In this paper,we comment on the article by Gu et al published in 2024,invest-igating whether there were differences in the clinical/perioperative outcomes of endoscopic and laparoscopic resections of gastric stromal t...In this paper,we comment on the article by Gu et al published in 2024,invest-igating whether there were differences in the clinical/perioperative outcomes of endoscopic and laparoscopic resections of gastric stromal tumors.Compared with most carcinomas,gastrointestinal stromal tumors are quite common worldwide and have a better prognosis.However,they respond to specific chemotherapies and do not routinely require standard lymphadenectomy.The gastric origin is known to be the most represented.Survival after proven radical surgery is ex-cellent,with recurrences being extremely infrequent.Currently,induction/pe-rioperative chemotherapy for high-risk tumors larger than 5 cm can downstage neoplasia and maintain good survival.Therefore,the standard of care for non-metastatic,resectable tumors is surgical excision(avoiding formal lymphaden-ectomy)with or without chemotherapy.In the case of small-(2 cm)to medium-(5 cm)sized tumors,minimally invasive surgical approaches(laparoscopic or ro-botic)have been advocated,and more recently,a purely endoscopic technique has also been proposed.All these interventions are feasible and effective,although no definitive results have been published to prove the superiority of one over another;however,further investigation of its associated oncologic outcomes is still needed.Unfortunately,rigorous,prospective,randomized controlled trials are challenging to conduct,develop,and receive ethical approval for,whereas the final decision of the surgical route is often related to the availability of instru-mentation and local expertise.展开更多
The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasives...The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasivesurgery(MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.展开更多
Pancreatic ductal adenocarcinoma (PDAC) is the fourth cause of cancer death with an overall survival of 5% at five years. The development of PDAC is characteristically associated to the accumulation of distinctive gen...Pancreatic ductal adenocarcinoma (PDAC) is the fourth cause of cancer death with an overall survival of 5% at five years. The development of PDAC is characteristically associated to the accumulation of distinctive genetic mutations and is preceded by the exposure to several risk factors. Epidemiology has demonstrated that PDAC risk factors may be non-modifiable risks (sex, age, presence of genetic mutations, ethnicity) and modifiable and co-morbidity factors related to the specific habits and lifestyle. Recently it has become evident that obesity and diabetes are two important modifiable risk factors for PDAC. Obesity and diabetes are complex systemic and intertwined diseases and, over the years, experimental evidence indicate that insulin-resistance, alteration of adipokines, especially leptin and adiponectin, oxidative stress and inflammation may play a role in PDAC. Peroxisome proliferator activated receptor-γ (PPARγ) is a nuclear receptor transcription factor that is implicated in the regulation of metabolism, differentiation and inflammation. PPARγ is a key regulator of adipocytes differentiation, regulates insulin and adipokines production and secretion, may modulate inflammation, and it is implicated in PDAC. PPARγ agonists are used in the treatment of diabetes and oxidative stress-associated diseases and have been evaluated for the treatment of PDAC. PPARγ is at the cross-road of diabetes, obesity, and PDAC and it is an interesting target to pharmacologically prevent PDAC in obese and diabetic patients.展开更多
Gallstones and common bile duct calculi are found to be associated in 8%-20% of patients, leading to possible life-threatening complications, such as acute biliary pancreatitis, jaundice and cholangitis. The gold stan...Gallstones and common bile duct calculi are found to be associated in 8%-20% of patients, leading to possible life-threatening complications, such as acute biliary pancreatitis, jaundice and cholangitis. The gold standard of care for gallbladder calculi and isolated common bile duct stones is represented by laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography, respectively, while a debate still exists regarding how to treat the two diseases at the same time. Many therapeutic options are also available when the two conditions are associated, including many different types of treatment, which local professionals often administer. The need to limit maximum discomfort and risks for the patients, combined with the economic pressure of reducing costs and utilizing resources, favors single-step procedures. However, a multitude of data fail to strongly demonstrate the superiority of any technique(including a two or multi-step approach), while rigorous clinical trials that include so many different types of treatment are still lacking, and it is most likely unrealistic to conduct them in the future. Therefore, the choice of the best management is often led by the local presence of professional expertise and resources, rather than by a real superiority of one strategy over another.展开更多
After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts,some surgeons started to treat malignancies by the same way.However,if the limits of laparoscopy for...After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts,some surgeons started to treat malignancies by the same way.However,if the limits of laparoscopy for benign diseases are mainly represented by technical issues,oncologic outcomes remain the foundation of any procedures to cure malignancies.Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy,worsened quality of life due to surgery itself and adjuvant therapies,and challenging psychological impact.All these issues could,potentially,receive a better management with a laparoscopic surgical approach.In order to confirm such aspects,similarly to testing the newest weapons(surgical or pharmacologic)against cancer,long-term follow-up is always recommendable to assess the real benefits in terms of overall survival,cancer-free survival and quality of life.Furthermore,it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies.Therefore,laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences,as compared to those achieved for inflammatory bowel diseases,gastroesophageal reflux disease or diverticular disease.This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.展开更多
Pancreatic surgery for malignancy is recognized as challenging for the surgeons and risky for the patientsdue to consistent perioperative morbidity and mortality. Furthermore, the oncological long-term results are lar...Pancreatic surgery for malignancy is recognized as challenging for the surgeons and risky for the patientsdue to consistent perioperative morbidity and mortality. Furthermore, the oncological long-term results are largely disappointing, even for those patients who experience an uneventfully hospital stay. Nevertheless, surgery still remains the cornerstone of a multidisciplinary treatment for pancreatic cancer. In order to maximize the benefits of surgery, the advent of both laparoscopy and robotics has led many surgeons to treat pancreatic cancers with these new methodologies. The reduction of postoperative complications, length of hospital stay and pain, together with a shorter interval between surgery and the beginning of adjuvant chemotherapy, represent the potential advantages over conventional surgery. Lastly, a better cosmetic result, although not crucial in any cancerous patient, could also play a role by improving overall well-being and patient self-perception. The laparoscopic approach to pancreatic surgery is, however, difficult in inexperienced hands and requires a dedicated training in both advanced laparoscopy and pancreatic surgery. The recent large diffusion of the da Vinci® robotic platform seems to facilitate many of the technical maneuvers, such as anastomotic biliary and pancreatic reconstructions, accurate lymphadenectomy, and vascular sutures. The two main pancreatic operations, distal pancreatectomy and pancreaticoduodenectomy, are approachable by a minimally invasive path, but more limited interventions such as enucleation are also feasible. Nevertheless, a word of caution should be taken into account when considering the increasing costs of these newest technologies because the main concerns regarding these are the maintenance of all oncological standards and the lack of long-term follow-up. The purpose of this review is to examine the evidence for the use of minimally invasive surgery in pancreatic cancer(and less aggressive tumors), with particular attention to the oncological results and widespread reproducibility of each technique.展开更多
Because distal pancreatectomy(DP)has no reconstructive steps and less frequent vascular involvement,it is thought to be the easier counterpart of pancreaticoduodenectomy.This procedure has a high surgical risk and the...Because distal pancreatectomy(DP)has no reconstructive steps and less frequent vascular involvement,it is thought to be the easier counterpart of pancreaticoduodenectomy.This procedure has a high surgical risk and the overall incidences of perioperative morbidity(mainly pancreatic fistula),and mortality are still high,in addition to the challenges that accompany delayed access to adjuvant therapies(if any)and prolonged impairment of daily activities.Moreover,surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes.From this perspective,new surgical approaches,and aggressive techniques,such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection,could lead to improved survival in those affected by more locally advanced tumors.Conversely,minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress.The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications,length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy.Because a dedicated multidisciplinary team is crucial to pancreatic surgery,hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign,borderline,and malignant diseases of the pancreas.The purpose of this review is to examine the state of the art in distal pancreatectomies,with a special focus on minimally invasive approaches and oncological-directed techniques.The widespread reproducibility,cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.展开更多
In this editorial,I comment on the article by Li et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2023,investigating the role of some novel prognostic factors for early survival ...In this editorial,I comment on the article by Li et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2023,investigating the role of some novel prognostic factors for early survival after radical resection of liver cancer.Liver cancer is an important burden among Asian and Western popu-lations,despite recent advances in both medicine(from virus eradication to systemic target therapies)and surgery.However,survival after proven radical surgery remains poor,with recurrences being the rule.Many prognostic scores have been developed and validated to select those patients who will best benefit from radical liver surgery,although the final general and oncological outcomes continue to be highly jeopardized.Unfortunately,no single biomarker can resolve all these issues for hepatocellular carcinoma,and it remains to be proven whether some of them main-tain predictive power in the long-term follow-up.In the ongoing era of“preci-sion”medicine,the novel prognostic markers,including immune inflammatory and nutritional indexes could be of great help in better stratify surgical candi-dates.展开更多
To the Editor： We read with keen interest the recent paper by El Nakeeb et al, and the subsequent editorial published by Dudeja and Livingstone. Globally, the authors have correctly and timely portrayed the current r...To the Editor： We read with keen interest the recent paper by El Nakeeb et al, and the subsequent editorial published by Dudeja and Livingstone. Globally, the authors have correctly and timely portrayed the current role of pancreaticoduodenectomy in the elderly.展开更多
文摘In this paper,we comment on the article by Gu et al published in 2024,invest-igating whether there were differences in the clinical/perioperative outcomes of endoscopic and laparoscopic resections of gastric stromal tumors.Compared with most carcinomas,gastrointestinal stromal tumors are quite common worldwide and have a better prognosis.However,they respond to specific chemotherapies and do not routinely require standard lymphadenectomy.The gastric origin is known to be the most represented.Survival after proven radical surgery is ex-cellent,with recurrences being extremely infrequent.Currently,induction/pe-rioperative chemotherapy for high-risk tumors larger than 5 cm can downstage neoplasia and maintain good survival.Therefore,the standard of care for non-metastatic,resectable tumors is surgical excision(avoiding formal lymphaden-ectomy)with or without chemotherapy.In the case of small-(2 cm)to medium-(5 cm)sized tumors,minimally invasive surgical approaches(laparoscopic or ro-botic)have been advocated,and more recently,a purely endoscopic technique has also been proposed.All these interventions are feasible and effective,although no definitive results have been published to prove the superiority of one over another;however,further investigation of its associated oncologic outcomes is still needed.Unfortunately,rigorous,prospective,randomized controlled trials are challenging to conduct,develop,and receive ethical approval for,whereas the final decision of the surgical route is often related to the availability of instru-mentation and local expertise.
文摘The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasivesurgery(MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.
基金Supported by Fondo per gli Investimenti della Ricerca di BaseNo.RBAP10MY35_002+1 种基金Ente Cassa di Risparmio di Firenzeand Fior Gen ONLUS to Galli A
文摘Pancreatic ductal adenocarcinoma (PDAC) is the fourth cause of cancer death with an overall survival of 5% at five years. The development of PDAC is characteristically associated to the accumulation of distinctive genetic mutations and is preceded by the exposure to several risk factors. Epidemiology has demonstrated that PDAC risk factors may be non-modifiable risks (sex, age, presence of genetic mutations, ethnicity) and modifiable and co-morbidity factors related to the specific habits and lifestyle. Recently it has become evident that obesity and diabetes are two important modifiable risk factors for PDAC. Obesity and diabetes are complex systemic and intertwined diseases and, over the years, experimental evidence indicate that insulin-resistance, alteration of adipokines, especially leptin and adiponectin, oxidative stress and inflammation may play a role in PDAC. Peroxisome proliferator activated receptor-γ (PPARγ) is a nuclear receptor transcription factor that is implicated in the regulation of metabolism, differentiation and inflammation. PPARγ is a key regulator of adipocytes differentiation, regulates insulin and adipokines production and secretion, may modulate inflammation, and it is implicated in PDAC. PPARγ agonists are used in the treatment of diabetes and oxidative stress-associated diseases and have been evaluated for the treatment of PDAC. PPARγ is at the cross-road of diabetes, obesity, and PDAC and it is an interesting target to pharmacologically prevent PDAC in obese and diabetic patients.
文摘Gallstones and common bile duct calculi are found to be associated in 8%-20% of patients, leading to possible life-threatening complications, such as acute biliary pancreatitis, jaundice and cholangitis. The gold standard of care for gallbladder calculi and isolated common bile duct stones is represented by laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography, respectively, while a debate still exists regarding how to treat the two diseases at the same time. Many therapeutic options are also available when the two conditions are associated, including many different types of treatment, which local professionals often administer. The need to limit maximum discomfort and risks for the patients, combined with the economic pressure of reducing costs and utilizing resources, favors single-step procedures. However, a multitude of data fail to strongly demonstrate the superiority of any technique(including a two or multi-step approach), while rigorous clinical trials that include so many different types of treatment are still lacking, and it is most likely unrealistic to conduct them in the future. Therefore, the choice of the best management is often led by the local presence of professional expertise and resources, rather than by a real superiority of one strategy over another.
文摘After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts,some surgeons started to treat malignancies by the same way.However,if the limits of laparoscopy for benign diseases are mainly represented by technical issues,oncologic outcomes remain the foundation of any procedures to cure malignancies.Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy,worsened quality of life due to surgery itself and adjuvant therapies,and challenging psychological impact.All these issues could,potentially,receive a better management with a laparoscopic surgical approach.In order to confirm such aspects,similarly to testing the newest weapons(surgical or pharmacologic)against cancer,long-term follow-up is always recommendable to assess the real benefits in terms of overall survival,cancer-free survival and quality of life.Furthermore,it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies.Therefore,laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences,as compared to those achieved for inflammatory bowel diseases,gastroesophageal reflux disease or diverticular disease.This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.
文摘Pancreatic surgery for malignancy is recognized as challenging for the surgeons and risky for the patientsdue to consistent perioperative morbidity and mortality. Furthermore, the oncological long-term results are largely disappointing, even for those patients who experience an uneventfully hospital stay. Nevertheless, surgery still remains the cornerstone of a multidisciplinary treatment for pancreatic cancer. In order to maximize the benefits of surgery, the advent of both laparoscopy and robotics has led many surgeons to treat pancreatic cancers with these new methodologies. The reduction of postoperative complications, length of hospital stay and pain, together with a shorter interval between surgery and the beginning of adjuvant chemotherapy, represent the potential advantages over conventional surgery. Lastly, a better cosmetic result, although not crucial in any cancerous patient, could also play a role by improving overall well-being and patient self-perception. The laparoscopic approach to pancreatic surgery is, however, difficult in inexperienced hands and requires a dedicated training in both advanced laparoscopy and pancreatic surgery. The recent large diffusion of the da Vinci® robotic platform seems to facilitate many of the technical maneuvers, such as anastomotic biliary and pancreatic reconstructions, accurate lymphadenectomy, and vascular sutures. The two main pancreatic operations, distal pancreatectomy and pancreaticoduodenectomy, are approachable by a minimally invasive path, but more limited interventions such as enucleation are also feasible. Nevertheless, a word of caution should be taken into account when considering the increasing costs of these newest technologies because the main concerns regarding these are the maintenance of all oncological standards and the lack of long-term follow-up. The purpose of this review is to examine the evidence for the use of minimally invasive surgery in pancreatic cancer(and less aggressive tumors), with particular attention to the oncological results and widespread reproducibility of each technique.
文摘Because distal pancreatectomy(DP)has no reconstructive steps and less frequent vascular involvement,it is thought to be the easier counterpart of pancreaticoduodenectomy.This procedure has a high surgical risk and the overall incidences of perioperative morbidity(mainly pancreatic fistula),and mortality are still high,in addition to the challenges that accompany delayed access to adjuvant therapies(if any)and prolonged impairment of daily activities.Moreover,surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes.From this perspective,new surgical approaches,and aggressive techniques,such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection,could lead to improved survival in those affected by more locally advanced tumors.Conversely,minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress.The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications,length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy.Because a dedicated multidisciplinary team is crucial to pancreatic surgery,hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign,borderline,and malignant diseases of the pancreas.The purpose of this review is to examine the state of the art in distal pancreatectomies,with a special focus on minimally invasive approaches and oncological-directed techniques.The widespread reproducibility,cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.
文摘In this editorial,I comment on the article by Li et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2023,investigating the role of some novel prognostic factors for early survival after radical resection of liver cancer.Liver cancer is an important burden among Asian and Western popu-lations,despite recent advances in both medicine(from virus eradication to systemic target therapies)and surgery.However,survival after proven radical surgery remains poor,with recurrences being the rule.Many prognostic scores have been developed and validated to select those patients who will best benefit from radical liver surgery,although the final general and oncological outcomes continue to be highly jeopardized.Unfortunately,no single biomarker can resolve all these issues for hepatocellular carcinoma,and it remains to be proven whether some of them main-tain predictive power in the long-term follow-up.In the ongoing era of“preci-sion”medicine,the novel prognostic markers,including immune inflammatory and nutritional indexes could be of great help in better stratify surgical candi-dates.
文摘To the Editor： We read with keen interest the recent paper by El Nakeeb et al, and the subsequent editorial published by Dudeja and Livingstone. Globally, the authors have correctly and timely portrayed the current role of pancreaticoduodenectomy in the elderly.
