Alessandro Neri

COVID‐19 has been declared a pandemic by the World Health Organization. As of April 1, 2020, Italy was the country with the second highest number of cases in the world. The spread of COVID‐19 has required a rapid reorganization of health service delivery in face of the pandemic. Breast cancer units have reprioritized their workload to guarantee the health of oncologic patients at the highest risk and regular screening activities. However, at the end of the pandemic emergency, many benign and reconstructive cases will return to our attention and their surgical treatment will be necessary as soon as possible.

Postoperative peritonitis (PoP), despite their relatively low incidence, are associated with high mortality. Such poor outcomes are also related to the high proportion of aged patients, whose intra-abdominal infections are difficult to manage. The study included 84 consecutive patients with PoP. The aim was the validation of the Mannheim Prognostic Index (MPI) in the context of PoP and the assessment of the prognostic impact of age and other clinical factors in a large series from a tertiary center. PoP had an incidence of 3.9% in all the abdominal surgeries in the study period. Surgical control of POP focus was achieved in 90.5% of cases and a complete abdominal clearance in 58.3%. Complication rate was 75% with a mortality of 26.2%. For MPI score, the ROC curve indicated a cut-off value of 29 with a sensitivity of 72.7% and specificity of 67.7% in predicting death. At univariate analysis, factors significantly related to poorer prognosis included advanced age (p 0.001), site of primary surgery (p 0.05), lack of abdominal clearance (p 0.003), generalized peritonitis (p 0.04) and high MPI score (p < 0.001). Age, MPI score and absence of abdominal clearance resulted in independent prognostic factors at multivariate analysis. MPI showed good efficacy in identifying POP patients at high risk of death. The increased risk of mortality related to advanced age should be considered with MPI score in planning the treatment. An aggressive and early diagnostic-therapeutic approach is required to reduce the MPI score and improve the prognosis.

Introduction: Acellular dermal matrix (ADM) were introduced in the early 2000s and more recently permitted new protocols for breast reconstruction allowing a short operative time with improved outcomes until the new muscle-sparing breast reconstruction proposed in 2014 using the Braxon® ADM. The aim of this research is to propose a technique to improve the aesthetic outcome using Braxon ADM with prepectoral implants. Materials and Methods: The enrolled patients were submitted to a nipple skin-sparing mastectomy leaving 1 additional centimeter of subcutis on the proximal part of the upper pole of the breast (see Surgical Technique). Aesthetic outcomes were compared to those obtained with traditional breast reconstruction with prosthesis and the Braxon ADM placed in the prepectoral space. Mean values of aesthetic outcomes were analyzed using the Student t test, and the κ test was used to analyze interobserver variability. Results: The overall aesthetic score was improved of 29.6% of the patients; in particular the most improved score was that for contour (+98.01%). Statistical significance was found for contour, upper pole definition, and total score average (p < 0.05).The κ test showed interobserver variability with a good level of agreement on contour (κ = 0.832). Conclusions: The proposed technique has allowed attainment of good results in terms of aesthetic outcomes. In a small sample we did not register any particular complications but we verified a better satisfaction on the evaluation of the aesthetic result (level of evidence: 3).

Introduction Laparoscopic surgery has been adopted in some parts of the world as an innovative approach to the resection of gastric cancers. However, in the modern era of surgical oncology, to overcome intrinsic limitations of the traditional laparoscopy, the robotic approach is advocated as able to facilitate the lymph node dissection and complex reconstruction after gastrectomy, to assure oncologic safety also in advanced gastric cancer patients. Previous meta-analyses highlighted a lower complication rate as well as bleeding in the robotic approach group when compared with the laparoscopic one. This potential benefit must be balanced against an increased time of intervention. The aim of this umbrella review is to provide a comprehensive overview of the literature for surgeons and policymakers in order to evaluate the potential benefits and harms of robotic gastrectomy (RG) compared with the laparoscopic approach for gastric cancer. Methods and analysis We will perform a comprehensive search of the PubMed, Cochrane and Embase databases for all articles published up to May 2019 and reference list of relevant publications for systematic review and meta-analyses comparing the outcomes of RG and laparoscopic gastrectomy in patients with gastric cancer. Studies will be selected by two independent reviewers based on prespecified eligibility criteria and the quality will be assessed according to AMSTAR (A MeaSurement Tool to Assess systematic Reviews) checklist. All information will be collected using piloted and standardised data-extraction forms in DistillerSR developed following the Joanna Briggs Institute’s recommended extraction items. Ethics and dissemination This umbrella review will inform clinical and policy decisions regarding the benefits and harms of RG for treating gastric cancer. The results will be disseminated through a peer-reviewed publication, conference presentations and the popular press. Formal ethical approval is not required as primary data will not be collected. PROSPERO registration number CRD42019139906.

Treatment options to gastric cancer (GC) have been changing in recent years from a standard to a tailored approach. Different individualized procedures can range from endoscopic resection, D2 with open or minimally invasive approach, to neo-adjuvant therapy followed by extended surgery. In more advanced stages, a combined approach with the inclusion of intraperitoneal chemo-hyperthermia (HIPEC) may represent a new advanced option. The inclusion of histological type according to Laurén classification in the flowchart of treatment could increase both accuracy and effectiveness of such tailored approach. New molecular classifications of GC have been introduced recently and translational clinical studies are ongoing. These classifications are expected to be included in multidisciplinary treatment of GC. In particular, in the group with microsatellite instability a less extended lymphadenectomy may be proposed. Also tailored neo-adjuvant treatment may be proposed according to molecular classifications. The group of patients with epithelial-to-mesenchymal transition shows very high propensity to peritoneal dissemination, as well as N-metastases, and may benefit from prophylactic HIPEC and extended lymphadenectomy when confirmed in prospective trials.