Elisa Cassinotti

DNA methylation patterns in blood of patients with colorectal cancer and adenomatous colorectal polyps

Colorectal cancer (CRC) screening rates are currently suboptimal. Blood‐based screening could improve rates of earlier detection for CRC and adenomatous colorectal polyps. In this study, we evaluated the feasibility of plasma‐based detection of early CRC and adenomatous polyps using array‐mediated analysis methylation profiling of 56 genes implicated in carcinogenesis. Methylation of 56 genes in patients with Stages I and II CRC (N = 30) and those with adenomatous polyps (N = 30) were compared with individuals who underwent colonoscopy and were found to have neither adenomatous changes nor CRC. Composite biomarkers were developed for adenomatous polyps and CRC, and their sensitivity and specificity was estimated using five‐fold cross validation. Six promoters (CYCD2, HIC1, PAX 5, RASSF1A, RB1 and SRBC) were selected for the biomarker, which differentiated CRC patients and controls with 84% sensitivity and 68% specificity. Three promoters (HIC1, MDG1 and RASSF1A) were selected for the biomarker, which differentiated patients with adenomatous polyps and controls with sensitivity of 55% and specificity of 65%. Methylation profiling of plasma DNA can detect early CRC with significant accuracy and shows promise as a methodology to develop biomarkers for CRC screening.

Commonality and differences of methylation signatures in the plasma of patients with pancreatic cancer and colorectal cancer

Profiling of DNA methylation status of specific genes is a way to screen for colorectal cancer (CRC) and pancreatic cancer (PC) in blood. The commonality of methylation status of cancer‐related tumor suppressor genes between CRC and PC is largely unknown. Methylation status of 56 cancer‐related genes was compared in plasma of patients in the following cohorts: CRC, PC and healthy controls. Cross validation determined the best model by area under ROC curve (AUC) to differentiate cancer methylation profiles from controls. Optimal preferential gene methylation signatures were derived to differentiate either cancer (CRC or PC) from controls. For CRC alone, a three gene signature (CYCD2, HIC and VHL) had an AUC 0.9310, sensitivity (Sens) = 0.826, specificity (Spec) = 0.9383. For PC alone, an optimal signature consisted of five genes (VHL, MYF3, TMS, GPC3 and SRBC), AUC 0.848; Sens = 0.807, Spec = 0.666. Combined PC and CRC signature or “combined cancer signature” was derived to differentiate either CRC and PC from controls (MDR1, SRBC, VHL, MUC2, RB1, SYK and GPC3) AUC = 0.8177, Sens = 0.6316 Spec = 0.840. In a validation cohort, N = 10 CRC patients, the optimal CRC signature (CYCD2, HIC and VHL) had AUC 0.900. In all derived signatures (CRC, PC and combined cancer signature) the optimal panel used preferential VHL methylation. In conclusion, CRC and PC differ in specific genes methylated in plasma other than VHL. Preferential methylation of VHL is shared in the optimal signature for CRC alone, PC alone and combined PC and CRC. Future investigations may identify additional methylation markers informative for the presence of both CRC and PC.

Single port versus standard laparoscopic right colectomies: results of a case–control retrospective study on one hundred patients

Several prospective, multicenter, randomized clinical trials 1–3 and subsequent meta-analyses 4,5 have clearly demonstrated the safety, superiority regarding short-term outcomes and non-inferiority regarding oncological results and long-term outcomes of laparoscopic surgery as treatment for colonic malignancies in comparison to open surgery. During the last few years, in attempts to reduce the surgical trauma, new surgical approaches to the abdominal cavity have been proposed. Among them, single-port laparoscopic surgery is gaining great attention and is being widely adopted in many centers, even for the treatment of different colorectal diseases. However, while safety and feasibility have already been proved by small series 6,7 and case–control studies, 8–12 there is still a need to compare single-port with the conventionalmulti-port laparoscopic approach and hence to demonstrate possible advantages. The aim of this study is to retrospectively compare results from a consecutive series of 50 cases of single-port right colectomies with 50 cases of standard laparoscopic right colectomies performed in the same center by the same surgeon (LB).

Free circulating DNA as a biomarker of colorectal cancer

OBJECTIVES The purpose of this study is to evaluate the sensitivity and specificity of free circulating DNA (FCDNA) as a biomarker in patients suffering from colorectal cancer (CRC), investigating both its prognostic value correlated with stage of disease and its potential role in early recurrence diagnosis. METHODS The quantification of plasma DNA was achieved through the use of real time quantitative polymerase chain reaction (PCR) amplification of the RNAse P gene. The study enrolled patients undergoing surgery for primary CRC, at different stages of disease; samples were collected before surgery and during follow-up examinations every 3 months after surgery. Data were statistically analyzed using Software Packages SPSS® for Windows. RESULTS FCDNA was detectable in all pre-operative samples and the mean value was 47.8 ng/mL. FCDNA values increased progressively related to UICC stage of disease, although statistical significance was demonstrated only when comparing patients by pT stage. The analysis of postoperative samples showed a significant decrease of FCDNA quantity after radical surgery and in specific cases a rise preceding disease recurrence. CONCLUSIONS This study shows that absolute quantification of FCDNA in CRC patients could have a prognostic value, being related to stage of disease, and could be used as potential tool for early detection of recurrences.

Use of 3 mm percutaneous instruments with 5 mm end effectors during different laparoscopic procedures

BACKGROUND AND PURPOSE With a recent focus on minimizing the visibility of scars, new techniques have been developed. Minilaparoscopy reemerged as an attractive option for surgery as it limits tissue trauma, reduces post-operative pain and improves cosmesis. This study was designed to describe our experience with percutaneous trocarless 3 mm instruments used in combination with standard 5 mm and 10 mm laparoscopic instruments in different general surgery procedures. METHODS We used the PSS (Percutaneous Surgical Set, Ethicon Endo surgery, Cincinnati, OH, USA) in different surgical procedures as accessory instruments in combination with standard 5 mm and 10 mm standard laparoscopic instruments. MAIN FINDINGS The use of percutaneous instruments was safe and feasible in all performed procedures. The surgical technique was not modified. The percutaneous instruments can assure a good grip and can be used for traction and counter-traction. No complications have been described. No pain at the site of insertion has been reported. The skin, muscle and peritoneal defects were smaller than with the 3 mm laparoscopic traditional instruments. CONCLUSIONS Percutaneous approach seems to be a good option in general surgery in terms of efficiency, offering better cosmetic results and good pain control.

Laparoscopic caecal wedge resection with intraoperative endoscopic assistance

BACKGROUND AND PURPOSE Cancer is a potential evolution of adenomatous polyps, that is why nowadays screening programs for colorectal cancer are widely diffused. Colonoscopy is the gold standard procedure for identifying and resecting polyps; however, for some polyps resection during colonoscopy is not possible. The aim of the present study is to identify a fast and safe procedure for endoscopically resecting unresectable polyps. METHODS Patients with endoscopically unresectable polyps were scheduled for laparoscopic wedge resection under colonoscopic assistance. RESULTS From November 2010 to November 2012 we treated 15 patients with endoscopically unresectable adenomatous polyps. All patients underwent a laparoscopic caecal wedge resection with intraoperative endoscopic assistance. All procedures were completed without complications and in all cases complete resection of the polyps was achieved. CONCLUSIONS Laparoscopic wedge caecal resection with intraoperative colonoscopy is a fast and safe procedure that can be performed for large polyps that could not be treated endoscopically.

LAP-VEGaS Practice Guidelines for Reporting of Educational Videos in Laparoscopic Surgery: A Joint Trainers and Trainees Consensus Statement.

Objective: Consensus statement by an international multispecialty trainers and trainees expert committee on guidelines for reporting of educational videos in laparoscopic surgery. Summary of Background Data: Instructive laparoscopy videos with appropriate exposition could be ideal for initial training in laparoscopic surgery, but there are no guidelines for video annotation or procedural educational and safety evaluation. Methods: Delphi questionnaire of 45 statements prepared by a steering group and voted on over 2 rounds by committee members using an electronic survey tool. Committee selection design included representative surgical training experts worldwide across different laparoscopic specialties, including general surgery, lower and upper gastrointestinal surgery, gynecology and urology, and a proportion of aligned surgical trainees. Results: All 33 committee members completed both the first and the second round of the Delphi questionnaire related to 7 major domains: Video Introduction/Authors’ information; Patient Details; Procedure Description; Procedure Outcome; Associated Educational Content; Peer Review; and Use in Educational Curriculae. The 17 statements that did not reach at least 80% agreement after the first round were revised and returned into the second round. The committee consensus approved 37 statements to at least an 82% agreement. Conclusion: Consensus guidelines on how to report laparoscopic surgery videos for educational purposes have been developed. We anticipate that following our guidelines could help to improve video quality. These reporting guidelines may be useful as a standard for reviewing videos submitted for publication or conference presentation.

How to reduce surgical complications in rectal cancer surgery using fluorescence techniques

Anastomotic leakage (AL) is a serious complication in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. Adequate bowel perfusion has been stressed as one of the key elements for suture healing. Currently, there is no widespread method to assess and quantify the perfusion of gastrointestinal anastomoses intraoperatively, besides the subjective evaluation by the surgeon. The aim of this paper is to describe the basis of Indocyanine Green (ICG) fluorescence guided surgery applied to assessment of bowel perfusion and to highlight studies on the use of fluorescence angiography (FA) in laparoscopic rectal surgery. ICG fluorescence guided surgery has increasingly been used as a tool for intraoperative diagnostics to assess microperfusion and viability of tissues by means of a real-time FA; this technique has achieved the role of major contribution to intraoperative decision making during surgical procedures, especially in order to assess bowel perfusion before anastomosis creation in colorectal surgery. Several studies in literature already reported that ICG FA as a feasible technique to decrease AL rate in colorectal surgery; to date no randomized controlled trials have been completed but large series and prospective studies that focus on fluorescence perfusion assessment in rectal surgery have been published. Real time intraoperative ICG fluorescent angiography (FA) is a safe and feasible technique to guide the surgeon in intraoperative decision-making process. ICG FA seems to reduce AL rates following rectal surgery for cancer. However large well-designed RCTs are needed to provide evidence for its routine use.

Laparoscopic Transperitoneal Adrenalectomy

First described by Gagner et al. and Higashihara et al. in 1992 laparoscopic adrenalectomy is now considered the gold standard treatment for removal of adrenal masses. Reduction in post-operative stay, wound related complications, pain and faster return to normal activities in comparison to standard open technique represent the main benefits of the minimally invasive approach. Current indications for laparoscopic transperitoneal approach to the adrenal glands are removal of benign functioning and non-functioning tumors of the adrenal gland <12-cm.

Laparoscopic Right Colectomy

Jacobs et al. first reported a case of laparoscopic right colectomy was in 1991. Since then several reports, large series and randomized controlled trials proved that laparoscopic right colectomy is equal to open surgery in terms of oncological results. Furthermore, minimally invasive approach to right colon has also been proved safe and feasible for benign disease. Recent data also demonstrated that the laparoscopic approach has several advantages in comparison to open techniques including shorter postoperative stay, lesser use of analgesia, shorter postoperative ileus, reduction in wound related complications and incisional hernia rate and faster return to normal life activities.