Mean Number Of Nodes Research Articles

The association of nodal upstaging with surgical approach and its impact on long-term survival after resection of non-small-cell lung cancer.

Proponents of open thoracotomy (OPEN) and robot-assisted thoracic surgery (RATS) claim its oncological superiority over video-assisted thoracic surgery (VATS) in terms of the accuracy of lymph node staging. The National Cancer Database was queried for patients with non-small-cell lung cancer (NSCLC) undergoing lobectomy without neoadjuvant therapy from 2010 to 2014. Nodal upstaging rates were compared using a surgical approach. Overall survival adjusted for confounding variables was examined using the Cox proportional hazards model. A total of 64676 patients fulfilled the selection criteria. The number of patients who underwent lobectomy by RATS, VATS and OPEN approaches was 5470 (8.5%), 17545 (27.1%) and 41661 (64.4%), respectively. The mean number of lymph nodes examined for each of these approaches was 10.9, 11.3 and 10 (P < 0.01) and upstaging rates were 11.2%, 11.7% and 12.6% (P < 0.01), respectively. For patients with clinical stage I disease (N = 46826; RATS = 4338, VATS = 13416 and OPEN = 29072), the mean lymph nodes examined were 10.6, 10.8 and 9.4 (P < 0.01), and upstaging rates were 10.8%, 11.1% and 12.1% (P < 0.01), respectively. A multivariable analysis suggested an association with improved survival with RATS and VATS compared with OPEN surgery [hazard ratio (HR) = 0.89 and 0.89, respectively; P < 0.01] for patients with all stages. In stage I disease, VATS but not RATS was associated with increased overall survival compared with the OPEN approach (HR = 0.81; P < 0.01). RATS lobectomy is not superior to VATS lobectomy with respect to lymph node yield or upstaging of NSCLC. Increased nodal upstaging by the OPEN approach does not confer a survival advantage in any stage of NSCLC and may be associated with decreased overall survival.

P210 HYBRID LAPAROSCOPIC ROBOT-ASSISTED MINIMALLY-INVASIVE ESOPHAGECTOMY: A PROSPECTIVE EXPERIENCE IN A REFERRAL CENTER

Abstract Aim To report the prospective experience in Hybrid Laparoscopic Robot-assisted Minimally-invasive Esophagectomy (HLRAMIE) in a referral Center. Background &amp; Methods The minimally-invasive esophagectomy (MIE) is an attractive and established technique to improve the reduction of post-operative morbility with sound oncological results. The hybrid combination of laparoscopy and full robotic thoracic phase (HLRAMIE) is an approach aimed to be as effective as MIE to treat esophageal neoplasms. Inclusion criteria: patients undergone to multimodal medical advice panel, affected from non-cT4, from mid thoracic to cardia, esophageal neoplasms, with and without neoadjuvant treatment, fit for minimally-invasive surgery. HLRAMIE: laparoscopic stage plus full robotic thoracic stage by Da Vinci Xi® (Intuitive Surgical, US), with gastric-pull first-choice conduit. Prospective, dedicated database. Results From October 2015 to April 2019, 33 patients underwent to HLRAMIE (site of neoplasm: 1 mid thoracic; 9 inferior; 23 cardia). 5 out 33 were converted to open. 27/28 underwent to a Ivor Lewis esophagectomy, 1/28 to McKeown procedure. The mean total surgical time was 517 minutes, mean robotic docking time 12 min with mean thoracic time 269 min (positive trend). Gastric pull-up was performed in 28/28. In 23/28 patients the esophago-gastric anastomosis was performed full robotic after the fashion of hand, in 5/28 was performed by circular stapler. The mean extubation time was 12 hours. The mean number of lymph node removed was: overall fields 32.4 (range 15-58), thorax 9.8 (3-27). The mean number of metastatic lymph node was 3.8 (0-18). 100% were R0 resections. The mean hospital-stay was 15 days. The perioperative mortality and 30-day mortality were both 0%. The overall post-operative morbility was 32.1%. 4/28 (14.2%) patients developed an anastomotic leakage, 75% were managed by endoscopy. 11/28 (39.2%) patients developed a late anastomotic stenosis (all in the hand made group). Conclusion In our experience, HLRAMIE is surgically reproducible with the principle of learning curve; oncologically adequate in relation to radical dissection; safe and effective in relation to post-operative early morbility and mortality. Long-term follow up and more powerful, randomized series are needed to establish the definitive clinical and oncological results of HLRAMIE.

Quand introduire une hormonothérapie après prostatectomie totale avec curage ganglionnaire positif ? Étude des facteurs influençant le délai d’introduction de l’hormonothérapie

Adjuvant hormone therapy is the standard treatment after total prostatectomy with positive lymph node. However, this treatment has side effects and at the time of the PSA era and extensive lymph node dissection, this principle is questioned. The aim of this study is to describe the oncological characteristics of patients that may explain the delay in introducing hormone therapy in patients with positive lymph node. Monocentric, retrospective study of 161 patients from November 1988 to February 2018 in a single French University Hospital, having undergone radical prostatectomy with positive lymph nodes on pathology. For each patient, preoperative data (age, clinical stage, biopsy results, d'Amico classification) and postoperative data (pathological results, number of lymph nodes removed, number of positive lympnodes, recurrence free survival, specific survival and overall survival) were collected. The date of introduction of hormone therapy was noted and survival without hormonal therapy was established according to the Kaplan Meier curve. The pre- and post-operative oncological factors that could influence hormone therapy introduction were investigated with Chi2 and Student tests (statistically significant when P<0.05). The mean number of lymph nodes removed was 12 [1-40]. The mean number of positive lymph nodes was 2.5 [1-24], the mean percentage of positive lymph nodes was 25% (2.5-100). After a mean follow-up of 95 months (3-354), 88 patients (54.6%) had no hormonal treatment. The average time to hormonal treatment was 40 months [0-310]. At 3 years, survival without hormone therapy was 52% and 51% at 5 years. Only the percentage of positive lymphnodes appeared to be a significant predictor of the introduction of hormone therapy. (29.32% vs. 21.99%, P=0.047). Hormone-free survival was significantly higher in patients with lymph node involvement less than 25% (P<0.0001) or with less than 2 positive lymph nodes (P=0.0294). Lymph node invasion is a factor of poor prognosis after total prostatectomy and leads to introduce hormone therapy. Our study identified the percentage and number of positive lymph nodes as factors that identify patients who may be delayed in introducing this hormone therapy. 3.

Colonic splenic flexure carcinoma: is laparoscopic segmental resection a safe enough oncological approach?

The surgical approach to the colonic splenic flexure cancer (SFC) is yet to be technically standardized. The aim of this study has been to retrospectively evaluate the oncologic long-term results of our cases comparing our data with other authors' experiences. Clinical data of patients with SFC operated on at our institute were retrospectively analyzed. The laparoscopic approach was used in the whole series, with limited resection distally and proximally to splenic flexure and the origin ligation of left colic artery and left branch of middle colic artery. Data on the oncological long-term safety were compared to our laparoscopic series of extended right colectomy for proximal two-third transverse colon cancer and high anterior resections for sigmoid-high rectal cancer and to the main evidences in the literature, found after a comprehensive review. From March 2008 to May 2018, we completed 53 laparoscopic splenic flexure resections (26 female and 27 male, age 71.5 ± 15.4years). The conversion rate was 3.8%. Most of the cases were stage II (pT3 73.5%, the mean number of lymph nodes harvested was 19.1, with positivity for malignancy in 45.3%). During the FU (43.5months), 2 patients dropped out. Out of the 51 residual cases, 37 were alive (72.5%) and 14 are deceased (27.5%). Compared to the literature, our survival rate does not show significant differences. The other oncological outcomes seem to be comparable with the data evaluated. More extended resections seem not to confer an increase of the overall survival rate.

Perioperative chemotherapy versus neoadjuvant chemoradiation for patients with adenocarcinoma of the distal esophagus in Austria: a retrospective analysis

BackgroundThe aim of this study was to compare the outcome of patients with adenocarcinoma of the distal esophagus (AEG type I) treated with neoadjuvant chemoradiation or perioperative chemotherapy.MethodsEligible patients from four Austrian centers were selected to conduct a retrospective analysis. All patients treated between January 2007 and October 2017 with chemotherapy according to EOX-protocol (Epirubicin, Oxaliplatin, Xeloda) or chemoradiation according to CROSS-protocol (carboplatin/paclitaxel + RTX 41.4 Gy), before esophagectomy were included. Primary outcomes disease-free survival (DFS) and overall survival (OS) as well as secondary outcomes downstaging of T- or N-stage and achievement of pathological complete response pCR (ypT0N0M0) were analyzed. Data of 119 patients were included.ResultsComplete data was available in 104 patients, 53 patients in the chemoradiation group and 51 patients in the chemotherapy group. The mean number of lymph nodes removed was significantly higher in the EOX group (EOX 29 ± 15.5 vs. CROSS 22 ± 8.8; p < 0.05). Median follow-up in the CROSS group was 17 months (CI 95% 8.8–25.2) and in the EOX group 37 months (CI 95% 26.5–47.5).In the chemotherapy group, the OS rate after half a year, − 1, and 3 years was 92%, 75%, and 51%. After chemoradiation, overall survival after half a year was 85 %, after 1 year 66%, and after 3 years 17%. In the EOX group DFS after ½, − 1, and 3 years was 90%, 73%, and 45%, in the chemoradiation group after half a year 81%, after 1 year 55% and after 3 years 15%. Pathological complete response (pCR) was achieved in 23% of patients after CROSS and in 10% after EOX (p < 0.000).ConclusionsThere seem to be clear advantages for chemoradiation, concerning the major response of the primary tumor, whereas a tendency in favor for chemotherapy is seen in regards to systemic tumor control. Furthermore, the type of neoadjuvant treatment has a significant influence on the number of lymph nodes resected.

Oncological safety of laparoscopic versus open colorectal cancer surgery in obesity: a systematic review and meta-analysis.

Colorectal cancer resection in the obese (OB) patients can be technically challenging. With the increasing adoption of laparoscopic surgery, the benefits remain uncertain. Hence, the aim of this study is to assess the short- and long-term outcomes of laparoscopic compared to open colorectal cancer resection in the OB patients. A systematic review and meta-analysis was performed according to the PRISMA guidelines. The outcome measures were 5-year disease-free survival, overall survival, circumferential resection margin and local and distant recurrence. A total of 20 studies were included, with a total number of 6779 participants, of whom 1785 (26.3%) were OB and 4994 (73.7%) were non-obese (NOB) participants. The OB patients had higher R1 resection (OB 6.9% versus NOB 3.1%; P = 0.011) and lower mean number of lymph nodes harvested, with standard mean difference of -0.29; P = 0.023, favouring the NOB patients. However, there was no statistical difference for local (OB 2.8% versus NOB 3.4%) or distant recurrence (OB 12.9% versus NOB 15.2%) rate between the two cohorts. There was no difference in 5-year disease-free survival (OB 81% versus NOB 77.4%; odds ratio 1.25, P = 0.215) and overall survival (OB 89.4% versus NOB 87.9%; odds ratio 1.16, P = 0.572). Lastly, the OB group had higher mean total blood loss, total operative time and length of hospital stay when compared to NOB patients. From a pooled non-randomized study, laparoscopic colorectal cancer resection is safe in OB patients with equivalent long-term outcomes compared to NOB patients. However, there is a higher morbidity rate with an increased demand on hospital resources for the OB cohort.

Splenic flexure mobilization in low anterior resection

Background: The use of splenic flexure mobilization (SFM) for rectal cancer surgery is still controversial. SFM includes division of the splenocolic, phrenocolic, gastrocolic and pancreaticomesocolic ligaments, which is time-consuming. The aim of present prospective study of low anterior resection in case of cancer rectum was to compare splenic flexure mobilization (SFM) carried out by an extended medial approach with that by a lateral approach.Methods: A prospective study was carried out in General Surgery Department, Menoufia University, Egypt between October 2017 and December 2018. Patients were allocated randomly into two groups in which first group (group A) allocated to medial mobilization of splenic flexure and the second group was allocated into lateral approach of splenic flexure. The extended medial involved continuing the medial to lateral approach upwards to enter the lesser sac over the pancreas, thus permitting detachment of the splenic flexure. However, lateral approach involves dissection of retroperitoneal fascia.Results: Thirty patients, including 20 undergoing a lateral SFM and 10 an extended medial SFM, were evaluated. Mean number of lymph nodes in lateral and medial approach are (17.7±5.6, 24.3±6 respectively) with significant (P-value=0.04). Interestingly, Intra-operative blood loss in lateral approach is more than medial approach (175±25.3, 160.1±30 respectively) with significant (p-value=0.02). The interval to oral intake (3±0.3 days extended medial, 4.1±0.7 lateral, P=0.14).Conclusions: An extended medial approach for SFM during low anterior resection of rectal cancer appears to be an improvement over the previously used lateral approach because it may provide a shorter operation time and higher number of harvested lymph nodes with less intra-operative blood loss.

Short- and Long-term Outcomes of Surgical Treatment for Remnant Gastric Cancer After Distal Gastrectomy.

Remnant gastric cancer (RGC) after distal gastrectomy occurs in 1-2% of patients, while the biological features of RGC are unknown. A total of 22 consecutive patients with RGC who underwent total gastrectomy were analyzed. Their disease history included either gastric cancer (n=16) or peptic ulcer (n=6). Overall, 18 underwent open total gastrectomy (OTG) and 4 underwent laparoscopic total gastrectomy (LTG). The mean number of lymph nodes dissected and metastatic lymph nodes was larger in the Ulcer group than in the Carcinoma group (p<0.005). The mean operation time was longer in the LTG than OTG (p<0.005). The median blood loss tended to be smaller in the LTG (p=0.090). Five-year overall and recurrence-free survival rates were 94% and 81%, respectively. The status of lymph node metastasis after surgery for RGC should be cautiously considered in the context of disease history. Both LTG and OTG can be treatment options for RGC.

Clinical outcomes of minimally invasive retroperitoneal lymph node dissection and single dose carboplatin for clinical stage IIa seminoma.

530 Background: Standard management of Stage 2 seminoma (SEM) is 3 cycles of cisplatin based multi-agent chemotherapy or paraaortic/pelvic radiotherapy. Both treatments have potential short and long term toxicity. We report the use of minimally invasive (robotic or laparoscopic) retroperitoneal lymph node dissection (MI-RPLND) and adjuvant carboplatin. Methods: From 01/2013-04/2017, patients (pt) with SEM and Stage 2a disease on computed tomography (CT) staging scan were considered for MI-RPLND included the radiologically enlarged lymph nodes for Stage 2a SEM. Adjuvant carboplatin (AUC 7) x 1 cycle was administered after confirmation of nodal involvement. Post-operative outcomes including length of stay, Clavien-Dindo 1 complications and pathological staging were recorded. CT was performed at 3 months to verify nodal clearance and then pts monitored with a standard surveillance protocol. Results: Twenty modified unilateral templates were performed. Median and mean post-operative stay was 1 and 1.5 days. One pt required conversion to open surgery and two experienced Clavien-Dindo 1 complications. All pts had preserved ejaculation. Mean number of nodes removed per pt 14.3 (range 5-31) with average 1.75 nodes involved (range 0-5). In 2 pts the enlarged nodes were pN0; they were surveyed and are relapse free at 44+ months. In one case the enlarged lymph node contained embryonal carcinoma (EC) despite primary histology of pure SEM. The remaining 17 pts had confirmed pathological stage 2 SEM. The pt with EC and one pt who had adjuvant carboplatin for stage 1 disease received (B) EP x 2 cycles. 16 patients received a single cycle of adjuvant carboplatin (AUC 7). After median follow-up of 41 months (range 22-70), one patient has relapsed. This occurred at 18 months outside the template of dissection. This patient initially had multifocal disease with 3 pathologically involved nodes. He received BEP X 3 with complete radiological resolution of disease and remains disease free. Conclusions: MI-RPLND in conjunction with a single dose of carboplatin may potentially be an option for the management of Stage 2a SEM. In this series, a subset of pts were overstaged using standard CT imaging.

Feasibility and safety of needle-assisted endoscopic thyroidectomy with lateral neck dissection for papillary thyroid carcinoma: a preliminary experience.

Endoscopic thyroidectomy is popular among patients with cosmetic requirements. However, when lateral neck dissection (LND) is required, endoscopic surgery may be challenging. Therefore, we introduced needle-assisted endoscopic technique to achieve endoscopic LND procedure and evaluated its safety and feasibility in the present study. Medical records of 37 patients who underwent needle-assisted endoscopic thyroidectomy with LND were retrospectively reviewed. All of 37 patients had excellent cosmetic outcomes. The mean operative time was 338.2 ± 58.74 minutes. Mean number of lymph nodes retrieved in the lateral was 33.5 ± 11.69 and 15.9 ± 7.51 in the central neck. The rates of transient and permanent hypocalcemia were 32.4% and 2.7% and the rates of transient and permanent recurrent laryngeal nerve palsy were 8.1% and 0%, respectively. Needle-assisted endoscopic thyroidectomy with lateral neck dissection shows potential feasibility but further study is needed to better characterize its safety and applicability.

A prospective study of robotic rectal surgery for carcinoma rectum assessing the functional and oncological outcomes: Hype or hope?

661 Background: Robotic surgical systems have dramatically changed minimally invasive surgery as they could potentially address limitations of laparoscopic rectal surgery. This prospective observational study is conducted to evaluate the safety, technique, and outcomes (operative, postoperative,functional and oncological long term) of robotic-assisted rectal surgery for carcinoma rectum in the Indian set up. Methods: This was a prospective observational study conducted between 2010 and 2018, including 135 patients, diagnosed of rectal carcinoma. Patients underwent robotic rectal cancer surgery in form of either low anterior resection (LAR) or abdominoperineal resection (APR). Intraoperative, postoperative data were analysed. Results: Out of 135 patients, 67.5% were male, aged between 34-80 years, 85% had ECOG 0. All patients had adenocarcinoma rectum, with 15% mid rectum and 55% in lower rectum. 85% had stage III disease. 77.5% had received neoadjuvant chemoradiation. 82.5% had LAR and 17.5% APR. Average operative time including docking time and surgery time was 226.32 min (170-300 min), mean blood loss was 146.76 ml (120-200 ml), there were 3 conversion to open surgery. Bowel sounds appeared on average on 3rd day. All margins were negative in all patients, mesorectal grade was complete in 95% and near complete in 5%. Mean number of lymph nodes harvested is 9.5 (2-32). Complete pathological response rate was 39%. 2 patients had anastomotic dehiscence after 1 month. Minor complications were noticed in 10% patients. All had acceptable quality of life and well retained bladder function, with 18% sexual dysfunction. Five year DFS was 85% and OS was 94%. Local recurrence was 2.1%. Conclusions: This is one of the largest single center Indian data available. In conclusion, robotic rectal surgery has several benefits in the treatment and should be part of the armamentarium of the experienced surgeon dealing with rectal cancer. We conclude that the robotic-assisted rectal cancer surgery is safe and an oncologically feasible technique with well retained functional outcomes and has lived up to its hope.

The Lymph Node Content of Supraclavicular Lymph Node Flap: A Histological Study on Fresh Human Specimens.

Introduction: Vascularized lymph node transfer (VLNT) has become the established treatment for secondary lymphedema. The proposed mechanisms of VLNT include lymphangiogenesis and absorptive action of transplanted lymphatic tissue. Therefore, in theory, the lymph node content of lymph node flap is crucial to clinical response. The supraclavicular lymph node flap (SCLNF) has been described as one of the flap options for VLNT. However, its lymph node content has not been fully studied. The aim of this study is to find out the lymph node content of SCLNF with histological examination. Methods: Patients who required radical neck dissection or modified radical neck dissection due to cervical lymph node metastasis from head and neck cancer were included in this study. The SCLNF harvesting was performed as the first part of neck dissection. After flap harvesting, neck dissection was continued. The fresh SCLNF specimens were then sent for histological study. Results: Twelve SCLNFs were studied. The mean age of patients was 67.5 (range, 54-84) years. There were 10 males and 2 females. Seven flaps were harvested from the left side of neck, while five flaps were harvested from the right side of neck. The mean width, height, and thickness of SCLNF were 5.9 ± 0.6, 4.0 ± 0.5, and 1.8 ± 0.2 cm, respectively. The mean number of lymph nodes per flap was 8 ± 4.7 (range, 3-15). Conclusion: The lymph node content of SCLNF was confirmed. Its lymph node content is comparable to other lymph node flaps used in VLNT.

Immediate intraoperative sentinel lymph node analysis by frozen section is predictive of lymph node metastasis in endometrial cancer.

Sentinel lymph nodes sampling (SLN) in endometrial cancer is being evaluated as a means to gather prognostic information about lymphatic metastasis while avoiding the morbidity associated with complete lymphadenectomy. SLN ultrastaging has been advocated to identify low-volume metastases, but its value remains uncertain. This study aims to evaluate a pathological protocol for the immediate intraoperative SLN work-up using H&E staining alone. In this retrospective single-center study, patients received standardized cervical injection of indocyanine green, SLN mapping followed by pelvic lymphadenectomy with or without para-aortic lymphadenectomy. SLNs were entirely frozen, multiple H&E stained sections prepared and evaluated intraoperatively. No immunohistochemistry was performed. SLN results were compared with the complete lymphadenectomy specimen. Over 3.5 years, 90 patients were identified who underwent SLN mapping and subsequent complete pelvic lymphadenectomy. At least one SLN was detected in 79 (88%) patients. The median number of SLNs removed was 2.0. Para-aortic SLNs were detected in 7%. Final pathology showed 67% Type I tumors, 76% locally confined. The mean number of lymph nodes removed during complete lymphadenectomy was 21. In this series, only 6 patients had lymph node metastases. 5/6 were identified by the described SLN approach resulting in 83.3% sensitivity and a negative predictive value of 98.7%. Our approach permits immediate intraoperative results and helps guide the primary surgery. The immediate SLN work-up using frozen sections showed both high accuracy and negative predictive value. The comparably lower sensitivity may be related to the low number of patients with positive lymph nodes (7.6%).

Simplified synchronous disconnection of pulmonary arteries and veins for right upper lobectomy.

Video-assisted thoracoscopic lobectomy with lymphadenectomy is considered one of the most effective treatments for early non-small cell lung cancer. We developed a novel approach for lobectomy in patients with right upper lung cancer through simplified synchronous disconnection of pulmonary arteries and veins. This study aimed to evaluate the feasibility, efficacy, safety, and cost-effectiveness of this minimally invasive technique in managing right upper lobectomy. From March 2016 to September 2017, 62 patients with right upper lung cancer underwent lobectomy via simplified synchronous disconnection of pulmonary arteriovenous by video-assisted thoracoscopic surgery. All patients were followed up for 6-12 months after the procedure through clinic visits or telephone/e-mail interviews. Of the 62 patients (mean age, 57.2 ± 8.7years), 28 were men (45.2%) and 34 (54.8%) were women. All procedures were successfully performed by thoracoscopy, with a mean operating time of 66.2 ± 9.0min. The mean blood loss was 40.3 ± 19.5mL. Only 1 (1.61%) patient required blood transfusion. The mean number of endoscopic linear stapling devices used was 2.6 ± 0.7. The mean number of lymph nodes harvested was 16.0 ± 1.6. Postoperative pneumonia was encountered in 4 (6.45%) patients. There was no postoperative mortality. The mean length of hospital stay was 5.3 ± 1.3days. Six-month follow-up revealed an excellent clinical result and degree of satisfaction. Simplified synchronous disconnection of pulmonary arteries and veins is a feasible, economical, safe, and effective therapeutic procedure for right upper lung carcinoma. This novel procedure shows promise as a viable surgical approach for right upper lobectomy.

Early outcomes of robotic-assisted resection for perihilar cholangiocarcinoma

Introduction: Minimally invasive approach for radical treatment of perihilar cholangiocarcinoma is not validated option and outcomes of robotic procedures are only starting to be evaluated. Method: Data were collected for four years (2014-2016) in a single Russian high-volume centers. All patients underwent surgery with intention to treat for hilar cholangiocarcinoma. The standard procedure included major liver resection with segmentectomy 1, extrahepatic bile duct resection and Roux-en-Y biliary reconstruction with D2 lymphadenectomy. In case of insufficient (<40%) volume of FLR its hypertrophy was induced by modified variant of ALPPS (PRALPPS). Result: Thirteen patients were treated. Major liver resection was performed in 12 patients. Final histological examination confirmed hilar cholangiocarcinoma in 10 patients with exception of 2 patients with benign strictures and gallbladder sarcoma in one patient. In two patients there was conversion to open procedure due to vascular invasion required vascular resection and reconstruction. The mean operation time was 699 (490-980) min for totally laparoscopic cases. After initial period of the first 4 procedures the mean time decreased from 858 (560-980) min to 608 (490-690) min without significant differences. Mean blood loss was 392 (50-950) mL. The rate of R0/R1 resection was 10/1 in patients with malignancy. The mean number of lymph nodes harvested was 8 (4-9). Severe complications (>2, Clavien-Dindo) revealed in 10 patients. In seven of them IIIa,b grade morbidity was observed. One patient died due to liver failure. The mean hospital stay was 22 (11-37) days. The mean follow up time was 8 (1-19) months. One patient died due to tumor progression 18 months after procedure. Conclusion: The initial experience of robot-assisted resection for hilar cholangiocarcinoma suggests that robotic approach may be validated in highly selected patients. Further evaluation is needed to clarify the surgical and oncological safety.

Robotic total gastrectomy with \u03c0-shaped esophagojejunostomy using a linear stapler as a novel technique

ObjectiveTo evaluate the intraoperative and short-term postoperative outcomes of a novel robotic intracorporeal π-shaped esophagojejunostomy (EJS) after D2 total gastrectomy (TG) using the Da Vinci robotic surgical system for intracorporeal anastomosis after TG.BackgroundIntracorporeal π-shaped EJS, using a linear stapler, was recently reported for laparoscopic total gastrectomy in patients with gastric cancer. However, robotic intracorporeal π-shaped EJS using a linear stapler has not been reported. This report aimed to describe the use of a novel technique for π-shaped EJS using the Da Vinci robotic system.MethodsRobotic intracorporeal π-shaped esophagojejunostomy after total gastrectomy was performed in 11 consecutive patients diagnosed with early gastric cancer, and their perioperative outcomes were analyzed.ResultsAll the operations were successful without conversion to open or laparoscopic surgery and postoperative complications. The total number of patients was 11 (7 males and 4 females). The mean age of the patients was 63.36 ± 10.56 years old. Seven patients were diagnosed with cardia cancer, 3 patients were diagnosed with gastric body cancer, and 1 patient was diagnosed with gastric antrum cancer. The patients’ mean proximal resection margin was 3.18 ± 1.17 cm, the distal resection margin was 6.18 ± 1.40 cm, the mean length of the incision was 4.55 ± 0.69 cm, the mean operative time was 287.27 ± 30.69 min, the mean day of first flatus was 3.27 ± 0.79 days, the mean day of the start of diet was 2.91 ± 0.94 days, the mean postoperative hospital stay was 11.45 ± 5.13 days, and the mean operative blood loss was 47.27 ± 31.33 ml. No complications were observed during anastomosis, and the median anastomosis time was 19.5 min. The mean number of lymph node dissections was 17.91 ± 4.59, the mean number of positive lymph nodes was 0.45 ± 0.69, all patients were diagnosed with stage I–II gastric cancer, and the mean maximum diameter of the tumor was 2.67 ± 1.30 cm. All the patients had a smooth hospital discharge.ConclusionA novel robotic gastrectomy with intracorporeal π-shaped EJS for esophagojejunal anastomosis described and shows acceptable resulted. This technique has the potential to offer better short-term surgical outcomes and overcomes the drawbacks of laparoscopy with a decreased risk of complications during and after surgery.

Results of a randomized controlled trial of level IIb preserving neck dissection in clinically node-negative squamous carcinoma of the oral cavity

BackgroundThe lymphatic spread from the cancers of the oral cavity follows an orderly progression and involvement of lower nodes without involvement of upper nodes and skip metastasis is rare. Selective neck dissections are increasingly being performed for node-positive patients; however, in node-negative patients the options of wait and watch, prophylactic radiotherapy, and prophylactic elective node dissections are debated. Quality of life and shoulder functions are important to choose the appropriate therapeutic modality.Patients and methodsPatients with oral squamous carcinoma with clinically and radiologically negative neck were randomized to IIb preserving superselective neck dissection or conventional supraomohyoid neck dissection. The primary end point of the study was recurrence of disease (clinical or radiological) and shoulder function as demonstrated by the clinical examination and electromyography. The secondary end point was quality of life as measured by the FACT-HN version 4 questionnaire at the end of 1 year follow-up.ResultsThe mean number of lymph node harvested per patient was 25.6 (range 8–85). Of the 32 patients, 3 had histologically positive node in level Ib, one of these patients had single positive node while the remaining two had three positive nodes in level Ib. At median follow-up of 36 months disease-free survival in IIb, sparing group was 83% compared to 91% in control arm, the difference in survival between two groups was statistically not significant (p = 0.694). EMG of the shoulder showed denervation pattern in 45% patients undergoing IIb preserving surgery at 1 month follow-up compared to 95% in conventional surgery group, this recovered in all patients but one at 3 months and 100% recovery was seen at 6 months.ConclusionsThe results of the present study indicate that superselective IIb preserving neck dissections are technically feasible and appear to be oncologically safe procedures when performed as elective prophylactic procedures in highly select group of patients. A significant number of occult metastasis seen in the present study suggests prophylactic dissection to be better than wait and watch policy. Results also show initial higher shoulder morbidity at 1 month in patients undergoing IIb preserving dissections; however, at the end of 1 year recovery is complete and both procedures are comparable.Trial registrationThe trial is registered at clinicaltrials.gov with registration no NCT00847717; registered on February 19, 2009.

Transanal total mesorectal excision (TaTME): single-centre early experience in a selected population.

Total mesorectal excision (TME) represents the key principle in the surgical treatment of rectal cancer. Transanal mesorectal excision was introduced as a complement to conventional surgery to overcome its technical difficulties. The aim of this study was to evaluate the early surgical results following the introduction of this novel technique at our Unit. Between January and May 2016, 12 patients diagnosed with mid-low rectal adenocarcinoma were enrolled into this study and evaluated with regards demography, histopathology, peri-operative data and postoperative complications. The tumor was located in the middle rectum in 6 patients (50%), in the lower rectum in 6 patients (50%). Mean operative time was 356.5 ± 76.2min (range 240-494). Eleven out 12 patients (91.6%) had less than 200mL of intraoperative blood loss. Mean hospital stay was 10.9 ± 4.6days (range 5-19). No mortality was recorded. Intraoperative complications were recorded in 1, while early post-operative complications (< 30days) were observed in 5 patients (41.6%). Histopathology showed in all cases an intact mesorectum. Mean number of lymphnodes harvested was 13.6 ± 6.6 (range 4-29). Distal and circumferential margin was, respectively, of 20.8 ± 14.2mm (range 2-45mm) and 16.1 ± 7.6mm (range 3-30mm). The comparative analysis showed significant differences concerning mean operative time (p = 0.0473) and estimated blood loss (p = 0.0367). This study confirms this technique is safe and feasible, but more evidence to support its use over conventional laparoscopic surgery is needed.

Lymph node upstaging for non-small cell lung cancer after uniportal video-assisted thoracoscopy.

Radical lymph node dissection (LND) plays a major role in the treatment of non-small cell lung cancer (NSCLC). This study presents the analysis of the results after uniportal video-assisted thoracoscopy (VATS) lymphadenectomy during anatomical lung resections for NSCLC, focusing on pathological nodal upstaging. Any possible risk factor affecting nodal upstaging was also investigated. The prospectively collected clinical data of 136 patients undergone uniportal VATS anatomical lung resections, from June 2012 to September 2017, were reviewed. In particular, all details inherent the clinical and pathological node stage and any possible risk factor affecting nodal upstaging were analyzed. The patient population consisted of 90 males and 46 females; their mean age was 67.42±10.64 years. The mean number of lymph nodes retrieved during uniportal VATS lymphadenectomy was 20.14±10.73 (7.27±5.90 and 12.60±7.96 in N1 and N2 stations, respectively). The incidence of nodal upstaging was 13.3% (18 cases). In particular there was a N0-1 upstaging in 10 cases (7.4%), a N1-2 upstaging in 3 (2.2%) and a N0-2 in 4 (3%). The ROC analysis showed that the resection of 18 lymph nodes was the best predictor of a general upstaging with an AUC-ROC of 0.595, while the resection of 7 hilar lymph nodes was the best predictor of N1 upstaging (AUC-ROC: 0.554) and 11 mediastinal nodes was the best predictor of N2 upstaging (AUC-ROC: 0.671). The number of positive lymph nodes of stations 5-6 (OR: 2.035, 95% CI: 1.082-3.826, P=0.027) and stations 2-3-4 (OR: 6.198, 95% CI: 1.580-24.321, P=0.009) were confirmed to be the only independent risk factors for N2 upstaging by multivariate analysis. According to our experience, uniportal VATS allows a safe and effective radical lymphadenectomy, with a satisfactory pathological nodal upstaging, comparable to other minimally invasive techniques.

Minimally Invasive Approaches Do Not Compromise Outcomes for Pneumonectomy: A Comparison Using the National Cancer Database

IntroductionMinimally invasive approaches are increasingly being used for the conduct of complex surgical procedures. Whether the benefits of minimally invasive approaches compared to thoracotomy for sublobar and lobar lung resection for NSCLC are realized for patients undergoing pneumonectomy is not clear. MethodsThe National Cancer Database was queried for patients who underwent pneumonectomy for NSCLC from 2010 to 2014. Case data from patients who underwent resection by minimally invasive surgery (MIS) were compared with those from patients who received thoracotomy (open) in an intention-to-treat analysis. Associations between potential covariates and treatment were analyzed using the Pearson chi-square test for categorical variables and Wilcoxon rank sum test for continuous variables. Univariable and multivariable logistic models and proportional hazards model were used to assess the effect of surgical approach on 30-day and 90-day mortality and overall survival. Relative prognosis was summarized using odds ratios and hazards ratios estimates and 95% confidence limits. ResultsA total of 4,938 patients underwent pneumonectomy during the study period, of which 755 (15.3%) were completed by MIS. No difference was noted in 30- and 90-day mortality rates for MIS compared to open approaches (6.8% and 12.3% versus 6.7% and 11.9%, respectively; p = 0.9 and 0.86, respectively). Tumor histology and stage characteristics were similar between the two groups. The mean number of lymph nodes examined was higher in the MIS group compared to the open thoracotomy group (17.1 ± 0.4 versus 16.1 ± 0.2, p = 0.034). The conversion rate for the MIS cohort was 36.7%. Surgical approach was not associated with any difference in perioperative mortality with univariable or multivariable analysis. MIS was associated with improved overall survival on univariable analysis, but this was not evident with multivariable analysis. ConclusionsPneumonectomy performed by minimally invasive approaches does not compromise perioperative mortality or long-term outcomes. Further investigation into the impact of minimally invasive approaches on perioperative outcomes for whole-lung resection is warranted.