, though these differences did not reach statistical significance. CONCLUSION： EUS and MRI are accurate imaging techniques for staging rectal cancer, However, after neoadjuvant RT-CT, the role of both methods in the assessment of residual rectal tumors remains uncertain.

TM6SF2 E167K variant predicts severe liver fibrosis for human immunodeficiency/hepatitis C virus co-infected patients, and severe steatosis only for a non-3 hepatitis C virus genotype

AIM To evaluate the impact of the Glu167Lys(E167K) transmembrane 6 superfamily member 2(TM6SF2) variant on the biochemical and morphologic expression of liver lesions in human immunodeficiency virus(HIV)/hepatitis C virus(HCV) co-infected patients.METHODS The study comprised 167 consecutive patients with HIV/HCV coinfection and biopsy-proven chronic hepatitis. A pathologist graded liver fibrosis and necroinflammation using the Ishak scoring system, and steatosis using Kleiner's scoring system. Patients were genotyped for TM6SF2 E167K(rs58542926) by real-time Polymerase chain reaction. The 167 patients, 35 therapy-naive and 132 receiving ART, were prevalently males(73.6%), the median age was 40.7 years and the immunological condition good(median CD4+ cells/mm3 = 505.5).RESULTS The 17 patients with the TM6SF2 E167 K variant, compared with the 150 with TM6SF2-E/E, showed higher AST(P = 0.02) and alanine aminotransferase(P = 0.02) and higher fibrosis score(3.1 ± 2.0 vs 2.3 ± 1.5, P = 0.05). In a multivariate analysis, TM6SF2 E167 K was independently associated with severe fibrosis. The same analysis showed that HCV-genotype 3, present in 42.2% of patients was an independent predictor of severe steatosis. The association of TM6SF2 E167 K with severe steatosis, absent for the whole group of 167 patients, was re-evaluated separately for HCVgenotype 3 and non-3 patients: No factor was independently associated with severe steatosis in the HCV-genotype-3 subgroup, whereas an independent association was observed between severe steatosis and TM6SF2 E167 K in non-3 HCV genotypes. No association between the TM6SF2 E167 K variant and severe liver necroinflammation was observed.CONCLUSION In HIV/HCV coinfection the TM6SF2 E167 K variant is an independent predictor of severe fibrosis, but appears to be independently associated with severe steatosis only for patients with a non-3 HCV genotype.

Enhanced recovery pathways in pancreatic surgery: State of the art

Pancreatic surgery is being offered to an increasing number of patients every year. Although postoperative outcomes have significantly improved in the last decades, even in high-volume centers patients still experience significant postoperative morbidity and full recovery after surgery takes longer than we think. In recent years, enhanced recovery pathways incorporating a large number of evidence-based perioperative interventions have proved to be beneficial i n t e r m s o f i m p rove d p o s t o p e ra t i ve o u t c o m e s, and accelerated patient recovery in the context of gastrointestinal, genitourinary and orthopedic surgery. The role of these pathways for pancreatic surgery is still unclear as high-quality randomized controlled trials are lacking. To date, non-randomized studies have shown that care pathways for pancreaticoduodenectomy and distal pancreatectomy are safe with no difference in postoperative morbidity, leading to early discharge and no increase in hospital readmissions. Hospital costs are reduced due to better organization of care and resource utilization. However, further research is needed to clarify the effect of enhanced recovery pathways on patient recovery and post-discharge outcomes following pancreatic resection. Future studies should be prospective and follow recent recommendations for the design and reporting of enhanced recovery pathways.

Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage:A critical analysis

Endoluminal vacuum-assisted therapy(EVT)has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients.Its application has been mainly reserved to low colorectal and colo-anal anastomoses.The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity,to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity.The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement,percutaneous drainage,endoscopic clipping of the anastomotic defect or stent placement.Nevertheless,despite this procedure is gaining acceptance among the surgical community,indications,inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous,making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure.Moreover,long-term and functional results are poorly reported.The present review is focused on critically analyzing the theoretical benefits and risks of the procedure,short-and long-term functional results and future direction in the application of EVT.

Prognostic role of ultrasonography staging in patients with anal cancer

BACKGROUND Carcinomas of the anal canal are staged according to the size and extent of the disease;however,we propose including a novel ultrasound(US)staging system,based on depth of tumor invasion.In this study the clinical American Joint Committee on Cancer(AJCC)staging guidelines and the US classificationss in patients with anal cancer were compared.AIM To evaluate the prognostic role of the US staging system in patients with anal cancer.METHODS The data of 48 patients with anal canal squamous cells carcinoma,observed at our University Hospital between 2007 and 2017,who underwent pre-treatment assessment with pelvic magnetic resonance imaging(MRI),total body computed tomography(CT)scan and endoanal US were retrospectively reviewed.Anal canal tumors were clinically staged according to AJCC,determined by MRI by measurement of the longest tumor diameter,and CT scan.Endoanal US was performed with a high multi-frequency(9-16 MHz),360°rotational mechanical probe;US classification was based on depth of tumor penetration through the anal wall,according to Giovannini’s study.All patients were treated with definitive radiation combined with 5-fluorouracile and Mitomycin-C.After treatment patients were followed-up regularly.RESULTS At baseline there were 30 and 32 T1-2,18 and 16 T3-4,31 and 19 N+patients classified according to the clinical AJCC and US staging system respectively.After a mean follow-up of 98 months,38 patients(79.1%)are alive and 28(58.3%)are disease free.During follow up 20 patients(41.6%)experienced recurrences.After univariate analysis,American Society of Anesthesiologists(ASA)score(P=0.00000001)and US staging(P=0.009)were significantly related to disease-free survival(DFS).When overall survival and DFS functions were compared,a statistically significant difference was observed for DFS survival when the US staging was applied with respect to the clinical AJCC staging.By combining the 2 significant prognostic variables,namely the US staging with the ASA score,four risks groups with different prognoses were identified.CONCLUSION Our findings suggest that US staging may be superior to traditional clinical staging,since it is significantly associated with DFS in anal cancer patients.

Innovative microsurgical treatment of male external genitals lymphedema

Secondary lymphedema of male external genital organs,characterized by increase in genital organs volume,tissue fibrosis,erysipelas,and objective difficulties in the normal use of lower limbs and the penis,is a very common and impairing consequence of invasive surgery,radical lymphadenectomy and radiotherapy of the pelvic-inguinal area.Standard surgical approach to lymphedema are either very invasive and/or at high risk of lymphedema recurrence and do not guarantee an efficient long-term treatment.Alternatively,we developed a microsurgical technique to perform direct anastomoses between the lymphatic collectors of the spermatic funiculum afferent to the external iliac chains and the vessels tributary to the spermatic vein.This innovative approach,although surgically demanding,provided a long term successful treatment of external genitals with no clinical complications,low invasivity,rapid post-surgical recovery,minor tissue demolition and satisfactory post-surgical functional and esthetic results.In addition,lympho-venous microsurgery seems to trigger the local development of new lymphatic vessels that notonly canalize along new collecting channels,but also form complex meshes in proximity to the anastomosis area,thus improving lymphedema also in adjacent tissues like lower limbs,supplied by lymphatics emptying into common developed lymphatic shunt.

Answer:vascular changes in age-related macular degeneration

We were very pleased by the paper of Borrelli and colleagues(1)and we would thank for their consideration.Nowadays,macular diseases,such as age-related macular degeneration(AMD)underwent a strong improvement in terms of pathophysiology understanding and treatments efficacy monitoring,thank to multimodal imaging techniques.These methodologies are reliable,feasible,easily reproducible,and provide very detailed microstructural information regarding retinal status in a non invasively way.Their introduction in clinical practice opened new frontiers for the ophthalmologists to face macular diseases.One of the most recently introduced technique is optical coherence tomography angiography(OCTA),which offered for the first time the opportunity to study in detail the retinal vascular network without the adoption of dye.Although multimodal imaging is mainly analyzed from the qualitative point of view,in the last years even more advanced quantitative approaches were introduced to further improve the amount of information reached by images analyses.In the context of OCTA,vessel density still represents the most used measure;it provides useful information regarding vascular deficits occurring in macular diseases(2).However,vessel density reductions resulted not pathognomonic of given retinal diseases.

Video-Assisted Anterior Retroperitoneal Approach to the Lumbar Spine. A Minimal Invasive Technique Improved by the Use of Endoscopic Camera to Treat Lumbar Spine Diseases

The anterior retroperitoneal approach is a technique to treat disc degenerative disease (DDD), spinal deformities, traumas, tumors and infections. It can be used to perform Anterior Lumbar Interbody Fusions (ALIF) or Total Disc Replacements (TDR). Though being a fast procedure that is becoming more often used by spinal surgeons, the anterior approach requires an adequate knowledge of the anatomy of the abdomen to lessen the risks of intraoperative complications. The authors’ preferred technique is the left retroperitoneal video-assisted approach, using an endoscope to visualize and magnify the deep anatomical structures, discectomy procedure and hardware implant. In a review of our casuistry from 2010 to 2012, 163 patients underwent an anterior lumbar approach, and 139 of these had a single L4-5 or L5-S1 level treatment. A 3.6% rate of global complications (1.44% of major vascular injuries) has been observed, with a mean operation time of 116.4 minutes and a mean blood loss of 156.1 ml. These values show how the anterior retroperitoneal video-assisted approach for the treatment of lumbar diseases is a fast procedure that implies low blood loss, with a low rate of intraoperative complications.

非诺多泮对接受心脏手术高危患者的肾保护作用:一项前瞻性、双盲、随机临床研究

Background-Acute renal failure is a serious complication of cardiac surgery causing high morbidity and mortality. The aim of this study was to evaluate the usefulness of fenoldopam, a specific agonist of the dopamine-1 receptor, in patients at high risk of perioperative renal dysfunction. Methods and Results-A prospective single-center, randomized, double-blind trial was performed after local ethical committee approval and after written consent was obtained from 80 patients undergoing cardiac surgery. Patients received either fenoldopam at 0.05 μg/kg per minute or dopamine at 2.5 μg/kg per minute after the induction of anesthesia for a 24-hour period. All these patients were at high risk of perioperative renal dysfunction as indicated by Continuous Improvement in Cardiac Surgery Program score >10. Primary end point was defined as 25%creatinine increase from baseline levels after cardiac surgery. The 2 groups(fenoldopam versus dopamine) were homogeneous cohorts, and no difference in outcome was observed. Acute renal failure was similar: 17 of 40(42.5%) in the fenoldopam group and 16 of 40(40%) in the dopamine group(P=0.9). Peak postoperative serum creatinine level, intensive care unit and hospital stay, and mortality were also similar in the 2 groups. Conclusions-Despite an increasing number of reports of renal protective properties from fenoldopam, we observed no difference in the clinical outcome compared with dopamine in a high-risk population undergoing cardiac surgery.

Increased risk of postsurgical macular edema in high stage idiopathic epiretinal membranes

Purpose:To assess the rate of occurrence and the risk factors of postsurgical macular edema(PSME)in eyes with idiopathic epiretinal membrane(iERM)or full-thickness macular hole(FTMH).Methods:Retrospective longitudinal analysis of all subjects scheduled for vitrectomy with or without combined cataract surgery over a 6-month period.Electronic medical charts and imaging data were analyzed preoperatively and at 1,3 and 6 months after surgery.Results:From 101 patients diagnosed with iERM or FTMH,71 patients were eligible for the study.Forty-nine eyes with iERM(69.0%)and 22 eyes with FTMH(31.0%)underwent vitrectomy either isolated(31.0%)or combined with cataract extraction(69.0%).The overall rate of PSME was 26.7%,without differences between the two groups(P=0.9479).Combined cataract extraction did not affect the overall occurrence of PSME rate in both groups(P=0.9255 in FTMH and P=0.8658 in iERM).If grouped by stage,eyes with stage 4 iERM though disclosed an increased rate of PSME(57.1%)compared to lower(1 to 3)stages(14.3%,P=0.0021),particularly when combined with cataract surgery(71.4%vs.15.4%in stages≤3,P=0.0021).The PSME odds ratio for a stage 4 iERM is 8(95%CI:1.933-33.1;P=0.0041)compared to stages 3 and below.Conclusions:PSME remains a clinically relevant and frequent event after surgery for iERM and FTMH.Patients with stage 4 iERM have an 8-fold higher likelihood of developing PSME in a 6-month postsurgical period compared to iERM in 1-3 stages,especially when combined with cataract extraction.

Radiological imaging and non-surgical local treatments for cholangiocarcinoma

Cholangiocarcinoma(CC)is a malignancy with a very heterogeneous spectrum of morphopathological and prognostic characteristics.Diagnostic imaging is fundamental for early detection,preoperative staging,and resectability assessment,as well as early recognition of prognostic factors.Radical surgical treatment is limited by disease stage and technical feasibility.Interventional radiology has acquired a critical function in addressing disease control and survival improvement through loco-regional therapies,specifically in the setting of intrahepatic CC.In this review,we will describe the current state of art of diagnostic imaging,focusing on intrahepatic CC and proximal extrahepatic CC,and delineate the available loco-regional therapies strategies for unresectable intrahepatic CC.