Length Of Margin Research Articles

Comparative analysis of tertiary lymphoid structures for predicting survival of colorectal cancer: A whole-slide images-based study

Abstract Background Tertiary lymphoid structures (TLS) are major component in immune microenvironment, correlating with a favorable prognosis in colorectal cancer. However, the methods used to define and characterize TLS were not united, hindering its's clinical application. This study aims to seek a more stable method to characterize TLS and clarify its prognostic value in larger multicenter cohorts. Methods A total of 1609 patients from four hospitals and the TCGA database were analyzed. We quantified the number and maximum length of TLS along the invasive margin of tumor using hematoxylin and eosin (HE)-stained whole-slide images (WSIs). Additionally, the length of the invasive margin was determined to calculate the TLS density. The prognostic value of the TLS for overall survival was evaluated. In addition, we examined the association between TLS density and immune cell infiltration using immunohistochemistry-stained WSIs. The performance for predicting overall survival was measured using hazard ratios (HR) with 95% confidence intervals (CI). Results Among the three TLS quantification methods, TLS density has the strongest discriminative performance. Survival analysis indicated that higher TLS density correlated with better overall survival (HR for high vs. low 0.57 [95% CI 0.42–0.78] in primary cohort; 0.49 [0.35–0.69] in validation cohort; 0.35 [0.18–0.67] in TCGA cohort). A high TLS density was associated with a high level of CD3+ T cells infiltration. Conclusions Based on this comparative multicenter analysis, TLS density was identified as a simple, robust, and effective immune prognostic index for colorectal cancer.

Esophagojejunostomy using a circular stapler vs. a linear stapler for gastric cardia cancer patients: impact of upper margin length and tumor size on the survival rate.

The incidence of gastric cancer is concomitantly rising with gastric cardia cancer worldwide. While the improvement of gastric cancer surgical techniques is glowing, this study assesses the impact of the upper margin length and tumor size on the survival rate for gastric cardia cancer patients who underwent total laparoscopic total gastrectomy(TLTG) or laparoscopic assisted total gastrectomy(LATG). A total of 63 patients with gastric cardia cancer who underwent laparoscopic total gastrectomy were retro-prospectively collected from January 2021 to May 2023. While assessing the impact of upper margin length and tumor size on the survival rate, esophagojejunostomy using a linear stapler has been compared to a circular stapler. The sixty-three patients met inclusion criteria; 32 (51%) underwent LATG and 31 (49%) underwent TLTG. Their mean age was 65 years (range, 45-77). The blood loss means in LATG and TLTG was 74.69 and 50.16 ml, respectively (p = 0.005), and surgery duration was higher in LATG than LATG with respective means of 247 min and 222.42 min. (p = 0.006). However, the tumor size means (p = 0.5), and upper margin length means (p = 0.052) were not significantly different in the LATG and TLTG groups, respectively. The number of resected and assessed lymph node was adequate in the LATG and TLTG groups. The current study still does not find an independent related risk from the upper margin length and tumor size to the survival rate according to the multiple regression analysis (p = 0.080). The upper margin length and tumor size do not have a relationship with the survival rate of the compared esophagojejunostomy (EJS) methods. The EJS using a linear stapler requires a shorter surgery duration and less blood loss than EJS using a circular stapler.

346. ESOPHAGOGASTRIC JUNCTION SIEWERT II TUMORS, A CHALLENGE FOR THE SURGEON: RESULTS OF TRANSHIATAL EXTENDED GASTRECTOMY VS. IVOR LEWIS ESOPHAGECTOMY

Abstract Background Esophagogastric junction (EGJ) Siewert type II tumors pose unique challenges in terms of adequate surgical treatment due to their anatomical location and potential for abdominal and mediastinal lymph node metastasis. The optimal surgical approach for these tumors remains a topic of debate, with options including transhiatal extended gastrectomy or transthoracic esophagectomy. Understanding the different outcomes associated with these surgical interventions is crucial for informed decision-making and patient-tailored management. The aim of this study was to compare the perioperative and oncological outcomes of these two surgical technique to access which could be the treatment of choice for Siewert II type tumours. Methods This study is a retrospective non-randomized cohort study from a single center. We reviewed the data of all the patients who underwent surgery for EGJ Siewert type II tumors between December 2014 and February 2023. The patients were divided into two groups: those who underwent transthoracic esophagectomy were assigned to “TE group” (72 patients) and those who underwent transhiatal extended gastrectomy were assigned to “TEG group” (21 patients). Results Patients in the TEG group were older (p=0.011) and in worst clinical condition (Charlson Comorbidity Index 4.15±1.78 vs. 4.95±1.46, p=0.064). The tumour stage at the diagnosis was more advanced in the TE group (p=0.004), and upfront surgery was infrequent in this group (p<0.001). The average duration of surgery was higher in the TE group (p<0.001). No difference was seen in the tumour length (p=0.924), implying a statistically significant difference in the proximal margin length (p<0.001), and distal margin length (p<0.001), with a R0 resection rate higher in the TE group (93.1% vs. 66.7%, p=0.002). The higher rate of R1 resection in the TEG group was mainly due to proximal margin infiltration. No difference was seen in the number of harvested lymph nodes (p=0.339). Overall postoperative complications rates were similar (p=0.144). No differences were found in the length of ICU stay (p=0.676) and in hospital stay (p=0.075). At a median follow up of 20 months, there were no statistical differences in Overall Survival and Disease-Free Survival at 5 years. Conclusion Our data suggests that transthoracic esophagectomy for EGJ Siewert type II tumors should be the treatment of choice for patients in good clinical condition, but transhiatal extended gastrectomy could be a good choice for patients presenting in worse clinical condition. A multidisciplinary approach is essential for optimal patient care, and the selection of the surgical technique should be based on a thorough evaluation of the patient's condition and tumor characteristics

538. COMPARISON OF EARLY POSTOPERATIVE OUTCOMES OF CERVICAL ANASTOMOSIS TO HIGH INTRATHORACIC ANASTOMOSIS AMONG PATIENTS WITH UPPER THORACIC ESOPHAGEAL CANCER

Abstract Background For upper thoracic esophageal cancer, esophagectomy combined with cervical esophagogastrostomy (cervical anastomosis, CA) and three-field lymph node dissection (3FLND) has been proposed as the standard surgical approach. However, while CA provides sufficient length of proximal resection margins, it is associated with a higher incidence of postoperative complications such as anastomotic leaks, recurrent laryngeal nerve (RLN) injury, and increased mortality. As an alternative, high-intrathoracic esophagogastric anastomosis (high-ITA) with 3FLND has been performed. We aimed to evaluate the benefits and limitations of high-ITA compared to conventional CA in terms of early postoperative outcomes. Methods A total of 232 patients, who underwent curative esophagogastrostomy with 3FLND and either of high-intrathoracic anastomosis (high-ITA) or cervical anastomosis (CA) for upper thoracic esophageal cancer a tertiary hospital from January 2010 to December 2021. Collected data from medical records were analyzed retrospectively regarding morbidity and mortality rates. The primary end point was recurrence. Anastomotic leak, RLN palsy, hospital stay, and 90-day mortality and in-hospital mortality were evaluated using Chi-squared test, Fisher’s exact test, and T-test. The risk of mortality and recurrence were analyzed using Cox-proportional hazard regression with a median follow-up of 39.1(IQR 17.8, 80.2) months. Results Among the fifty patients with high-ITA and 182 patients with CA, the high-ITA group reported fewer anastomotic leaks (6.0% vs. 19.8%, p=0.02) and a shorter hospital stay (median 12days vs. 15 days, p<0.001). No significant difference was observed in RLN palsy (6.0% vs. 13.7%, p=0.22) and the 90-day or in-hospital mortality rate (2.0% vs. 2.2%, p=1.0). The number of lymph nodes dissected (LND) was similar between the groups (47.4(±15.4) vs. 52.7(±18.3), p=0.06), and there was no difference in the risk of mortality and recurrence according to the high-ITA method (HR 0.9, 95% CI 0.6-1.6; HR 1.0, 95% CI 0.6-1.7) after adjustment for age, sex, and stage. Conclusion In the esophagogastrostomy with three-field lymph node dissection, performing high-intrathoracic anastomosis may reduce the incidence of anastomotic leaks and shorten the hospital stay without adversely affecting overall survival.

Variation of the Tegmen and Cercus in Sinopodisma rostellocerca (Orthoptera: Acrididae: Melanoplinae) with Proposal of a New Synonym.

Intraspecific variation is ubiquitous from individual traits to population level and plays an important role in a variety of fields. However, it is often ignored by systematists and comparative evolutionary biologists. In view of the limited knowledge of intraspecific variation, morphology-based identification has hindered the recognition of species borders and led to a great number of problems in the field of taxonomy and systematics. In this study, the intraspecific variation of the tegmen and cercus in Sinopodisma rostellocerca was examined, the variation patterns were summarized and the relationship between S. rostellocerca and S. hengshanica was discussed. The results showed that the intraspecific variation in the tegmen and male cercus was mainly manifested in the length and shape of the apical margin and dorso- and ventro-apical angles; this substantial variation occurred not only among intrapopulation individuals but also between the different sides of the same individuals, and all types of variation in S. hengshanica fell into the range of variation in S. rostellocerca, leading to the disappearance of the boundary between the two species. Therefore, S. hengshanica was herein considered as a new junior synonym of S. rostellocerca.

Precise reconstruction of the aortic valve using glutaraldehyde-treated autologous pericardium in new formula: a case report

BackgroundThe current study presents a novel and precise surgical technique for complete reconstruction of the aortic valve using glutaraldehyde-treated autologous pericardium in a patient with aortic valve disease and endocarditis. The technique aims to provide a more effective and reproducible method for aortic valve repair, with the goal of improving outcomes and quality of life for patients with aortic valve disease.Case presentationA 35-year-old Iranian male with aortic valve disease and endocarditis underwent aortic valve reconstruction surgery. Preoperative echocardiography showed a degenerative aortic valve with severe regurgitation, reduced left ventricular ejection fraction, and specific aortic root dimensions. The surgical technique involved precise measurements and calculations to design the size and shape of the new aortic valve cusps using autologous pericardium, with the goal of optimizing coaptation and function. The surgeon calculated the intercommissural distance based on the aortic annulus diameter to determine cusp size and shape. He tailored the pericardial cusps to have a height equal to 80% of the coaptation margin length. Detailed suturing techniques were used to ensure proper alignment and coaptation of the new cusps. Intraoperative evaluation of the valve function using suction and transesophageal echocardiography showed good coaptation and minimal residual regurgitation. At the 3-year follow-up, the patient had a well-functioning aortic valve with only trivial leak and was in satisfactory clinical condition.ConclusionsGlutaraldehyde-treated autologous pericardium is a validated leaflet alternative, and the causes of its failure are late annular dilatation and other technique breakdowns. Current evidence reveals that aortic valve reconstruction with glutaraldehyde-treated autologous pericardium is associated with many advantages with the potential to improve patient outcomes and quality of life. Further clinical studies are warranted to evaluate the long-term durability and efficacy of this approach.

Aortic valve cusp size and shape in dilated trileaflet aortic roots

ObjectivesThe objective of the study was to quantify the differences in cusp size and shape in patients with normal and dilated trileaflet aortic roots and in dilated roots with or without aortic regurgitation. MethodsA retrospective analysis of computed tomography studies in patients with normal and dilated trileaflet aortic roots was performed measuring root and cusp dimensions. Normal root size was defined as sinuses of Valsalva diameter less than 40 mm, dilated as 45 mm or greater. Root measurements normalized to basal ring diameter and cusp measurements normalized to geometric height were analyzed to assess the shape. Additionally, comparison of dilated roots with or without aortic regurgitation was made. ResultsWe analyzed 146 normal and 104 dilated aortic roots and 73 propensity-matched pairs. Dilated roots were larger in all dimensions and had increased ratio between commissural and basal ring diameter (1.58 ± 0.23 vs 1.11 ± 0.10, P < .001). Cusps in dilated roots were larger in all measured dimensions and were elongated with increased normalized cusp insertion length (3.64 ± 0.39 vs 3.26 ± 0.20, P < .001) and normalized free margin length (2.53 ± 0.30 vs 2.16 ± 0.19, P < .001). In patients with dilated root and no cusp prolapse (n = 83), those with moderate or severe aortic regurgitation had larger commissural diameter but similar cusp dimensions compared with those with no or mild aortic regurgitation. ConclusionsThe cusps in dilated roots elongate transversely and to a lesser degree radially. Functional aortic regurgitation is caused by extensive commissural dilatation and not by inadequate cusp adaptation.

The role of length of oral resection margin and survival in esophageal cancer surgery after neoadjuvant therapy: A retrospective propensity score-matched study

BackgroundMultimodal therapy regimens became the standard of care for patients with esophageal cancer, whereas surgical resection remains at the center of curative treatment modalities. Current guidelines provide no recommendations on the extent of the oral resection margin, especially in the era of neoadjuvant therapy. Therefore, this study aimed to evaluate the relationship between the oral tumor-free resection margin and overall survival. MethodsRetrospective study with 382 1:1 propensity-matched patients out of 660 patients, operated between 2013 and 2019, with an Ivor-Lewis-esophagectomy for adenocarcinoma and squamous cell carcinoma of the esophagus or esophagogastric junction after neoadjuvant therapy. Independent pathologists measured the oral resection margin after formalin fixation. ResultsThe mean oral tumor-free resection margin was 37.2 ± 0.6 mm. The ideal cut-off for survival differences was determined for 33 mm. Patients with an oral resection margin of more than 33 mm had a better median overall survival (≤33 mm: 45.0 months, 95% confidence interval: 22.4–67.6 months, >33 mm: not reached, P = .005). An oral resection margin of more than 33 mm proved to be an independent favorable prognostic factor for patients' overall survival in multivariate Cox regression analyses (P = .049). ConclusionThis study analyzed a patient cohort retrospectively after curative intended Ivor-Lewis-esophagectomy after neoadjuvant therapy. An oral resection margin of more than 33 mm is a factor for improved overall survival. Therefore, a minimum resection margin of 34 mm after fixation could be suggested.

Comparison efficacy and safety of total laparoscopic gastrectomy and laparoscopically assisted total gastrectomy in treatment of gastric cancer.

The development of laparoscopic technology has provided a new choice for surgery of gastric cancer (GC), but the advantages and disadvantages of laparoscopic total gastrectomy (LTG) and laparoscopic-assisted total gastrectomy (LATG) in treatment effect and safety are still controversial. The purpose of this study is to compare the efficacy and safety of the two methods in the treatment of GC, and to provide a basis for clinical decision-making. To compare the efficacy of totally LTG (TLTG) and LATG in the context of radical gastrectomy for GC. Additionally, we investigated the safety and feasibility of the total laparoscopic esophagojejunostomy technique. Literature on comparative studies of the above two surgical methods for GC (TLTG group and LATG group) published before September 2022 were searched in the PubMed, Web of Science, Wanfang Database, CNKI, and other Chinese and English databases. In addition, the following search keywords were used: Gastric cancer, total gastrectomy, total laparoscopy, laparoscopy-assisted, esophagojejunal anastomosis, gastric/stomach cancer, total gastrectomy, totally/completely laparoscopic, laparoscopic assisted/laparoscopy assisted/laparoscopically assisted, and esophagojejunostomy/esophagojejunal anastomosis. Review Manager 5.3 software was used for the meta-analysis after two researchers independently screened the literature, extracted the data, and evaluated the risk of bias in the included studies. After layer-by-layer screening, 258 pieces of literature were recovered, and 11 of those pieces were eventually included. This resulted in a sample size of 2421 instances, with 1115 cases falling into the TLTG group and 1306 cases into the LATG group. Age or sex differences between the two groups were not statistically significant, according to the meta-analysis, however the average body mass index of the TLTG group was considerably higher than that of the LATG group (P = 0.01). Compared with those in the LATG group, the incision length in the TLTG group was significantly shorter (P < 0.001), the amount of intraoperative blood loss was significantly lower (P = 0.003), the number of lymph nodes removed was significantly greater (P = 0.04), and the time of first postoperative feeding and postoperative hospitalization were also significantly shorter (P = 0.03 and 0.02, respectively). There were no significant differences in tumor size, length of proximal incisal margin, total operation time, anastomotic time, postoperative pain score, postoperative anal exhaust time, postoperative anastomosis-related complications (including anastomotic fistula, anastomotic stenosis, and anastomotic hemorrhage), or overall postoperative complication rate (P > 0.05). TLTG and esophagojejunostomy are safe and feasible. Compared with LATG, TLTG has the advantages of less trauma, less bleeding, easier access to lymph nodes, and faster postoperative recovery, and TLTG is also suitable for obese patients.

Laparoscopic versus open total gastrectomy for T4a gastric cancer: a propensity score-matched analysis of long-term outcomes.

Evidence of implementation of laparoscopic total gastrectomy (LTG) for surgical T4a stage (sT4a) gastric cancer (GC) remains inadequate. This study aimed to compare short- and long-term outcomes of LTG versus open total gastrectomy(OTG) for sT4a GC. This retrospective cohort study was conducted using data from patients with sT4a GC underwent total gastrectomy from 2014 to 2020. Short-term outcomes included operative characteristics and postoperative complications. Long-term oncological outcomes focused on 3-, and 5-year overall survival (OS) and disease-free survival (DFS). Propensity score matching (PSM) was applied to reduce potential biases in baseline characteristics between groups. There was a total of 161 patients, in which 96 underwent LTG and 65 underwent OTG. After PSM, both groups consisted of 51 patients each, with balanced baseline characteristics. There were no significant differences between the two groups regarding blood loss, length of proximal resected margin, postoperative hospital stays, and overall and major postoperative complications. Most of the complications were classified as minor according to the Clavien-Dindo classification. Operating time was significantly longer in the LTG group (mean: 257min vs. 231min, p = 0.006). LTG was superior to OTG groups in time to flatus (mean: 3.0 days vs 3.9 days, p < 0.001). Five-year OS and DFS rates were similar between the two groups (44% and 33% vs. 43% and 28% in the LTG and OTG groups, respectively). Our findings indicate that LTG is a feasible and safe technique, exhibiting comparable long-term oncological outcomes to OTG for sT4a GC. LTG may be an acceptable alternative to OTG for the treatment of sT4a GC.

Three-dimensional modelling of aortic leaflet coaptation and load-bearing surfaces: in silico design of aortic valve neocuspidizations.

Three-dimensional (3D) modelling of aortic leaflets remains difficult due to insufficient resolution of medical imaging. We aimed to model the coaptation and load-bearing surfaces of the aortic leaflets and adapt this workflow to aid in the design of aortic valve neocuspidizations. Geometric morphometrics, using landmarks and semilandmarks, was applied to the geometric determinants of the aortic leaflets from computed tomography, followed by an isogeometric analysis using Non-Uniform Rational Basis Splines (NURBS). Ten aortic valve models were generated, measuring determinants of leaflet geometry defined as 3D NURBS curves, and leaflet coaptation and load-bearing surfaces were defined as 3D NURBS surfaces. Neocuspidizations were obtained by either shifting the upper central coaptation landmark towards the sinotubular junction or using parametric neo-landmarks placed on a centreline drawn between the centroid of the aortic root base and centroid of a circle circumscribing the 3 upper commissural landmarks. The ratio of the leaflet free margin length to the geometric height was 1.83, whereas the ratio of the commissural coaptation height to the central coaptation height was 1.93. The median coaptation surface was 137 mm2 (IQR 58) and the median load-bearing surface was 203 mm2 (60) per leaflet. Neocuspidization multiplied the central coaptation height by 3.7 and the coaptation surfaces by 1.97 and 1.92 using the native coaptation axis and centroid coaptation axis, respectively. Geometric morphometrics reliably defined the coaptation and load-bearing surfaces of aortic leaflets, enabling an experimental 3D design for the in silico neocuspidization of aortic valves.

Pulmonary Surgical Margins for Metastatic Osteosarcoma: Is Negative Margin Enough?

BackgroundIn advanced osteosarcoma, the lung is the most frequent site of distant metastasis, with metastasectomy often used for local disease control. The influence of pulmonary resection margin length on outcomes for osteosarcoma has not been well explored. This study sought to evaluate the impact of margin length relative to tumor size on local recurrence and survival in lung-limited metastatic osteosarcoma. MethodsPatients with metastatic osteosarcoma who underwent lung resection between 2000 and 2020 were identified from a single institution. Clinicopathologic variables were collected. The margin length-to-tumor size ratio (MTR) was calculated per nodule and classified relative to an MTR of 0.5. The primary outcome was development of local recurrence per nodule. Multivariate logistic regression was used to investigate covariates. ResultsA total of 142 patients with 689 nodules met inclusion criteria, with mean age of 35.6 years (interquartile range [IQR], 20.9-46.6 years). Patients were predominantly male (n = 87; 61.3%) and White (n = 106; 72.5%). Most nodules (n = 644; 93.5%) were resected through thoracotomy. The mean tumor size was 0.8 cm (IQR, 0.5-1.70 cm), with an average margin length of 0.3 cm (IQR, 0.1-0.7 cm). Among all nodules, 299 (43.4%) had an MTR >0.5. Systemic therapy was received by 94 patients (66.2%) preoperatively and by 100 patients (70.4%) postoperatively. Importantly, the study found that an MTR >0.5 conferred a protective effect against disease recurrence (hazard ratio, 0.67; 95% CI, 0.52-0.87; P = .003). ConclusionsIn resected pulmonary metastatic osteosarcoma, a margin length greater than one-half the size of the pulmonary nodule is associated with a lower incidence of local disease recurrence. This finding has implications for the subsequent need for additional therapy and disease-free status, thus meriting attentive intraoperative consideration.

Quantitative analysis of the eyelid curvature in patients with blepharoptosis

BackgroundThe aim of this study was to evaluate the ability of two novel eyelid curvature measurements to distinguish between normal eyes and different severities of blepharoptosis.MethodsA comparative cross-sectional analysis of upper eyelid curvature was performed for different severities of patients with unilateral blepharoptosis (congenital and aponeurotic) and normal controls. Mean upper lid contour index (ULCI) and area circularity index (ACI) were calculated for each group by dividing the intercanthal distance by upper eyelid margin length (ULCI) and dividing the interpalpebral area by the area of a circle enclosing the eye (ACI). The ratio of each index for the study and fellow normal eye of each patient was also calculated and compared between groups.ResultsA total of 106 eyes including 30 eyes in the control group and 25, 27, and 24 eyes in the mild, moderate, and severe ptosis groups were enrolled in the study. ULCI and ACI showed a statistically significant difference between the groups (p < 0.001, p < 0.001). The inter-eye ratio (ULCI-ratio and ACI-ratio) of indices was also significantly different between groups (p = 0.002, p < 0.001). Pairwise comparisons revealed that ACI and ACI-ratio were significantly different between all pairs of study groups.ConclusionThe results of our study showed that ACI based on area measurements may distinguish blepharoptosis patients from normal controls and from each other. Including the data from the fellow normal eyes in the form of ratio indices may improve the differentiating power. These results can be useful in designing the optimal eyelid curvature measurements.

Age affects vascular morphology and predictiveness of anatomical landmarks for aortic zones in trauma patients: implications for resuscitative endovascular balloon occlusion of the aorta.

Understanding the vascular morphology is fundamental for resuscitative endovascular balloon occlusion of the aorta. This study aimed to evaluate the effect of aging on length and diameter of aorta and iliac arteries in trauma patients, and to investigate the predictiveness of anatomical landmarks for aortic zones. A total of 235 patients in a regional trauma center registry from September 1, 2018, to January 3, 2024, participated in the study. Reconstruction of computed tomography was applied to the torso area. The marginal diameter and length of aorta and iliac arteries were measured. Anatomical landmark distances and aortic marginal lengths were compared. The length and diameter of aorta and iliac arteries increased with age, and a tortuous and enlarged morphology was observed in older patients. There was a good regression between age and diameter of the aorta. Neither the jugular notch, the xiphisternal joint, nor the umbilicus could reliably represent specific margins of aortic zones. The distance between the mid-sternum and femoral artery (427 ± 25 to 442 ± 25mm for right, and 425 ± 28 to 440 ± 26mm for left) was predictive for zone 1 in all groups. The distance between the lower one-third junction of the xiphisternum to the umbilicus and femoral artery (232 ± 19 to 240 ± 17mm for right, and 229 ± 20 to 237 ± 19mm for left) was predictive for zone 3 aorta. Aging increases the length and diameter of aorta and iliac arteries, with a tortuous and enlarged morphology in geriatric populations. The mid-sternum and the lower one-third junction of the xiphisternum to the umbilicus were predictive landmarks for zone 1 and zone 3, respectively.

The impact of the length of proximal margin on the prognosis of adenocarcinoma of gastroesophageal junction and strategies:A real-world study

BackgroundThe optimal proximal margin (PM) length for Siewert II/III adenocarcinoma of the esophagogastric junction (AEJ) remains unclear. This study aimed to determine the optimal PM length using an abdominal approach to guide surgical decision-making. MethodsA prospective study analyzed 304 consecutive patients diagnosed with Siewert II/III AEJ between January 2019 and December 2021. Total gastrectomy was performed via the abdominal approach, and PM length was measured on fixed gross specimens. X-Tile software determined the optimal PM cut-point based on progression-free survival (PFS). Univariate analyses compared baseline characteristics across PM groups, while survival analyses utilized Kaplan–Meier estimation and Cox proportional hazards regression for assessing the impact of margin length on survival. Multivariable analyses were conducted to adjust for confounding variables. ResultsThe study included 264 AEJ cases classified as Siewert II (71.97%) or III (28.03%). The median gross PM length was 1.0 cm (IQR: 0.5 cm–1.5 cm, range: 0 cm–6 cm). PM length ≥1.2 cm was associated with a lower risk of disease progression compared to PM length 0.4 cm on PFS (HR = 0.41, 95% CI 0.20–0.84, P = 0.015). Moreover, PM ≥ 1.2 cm improved prognosis in subgroups of T4 or N3, tumor size <4 cm, Siewert II, and Lauren classification. ConclusionsFor Siewert type II/III AEJ, a proximal margin length ≥1.2 cm (1.65 cm in situ) is associated with improved outcomes. These findings offer valuable insights into the association between PM length and outcomes in Siewert II/III AEJ, providing guidance for surgical approaches and aiding clinical decision-making to enhance patient outcomes.

Adaptability of VisCalor versus bulk-fill composites using scanning electron microscope: an in-vitro study

Purpose To evaluate the marginal integrity of two types of bulk-fill composite resins in Class I box-shaped cavities. Materials and methods Forty extracted human sound molars were selected. The teeth were fixed with sticky wax to the base of plastic cylinder and the cylinder was filled with self-curing acrylic resin so that only root was embedded. Simple Class I box-shaped cavities were prepared using a fissure carbide bur with water spray and finished with fine-grained flame burs. The overall dimensions and depth of the cavities were standardized as follows: 4 mm length mesiodistally and 3 mm width buccolingually and up to 4 mm depth. All prepared cavities were bonded using Futurabond M+ one-step self-etch adhesive system. The teeth were randomly divided into two groups (n = 20 teeth each): group I: specimens were restored with VisCalor composite bulk-fill composite resin, which is heated before insertion using a VisCalor dispenser dental device. Group II: specimens were directly restored with X-tra fill bulk-fill composite resin without preheating. After curing, finishing and polishing were performed. Each group was subdivided into two subgroups a and b (n = 10) according to whether subjecting 500 thermocycling fluctuations or not. Each specimen was sectioned buccolingually through the center of the composite resin restoration in two halves, and then cleaned under running tap water and subjected to thorough ultrasonic cleaning to get rid of both soft and hard surface deposits. All sectional samples were fixated in cylindrical carriers, and a thin layer of gold was applied to the surfaces. The marginal adaptation of composite restorations and ultramorphology of adhesive bonds were analyzed at ×50, ×1000 magnification, with a scanning electron microscope. ×50 magnification was utilized to measure the length of margins free gap in enamel and dentin by Autodesk Auto CAD program and expressed in mm/percent. All data of measurements of the length of nongaped margins in enamel and dentin are collected, tabulated, and statistically analyzed. Results Group Ia (VisCalor bulk-fill not thermocycled), recorded the highest mean value of marginal free-gap with 10.26 ± 0.27 mm (93.31%), while group IIb (X-tra-fill bulk-fill thermocycled) recorded the lowest mean value in 7.90 ± 0.26 mm (73.04%) and the difference was statistically highly significant (P = 0.000). In general, group I recorded higher mean values of marginal free gap and adaptation in mm/percent than group II, and the difference was statistically highly significant at P value of 0.000 (9.86 ± 0.55 and 8.23 ± 0.39 mm and 89.15 ± 5.38 and 74.89 ± 3.69%, respectively). Bulk-fill restorations without thermocycling exhibited a higher mean value of marginal free gap and adaptation in mm/percent than the thermocycled one with a significant difference recorded at P value of 0.005. Conclusion Using preheated VisCalor bulk-fill composites could decrease the marginal gap formation improving the continuity at the tooth–restorative material interface than conventional bulk-fill restorations. On the other hand, thermocycling.

The effect of flowable composite and glass ionomer liner on the marginal integrity of class II composite resin restorations

Aim of the study To evaluate the effect of flowable composite and glass ionomer liner on the marginal integrity of Class II composite resin restorations. Materials and methods A total of thirty non-carious human maxillary molar teeth were mounted in acrylic blocks. Simple Class II cavity with parallel walls was prepared. The cervical margin was established 1.5 mm above the cemento- enamel junction. The overall dimensions and depth of the cavities were standardized as follow: 4 mm length occlusocervically, 4 mm width buccolingulaly and 2 mm depth axially. Specimens were randomly divided into three equal groups (10 each). Group 1: The cavities were restored with Xtra Fil bulk fill composite without liner. Group 2: Xtra base flowable composite (1 mm thickness) was applied, followed by Xtra Fil bulk fill. Group 3: Ionoseal glass ionomer was applied as a base (1 mm thickness), followed by Xtra Fil bulk. Specimens were then subjected to 500 thermal cycles from 5 to 55oC with 30 s dwell time, and 15 s transfer time. Impressions of the teeth were made using a polyvinyl siloxane material, poured with epoxy resin. These replicas were left 24 h for complete setting. Then, Gold sputtered to be examined under scanning electron microscopy (SEM). Results were expressed as percentage of open margins for the total margin length for proximal and cervical margins and also the width of the gap were measured. The recorded data was collected, tabulated, and statistically analyzed using SPSS version 25. Results It was found that there was a significant difference in total gap length between group 1 and group 2 with P value = 0.000. Where group 1 has the biggest marginal gap length and the smallest marginal gap length belongs to Group 2. While there was no significant difference between group 1 and group 3 with P value 0.124. It was also found that there was no significant difference between groups in marginal gap widths. Conclusions The use of flowable composite and glass ionomer as liner could reduce microleakage of bulkfill composite restorations.

Virtual Reality Computed Tomography Evaluation - Anatomy and Clinical Implications for Valve-Sparing Aortic Root Replacement.

Three-dimensional aortic root evaluation using virtual reality (VR) techniques for valve-sparing aortic root replacement (VSARR) preparation has not yet been implemented, so we demonstrated VR computed tomography (VR-CT) and assessed its utility for VSARR.Methods and Results: We enrolled 72 patients who underwent multidetector CT before elective VSARR for annuloaortic ectasia with tricuspid aortic valve. The geometries of their aortic roots were measured with a VR-CT workstation. The mean values of geometric height (GH), free margin length (FML), and commissural height (CH) were 17.2±2.4 mm, 36.0±5.2 mm, and 24.0±4.3 mm, respectively. The right coronary/noncoronary CH was significantly greater than the left coronary/right coronary and left coronary/noncoronary CH. The left coronary cusp had the shortest FML, intercommissural distances (ICD), and smallest central angle. Although the right coronary cusp had the largest values for FML, ICD, and central angle, the right coronary cusp had the lowest GH and EH. The VR-CT measurements strongly correlated with intraoperative alternatives, especially with mean GH (R2=0.75) and left coronary/noncoronary CH (R2=0.79). Furthermore, mean GH was observed to be significantly different among the selected graft size groups; therefore, the preoperative mean GH could play a significant role in graft sizing. VR-CT evaluation allows a thorough understanding of aortic root anatomy, which could facilitate VSAAR.

Transthoracic single-port-assisted laparoscopic gastrectomy versus laparoscopic transhiatal approach for Siewert type II adenocarcinoma of the esophagogastric junction: a single-center retrospective study.

The surgical approach for patients with Siewert type II AEG remains controversial. Several studies have described a new laparoscopic radical resection approach of Siewert type II AEG through the left diaphragm. However, the technical safety and feasibility of the new surgical approach compared with the transhiatal approach have not yet been tested. We retrospectively reviewed patients with AEG who underwent TSLG and LTH operations in the Guangdong Provincial Hospital of Chinese Medicine between January 2017 and April 2021. Histologically confirmed AEG and D2 lymphadenectomy with curative R0 patients were included, and patients with Siewert I/III AEG or distant metastasis were excluded. Blood loss, the amount of harvested lymph node, and complications related to surgery were evaluated. A total of 99 patients with Siewert type II AEG were analyzed, 44 in the TSLG group and 55 in the LTH group. There was no difference in clinicopathological features between the two groups. The more harvested lymph node (23.33±11.41 vs. 32.18±12.85, p < 0.01), lower mediastinal lymph node (1.07±2.08 vs. 3.25±3.31, p < 0.01), and longer proximal margin length (3.08±1.19 vs. 4.47±0.95cm, p < 0.01) were observed in the TSLG group. The rate of cure (R0 gastrectomy) in the TSLG group was higher than that in the LTH group (100% vs. 89.09%, p = 0.03). The TSLG approach is associated with improved surgical views, simplified lymphatic dissection in the inferior mediastinum, and more reliable margins. TSLG surgery may be an effective addition to LTH surgery, particularly when lower mediastinal lymph node metastases are suspected.

Standardisation of Decision Making in Hilar Cholangiocarcinoma Management: A Case Series

Hilar Cholangiocarcinoma (CCA) is a very complex disease that requires the best multidisciplinary decisions. Improved outcomes are reported only in high-volume centres with good expertise and the latest technology in radiology for imaging and intervention, endoscopy, and surgery. However, in India, only very few centres have very good infrastructure for the same. Additionally, protocoldriven treatment is also not uniform in India. To fulfil this gap, authors believe that a strict, disciplined work-up of these complex cases is the only way to achieve optimal treatment. Authors propose a protocolised checklist involving multidisciplinary decisions for hilar CCA patients that could be used. This case series aims to assess the oncological outcome of hilar CCA using our checklist and, secondarily, to assess the immediate postoperative outcome and complications in these patients. Out of 20 patients, 13 underwent successful hepatectomy based on the decisions made. No mortality was noted in this case series. Two cases had a postoperative liver failure (Clavien Dindo 3A). All 13 patients had an R0 resection. The mean length of the tumour-free margin was 8.46 mm. Doing two-dimensional surgical simulation preoperatively and adhering to the special plane of transection helped in attaining R0 resection. Here, a small series of hilar CCA is presented which was managed successfully, signifying the importance of a protocol-based approach which can be easily adapted and reproduced.