The multidisciplinary management of patients suffering from colorectal cancer (CRC) has significantly increased survival over the decades and surgery remains the only potentially curative option for it. However, despite the implementation of minimally invasive surgery and ERAS pathway, the overall morbidity and mortality remain quite high, especially in rural populations because of urban − rural disparities. The aim of the study is to analyze the characteristics and the surgical outcomes of a series of unselected CRC patients residing in two similar rural areas in Italy. A total of 648 consecutive patients of a median age of 73 years (IQR 64–81) was enrolled between 2017 and 2022 in a prospective database. Emergency admission (EA) was recorded in 221 patients (34.1

Retroperitoneal sarcomas are rare neoplasms . They frequently reach a very large size and invade adjacent organs before they are detected. Involvent of the inferior vena cava is uncommon. Distant metastases are a late feature. The mainstay of treatment is compartmental resection and contiguous organ resection. We report two cases of right-sided massive primary retroperitoneal leiomyosarcoma in pauci symptomatic women. In both cases treatment consisted of radical surgery. En bloc resection of the tumor and surrounding tissues and organs as well as part of the right wall of the subrenal IVC. To close the wall defect direct suture repair was used resulting in a reduced caliber but no hemodynamic sequelae or endoluminal thrombi. All the resection margins, including the inferi-or vena cava wall, were negative. The postoperative course was unremarkable and caval blood flow was optimal. The current gold standard treatment for retroperitoneal sarcoma is en bloc multivisceral resectionresection.

Chronic pancreatitis and pancreatic lithiasis, isolated or associated, are infrequent diseases in western countries. They are linked to alcohol abuse, cigarette smoking, repeated episodes of acute pancreatitis and hereditary genetic factors. They are characterised by persistent or recurrent epigastric pain, digestive insufficiency, steatorrhoea, weight loss and secondary diabetes. They are easily diagnosed with CT and MRI ultrasound, but are difficult to treat. Medical therapy is symptomatic for diabetes and digestive failure. Invasive treatment is indicated only for pain that cannot be treated otherwise. For lithiasic forms, the therapeutic goal of removing stones can be achieved with shockwave and endoscopy, obtaining fragmentation and extraction of the stones. When this does not happen and these aids have proved ineffective, surgery must be used either as a partial or total resection of the afflicted pancreas, or as a derivation in the intestine of the pancreatic duct dilated and obstructed by Wirsung-jejunal anastomosis. These invasive treatments are effective in 80% of cases, but burdened with complications in 10% and relapses in 5%. KEY WORDS: Chronic Pancreatitis, Chronic Pain, Pancreatic Lithiasis.

The aim of this study was to evaluate the safety and compliance with the enhanced recovery after surgery (ERAS) protocol in octogenarian patients undergoing colorectal surgery in 12 Italian high-volume centers. A retrospective analysis was conducted in a consecutive series of patients who underwent elective colorectal surgery between 2016 and 2018. Patients were grouped by age (≥ 80 years vs < 80 years), propensity score matching (PSM) analysis was performed, and the groups were compared regarding clinical outcomes and the mean number of ERAS items applied. Out of 1646 patients identified, 310 were octogenarians. PSM identified 2 cohorts of 125 patients for the comparison of postoperative outcomes and ERAS compliance. The 2 groups were homogeneous regarding the clinical variables and mean number of ERAS items applied (11.3 vs 11.9, p-ns); however, the application of intraoperative items was greater in nonelderly patients (p 0.004). The functional recovery was similar between the two groups, as were the rates of postoperative severe complications and 30-day mortality rate. Elderly patients had more overall complications. Furthermore, the mean hospital stay was higher in the elderly group (p 0.027). Multivariable analyses documented that postoperative stay was inversely correlated with the number of ERAS items applied (p < 0.0001), whereas age ≥ 80 years significantly correlated with the overall complication rate (p 0.0419). The ERAS protocol is safe in octogenarian patients, with similar levels of compliance and surgical outcomes. However, octogenarian patients have a higher rate of overall complications and a longer hospital stay than do younger patients.

Background Numerous research studies have looked into how the primary tumor location (PTL) affects patients’ prognosis for colorectal cancer (CRC). Our research aimed to investigate the prognostic effects of PTL in patients with synchronous (SM) and metachronous (MM) colorectal cancer liver metastases (CRCLM). Material and methods From 2016 to 2021, we looked back at the records of patients at our institute who were affected by CRCLM. Results 109 patients were included, of whom 21.1% received CRCLM resection (R0=73.9%), with 57.7% having left-sided colon cancer (LCC) and 42.2% having right-sided colon cancer (RCC). SM predominated (69.7%). The median duration of follow-up was 21,3 months (95%CI=15,4-25,2). ≥5 hepatic metastases prevailed in the SM group (N=61; 83.5%). 21% of all patients underwent CRCLM resection (R0=78.2%). We observed a double rate of patients unresponsive to standard systemic antineoplastic treatments in the SM group (35.8% vs. 17.9% of the MM group) (p=0.27). We found a significantly longer median overall survival (OS) in patients with MM-LCC compared with the other groups (27.7 months; HR=0.3797; 95%CI=0.19-0.74; p=0.0205). The median OS, regardless of PTL, was higher in the MM group (16,5 months vs. 16,1 months; HR=0,29; 95%CI=0,13-0,67; p=0.0038) as well as progression-free survival (PFS) (11 months vs. 10,2 months; HR=0,61; 95%CI=0,33-1,12; p=0.11). Finally, in patients undergoing liver surgery, a noteworthy median OS was shown to be significantly in favor of patients with metachronous liver metastases from the primary left tumor (37.0 months; HR=0.47; 95%CI=0.11-1.96; p=0.0041). Conclusions Our real-life study demonstrated that patients with LCC, particularly MM-LCC, have the highest survival and that the timing of CRCLM should be a prognostic factor.

Background The aim of this study was to investigate how the COVID-19 pandemic influenced ERAS program application in colorectal surgery across hospitals in the Lazio region (central district in Italy) participating in the "Lazio Network" project. Methods A multi-institutional database was constructed. All patients included in this study underwent elective colorectal surgery for both malignant and benign disease between January 2019 and December 2020. Emergency procedures were excluded. The population was divided into 2 groups: a pre-COVID-19 group (PG) of patients operated on between February and December 2019 and a COVID-19 group (CG) of patients operated on between February and December 2020, during the first 2 waves of the pandemic in Italy. Results The groups included 622 patients in the PG and 615 in the CG treated in 8 hospitals of the network. The mean number of items applied was higher in the PG (65.6% vs. 56.6%, p < 0.001) in terms of preoperative items (64.2% vs. 50.7%, p < 0.001), intraoperative items (65.0% vs. 53.3%, p < 0.001), and postoperative items (68.8% vs. 63.2%, p < 0.001). Postoperative recovery was faster in the PG, with a shorter time to first flatus, first stool, autonomous mobilization and discharge (6.82 days vs. 7.43 days, p = 0.021). Postoperative complications, mortality and reoperations were similar among the groups. Conclusions The COVID-19 pandemic had a negative impact on the application of ERAS in the centers of the "Lazio Network" study group, with a reduction in adherence to the ERAS protocol in terms of preoperative, intraoperative and postoperative items. In addition, in the CG, the patients had worse postoperative outcomes with respect to recovery and discharge.

Many studies have investigated the impact of primary tumor location (PTL) on the prognosis of colorectal cancer (CRC) patients. Our analysis aimed to evaluate the prognostic implications of PTL among patients (pts) with synchronous liver metastases (SM) and metachronous (MM) colorectal liver metastases (CRLM). We retrospectively reviewed the data of pts affected by CLRM from 2016 to 2021 at our institute. Overall survival (OS) and Progression-free survival (PFS) were investigated. 109 pts were included, median age 70 yrs (35-91), M/F= 66/43, RAS wt 37.6%, RAS mt 34.9%, 57.7% with left-sided colon cancer (LCC), 42.2% with right-sided colon cancer (RCC), 50.4% with only liver metastases (mets), 49.5% with hepatic + other mets, 21.1% underwent CRLM resection (R0=73.9%), 42.2% with SM-LCC, 27.5% with SM-RCC, 15.5% with MM-LCC and 14.6% with MM-RCC. SM were prevalent (n=76, 69.7%). The median duration of follow-up was 14 mos (1-98). The 1-yr and 2-yrs survival rates were higher in MM, MM-LCC, and all liver resected pts as listed below namely, respectively: 70.4% and 60.8% in all pts; 74.6% and 61.2% in LCC vs 65% and 61.8% of RCC (p=0.57); 72.5% and 67.7% in MM pts vs 69.5% and 57.5% of SM pts (p=0.63); 71.5% and 53.6% in resected SM-LCC pts vs both 66.7% of resected SM-RCC pts (p=0.95); both 84.6% in resected MM-LCC pts vs 62.5% and 54.7% of resected MM-RCC pts (p=0.23); 100% and 93.8% in pts undergoing liver resection vs 62.7% and 50.6% of pts with unresected liver (p=0.004); 64.9% and 43.9% in unresected SM-LCC pts vs both 62.5% of unresected SM-RCC pts (p=0.90); both 71.4% in unresected MM-LCC pts vs 53.8% and 43.1% of unresected MM-RCC pts (p=0.35). PTL had no influence on 2-yrs survival in all pts and OS in SM-RCC pts. The mOS in liver resected pts was higher in SM-LCC pts (21 vs 18 mos) and in MM-LCC pts (18.5 vs 15 mos). The best PFS in no liver resected pts was observed in the MM, SM-LCC, and in MM-LCC groups as follows: 8 months (mos) (95%CI=4-12) in all pts; 8 mos (95%CI=1-18) in LCC vs 8 mos (95%CI=4-12) of RCC (p=0.82); 11 mos (95%CI=8-14) in MM vs 5 mos (95%CI=1-19) of SM (p=0. 42); 10 mos (95%CI=7-13) of SM-LCC vs 7 mos of SM-RCC (95%CI=2-11) (p=0.59); 12 mos (95%=1-31) of MM-LCC vs 5 mos (95%CI=1-11) of MM-RCC (p=0.34). Our real-life study identified the timing of liver metastases as a prognostic factor and showed that pts with LCC and especially MM-LCC have the higher survival.

BACKGROUND:ERAS implementation improved outcomes in patients undergoing colorectal surgery. The process of incorporating this pathway in clinical practice may be challenging. This observational study investigated the impact of systematic ERAS implementation on surgical outcomes in patients undergoing colorectal resections in a regional network of 10 institutions.METHODS:Implementation of ERAS pathway was designed using regular audits and a common protocol. All patients undergoing elective colorectal surgery between 2016 and 2017 were considered eligible. A collective database including 18 ERAS items, clinical and surgical data, and outcomes was designed. Univariate and multivariate analyses were performed for the following outcomes: morbidity, anastomotic leak, reinterventions, hospital stay, and readmissions.RESULTS:A total of 827 patients were included, and a mean of 11.3 ERAS items applied/patient was reported. Logistic regression indicated that an increased number of ERAS items applied reduced overall and severe morbidity (OR 0.86 and 0.87, respectively 95%CI 0.8197-0.9202 and 95%CI 0.7821-0.9603), hospitalization (OR 0.53 95%CI 0.4917-0.5845) and reinterventions (OR 0.84 95%CI 0.7536-0.9518) in the entire series. The same results were obtained for a prolonged hospitalization differentiating right-sided (OR 0.48 95%CI 0.4036-0.5801), left-sided (OR 0.48 95%CI 0.3984-0.5815), and rectal resections (OR 0.46 95%CI 0.3753-0.5851). An inverse correlation was found between the application of ERAS items and morbidity in right-sided and rectal procedures (OR 0.89 and 0.84, respectively 95%CI 0.7976-0.9773 and 95%CI 0.7418-0.9634).CONCLUSIONS:Systematic implementation of the ERAS pathway using multi-institutional audits can increase protocol adherence and improve surgical outcomes in patients undergoing colorectal surgery.

In patients with biliary papillomatosis, complete resection of the biliary tree (that is, liver transplant along with duodenocephalo-pancreatectomy) is considered the only potential curative treatment, given its diffuse pattern and likelihood of malignant transformation. Nevertheless, such a combined surgical approach can increase patient morbidity and mortality and should be considered only when the distal part of the common bile duct is involved. Here, we avoided duodenocephalo-pancreatectomy in a patient with distal common bile duct free from disease; this approach did not negatively influence survival and appeared to be safer during liver transplant.

Host genetic modifiers of the natural history of chronic hepatitis B (CHB) remain poorly understood. Recently, a genome‐wide association study (GWAS)‐identified polymorphism in the STAT4 gene that contributes to the risk for hepatocellular carcinoma (HCC) was shown to be associated with the full spectrum of hepatitis B virus (HBV) outcomes in Asian patients. However, the functional mechanisms for this effect are unknown and the role of the variant in modulating HBV disease in Caucasians has not been investigated.

Reoperation on malignant tumors of the pancreatic stump remaining from a previous resection for cancer is very rare. The literature reports few cases in which the tumors were mostly made up of intraductal papillary mucinous neoplasm (IPMN) sometimes associated with invasive carcinoma or adenocarcinoma (PDAC). One of those rare cases has come to our attention: a 62-year-old man, anicteric, with a massive tumor of the head of the pancreas 11x7x5, subjected to DCP for IPMN-MD with isolated areas of invasive cancer, misinterpreted at the beginning as PDAC. Nine years later, with markers remaining negative, it was reoperated on a total Pancreatectomy for recurrence of the same cancer of the pancreatic stump, despite negative lymph nodes. 15 years after the first surgery and 6 years after the second operation the patient is alive, healthy, diabetic, but disease free. The case is an opportunity to discuss the biological, epidemiological, therapeutic and prognostic differences between invasive carcinoma, developed on intraductal papillary mucinous tumors, and tubular primitive pancreatic adenocarcinoma.

SummaryBackgroundPatients with thalassaemia major depend on blood transfusions. In Italy, up to 80% of thalassaemia patients bear HCV antibodies due to HCV contaminated transfusions before 1990. Thalassaemia patients with HCV infection have high risk of developing HCC. Treatment based on Pegylated‐IFN (Peg‐IFN) and Ribavirin (RBV) was limited by relevant side effects.AimTo evaluate the impact of Sofosbuvir/Ledipasvir (SOF/LDV) fixed dose combination for 12 weeks without RBV, in patients with thalassaemia major and HCV Genotype 1 or 4 (GT1/4).MethodsOpen label, historically‐controlled, nationwide multicentre study in thalassaemia patients including naïve with cirrhosis and prior treatment failure without cirrhosis. SOF/LDV single pill was administered for 12 weeks to 100 patients of whom 16% had cirrhosis. The control group included 96 patients with comparable baseline characteristics treated with Peg‐IFN/RBV. The primary end point was sustained virologic response at follow‐up week 12 or 24 after IFN‐free or Peg‐IFN/RBV, respectively.ResultsIn the study group, sustained virological response (SVR) was reported in 98% of patients (95% CI 95.3%‐100%). Cirrhotic as well as prior treatment failure achieved 100% SVR. In the control group, SVR was 47.9% (95% CI 37.9%‐57.9%). Adverse events including fatigue, headache, nausea, decrease in haemoglobin or increase in ferritin levels were rare and significantly less common in the study than in the historical control group.ConclusionsIn conclusion, SOF/LDV for 12 weeks provides simple, highly effective and safe Peg‐IFN/RBV‐free treatment for HCV GT1/4 thalassaemia patients. EUDRACT number 2015‐002401‐1.

BACKGROUNDManagement of hepatocellular carcinoma (HCC) larger than 5 cm is still debated. The aim of our study was to compare morbidity and mortality after the surgical resection of HCC according to the nodule size.METHODSSince 2001, 429 liver resections for HCC were performed in our institution. We divided the cohort into two groups, 88 patients in group 1 patients with HCC diameter from 5 to 10 cm and 39 patients in group 2 with HCC diameter ≥10 cm.RESULTSIn 30.7% of cases in the first group and in 35.9% of cases in the second group the HCC grew into a healthy liver. A major liver resection was performed in 36.3% of cases in group 1 vs. 66.6% in group 2 (P=0.001). In two cases for the first group and in ten cases in the second group a laparoscopic approach was performed. Median operative time was higher in group 2 (P=0.001). The median post-operative hospital stay was similar in the two groups (P=0.897). The post-operative morbidity was not different between the two groups (P=0.595).CONCLUSIONSThe tumour size does not contraindicate a surgical resection of HCC even in patient with HCC ≥10 cm.

Pancreaticoduodenectomy (PD) is associated with high postoperative morbidity. The management of postoperative complications is paramount for reducing the mortality rate. The aim of this study was to evaluate the importance of surgical and hospital experience on outcomes by comparing postoperative results in three different hospitals with increasing resources for supporting the same surgical team. Patients data and surgical outcome of 300 consecutive patients undergoing PD were collected prospectively in the department database and divided into three periods (A = 1990–2000, B = 2001–March 2007, C = April 2007–2015). Pancreatico-jejunostomy was the procedure of choice between 1995 and 2004, and pancreatico-gastrostomy was performed afterwards. In the periods A, B and C, a total of 78, 85 and 137 PD were performed, respectively, and the number of PDs per year increased from 5 to 25. Between the three periods, the death rate (10.4 vs. 6 vs. 1.6%, p = 0.01) and intraoperative RBC transfusion rate (84.9 vs. 42.4 vs. 6.5%, p = 0.01) decreased significantly, whereas the vascular resection rate increased significantly (1.2 vs. 7 vs. 14.5, p < 0.002). Morbidity and reoperation rates did not change significantly between the three periods as well as operative time and median length of stay. Infectious complications and sepsis represented the most frequent major complication. Massive bleeding associated with uncontrolled pancreatic leak represented the major cause of morbidity and reoperation in the three periods, however, the relative mortality rate decreased significantly with no deaths in the last period. PD remains a challenging procedure with high morbidity and mortality rate. A multidisciplinary pancreatic team represents the “safety net” of pancreatic surgeon because it improves the results beyond the surgeon skills and experience.

Background: In case of liver tumor, surgical resection is the therapeutic gold standard to increase patient survival. Among liver resections, right hepatectomy (RH) is defined as a major hepatectomy. The first aim of this study was to analyze the overall morbidity and mortality of patients undergoing RH, the second aim was to assess changes in both patients characteristic and surgical parameters and mortality rates in a single center institution.Materials: From 2001 to December 2015, 225 RH were performed in our center. We analyzed two time period: 2001-2007 and 2008-2015.Results: Ninety days post operative mortality was observed in 9 cases (4%) for the overall cohort. We observed a difference between the two groups in the use of Pringle Maneuver (p < 0,001). This result is consistent in each major surgical indication: HCC (p = 0,001), CLM (p = 0,015) and BT (p = 0,015). The estimated blood losses improved (p = 0,028), particularly for the HCC cases (p = 0,024). No difference was observed in terms of number of transfusions received between the two groups. Reduced length of stay was observed in the second group (p <0,001), more markedly for CLM cases (p = 0,001).Conclusion: To further improve the outcomes of RH, it is important to performed this major hepatectomy in hepatobiliary centers with an overall liver resection experience of at least few hundred cases. (C) 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.