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LIRA Technique Versus IPOM Plus for Laparoscopic Repair of Ventral Hernia: An Observational Comparative Analysis
No full textBackground: The aim of this study is to compare the postoperative outcomes of laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique with the defect closure technique using sutures and intraperitoneal mesh (IPOM plus), evaluating recurrence and bulging rates at least one year postoperatively. The secondary objective is to compare postoperative complications: seroma and pain at 30 days, 6 months, and 1 year post-surgery.Methods: Patients with midline primary ventral and incisional hernias between 4 and 10 cm were included. A CT scan was performed on all patients to assess the correct spatial values preoperatively and at 1 month, 6 months, and 12 months postoperatively. Pain was evaluated using the visual analog scale.Results: A total of 50 patients underwent LIRA, and 48 patients underwent IPOM plus between January 2022 and May 2023. The mean defect area in the LIRA group was larger than in the IPOM plus group (63.5 +/- 37.5 cm2 versus 55.2 +/- 33.9 cm2). In the LIRA group, 2/48 instances of bulging (4.4%) occurred, whereas in the IPOM plus group, there were 6/50 instances of bulging (21.3%) and 2/50 recurrences (6.4%). One month post-surgery, a clinical seroma was observed in 8/48 patients (16%) and 9/50 patients (18.7%) in the LIRA and IPOM plus groups, respectively, with complete resolution at 6 months. Postoperative pain was found to be lower in the LIRA group.Conclusions: In this study, the LIRA technique demonstrated lower rates of bulging, recurrence, and postoperative pain compared with IPOM plus at 1 year of follow-up. Further multicentric prospective studies with a larger patient sample and longer follow-up are necessary to draw definitive conclusions
Impact of Tumor Size on the Survival Benefit of Anatomic Versus Non-Anatomic Resection for Intrahepatic Cholangiocarcinoma
Get PDFBackground: The role of anatomic resection (AR) versus non-anatomic resection (NAR) for intrahepatic cholangiocarcinoma (ICC) has not been thoroughly investigated. This study sought to define the impact of tumor size on the relative therapeutic benefit of AR versus NAR for ICC. Specifically, the study aimed to identify a threshold tumor size to define when AR rather than NAR may be warranted to achieve better survival outcomes for patients undergoing resection of ICC. Methods: Patients who underwent liver resection for ICC were identified from an international multi-institutional database. A multivariable Cox model with an interaction term was used to assess the relationship between tumor size and the survival impact of AR. Results: Among 969 patients, 506 (72.9 %) underwent AR, whereas 263 (27.1 %) had an NAR. Multivariable analysis demonstrated an interaction between tumor size and AR (hazard ratio [HR], 0.94; 95 % confidence interval [CI], 0.88–1.00; p = 0.045). A plot of the interaction demonstrated that AR was associated with improved outcomes for tumors size ≥4 cm. Among 257 (26.5 %) patients with tumors smaller than 4 cm, recurrence-free survival (RFS) did not differ between NAR and AR (3-year RFS: 65.2 % [95 % CI, 55.7–76.2] vs 58.1 % [95 % CI, 49.2–68.5]; p = 0.720). In contrast, among 712 (73.4 %) patients with tumors size ≥4 cm, AR was associated with improved RFS (3-year RFS: 34.7 % [95 % CI, 27.5–43.8] vs 44.9 % [95 % CI, 40.4–50.0]; p = 0.018). Conclusions: Anatomic resection was associated with improved RFS for ICC patients with tumors size ≥4 cm, indicating that tumor size may be a valuable criterion to determine the extent of liver resection for resectable ICC patients
Eosinophilic Annular Erythema: Clinicopathologic Analysis and Therapeutic Outcomes from a Multicenter Cohort
No full textA Prognostic Index for Advanced Biliary Tract Cancer Treated With Cisplatin, Gemcitabine and Durvalumab: The MAGIC‐D Index
No full textBackground: Over the years, prognostic indexes have been developed to help clinicians stratify patients with biliary tract cancers (BTC) into risk groups. This study aims to identify a new prognostic index for patients with BTC treated with cisplatin, gemcitabine and durvalumab (CGD) in the first-line setting. Patients and Methods: The study population consisted of patients with BTC from 11 Eastern and Western Countries. Using multivariate analysis for overall survival (OS), we identified 5 baseline statistically significant variables: stage, carcinoembryonic antigen (CEA) levels, albumin levels, gamma glutamyl transferase (GGT) levels, neutrophil-to-lymphocyte ratio (NLR). Metastatic disease is a prognostic factor with a superior weight considering the HR of 3.62, while all the others can be considered prognostic factors with equivalent weight as the HRs are quite similar (HRs between 1.55 and 1.92). Based on these reasons, we developed a prognostic model called the MAGIC-D index by assigning a score of 2 for metastatic disease, and a score of 1 for CEA increased levels, albumin decreased levels, GGT increased levels, NLR ≥ 3. Patients were stratified into three risk groups as follows: low-risk group (Score from 0 to 2), intermediate-risk group (Score from 3 to 4) and high-risk group (Score from 5 to 6). At the first data cutoff (April 2024), these data were available for 319 patients that composed the training cohort used for the analysis. At the second data cutoff (May 2025), 79 patients were further enrolled and composed the validation cohort. Results: Median progression-free survival was 11.7 months in low-risk group (20.7%), 8.7 months in intermediate-risk group (46.4%) and 5.4 months in high-risk group (32.9%) [low-risk hazard ratio (HR): 0.27, intermediate-risk HR: 0.55, high-risk HR: 1, p < 0.0001]. Median OS was 18.4 months in low-risk group,15.9 months in intermediate-risk group and 7.8 months in high-risk group (low-risk HR: 0.17, intermediate-risk HR: 0.43, high-risk HR: 1, p < 0.0001). There was no difference in overall response rate (low-risk: 31.8%, intermediate-risk: 36.5% and high-risk: 25.7%; p = 0.0718), while disease control rate was significantly different across the three risk groups (low-risk: 83.3%, intermediate-risk: 70.9% and high-risk: 60.9%; p < 0.0001) as well as the rate of patients receiving a second-line therapy (low-risk: 54.5%, intermediate-risk: 48.6% and high-risk: 25.7%; p = 0.0061). Finally, the prognostic role in terms of OS and PFS of the MAGIC-D index was confirmed in a validation cohort of 79 patients. Conclusion: The MAGIC-D index is an easy-to-use tool able to stratify patients with BTC with different prognoses undergoing first-line therapy with CGD
White matter microstructure in obesity and bipolar disorders: an ENIGMA bipolar disorder working group study in 2186 individuals
No full textAlthough specific risk factors for brain alterations in bipolar disorders (BD) are currently unknown, obesity impacts the brain and is highly prevalent in BD. Gray matter correlates of obesity in BD have been well documented, but we know much less about brain white matter abnormalities in people who have both obesity and BD. We obtained body mass index (BMI) and diffusion tensor imaging derived fractional anisotropy (FA) from 22 white matter tracts in 899 individuals with BD, and 1287 control individuals from 20 cohorts in the ENIGMA-BD working group. In a mega-analysis, we investigated the associations between BMI, diagnosis or medication and FA. Lower FA was associated with both BD and BMI in six white matter tracts, including the corpus callosum and thalamic radiation. Higher BMI or BD were uniquely associated with lower FA in three and six white matter tracts, respectively. People not receiving lithium treatment had a greater negative association between FA and BMI than people treated with lithium in the posterior thalamic radiation and sagittal stratum. In three tracts BMI accounted for 10.5 to 17% of the negative association between the number of medication classes other than lithium and FA. Both overweight/obesity and BD demonstrated lower FA in some of the same regions. People prescribed lithium had a weaker association between BMI and FA than people not on lithium. In contrast, greater weight contributed to the negative associations between medications and FA. Obesity may add to brain alterations in BD and may play a role in effects of medications on the brain
Prevalence, clinical characterization, management and evolution of bicuspid aortic valve classified according to the 2021 International Consensus Statement in a tertiary care hospital
No full textOBJECTIVES: The 2021 International Consensus for the congenital bicuspid aortic valve (BAV) condition recognizes 3 morphologies of BAV (fused, two-sinus and partial-fusion) and 3 types of aortopathy (ascending, root and extended). The clinical impact of BAV phenotyping on aortopathy evolution has not been evaluated so far. The aims were to assess: (i) prevalence of BAV phenotypes; (ii) frequency of BAV-related aortic valve dysfunction and aortopathy; and (iii) inter-phenotypic differences in aortopathy progression in a real-world population. METHODS: This was an observational cohort study on patients with BAV referred to our tertiary hospital between January 2018 and November 2022 to undergo a comprehensive transthoracic echocardiography. Baseline clinical, ultrasonographic and computed tomographic data were evaluated; even echocardiographic progression of aortic dilatation was assessed. RESULTS: Three hundred and two patients were evaluated: 245 (81.1%) had fused, 41 (13.6%) two-sinus and 16 (5.3%) partial fusion BAV. Aortopathy was documented in 101 (33.6%) cases and it was prevalent among patients with the fused type. The prevalence of aortic valve dysfunction was instead similar among the 3 groups. Two hundred and twelve patients underwent invasive management of clinically relevant aortic valve or aortic disease. Non-operated fused type presented the highest progression rate of aortic dilatation, whilst, among the interventional subpopulation, a more pronounced evolution was observed in the two-sinus type, at a median follow-up of 2 years. CONCLUSIONS: Fused type represented the BAV phenotype with the highest frequency and the most significant association with aortopathy. In terms of aortopathic progression, the mid-term growth rate of the thoracic aorta was more significant in the non-interventional fused BAVs
Laparoscopic versus open parenchymal preserving liver resections in the posterosuperior segments (ORANGE Segments): a multicentre, single-blind, randomised controlled trial
No full textBackground: An increasing number of liver resections are performed laparoscopically, while laparoscopic resection of lesions in the posterosuperior segments is technically challenging. We aimed to assess the outcomes of laparoscopic and open parenchymal preserving resection of lesions in the posterosuperior segments in a randomised controlled trial. Methods: In this multicentre, patient-blinded, superiority randomised controlled trial, patients requiring parenchymal preserving liver resection for tumours in segment 4a, 7, or 8 were enrolled at 17 centres and randomised 1:1 to laparoscopic or open surgery using a minimisation scheme stratifying for centre and lesion size. The primary endpoint was time to functional recovery measured in postoperative days. To detect a difference in time to functional recovery of two days the sample size needed 250 patients, an interim analysis was planned with 125 patients. Patients and outcome assessors were blinded to the allocation. The study was registered on clinicaltrials.gov, NCT03270917. Findings: Between November 2017 and November 2021, 251 patients were randomised to laparoscopic (n = 125) or open (n = 126) surgery. The majority of patients had a preoperative diagnosis of cancer (225/246 = 91.5%). Time to functional recovery was 3 days (IQR 3–5) in the laparoscopic group compared to 4 days (IQR 3–5) in the open group (difference −19.2%, 96% CI −28.8% to −8.4%; p < 0.001). Hospital stay was similarly shorter in the laparoscopic group (4 days, IQR 3–5 versus 5 days, IQR 4–7; p < 0.001). There were three deaths in the laparoscopic group (3/122 = 2.5%) and one in the open group (1/124 = 0.8%) within 90 days of resection (p = 0.336). Overall postoperative morbidity, severe morbidity, liver-specific morbidity, and readmission were not statistically significant different between the groups. The radical resection (R0) rate in patients with cancer was comparable (laparoscopic 93/106 = 87.7% versus open 97/113 = 85.8%, p = 0.539). Interpretation: For patients with lesions in the posterosuperior segments of the liver, laparoscopic surgery, as compared to open surgery, reduces time to functional recovery. However, this reduction in time to functional recovery did not meet the hypothesized difference in time to functional recovery of two days. Funding: This investigator-initiated trial was funded by Ethicon ( Johnson & Johnson), Cancer Research United Kingdom, and Maastricht University Medical Centre+
CT acquisition protocols by pathology, SIRM position paper part 1: head and neck, brain and spine, chest, cardiovascular
No full textThe current medical scenario in diagnostic imaging is characterized by an extremely frequent use of computed tomography, which becomes the main source of medical exposure. The radiation dose depends on patient’s characteristics, anatomical districts, and diseases under investigation; the first two parameters cannot be modified; the correct application of specific protocols for the disease under investigation, helps improve both standardization and dose reduction. This perfectly fits with the ALARA principles (As Low As Reasonably Achievable) according to which patients must be exposed to the right dose of radiation, which, in turn, must be as low as possibly achievable. To support the radiologists in the daily clinical practice and to standardize the exposure of patients, the Italian Society of Medical and Interventional Radiology (SIRM), through his specific subcommittee, has created this position paper
Effects of kynurenine pathway metabolites on choroid plexus volume, hemodynamic response, and spontaneous neural activity: A new mechanism for disrupted neurovascular communication and impaired cognition in mood disorders
No full textMajor Depressive Disorder (MDD) and Bipolar Disorder (BD) involve alterations of immune-inflammatory setpoints that activate the kynurenine pathway (KP), affecting serotoninergic and glutamatergic neurotransmission through indoleamine-2,3-dioxygenase (IDO) activity. This process produces metabolites like Kynurenine (Kyn), 3-Hydroxykynurenine (3-HK), Quinolinic acid (QuinA), and Kynurenic acid (KynA), these last two acting as agonist and antagonist at glutamatergic N-methyl-D-aspartate receptors (NMDARs), respectively. NMDARs, expressed in the choroid plexus (ChP) and arteriolar smooth muscle cells, regulate blood–brain-barrier permeability and cerebral artery dilation, suggesting that KP may influence neurovascular coupling, aligning blood flow with neural energy demand. KP's role in modulating vascular tone supports this hypothesis. Altered fractional amplitude of low-frequency fluctuations (fALFF) and disrupted default mode network (DMN) activity in mood disorders are linked to cognitive deficits possibly through neurovascular uncoupling like in neurological diseases. This makes fALFF and hemodynamic response function (HRF) potential indicators of these changes. We investigated KP associations with ChP volumes, functional-MRI at rest measures like spontaneous neural activity (fALFF) and hemodynamic response function (HRF) parameters within the default mode network (DMN), and cognitive performance in 42 MDD and 36 BD inpatients experiencing a depressive episode. Results revealed that lower QuinA/KynA ratios and higher KynA levels predict larger ChP volumes. Higher KYN and 3-HK levels, along with lower KynA levels, were associated with increased DMN fALFF and shorter time-to-peak (TTP) in HRF, suggesting altered neurovascular coupling. Mediation analyses indicated that KP metabolites influenced cognitive performance through their effects on resting state measures, affecting global cognitive functioning score, verbal fluency, and psychomotor coordination. These findings suggest that KP metabolites modulate brain function and structure via NMDAR-mediated pathways and vascular-based mechanisms, offering insights into the cognitive impairments observed in mood disorders and identifying potential therapeutic targets