Resected Cases Research Articles

Learning curve for endoscopic submucosal dissection (ESD) in the United States: Large, untutored, single-operator experience.

Background and study aims Endoscopic submucosal dissection (ESD) allows removal of tumors en-bloc. Western adoption of ESD has been hindered by its steep learning curve. Western data regarding ESD learning curve are limited. We analyzed the learning curve of a single endoscopist at a tertiary referral center in the United States. Patients and methods All consecutive ESDs performed by a single endoscopist at a tertiary referral center in the United States from 2015 through 2022 were identified. Descriptive statistics and CUSUM analysis were used to describe the learning curve for en-bloc, R0 resection, and resection speed. Results In our study, 503 patients with 515 lesions were included. Severe submucosal fibrosis was found in 17% of the lesions. The rates of en-bloc, R0, and curative resections were 81.9%, 71.1%, and 68.4%, respectively. CUSUM analysis showed that the learning curve plateaued at 268, 347, and 170 cases for en-bloc resection, R0 resection, and achieving a resection speed > 9 cm 2 /hr. Fibrosis significantly affected the R0 resection rate in the regression analysis (95% confidence interval 0.21-0.55). In colonic ESD curve analysis, the learning plateau was reached after 185 cases for both en-bloc and R0 resection. Conclusions Following ex-vivo training in an animal model, an untutored expert operator achieved competency in ESD between 250 and 350 procedures. Our data can inform development of future training programs in the West.

Risk Factors and Treatment of Chylothorax After Minimally Invasive Esophagectomy for Esophageal Cancer.

Background Postoperative chylothorax is a rare but life-threatening complication of esophagectomy. However, due to its rarity, researching the risk factors and selecting appropriate treatment options has been limited. Methods This study included 727 patients with esophageal cancer who underwent minimally invasive esophagectomy at our hospital. To detect the risk factors for chylothorax, we divided the patients into two groups, with and without postoperative chylothorax. We then compared patient characteristics, tumor-specific variables, and operative details. Subsequently, we analyzed the peri-treatment characteristics and outcomes for the three distinct treatment options we had chosen: surgery, conversion (the group that finally underwent surgery after unsuccessful conservative treatment), andconservative. Results Of the 727 patients, 18 (2.5%) developed a chylothorax. The mean BMI was lower (20.3 vs. 21.9, p=0.057), and more cases of thoracic duct resection were found in the chylothorax group (33.3% vs. 6.2%, p=0.001), with statistical significance. Multivariate analysis identified thoracic duct resection as a risk factor (adjusted odds ratio, 6.83). The drainage volume two days after chylothorax was higher in the surgery group, although the difference was not statistically significant (surgery group, 1,405 ml vs. conversion group, 260 ml vs. conservative group, 310 ml; p=0.073). The surgery group had the shortest median postoperative hospital days among these groups (21.5 as compared to 102 and 25.0 days in the conversion and conservative groups, respectively; p<0.001). None of the patients died during their hospital stays. Conclusion Thoracic duct resection during the initial minimally invasive esophagectomy was an independent risk factor for chylothorax. If drainage volume does not decrease on the second day, early surgery may lead to earlier discharge.

Gasless transoral endoscopic thyroidectomy in a primary substernal goitre patient: First case.

For most primary substernal goitre (SG) surgeries, sternotomy is required because the blood supply vessels of tumours come from the mediastinum. However, sternal dehiscence may lead to several surgical complications. We reported an older patient who underwent simultaneous removal of a primary SG and parathyroid adenoma through a gasless transoral endoscopic approach. The patient recovered well with no hoarseness, post-operative bleeding or other complications after the operation. To the best of our knowledge, this is the first reported case of gasless transoral endoscopic parathyroid adenoma and primary SG resection in the real world. We found that gasless transoral endoscopic surgery is feasible in patients with small primary SG and parathyroid adenoma.

Resection of pleural solitary fibrous tumors with distinct feeding vessels arising from the descending aorta: a case report

BackgroundPleural solitary fibrous tumors (pSFTs) are rare mesenchymal pleural tumors with rich vascularity. Surgical resection is the cornerstone of pSFTs treatment, requiring careful preoperative imaging to delineate lesion extent and vascular supply including contrast-enhanced computed tomography and other examinations depending on its size and characteristics.Case presentationThe patient was a 34-year-old female with a mass measuring approximately 67 × 42 × 65 mm in the left posterior mediastinum. Intraoperatively, the mass demonstrated rich vascularity. Two veins originating from the abdominal cavity entered the lower pole, one converged from the superior pole, draining into the brachiocephalic vein. Additionally, two arteries arose directly from the descending aorta, while several veins drained into the intercostal veins. In response to unexpected intraoperative vascular findings, vascular clips and silk threads were used to ligate them. Subsequently, the tumor was successfully dissected, with approximately 600 ml of blood loss recorded during the 4-hour surgery. The patient exhibited a satisfactory postoperative recovery, and follow-up spanning over six months revealed no indications of recurrence or metastasis.ConclusionsWe firstly present a case of successful resection of a pSFT in a 34-year-old woman with a distinct feeding vessel arising from the descending aorta and describe the related surgical procedures. This case highlights preoperative evaluation of mass vascularity based on contrast-enhanced computed tomography. When blood supply is challenging to clarify, angiography can offer additional details, especially for giant pSFTs. Despite this, thorough intraoperative exploration remains essential to detect unexpected vessels. Appropriate interventions should be customized based on the vascular origins and the surrounding anatomical structures.

Endoscopic submucosal dissection versus endoscopic mucosal resection for the treatment of rectal lesions involving the dentate line

BackgroundThe ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line.MethodsWe identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed.ResultsWe identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions.ConclusionESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice.

ETMR-03. REPORT OF 9 CASES OF EMBRYONAL TUMORS OF THE CENTRAL NERVOUS SYSTEM WITH MULTILAYERED ROSETTES (ETMR)

Abstract OBJECTIVE Embryonal Tumors of the Central Nervous System with Multilayered Rosettes (ETMR) are rare, and there’s no standard treatment protocol. This article reports on the current treatment status and prognosis of ETMR in our hospital. METHODS We retrospectively collected patients with ETMR who received treatment in the Oncology Department of Guangdong sanjiu Brain Hospital from January 2017 to January 2021, analyzed their clinical data. RESULTS Among 31 cases of central nervous system embryonic tumors (excluding medulloblastoma and ATRT), 9 (29.03%) were ETMR. The median age at diagnosis was 3 years old (1-15), and the male to female ratio was 4:5. Among them, 5 cases were accompanied by C19MC gene variation. Tumor location:6 was in supratentorial, 1 in the pineal region, 1 in the pons, 1 in the cerebellopontine. Eight patients underwent surgical resection at the first diagnosis, with 6 cases of total resection, 1 case of partial resection, and 1 case of biopsy. One case was misdiagnosed as a germinoma in the pineal region at the initial. After recurrence, surgical resection was performed to confirm the pathology as ETMR. One case was misdiagnosed as glioblastoma during the first surgery. The initial treatment for 4 patients after surgery was radiotherapy combined with concurrent chemotherapy. Recurrence patterns: 2 cases were intracranial dissemination, 2 cases were local recurrence, 1 was spinal cord dissemination. One patient did not receive treatment after surgery and tumor recurrence 3 months later. Survival analysis: The median survival time was 20 months. The 1-year progression-free survival rate (PFS) and overall survival rate (OS) were 22% and 61%, and the 2-year overall survival rate (OS) was 31%. CONCLUSION ETMR has a low incidence and poor prognosis. It is easy to misdiagnose and NGS is necessary to assist diagnosis when needed. More effective treatment methods need to be explored.

Transvaginal resection of a gastrointestinal stromal tumor of the rectum: a case report

BackgroundThe most common curative treatment for gastrointestinal stromal tumors (GISTs) is local excision. For rectal GISTs, however, local excision is difficult because of the anatomical features of the rectum. The optimal surgical approach is still under debate, and less invasive methods are desired. We herein report a case of transvaginal resection of a rectal GIST in a young woman.Case presentationA 21-year-old woman was diagnosed with a resectable GIST in the anterior rectal wall and underwent transvaginal tumor resection. The posterior vaginal wall was incised, revealing the tumor fully covered by the rectal mucosa. The rectal adventitia and muscular layer were incised, and the tumor was resected en bloc without rupture. The postoperative course was favorable, and the patient was discharged on postoperative day 12. No findings consistent with recurrence were present 6 months postoperatively.ConclusionTransvaginal tumor resection is a treatment option as a minimally invasive procedure for GISTs in the anterior rectal wall in female patients.

Correlation of CT features of lung adenocarcinoma with sex and age

This study aimed to retrospectively examine the computed tomography (CT) features of lung adenocarcinoma across different demographic groups. Preoperative chest CT findings from 1266 surgically resected lung adenocarcinoma cases were retrospectively analyzed. Lung adenocarcinomas were categorized based on CT characteristics into pure ground glass (pGGO), nodule-containing ground glass opacity (mGGO), and pure solid without containing ground glass opacity (pSD). These categories were correlated with sex, age, EGFR status, and five histopathological subtypes. The diameters of pGGO, mGGO, and pSD significantly increased across all patient groups (P < 0.05). Males exhibited a significantly higher proportion of pSD than females (P = 0.002). The mean diameters of pGGO and pSD were significantly larger in males than in females (P = 0.0017 and P = 0.043, respectively). The frequency of pGGO was higher in the younger age group (≤ 60 years) compared to the older group (> 60 years) for both males (P = 0.002) and females (P = 0.027). The frequency of pSD was higher in the older age group for both sexes. A linear correlation between age and diameter was observed in the entire cohort as well as in the male and female groups (P < 0.0001 for all groups). EGFR mutations were less frequent in pSD compared to pGGO (P = 0.0002) and mGGO (P < 0.0001). The frequency of lesions containing micropapillary components increased from pGGO to mGGO and pSD (P < 0.0001 for all). The frequency of lesions containing solid components also increased from pGGO to mGGO and pSD (P = 0.045, P < 0.0001, and P < 0.0001, respectively). The CT features of lung adenocarcinoma exhibit differences across genders and age groups. Male gender and older age are risk factors for lung adenocarcinoma growth.

Extended-sleeve resection for endoluminal recurrence of B3 thymoma: does aerogenous spread really exist?

Thymomas are a variant of thymic epithelial tumours. They are considered malignant due to their tendency to local invasion and they showed lower metastatic behaviour. Distal metastasis is rare and an endobronchial mass is a rare presentation. First-line treatment for early-stage thymomas is surgery; for Masaoka-Koga stage III, neoadjuvant or adjuvant chemoradiation therapy should be considered in association with surgery after Multidisciplinary Tumour Board evaluation. We report a rare case of radical resection with type A extended-sleeve lobectomy in a 63-year-old woman who was affected by endobronchial recurrence of B3 thymoma, 31 months after complete and radical thymectomy.

Deep learning-based risk stratification of preoperative breast biopsies using digital whole slide images

BackgroundNottingham histological grade (NHG) is a well established prognostic factor in breast cancer histopathology but has a high inter-assessor variability with many tumours being classified as intermediate grade, NHG2. Here, we evaluate if DeepGrade, a previously developed model for risk stratification of resected tumour specimens, could be applied to risk-stratify tumour biopsy specimens.MethodsA total of 11,955,755 tiles from 1169 whole slide images of preoperative biopsies from 896 patients diagnosed with breast cancer in Stockholm, Sweden, were included. DeepGrade, a deep convolutional neural network model, was applied for the prediction of low- and high-risk tumours. It was evaluated against clinically assigned grades NHG1 and NHG3 on the biopsy specimen but also against the grades assigned to the corresponding resection specimen using area under the operating curve (AUC). The prognostic value of the DeepGrade model in the biopsy setting was evaluated using time-to-event analysis.ResultsBased on preoperative biopsy images, the DeepGrade model predicted resected tumour cases of clinical grades NHG1 and NHG3 with an AUC of 0.908 (95% CI: 0.88; 0.93). Furthermore, out of the 432 resected clinically-assigned NHG2 tumours, 281 (65%) were classified as DeepGrade-low and 151 (35%) as DeepGrade-high. Using a multivariable Cox proportional hazards model the hazard ratio between DeepGrade low- and high-risk groups was estimated as 2.01 (95% CI: 1.06; 3.79).ConclusionsDeepGrade provided prediction of tumour grades NHG1 and NHG3 on the resection specimen using only the biopsy specimen. The results demonstrate that the DeepGrade model can provide decision support to identify high-risk tumours based on preoperative biopsies, thus improving early treatment decisions.

Prognostic Impact of Perioperative CA125 Status in Gastric Cancer Based on New Cutoff Values.

Objectives The current carbohydrate antigen 125 (CA125) cutoff value demonstrated high specificity but low sensitivity. Therefore, we used new cutoff values to evaluate the clinical impact of perioperative CA125 in gastric cancer. Methods This study retrospectively analyzed 525 patients with gastric cancer (349 males and 176 females), of whom 445 patients underwent R0 resection and 80 patients underwent R1/R2 resection between 2011 and 2020. The receiver operating characteristic curve indicated preoperative and postoperative cutoff CA125 values of 15.7 IU/mL and 17.3 IU/mL, respectively, to predict overall survival. Furthermore, we analyzed changes in postoperative CA125 levels and evaluated their prognostic impact using multivariate analysis. Results The preoperative CA125-positive rate was 25%. Males, advanced TNM factors, and noncurative resection cases demonstrated significantly higher positive rates than the other group. The preoperative CA125-positive group exhibited a significantly higher noncurative resection rate than the preoperative CA125-negative group (32% versus 10%, P < 0.01). Preoperatively, CA125-positive status was an independent poor prognostic factor (P < 0.01), and at three months postoperatively, it tended to be a poor prognostic factor. Conclusions High preoperative CA125 (>15.7 IU/mL) was a significant predictor for noncurative resection and poor overall prognosis in gastric cancer. Furthermore, postoperative CA125-positive status three months postoperatively was also a potential predictor of recurrence and poor prognosis.

Resectability rate of pancreatic cancer after neoadjuvant therapy.

e16348 Background: Pancreatic Cancer is one of the leading causes of cancer death in Saudi Arabia. Surgery is the mainstay of treatment in resectable non-metastatic cases. Working on improving the resectability rate to achieve R0 resection is the standard of care. Methods: Unresectable cases of pancreatic adenocarcinoma seen from 2004 till 2018 in three hospitals in Saudi Arabia were reviewed to know the conversion rate from unresectable or borderline resectable to resectable after neoadjuvant chemotherapy and to explore the possible prognostic factors. The characteristics and outcomes of these patients were reviewed, with more attention on the known prognostic factors and their impact on the outcome. Notably, performance status, CA19-9, Neutrophil Lymphocyte Ration (NLR), and Platelet Lymphocyte Ratio (PLR). Overall response to neoadjuvant therapy, R0 resection, relapse free survival and overall survival were all reported. Results: Two hundred seventy-three captured cases of all types of pancreatic tumors from the tumor registry in the years between 2004 and 2018. 39 cases were unresectable or borderline resectable cases. The median age was 60 years (range:29-79), and 25 patients were males. 30 patients had an ECOG PS of 0-1and 6 had an ECOG PS of 2. The head of the pancreas was the primary tumor site in 31 patients and the body or tail was in 8 patients. 21 patients (54%) presented with weight loss ( &gt; 5kg), and 21 patients (54%) presented with obstructive jaundice. Neoadjuvant chemotherapy protocols were FOLFORINOX (13 patients, 33%), Gemcitabine/Capecitabine (10 patients), single agent Gemcitabine (10 patients), and other regimens in 6 patients. The median number of chemotherapy cycles was 6 (range: 1-14). 17 patients had dose reduction. 6 patients had preoperative radiation. Response to chemotherapy: ORR: 36%, SD: 26% and PD: 38% .Surgery was done after neoadjuvant therapy in 12 patients (31%). Only 4 out 12 had confirmed R0. Median Overall Survival (MS) and Progression-Free survival (PFS) in all patients were 30 mo (95% CI: 17.75 - 42.56) and 8 mo (95% CI: 5.65 - 11.89) respectively. MS in the surgery and the non-surgery groups was 30 and 25 mo (p- value = 0.26) respectively. The median PFS in the surgery and the non-surgery groups was 19.6 and 5.8 mo (p- value = 0.008) respectively. Multivariate regression analysis done for the following variables: ECOG PS of 2, elevated CA 199, high NLR &gt; 3, high PLR &gt; 225, weight loss and results showed numerical difference of both MS and PFS with no statistical significance (Type 2 error). Conclusions: The conversion rate from unresectable or borderline resectable to resectable after neoadjuvant therapy is 31% which is consistent with the international data. There is PFS improvement in those who underwent surgery (19.6 mo vs. 5.8 mo) with statistical significance (p:0.008), and there is numerical improvement of MS (30 mo vs. 25 mo) that did not reach statistical significance.

Simultaneous laparoscopic colectomy and liver metastasectomy with natural orifice specimen extraction: A proof-of-concept study

Background, Natural orifice specimen extraction (NOSE) via the anus or vagina is an alternative to conventional transabdominal specimen extraction in laparoscopic colorectal cancer surgery. NOSE has been shown to be safe and effective, resulting in decreased postoperative pain, analgesia use, and improved recovery, without oncological compromise. We aimed to demonstrate the feasibility of NOSE for combined colectomy with liver metastasectomy.Methods, From July 2022 to April 2024, all cases of laparoscopic colorectal cancer resection and synchronous liver metastasectomy with NOSE were included in the study. Selection criteria included a maximum specimen diameter of less than 5 cm and patient body mass index of less than 35 kg/m2.Results, Over the 22-month duration, four consecutive patients (two males, two females) underwent combined resection with NOSE. Mean age and BMI were 74.8 (range 63–81) years and 20.9 (range 19.5–22.3) kg/m2 respectively. Patient A and D underwent anterior resection for sigmoid cancer, Patient B underwent D3 right hemicolectomy for cecal cancer, and Patient C underwent subtotal colectomy for synchronous cecal and descending colon cancer. All patients underwent liver metastasectomy at the same sitting. Patient A and D had transanal NOSE while Patients B and C underwent transvaginal NOSE. Mean operative time and blood loss was 416 (range 330–535) minutes and 338 (range 50–500) ml respectively. All patients recovered gastrointestinal function within the first two postoperative days. Infected seroma of the liver bed occurred in one patient requiring percutaneous drainage. The average maximum colon tumor diameter was 2.9 (range 1.3–4.0) cm. All resection margins were clear. Mean duration of follow-up was 7.5 (range 2–12) months.Conclusions, Simultaneous colectomy and liver metastasectomy with NOSE for colorectal cancer is feasible and safe in highly selected patients, resulting in good postoperative outcomes. This proof-of-concept analysis paves the way for larger studies to draw definitive conclusions.

The effectiveness of adequate lymphadenectomy in radically-resected cases with pathologically-confirmed node-negative biliary tract cancers: A SEER-based retrospective cohort study

ObjectiveCurrent study was performed to evaluate the effectiveness of adequate lymph node dissection (ALND) in pathologically-confirmed node-negative cases with biliary tract cancers (BTCs). MethodsCases with pathologically confirmed BTCs from SEER data between 2000 and 2020 were retrospectively reviewed and analyzed. Comparative analyses in terms of clinic-pathological features and long-term survival based on the performance of ALND were performed. ALND was defined as a minimum number of resected lymph nodes with 6. ResultsA total of 1698 cases radically-resected cases with pathologically-confirmed BTCs were finally included (ALND received: 450, ALND not received: 1248). ALND (+) cases were generally in a more advanced stage than ALND (-) cases that the percentage of cases with T3-4 disease was significantly higher (P<0.001). Comparable incidence of receiving adjuvant chemotherapy (46.7% vs 46.1%, P=0.829) and adjuvant radiotherapy (16% vs 16.8%, P=0.686) were acquired between two groups. ALND (+) cases shared a more favorable prognosis than ALND (-) cases, especially when focused on different T categories. ALND was not a prognostic factor for radically resected cases with BTCs. Propensity score matching analysis was performed and the results were similar before matching. ConclusionALND was associated with obvious survival benefit among radically resected cases with pathologically confirmed node-negative BTCs and therefore the conventional application of ALND is strongly recommended, even for node-negative cases. Future multi-center studies focusing on the optimal number of resected lymph nodes regarding adequate lymphadenectomy for cases with BTCs, especially based on different tumor locations, are required.

Bridging theory and practice: A comprehensive algorithm for imageless total knee arthroplasty

Total knee arthroplasty (TKA) is a surgical procedure to treat severe knee osteoarthritis. Among several techniques available for performing TKA, imageless TKA is known for achieving precise alignment while minimizing invasiveness. This work proposes a comprehensive algorithm for imageless TKA device to calculate the varus/valgus and flexion/extension angles, as well as resection depths for cutting planes at distal femur and proximal tibia. Moreover, the algorithm calculates the hip-knee-ankle (HKA) and flexion angles of the leg. Initially, the proposed algorithm was validated in a virtual environment using a CT-scanned bone model in Solidworks. Subsequently, for the real-world validation, a SoftBone model was resected with conventional intra and extramedullary rods and cross-checked with the proposed algorithm. For the third validation, another SoftBone model was resected with the proposed algorithm and cuts were measured with a vernier caliper. During this experiment, there was an error of approximately 1 mm for both femoral and tibial resection cases when using an infrared camera with an accuracy of ±0.5 mm. However, this error could be reduced using an infrared camera with higher accuracy.

Secondary ileal lymph node metastases from rectal cancer: a case report

BackgroundColorectal cancer can invade adjacent organs, but rarely metastasizes to the regional lymph nodes (LNs) of the invaded organ. Herein, we report a case of rectal cancer invading the ileum and metastasized to the regional ileal LNs.Case presentationA 77-year-old male presented abdominal pain and anorexia, diagnosed with rectal cancer invading the small intestine and concurrently metastasized to the regional LN of the intestine and liver. High anterior resection and partial resection of the small intestine was performed, then, the patient was referred to our hospital for chemotherapy. We performed 17 cycles of systemic chemotherapy that achieved a partial reduction in size of the LN, followed by an ileocecal resection with ileal mesentery resection for regional LNs removal. Histopathological analysis of the resected ileal LNs and six liver lesions revealed a moderately differentiated tubular adenocarcinoma. The patient was discharged on postoperative day 18. Cancer recurrences developed in the lungs 5 months after the surgery, then to the liver and peritoneum, and further surgery and chemotherapy were performed. Despite the challenging presentation, the patient survived for 40 months after the first surgery.ConclusionsWe report a rare case of a surgical resection of a secondary ileal LN metastasis from rectal cancer. The patient survives for a relatively long time after surgical resection. When colorectal cancer invades the small intestine, clinicians should consider the possibility of secondary LN metastasis in the invaded site.

Outcomes Following Different Management of Mycotic Infrarenal Abdominal Aortic Aneurysms.

The objective was to present our experience on managing mycotic infrarenal abdominal aortic aneurysm (MIAAA) through a retrospective cohort study. Data of patients with MIAAA managed in our center from July 2016 to October 2022 were retrospectively analyzed. The diagnosis of MIAAA was made based on: (1) preoperative clinical signs of infection; (2) elevated serologic infection parameters; (3) para-aneurysmal infection features on enhanced computed tomography; and (4) positive blood or tissue cultures. All the patients received standard antibiotic therapy. Surgical management including endovascular aneurysm repair (EVAR), initial EVAR followed by open re-operation, and initial open surgical repair (OSR) were conducted according to disease seriosity, physical condition, and patient's will. Infection index and clinical outcome were evaluated during the follow-up time. A total of 23 patients (21 men; averaged=66.3 years, range=49-79 years) were included, with a mean follow-up time of 19.9 months (range=1-75 months). Bacteria culture from blood or tissue specimen was positive in 15 patients (Salmonella, n=8; Escherichia coli, n=3; methicillin-sensitive Staphylococcus aureus [MSSA], n=1; Klebsiella pneumoniae, n=1; Staphylococcus epidermidis, n=1; Mycobacterium tuberculosis, n=1). Seven patients received OSR as the initial surgical intervention, whereas 14 patients chose EVAR instead. The 2 conservatively managed patients (refused surgery) died within 30 days. The 7 patients who received initial OSR survived till now. Among the 14 patients who underwent initial EVAR, infection deteriorated without exception (14/14, 100%). Three of these patients refused re-operation and died within 6 months. Eleven patients received secondary surgical intervention (10 cases of aneurysm and endograft resection, thorough debridement, subclavian to bi-femoral artery bypass, or in situ aorta reconstruction; 1 case of laparoscopic debridement) and 7 survived the follow-up time. The overall mortality rate was 39.1% (9/23). The mortality rates differed greatly following different intervention methods (merely antibiotic management, 100%; initial open operation, 0%; initial EVAR without secondary operation, 100%; initial EVAR plus secondary operation, 36.4%). Open surgical repair is still the first choice for hemodynamically stable and low-risk patients. Merely EVAR is related with disastrous results, which should be reserved as a temporary alternative for patients with ruptured aneurysms, hemodynamic instability or high surgical risk, and followed by timely secondary OSR. The management of mycotic or primary-infected aortic aneurysm is challenging; treatment remains controversial. Our center has reviewed our experience over the past 6 years and found that open surgical repair is still the first choice for hemodynamically stable and low-risk patients. Merely endovascular aneurysm repair (EVAR) is related with disastrous results, which should be reserved as a temporary alternative for patients with ruptured aneurysms, hemodynamic instability or high surgical risk, and followed by timely secondary open surgical repair.

Perioperative complications of en bloc resection and anterior column reconstruction for thoracic and lumbar spinal tumors

PurposeTo evaluate the perioperative clinical outcomes of en bloc resection and anterior column reconstruction for thoracolumbar spinal tumors.MethodsThis study conducted a retrospective analysis of prospective data collection of 86 consecutive patients, including 40 males and 46 females, with an average age of 39 years (ranged from 10 to 71 years). There were 35 cases of a malignant primary tumor,42 cases of an aggressive benign tumor, and nine cases of metastases. The main lesions were located in 65 cases of thoracic spine, 17 cases of lumbar spine, and 4 cases of thoracolumbar spine. Tumors involved one level in 45 patients, two levels in 12 patients, three levels in 21 patients, four levels in five patients, five levels in two patients, and six levels in one patient.ResultsAccording to the Weinstein-Boriani-Biagini surgical staging system, all patients achieved en bloc resections, including 74 cases of total en bloc spondylectomy and 12 cases of sagittal resections. The mean surgical time was 559 min (210–1208 min), and the mean total blood loss was 1528 ml (260–5500 ml). A total of 122 complications were observed in 62(72.1%) patients, of which 18(20.9%) patients had 25 major complications and one patient (1.2%) died of complications. The combined approach (P = 0.002), total blood loss (P = 0.003), staged surgery (P = 0.004), previous surgical history (P = 0.045), the number of involved vertebrae (P = 0.021) and lumbar location (P = 0.012) were statistically significant risk factors for major complication. When all above risk factors were incorporated in multivariate analysis, only the combined approach (P = 0.052) still remained significant.ConclusionsEn bloc resection and anterior column reconstruction is accompanied by a high incidence of complications, especially when a combined approach is necessary.

Clinical outcomes for olfactory neuroblastoma.

Olfactory neuroblastoma (ONB) is a rare malignant tumor arising from the olfactory neuroepithelium. The standard of care for ONB is surgical resection; however, detailed treatment protocols vary by institution. Our treatment protocol consists of endoscopic skull base surgery (ESBS) for endoscopically resectable cases and induction chemotherapy followed by craniotomy combined with ESBS for locally advanced cases, with postoperative radiotherapy performed for all cases. Chemoradiotherapy (CRT) is performed in unresectable cases. In this study, we evaluate our treatment protocol and outcomes for ONB. A retrospective review of patients with ONB was conducted. Outcomes included survival outcomes and perioperative data. Fifteen patients (53.6%) underwent ESBS, 12 (42.9%) underwent craniotomy combined with ESBS, and 1 (3.6%) received CRT. The 5- and 10-year overall survival rates for all patients were 92.9% and 82.5%, respectively, with a median follow-up period of 81 months. The 5- and 10-year disease-free survival rates were 77.3% and 70.3%, respectively, and the 5- and 10-year local control rates were 88.2% and 80.2%, respectively. Patients undergoing ESBS demonstrated a significantly shorter operating time, period from operation to ambulation, hospitalization period, and less blood loss than those undergoing craniotomy combined with ESBS. Our treatment protocol was found to afford favorable outcomes. Patients who underwent endoscopic resection showed lower complication rates and better perioperative data than those who underwent craniotomy combined with ESBS. With appropriate case selection, ESBS is considered a useful approach for ONB.

Radiologic tumor border can further stratify prognosis in patients with pancreatic neuroendocrine tumor

Background and objectivesPancreatic neuroendocrine tumor (PanNET), although rare in incidence, is increasing in recent years. Several clinicopathologic and molecular factors have been suggested for patient stratification due to the extensive heterogeneity of PanNETs. We aimed to discover the prognostic role of assessing the tumor border of PanNETs with pre-operative computed tomography (CT) images and correlate them with other clinicopathologic factors. MethodsThe radiologic, macroscopic, and microscopic tumor border of 183 surgically resected PanNET cases was evaluated using preoperative CT images (well defined vs. poorly defined), gross images (expansile vs. infiltrative), and hematoxylin and eosin-stained slides (pushing vs. infiltrative). The clinicopathologic and prognostic significance of the tumor border status was compared with other clinicopathologic factors. ResultsA poorly defined radiologic tumor border was observed in 65 PanNET cases (35.5 %), and were more frequent in male patients (P = 0.031), and tumor with larger size, infiltrative macroscopic growth pattern, infiltrative microscopic tumor border, higher tumor grade, higher pT category, lymph node metastasis, lymphovascular and perineural invasions (all, P < 0.001). Patients with PanNET with a poorly defined radiologic tumor border had significantly worse overall survival (OS) and recurrence-free survival (RFS; both, P < 0.001). Multivariable analysis revealed that PanNET with a poorly defined radiologic border is an independent poor prognostic factor for both OS (P = 0.049) and RFS (P = 0.027). ConclusionPre-operative CT-based tumor border evaluation can provide additional information regarding survival and recurrence in patients with PanNET.