Fabio Francesco di Mola

Background: Enhanced Recovery After Surgery (ERAS) pathways have become the standard of care in elective colorectal surgery. However, implementation remains heterogeneous across institutions, and the relative contribution of ERAS pathways and minimally invasive surgery to improved postoperative outcomes remains uncertain. This study evaluated the association between ERAS implementation and short-term outcomes in two university-affiliated colorectal units with different levels of ERAS adoption. Methods: A retrospective bi-centre observational study was conducted, and comprised 802 consecutive patients who underwent elective colorectal resection between January 2016 and December 2024. Patients managed according to a standardized ERAS pathway (Group 1, n = 406) were compared with patients who received conventional perioperative care (Group 2, n = 396). Primary endpoints included postoperative morbidity, anastomotic leakage, and length of hospital stay (LOS). Secondary endpoints included mortality, readmission, postoperative complications, and hospitalization-related costs. Multivariable logistic regression was performed, adjusting for age, sex, ASA score, tumour stage, and tumour location. Results: Baseline demographic characteristics were largely comparable between groups, although patients in the conventional care group had a higher proportion of ASA III–IV status. Overall postoperative morbidity was significantly lower in the ERAS cohort (8.6% vs. 20.9%, p < 0.001), together with a lower incidence of anastomotic leakage (1.2% vs. 4.5%, p < 0.001). Median LOS was reduced from 9 to 8 days overall and, among patients who underwent laparoscopic surgery, from 6 to 4 days (p = 0.010). After multivariable adjustment, conventional perioperative management remained independently associated with higher postoperative morbidity (OR 2.62, 95% CI 1.60–4.09; p < 0.001) and anastomotic leakage (OR 1.92, 95% CI 1.01–4.98; p = 0.048). Mortality, surgical site infections, intra-abdominal abscesses, and other postoperative complications were comparable between groups. Based on regional reimbursement tariffs, ERAS implementation was associated with an estimated annual reduction of 567 hospital bed-days. Conclusions: Implementation of a standardized ERAS pathway was associated with reduced postoperative morbidity, lower anastomotic leakage rates, and shorter hospital stay after elective colorectal surgery. These benefits persisted after adjustment for major clinical confounders, supporting the effectiveness of standardized perioperative care. The greatest reduction in hospital stay was observed when ERAS was combined with minimally invasive surgery, emphasizing the complementary role of these strategies in optimizing postoperative recovery.

Giovanni Domenico Tebala, Fanny Massimi, Francesca Duro, Ahmed Abdelsamad, Stefano Avenia, Gian Luca Baiocchi, Andrea Barberis, Chafik Bouzid, Antoine Castel, Graziano Ceccarelli, Andrea Celotti, Nicola Cillara, Nicola Cinardi, Roberto Cirocchi, Maria Conticchio, Giuseppe Currò, Antonella Delvecchio, Raffaele Vincenzo De Rosa, Jacopo Desiderio, Antonio Di Cintio, Fabio Francesco Di Mola, Domenico Di Nardo, Alessia Fassari, Alessandro Gemini, Carlos Augusto Gomes, Gian Luca Grazi, Giuseppe Margani, Alessandro Mazzotta, Luca Morelli, Andrea Muratore, Fabrice Muscari, Edoardo Maria Muttillo, Alberto Patriti, Gaetano Piccolo, Luca Properzi, Alessandro Puzziello, Lucia Romano, Edoardo Rosso, Sara Saeidi, Andrea Sagnotta, Edoardo Saladino, Marcello Giuseppe Spampinato, Laurent Sulpice, Nádia Tenreiro, Paolo Ubiali, Riccardo Memeo, DoS-RAP Collaborative. Ann Hepatobiliary Pancreat Surg -0001;0:. https://doi.org/10.14701/ahbps.26-007

Pancreatic ductal adenocarcinoma (PDAC) is associated with intratumoral microbiota changes. However, defining the normal pancreatic microbial composition remains a challenge. Herein, we tested the hypothesis that the microbial profiling of normal pancreatic tissue from healthy organ donors (HC) could help in determining the signature of microbiota in PDAC. Matched pairs of tumor and normal tissues from PDAC patients (n = 32) and normal pancreatic tissues from HC (n = 17) were analyzed by 16S rRNA gene sequencing. Dissimilarities in all the beta metrics emerged in both normal samples and tumor samples, compared to HC (Bray–Curtis dissimilarity and Jaccard distance: p = 0.002; weighted UniFrac distances: p = 0.42 and p = 0.012, respectively; unweighted UniFrac distance: p = 0.009); a trend toward a lower Faith’s phylogenetic distance was found at the tumor level vs. HC (p = 0.08). Within PDAC, a lower Faith’s phylogenetic distance (p = 0.003) and a significant unweighted UniFrac distance (p = 0.024) were observed in tumor samples vs. normal samples. We noted the presence of a decreased abundance of bacteria with potential beneficial effects (Jeotgalicoccus) and anticancer activity (Acinetobacter_guillouiae) in PDAC vs. HC; bacteria involved in immune homeostasis and suppression of tumor progression (Streptococcus_salivarius, Sphingomonas) were reduced, and those implicated in tumor initiation and development (Methylobacterium-Methylorubrum, g_Delftia) were enhanced in tumor samples vs. normal samples. Metagenomic functions involved in fatty acid synthesis were reduced in normal samples compared to HC, while peptidoglycan biosynthesis IV and L-rhamnose degradation were more abundant in tumor samples vs. normal samples. Future prospective studies on larger populations, also including patients in advanced tumor stages and considering all potential existing confounding factors, as well as further functional investigations, are needed to prove the role of microbiota-mediated pathogenicity in PDAC.

Background: Different techniques have been proposed to manage Cholecysto-choledocholithiasis (CCL) advantageously in one stage. Among these, Laparoendoscopic Rendezvous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy, with insertion of a guide wire into the common bile duct through an incision of the cystic duct, followed by the clearance of the bile duct carried out by the endoscopists. The aim of this study was to evaluate the safety and the efficacy of the one-stage vs. a two-stage approach (pre-operative ERCP followed by cholecystectomy), and to compare our results with data from the current literature. Methods: All patients that underwent LERV in our facilities between January 2018 and December 2023 were evaluated. As a control group, we included patients that underwent a two-stage technique called the “sequential approach”. The primary outcome was to evaluate the efficacy in obtaining complete clearance of the common bile duct (CBD). The secondary outcomes included morbidity, mortality, operative time, conversion rate, hospital stay and CDB stone recurrence. Results: 120 patients in the LERV group were included; meanwhile, 70 patients underwent pre-operative ERCP plus cholecystectomy. A 97% bile duct clearance success rate in the LERV group and 93% in the ERCP group was observed, respectively. The median intraoperative time for the one-stage technique was 122 min (p < 0.001) and the median hospital stay was 4 days (p < 0.001). In the LERV group, an overall morbidity of 15% was reported (18/120): 15 Clavien–Dindo type 1, one type 3a and two type 3b (p < 0.001). At a median follow-up of 14 months, five patients experienced stone recurrence. In the ERCP group, we had a 93% success rate; meanwhile, we had longer hospitalization (p < 0.001), 27% post-ERCP pancreatitis (p < 0.001) and a cumulative morbidity of 30%. Conclusions: LERV offers the advantages of a being single-stage procedure and shorter hospitalization, with a lower risk of clinically relevant post-ERCP pancreatitis and failed CBD cannulation.

Background: The two-stage technique combining the Endoscopic Retrograde CholangioPancreatography (ERCP) with common bile duct (CBD) clearance carried out before the laparoscopic cholecystectomy represents the most common approach for CBD stones. Over time, different techniques have been proposed to manage cholecysto- choledocholithiasis (CCL) advantageously in one stage. Among these, the laparoendoscopic rendez-vous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy with insertion of a guide wire performed at initial stage of the procedure, followed by the clearance of the bile duct carried out by the endoscopists. The goal of this study was to evaluate the efficacy and safeness of LERV procedure recording results and complications, also making a comparison between our results and current literature. Methods: We reviewed our experience of all consecutive patients with cholecysto-choledocholithiasis managed with LERV between January 2018 and December 2023. LERV success rate, operative time, length of hospital stay, stone recurrence, incidence of endoscopic and surgical complications were analysed. Results: A total of 120 patients underwent LERV in our facilities. We reported a 97% LERV success rate, 1.6% conversion-to-open rate, a median intraoperative time of 122 (range 95-220) min. The median hospital stay was 4 (range 2-38) days. An overall morbidity of 15% was reported (18/120): 15 Clavien-Dindo type 1/2, 2 type 3a and one type 3b. In two cases a re-operation during the hospital stay was necessary. At a median follow-up of 14 months (3-59) five patients experienced stone recurrence requiring redo-ERCP in two cases. Conclusion: LERV offers the significant advantage of a single stage procedure and hospitalisation along with a lower risk of post-ERCP pancreatitis, failed CBD cannulation and complications. Our experience confirms safety and effectiveness of the technique for CCL management.

A 74-year-old man with advanced heart failure was admitted to the hospital with a diagnosis of colorectal cancer, and he underwent surgery. To maintain stable hemodynamics, the Impella CP device was used. The patient was weaned from the device shortly after surgery, and he had an uneventful postoperative course. This case may pave the way for non-procrastinating surgery in patients with poorly stable hemodynamics.

Pancreatic cancer (PC) is one of the leading causes of cancer-related death worldwide. Identification of novel tumor biomarkers is highly advocated in PC to optimize personalized treatment algorithms. Blood-circulating extracellular vesicles hold promise for liquid biopsy application in cancer. We used an optimized flow cytometry protocol to study leukocyte-derived EVs (CD45+) and PD-L1+ EVs in blood from 56 pancreatic cancer patients and 48 healthy controls (HCs). Our results show that PC patients presented higher blood levels of total EVs (p = 0.0003), leukocyte-derived EVs (LEVs) (p = 0.001) and PD-L1+ EVs (p = 0.01), as compared with HCs. Interestingly, a blood concentration of LEVs at baseline was independently associated with improved overall survival in patients with borderline resectable or primary unresectable PC (HR = 0.17; 95% CI 0.04–0.79; p = 0.02). Additionally, increased blood-based LEVs were independently correlated with prolonged progression-free survival (HR = 0.10; 95% CI 0.01–0.82; p = 0.03) and significantly associated with higher disease control rate (p = 0.02) in patients with advanced PC receiving standard chemotherapy. Notably, a strong correlation between a decrease in blood LEVs concentration during chemotherapy and disease control was observed (p = 0.005). These intriguing findings point to the potential of LEVs as novel blood-based EV biomarkers for improved personalized medicine in patients affected by PC.

Background. Laparoscopic reversal of Hartmann’s procedure (LHR) offers reduced morbidity compared with open Hartmann’s reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal. Materials and Methods. Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (n = 17) or OHR (n = 17). Variables such as numbers of patients, patient’s age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated. Results. The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; p value p value p value