Local Resection Research Articles

Prognostic impact of number of examined lymph nodes on survival of patients with appendiceal neuroendocrine tumors.

The prognosis of patients with appendiceal neuroendocrine tumors (ANETs) is related to lymph node (LN) metastasis and other factors. However, it is unclear how the number of examined LNs (ELNs) impact on survival. To determine the factors affecting the cancer-specific survival (CSS) of patients with ANET and to evaluate the impact of the number of ELNs on survival. A total of 4583 ANET patients were analyzed in the Surveillance, Epidemiology, and End Results database. Univariate survival analysis was used to identify factors related to survival and the optimal number of ELNs and lymph node ratio (LNR) were determined by the Kaplan-Meier method. The survival difference was determined by CSS. Except for sex, the other factors, such as age, year, race, grade, histological type, stage, tumor size, ELNs, LNR, and surgery type, were associated with prognosis. The 3-, 5-, and 10-year CSS rates of ANET patients were 91.2%, 87.5, and 81.7%, respectively (median follow-up period of 31 mo and range of 0-499 mo). There was no survival difference between the two surgery types, namely, local resection and colectomy or greater, in both stratifications of tumor size ≥ 2 cm (P = 0.523) and < 2 cm (P = 0.068). In contrast to patients with a tumor size < 2 cm, those with a tumor size ≥ 2 cm were more likely to have LN metastasis (χ 2 = 378.16, P < 0.001). The optimal number of ELNs was more than 11, 7, and 18 for all patients, node-negative patients, and node-positive patients, respectively. CSS rates of patients with a larger number of ELNs were significantly improved (≤ 10 vs ≥ 11, χ 2 = 20.303, P < 0.001; ≤ 6 vs ≥ 7, χ 2 = 11.569, P < 0.001; ≤ 17 vs ≥ 18, χ 2 = 21.990, P < 0.001; respectively). ANET patients with an LNR value ≤ 0.16 were more likely to have better survival than those with values of 0.17-0.48 (χ 2 = 48.243, P < 0.001) and 0.49-1 (χ 2 = 168.485, P < 0.001). ANET ≥ 2 cm are more likely to develop LN metastasis. At least 11 ELNs are required to better evaluate the prognosis. For patients with positive LN metastasis, 18 or more LNs need to be detected and lower LNR values (LNR ≤ 0.16) indicate a better survival prognosis.

Clinicopathological features and prognosis of colonic and rectal gastrointestinal stromal tumors: A propensity score matching analysis.

Colonic gastrointestinal stromal tumor (cGIST) and rectal gastrointestinal stromal tumor (rGIST) are two rare subtypes of gastrointestinal stromal tumor (GIST). The view that colonic and rectal carcinoma are different is generally accepted; however, whether there is a difference between cGIST and rGIST is still unknown. Here, we aimed to provide evidence for future clinical management and research by comparing the differences between the two types of GIST in the above-mentioned aspects. Patients were enrolled from three medical centers in China and published literature was collected following the inclusion and exclusion criteria. Propensity score matching was used to eliminate differences between cohorts. Between cGIST and rGIST patients, significant differences were observed in age, tumor size, mitotic index, NIH risk category, growth pattern, and symptoms. Adjuvant therapy is used in a high proportion of cGIST patients, and neoadjuvant therapy is used in a high proportion of rGIST patients. Although local resection is the main surgical method in both cohorts, the proportion is higher in cGIST patients. The overall survival of rGIST patients was better than that of the cGIST patients before propensity score matching (PSM). Interestingly, no significant differences in prognosis were observed after PSM. Although there were significant differences between cGIST and rGIST patients in baseline characteristics, clinicopathological features, treatment choice, and overall survival rate before PSM, no significant differences in long-term survival were observed between the two groups after PSM. In our study, there may be no differences in the tumor entity between cGIST and rGIST.

Is There a Role for Adjuvant Chemotherapy in Pathologic Node-Negative Locally Advanced Rectal Cancer After Neoadjuvant Chemoradiation Therapy?

Neoadjuvant chemoradiation therapy (NCRT, 5-fluorouracil and radiation) followed by resection and adjuvant chemotherapy (AC) is one of the standard treatment paradigms for locally advanced rectal adenocarcinoma. However, the utility of AC in patients with pathologic lymph node (pLN)-negative disease is unclear. Our aim is to assess the value of AC stratified by pLN status. The US Rectal Cancer Consortium database (2007-2017) was retrospectively reviewed for patients with clinical stage II and III rectal adenocarcinoma who received neoadjuvant chemoradiation (NACR) and curative-intent resection. Those who received neoadjuvant systemic chemotherapy or underwent local resection were excluded. Patients were categorized by pLN status. Primary outcome was overall survival (OS). Of 213 patients, 70% had pLN-negative disease and 30% pLN-positive disease. Median age was 57 years, 65% were male, and median follow-up was 31 months. Among patients with pLN-negative disease, 74% received AC. Receipt of AC was not associated with improved 5-year OS (82% versus 74%, respectively; p = 0.16). This finding persisted on multivariable analysis. Of patients with pLN-positive disease, 83% received AC. Patients with pLN-positive disease demonstrated improved 5-year OS with receipt of AC (72% compared with 0% with no adjuvant chemotherapy, p = 0.04). After receiving neoadjuvant chemoradiation, adjuvant chemotherapy for patients with pLN-negative disease does not appear to be associated with improved survival. Further validation and prospective studies are needed to evaluate the utility of adjuvant chemotherapy in this setting.

What Prevents Recurrence of Marjolin’s Ulcer and What the Best Treatment Is: A Systematic Review

Introduction: Marjolin’s Ulcer (MU) is defined as an ulcer that progresses through malignancy over a period of time. Pathophysiology of this disease is not 100% clear, although some findings suggest mutation of genes, responsible for cell division and apoptosis, is observed in MU patients. It takes 32 years on average for MU to develop after the first contact with the damaging agents. The best recommended treatment for MU is resection surgery for the affected area and amputation if the malignancy reaches the bone and deep tissue. Adjuvant therapy such as radiotherapy and chemotherapy are not supported by the literature to be in the treatment, however, some physicians decide to implement these non surgical interventions. Methodology: Utilizing the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), we managed to find 52 records and after exclusion, being left with 9 articles related to our questions in mind, which were “What is the best available intervention for MU?” and “what are the predicting factors for MU?”. Results: After carefully scanning 9 articles for possible answers to our question, we found 414 patients from different demographics. There was enough information in each article that together, a complete puzzle started revealing itself, suggesting that lymph node involvement is an important factor in recurrence and, possibly, survival of the patient. Also it has been revealed that adjuvant therapy is still not proven effective in treating MU. Conclusion: Based on our findings, we suggest health care providers first assess the degree of involvement. If it is only local, local resection might suffice. If there are any bone involvements, amputation is indicated. All the palpable lymph nodes must be removed to prevent further recurrence of MU. Radiotherapy and Chemotherapy are not indicated in MU patients.

Role of local therapy in the management of patients with metastatic anal squamous cell carcinoma: a National Cancer Database study.

About 10-20% of patients with anal squamous cell carcinoma (SCCa) present with metastatic disease and are usually treated with systemic chemotherapy. However, primary tumor control is crucial as local failure is associated with significant morbidity. Using the largest cohort to date, we report the impact of local therapy on survival among patients with metastatic anal SCCa. Data were collected from US hospitals that contributed to the National Cancer Database (NCDB) between 2004 and 2015. Patients who did not receive palliative systemic chemotherapy were excluded from analysis. Univariate (UVA) and multivariable analyses (MVA) were performed to identify factors associated with patient outcome. Kaplan-Meier analysis and Cox proportional hazards models were used to evaluate the association between tumor/patient characteristics and overall survival (OS). A total of 1,160 patients were identified over the 12 years of study. Median age was 57 years. Majority were female (64.9%), non-Hispanic Whites (79.1%) and had Charlson-Deyo Score of 0 (83.6%). Most common metastatic sites were liver (25.9%), lung (11.6%) and bone (8.5%). More than 79% of the patients had received radiation to the primary site, and 10.4% underwent surgical resection for local control. Use of local therapy correlated closely with OS on MVA (HR 0.66; 0.55-0.79; P<0.001), with a 12-month and 5-year OS rates of 72.8% and 25.7% respectively, compared with 61.1% and 14.6% for patients treated with chemotherapy only. Poor prognostic factors included male gender (HR 1.44; 1.24-1.67; P<0.001), age >70 years (HR 1.28; 1.02-1.62; P=0.034), lack of health insurance (HR 1.32; 1.02-1.71; P=0.034), and cloacogenic zone location (HR 4.02; 1.43-11.30; P=0.008). There was no benefit from abdominoperineal resection (mOS =19.7 months; HR 1.05; 0.48-2.29; P=0.909), but both local resection of the primary (mOS =24.8 months, HR 0.48; 0.29-0.80; P=0.005) and palliative radiation (mOS =22.6 months; HR 0.66; 0.55-0.79; P<0.001) were associated with improved OS. In addition to systemic therapy, resection of the primary tumor or palliative radiation improved OS in patients with anal SCCa. Patients unlikely to benefit from local control were those >70 years of age, male, lack of health insurance and cloacogenic carcinoma.

S144 Extent of Resection of the Primary Lesion With Draining Lymph Nodes Determines Long-Term Cancer-Specific Survival in Non-Mucinous Appendiceal Adenocarcinomas - A 15-Year National SEER Database Study

Introduction: Adenocarcinomas of the appendix are rare cancers for which no national comprehensive cancer network (NCCN) guidelines exist and for patients who undergo resection with curative intent, there is a paucity of data on prognostic factors affecting long-term cancer-specific survival. Methods: A retrospective study from National Cancer Institute’s -Surveillance Epidemiology and End Results on patients who underwent curative resection over a 15-year period (2004-2019) for primary appendiceal adenocarcinoma. Of a total of 16,699 patients, 14,945 were excluded (exclusion criteria were non-adenocarcinoma histological types, patients with regional or distant metastasis as per SEER stage). Effects of factors [Age, race, tumor biology (mucinous versus non-mucinous tumors), extent of resection of primary lesion &lymph nodes] on cancer-specific long-term survival were studied. Survival analysis was performed using the Kaplan-Meir method & statistical significance set at p< 0.05. Survival outcomes were reported as mean survival (months). Results: Of 1754 patients, 827 (47.1%) were females and 927 (52.1%) were males. The mean age in years (±SD) was 62.43± 14.3. The racial distribution was as follows-blacks 237(13.5%), whites 1398 (79.7%), and others 119 (6.8%). 771 (44.6%) underwent local resection (appendectomy or segmental resection of colon without lymph node resection) & 983 (55.4%) hemicolectomy with lymph node resection. Favorable survival prognosticators (Table) were age < 50, white race, and well-differentiated histology. Patients with mucinous tumors experienced better survival (Figure 1a). Patients who underwent right hemicolectomy with lymph node resection experienced better survival compared with those who had an appendectomy or segmental colonic resection, for non-mucinous tumors (Figure 1c), rather than mucinous tumors (Figure 1b). Conclusion: We report novel demographic, tumor-related, and operative prognostic factors impacting long-term cancer-specific survival in patients who undergo resection for appendiceal adenocarcinoma. These tumors are likely to be encountered by gastroenterologists in clinical practice, either preoperatively or post-operatively as part of a multi-disciplinary team. Our data, if validated by large trials would be invaluable in advocating an aggressive approach for eligible patients with a hemicolectomy and lymph node resection rather than appendectomy alone, especially in non-mucinous adenocarcinomas of the appendix.Figure 1.: a. Kaplan Meir survival curves of cancer-specific survival comparing mucinous versus non-mucinous adenocarcinomas of the appendix Figure 1b. Kaplan Meir survival curves of cancer-specific survival (mucinous adenocarcinomas of the appendix) comparing appendectomy or segmental resection versus right hemicolectomy with lymph node resection. Figure 1c. Kaplan Meir survival curves of cancer-specific survival (non-mucinous adenocarcinomas of the appendix) comparing appendectomy or segmental resection versus right hemicolectomy with lymph node resectionwrap> Table 1. - Demographic, tumor-related and operative factors impacting survival in adenocarcinoma of the appendix Factor studied Mean cancer-specific survival (months) P value Age (< 50 years vs. = or > 50 years) 169 157 0.01 Gender (Female vs. Male) 161 157 0.22 Race (white vs. black and other) 161 145 0.04 Median household income (Below vs. Above, $60,000) 152 162 0.054 Tumor biology (mucinous vs. non mucinous) 185 145 0.002 Differentiation (well vs. moderate or poorly differentiated) 185 155 0.01 Lymph node sampling or resection status (Yes vs. No) 166 143 < 0.001 Overall extent of resection (appendectomy or segmental resection vs. hemicolectomy with lymph node resection) 152 165 < 0.001 Mucinous subgroup: extent of resection (appendectomy or segmental resection vs. hemicolectomy with lymph node resection) 161 167 NS0.423 Non-mucinous subgroup: extent of resection (appendectomy or segmental resection vs. hemicolectomy with lymph node resection) 144 162 < 0.001

Pilonidal Cyst with Malignant Degeneration: A Case Report

Introduction: Pilonidal cyst is a frequent surgical pathology with low risk of malignancy.Here, we present a case of a chronic pilonidal cyst with transformation to skin squamous cell carcinoma. Case presentation: A 67-year-old male patient with a chronic presentation of injury in the sacrococcygeal region with occasional bleeding that got worse with progressive growth and purulent discharge. Initially was treated as a soft tissue infection with oral antibiotics but did not solve.A skin biopsy reported a squamous cell carcinoma, extension studies showed no secondary disease of the lesion. The patient was treated as if he was diagnosed a squamous cell carcinoma of the anal margin. Treatment was initiated with Nigro protocol chemoradiotherapy and wide local resection of the lesion with oncological margins of 1cm with success. Discussion: The pilonidal cyst is an episodic inflammatory disease in the sacrococcygeal zone that usually responses to antibiotic treatment and surgery if it’s necessary, malignant degeneration is rare, might it be related with chronic inflammation that affects repair mechanisms and create a predisposition for malignancy. The optimal treatment is in bloc surgical resection with tumor-free margins and complementary treatment depends on the histology. Conclusion: This is an uncommon case of a Pilonidal cyst with transformation to skin squamous cell carcinoma managed with Nigro protocol chemoradiotherapy and wide local resection. This case will give surgeons another tool to treat this condition.

'The parachute method': A novel technique for laparoscopic tumour handling.

Although laparoscopic surgery for submucosal tumours (SMTs) may require multiple support threads, the traction direction of a single thread is only one option and cannot be freely changed. To solve this problem, we introduced a novel innovative technique for tumour handling, named 'the parachute method'. Prior to suturing, the surrounding vessel was treated when the tumour was located near the lesser or greater curvature. A monofilament thread was ligated in the serous muscle layer along the peritumoural markings with approximately five stitches in a row, with moderate deflection. Next, the other monofilament thread was passed through the deflection and ligated; this resembled a parachute shape that could be pulled in any direction over the entire circumference with uniform tension. We performed this procedure in three patients with extramural growth-type gastrointestinal stromal tumours of approximately 2-3 cm. The median suturing time was 10 minutes. Laparoscopic local resection of the stomach was safely performed, and the patients were discharged without any complications. In this study, we demonstrate a novel, simple, inexpensive, useful and reasonable technique for handling SMTs, named 'the parachute method'. We believe that this technique will have additional applications in cooperative surgery with endoscopy.

Skull metastases from extramammary Paget's disease emerging 8 years after initial treatment with no local progression: illustrative case.

BACKGROUNDThe foci of distant metastasis from extramammary Paget’s disease (EMPD) are the lung, liver, truncal bones, vertebrae, and brain. However, skull metastases have not been reported.OBSERVATIONSThe authors treated a patient with calvarial and skull base metastases from EMPD who had undergone wide local resection of EMPD 8 years before, and they report his clinical course.LESSONSBecause EMPD with distant metastasis is fatal, it should be recognized that EMPD can metastasize to the skull even when it seemed to be in remission for several years.

494. GIANT GASTROINTESTINAL STROMAL TUMOR OF THE ESOPHAGUS: REPORT OF TWO CASES

Abstract Gastrointestinal stromal tumor (GIST) accounts for 1-3% of all gastrointestinal tumors. Most of GIST occurs in the stomach and small intestine, but GIST from the esophagus is relatively rare at about 2-5%. Surgical resection is the treatment of choice, but no routine procedure has been established. We report two cases of esophageal GIST that underwent surgical resection. [Case 1] A 75-year-old woman. She was diagnosed with an 11 cm-sized submucosal tumor was found in the esophagus by upper gastrointestinal endoscopy. Histopathological examination showed that the tumor was GIST. The patient's postoperative course was uneventful and the patient was discharged home in good condition on the 22nd postoperative day. [Case 2] A 58-year-old man. He was diagnosed a 9 cm-sized elevated lesion in the by CECT. The tumor suspected esophageal cancer sarcoma, we underwent esophagectomy. Finally, histopathological examination revealed that the tumor was GIST. His postoperative course was uneventful and he was discharged on the 19th postoperative day. [Case 1 result] Postoperative adjuvant chemotherapy with imatinib was failed, but the follow-up period continued without recurrence. [Case2 result] Postoperative adjuvant chemotherapy with imatinib was introduced. Contrast-enhanced CT 6 months after surgery revealed multiple liver metastases. 2nd line chemotherapy with sunitinib is still ongoing. [Discussion] Surgical treatment is the first choice for esophageal GIST, but no standard surgical procedure has been established. In the past, esophagectomy similar to esophageal cancer was often performed, but thoracoscopic local resection may be selected in recent years. Even in the case of giant esophageal GIST as like this two cases, if the general condition is stable and preoperative treatment is possible, it is possible to choose to perform preoperative neoadjuvant chemotherapy.

Impact of Local Control on Clinical Course in Stage IVC Anaplastic Thyroid Carcinoma.

The present study investigated the association between local resection and cause of death in anaplastic thyroid carcinoma (ATC) patients with stage IVC disease. A total of 54 ATC patients with stage IVC disease were included in the study. Information including patient characteristics, laboratory data including complete blood count, treatment, and death were collected for analysis. The median overall survival (OS) for patients with or without resection was 8.4 [95% confidence interval (CI) 5.9-14.4)] and 4.2 (95% CI 2.5-6.2) months, respectively (p < 0.001). No patients survived without resection at 1 year. Univariate analysis revealed that resection (p < 0.001) and radiotherapy (p = 0.018) were significantly associated with OS. Multivariate analysis revealed that resection (hazard ratio 0.257; 95% CI 0.115-0.575; p < 0.001) was the only independent prognostic factor of OS. In ATC patients with known resection status, the median OS for the patients with a resection status of R0/1 (n = 28) and R2 (n = 7) were 13.0 (95% CI 7.5-18.7) and 1.7 (95% CI 0.1-6.2) months, respectively (p < 0.001). The most common specific cause of death was respiratory insufficiency (35%), followed by airway obstruction (25%) and cerebral cardiovascular-related death (5%). The frequency of airway obstruction was significantly lower in patients with resection (p = 0.018). Resection probably impacts on clinical course in ATC patients despite the presence of distant metastasis. However, R2 resection is likely to be harmful and surgeons should carefully consider the resectability of thyroid tumors.

Review of sociodemographic risk factors for presentation with advanced non-melanoma skin cancer

ABSTRACT Purpose Non-melanoma skin cancers (NMSC) are often localized and associated with an excellent prognosis but a minority present with locally advanced or metastatic disease requiring extensive resection or systemic treatment. Medical factors that increase the risk of advanced skin cancers such as tobacco use, systemic immunosuppression or genetic syndromes have been described but the sociodemographic risk factors are relatively uninvestigated and under reported. In this review a cohort of patients presenting with periorbital NMSC is reviewed for social determinants of health correlated with presentation with advanced disease. Methods Patients presenting with periorbital NMSC during a 10-year period are categorized as advanced (those tumors requiring extensive local resection, sacrifice of the globe or systemic therapy) or non-advanced and demographic features are compared between the two groups. Results 274 cases of periorbital NMSC were classified as either non-advanced (177) or advanced (97). Patients with public safety net health insurance were twice as likely to present with advanced disease (25% vs 13%). Patients with advanced disease were significantly less likely to be under the care of a primary care physician, lived in economically depressed areas with lower mean household incomes, and lived further from tertiary medical care. Conclusion Financial and sociodemographic features are strongly associated with presentation with advanced NMSC. Further work is needed to determine which sociodemographic features are independent risk factors. A better understanding of the relevant barriers to care may reduce the burden of advanced disease at presentation in the future.

Clinical outcomes of gastroduodenal neuroendocrine tumors according to their WHO grade: A single-institutional retrospective analysis.

The management of gastroduodenal neuroendocrine tumor (NET) has been controversial between radical surgical resection and local excision including endoscopic resection. A gastroduodenal NET grade (G), measured by their mitotic rate and Ki67 proliferation index, is important to predict prognosis. In this study, we aimed to compare the clinical outcomes of gastroduodenal NET according to grades in order to identify poor prognostic factors of gastroduodenal NETs. Fifty-four gastroduodenal NETs diagnosed between December 2008 and December 2020 in a tertiary referral hospital were retrospectively reviewed. The clinical outcomes of gastroduodenal NETs, according to tumor grades and factors associated with NET G2-3, were analyzed. A total of 52 gastroduodenal NET patients was enrolled. The mean follow-up period was 56.2 ± 40.1 months. The mean size of gastric and duodenal NET was 7.9 ± 11.0 mm and 9.8 ± 7.6 mm, respectively. During the study period, 72.7% (16/22) of gastric NETs and 83.3% (25/30) of duodenal NETS were G1. All G1 gastroduodenal NETs showed no lymph node or distant metastasis during the study periods. All G3 gastroduodenal NETs showed metastasis (one lymph node metastasis and 3 hepatic metastases). Among metastatic NETs, the smallest tumor size was a 13 mm gastric G3 NET. Factors associated with G2-3 NETs were larger tumor size, mucosal ulceration, proper muscle or deeper invasion, and lymphovascular invasion. A small-sized gastroduodenal NET confined to submucosa without surface ulceration may be suitable for endoscopic resection. After local resection of a gastroduodenal NET (G1) without lymphovascular and muscle proper invasion, follow-up examination without radical surgical resection can be recommended. G3 NETs may be treated by radical surgical resection, regardless of tumor size.

Locoregional relapse after sparing mastectomies and immediate reconstruction in women with breast cancer

IntroductionIn recent years, cultural changes in today's society and improved risk assessment have increased the indication for mastectomies in women with breast cancer. Various studies have confirmed the oncological safety of sparing mastectomies and immediate reconstruction. The objective of this study is to analyze the incidence of locoregional relapses of this procedure and its impact on reconstruction and overall survival. Patients and methodsProspective study of patients with breast carcinoma who underwent a sparing mastectomy and immediate reconstruction. Locoregional relapses and their treatment and their impact on survival were analyzed. ResultsThe study group is made up of 271 women with breast carcinoma treated with a skin-sparing mastectomy and immediate reconstruction. The mean follow-up was 7.98 years and during the same 18 locoregional relapses (6.6%) were diagnosed: 72.2% in the mastectomy flap and 27.8% lymph node. There were no significant differences in the pathological characteristics of the primary tumor between patients with and without locoregional relapse, although the percentage of women with hormone-sensitive tumors was higher in the group without relapse. Patients with lymph node relapse had larger tumors (80% T2-T3) and 60% had axillary metastases at diagnosis, compared to 7.7% of women with skin relapse (p = 0.047). All patients operated on for locoregional relapse preserved their reconstruction. The incidence of metastases and deaths was significantly higher in patients with a relapse, causing a non-significant decrease in overall survival. ConclusionLocoregional relapses are a rare event in women with a sparing mastectomy and immediate reconstruction. Most patients with locoregional relapse can preserve their initial reconstruction through local resection of the tumor and adjuvant and / or neoadjuvant therapies.

Excellent oncological outcomes besides short-term safety of laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor.

Background and study aims Laparoscopic and endoscopic cooperative surgery (LECS) for gastric submucosal tumor was developed as a type of minimal local resection and is now widely used in Asian countries. However, the oncological safety of LECS for gastric gastrointestinal stromal tumor (GIST) remains unclear. LECS has potential oncology-related problems that may influence survival outcomes. Furthermore, the feasibility and safety of LECS have not yet been fully established. Patients and methods Patients who were intended to undergo LECS for gastric GIST from 2006 to 2020 were retrospectively selected. The indication for LECS was determined according to the guidelines. The completion of LECS, complications, and survival outcomes of the patients were analyzed. Results Two hundred fifty-nine patients were eligible in this study. According to intraoperative findings, 44 patients underwent local resection without luminal endoscopic procedures. Of the remaining 215 patients, 213 completely underwent LECS, which corresponds to a completion rate of 99.1 %. Six patients (2.8 %) had postoperative complications of Clavien-Dindo classification grade II or higher. Delayed gastric emptying was most commonly found in four patients (1.9 %). Old age ( P = 0.0349), female sex ( P = 0.0095), tumor located in the lesser curvature ( P = 0.0015), and large tumor diameter ( P = 0.0232) were significantly more common in patients with complications. The 3-year overall and disease-specific survival rates were 99 % and 100 %, respectively, in 215 patients who were intended to undergo LECS. Conclusions Despite several oncological concerns, LECS for gastric GIST is oncologically safe besides a feasible and safe procedure in the short-term.

Implementation of robotic rectal cancer surgery: a cross-sectional nationwide study

AimAn increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches.MethodsPatients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach.ResultsBetween 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13–16%) in 2018 to 22% (95% CI 20–24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3–5%) versus 7% (95% CI 6–8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38–46%) versus 29% (95% CI 26–31%)].ConclusionRectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.

Clip-guided local duodenectomy for safe and minimal local resection of nonampullary duodenal neoplasms

BackgroundLocal duodenectomy and primary closure is a simple option for some nonampullary duodenal neoplasms. Minimizing the resection area while ensuring curability is necessary for safe primary duodenal closure. However, it is often difficult to determine the appropriate resection line from the serosal side. We developed clip-guided local duodenectomy to easily determine the resection range and perform local duodenectomy safely, then performed a retrospective observational study to confirm the safety of clip-guided local duodenectomy.MethodsThe procedure is as follows: placing endoscopic metal clips at four points on the margin around the tumor within 3 days before surgery, identifying the tumor extent with the clips under X-ray imaging during surgery, making an incision to the duodenum just outside of the clips visualized by X-ray imaging, full-thickness resection of the duodenum with the clips as guides of tumor demarcation, and transversely closure by Gambee suture. We evaluated clinicopathological data and surgical outcomes of patients who underwent clip-guided local duodenectomy at two surgical centers between January 2010 and May 2020.ResultsEighteen patients were included. The pathological diagnosis was adenoma (11 cases), adenocarcinoma (6 cases), and GIST (1 case). The mean ± SD tumor size was 18 ± 6 mm, and the tumor was mainly located in the second portion of the duodenum (66%). In all cases, the duodenal defect was closed with primary sutures. The mean operation time and blood loss were 191 min and 79 mL, respectively. The morbidity was 22%, and all complications were Clavien–Dindo grade II. No anastomotic leakage or stenosis was observed. In the 6 adenocarcinoma patients, all were diagnosed with pT1a, and postoperative recurrence was not observed. The 1-year overall and recurrence free survival rate was 100%.ConclusionsClip-guided local duodenectomy is a safe and useful surgical option for minimally local resection of nonampullary duodenal neoplasms such as duodenal adenoma, GIST, and early adenocarcinoma.

Metformin administration is associated with enhanced response to transarterial chemoembolization for hepatocellular carcinoma in type 2 diabetes patients

Transarterial chemoembolization (TACE) is often used as a locoregional therapy for early hepatocellular carcinoma (HCC) when local ablation or resection are not feasible, but incomplete response and recurrence are commonly observed. In this study, we sought to determine the association between metformin administration and TACE outcomes for single nodular HCC in patients with type 2 diabetes mellitus (T2DM). The retrospective cohort analysis included 164 T2DM patients with single nodular HCC who underwent TACE as an initial treatment, and 91 were exposed to metformin before and after TACE. Propensity score (PS) matching was used to balance covariates. Logistic regression analysis was used to determine the predictors of tumor response after TACE, and Cox regression analysis assessed independent predictors of local tumor recurrence (LTR) in patients with complete response after TACE. Metformin use was associated with significantly higher objective response rate (ORR) in the overall and PS-matched cohort (79.1% vs. 60.3 and 78.7% vs. 57.5%; p = 0.008 and p = 0.029, respectively). Logistic regression analysis showed that metformin use was an independent predictor of ORR in all and PS-matched patients (odds ratio = 2.65 and 3.06; p = 0.016 and 0.034, respectively). Cox regression analysis showed metformin administration was an independent predictor for lower LTR in all and PS-matched patients (hazard ratio = 0.28 and 0.27; p = 0.001 and 0.007, respectively). Metformin administration is associated with better initial response and lower local recurrence after TACE for single nodular HCC in T2DM.

Rescue and Cooperation of Sudden Apnea in a Local Anesthesia Tumor Resection

Rescue and Cooperation of Sudden Apnea in a Local Anesthesia Tumor Resection

Patterns and Predictors of Cervical Lymph Node Metastasis in Parathyroid Carcinoma.

Simple SummaryParathyroid carcinoma (PC) is a rare endocrine malignancy with poor outcomes. Surgery remains the mainstay of PC treatment. However, due to the rarity of this malignancy, the optimal extent of PC surgery remains inconclusive, including whether to perform central lymph node dissection (LND). In the present study, we reported the patterns and predictors of cervical lymph node metastasis in PC based on a cohort of 68 PC patients. The results showed that the percentage of cervical lymph node metastasis in PC was 19.4% at initial surgery and 25.0% including reoperations for recurrencies. High-risk Schulte staging and CDC73 abnormalities were identified as risk factors for cervical lymph node metastasis. Central LND should be considered during remedial surgeries performed after previous local resection of PC for patients with high risk factors.Background: Parathyroid carcinoma (PC) is a rare endocrine malignancy with poor outcomes. Over 60% of PC patients experience repeated disease recurrence or metastasis. The significance of cervical lymph node dissection (LND) for PC remains inconclusive. Methods: PC patients diagnosed at Peking Union Medical College Hospital between 1992 and 2021 were reviewed retrospectively. Clinical data, initial tumor histological staging, parafibromin histochemical staining results, Ki67 index, CDC73 gene mutation status and outcome information were collected systemically. The risk factors for recurrence and lymph node or distant metastasis were explored. Results: Sixty-eight PC patients receiving LND were enrolled. Cervical lymph node metastasis was identified in 19.4% of patients at initial surgery and 25.0% of patients including reoperations for recurrences. The independent risk factor for PC recurrence was a Ki67 index ≥ 5% (HR4.41, 95% confidence interval (CI)1.30–14.95, p = 0.017). Distant metastasis was an independent prognostic factor for PC patient overall survival (HR 5.44, 95% CI 1.66–17.82, p = 0.005). High-risk Schulte staging (p = 0.021) and CDC73 abnormalities (p = 0.012) were risk factors for cervical lymph node metastasis. Conclusion: Most PCs were slow-growing, but lymph node metastasis was not rare. For patients planning to undergo remedial surgery after previous local resection of PC, central LND is suggested for tumors with high-risk Schulte staging or CDC73 abnormalities.