Multiple Resections Research Articles

Association between surgical difficulty and tumor location based on subsegments of the Glisson branches in laparoscopic liver resection

AbstractBackgroundLaparoscopic liver resection has a steep learning curve, and multiple difficulty‐scoring systems have been proposed to support safe implementation. Though the IWATE scoring system is widely used, the rationale for its tumor location score is unclear. The objective of our study was to establish a more accurate definition of tumor location based on subsegments of the Glisson branches.MethodsWe included 176 patients who underwent laparoscopic liver resection between January 2017 and February 2024, excluding those who underwent multiple or concomitant resections of other organs. Tumor location was defined by the most proximal subsegment of the Glisson branches (1sp, Spiegel; 1pc, para‐caval; 1cp, caudate process; 3a, apical; 3b, basal; 4a; 4b; 5v, ventral; 5d, dorsal; 6v; 6d; 6 L, lateral; 7v; 7d; 8v; 8d).ResultsWithin each segment, comparing operative time between subsegments showed significant differences, except for S1 (3a vs. 3b, p = 0.011; 4a vs. 4b, p = 0.001; 5v vs. 5d, p = 0.012; 6v vs. 6d vs. 6 L, p = 0.007; 7v vs. 7d, p = 0.003; 8v vs. 8d, p = 0.030). Blood loss significantly differed except for S1 (3a vs. 3b, p = 0.018; 4a vs. 4b, p = 0.002; 5v vs. 5d, p = 0.016; 6v vs. 6d vs. 6 L, p = 0.011; 7v vs. 7d, p = 0.013; 8v vs. 8d, p < 0.001). The incidence of postoperative complications did not differ significantly; however, hospital stay was significantly different only in S4 (4a vs. 4b, p = 0.049).ConclusionsThere are significant differences in the difficulty of laparoscopic liver resection among subsegments. More detailed scoring based on subsegments may improve accuracy, and we propose a new scoring system.

TMIC-84. MOLECULAR EVOLUTION OF THE TUMOR AND ITS MICROENVIRONMENT AT RECURRENCE

Abstract Changes in the glioma immune microenvironment at recurrence may contribute to disease progression and therapeutic resistance. In prior studies we demonstrated that the circumscribed glioma, pleomorphic xanthoastrocytoma (PXA), was relatively immune enriched including activated cytotoxic CD8+ T cells and Iba1+ microglia/macrophages. While PXA are often low-grade, a significant fraction can recur and progress to higher grade. To determine how the tumor and its immune microenvironment changes with recurrence, we examined a cohort of tumors from patients with multiple resections. Using single-nucleus RNA sequencing (snRNAseq) and spatial molecular imaging we investigate the temporal changes in the tumor and its microenvironment. To begin, we analyzed samples from three patients with paired initial and recurrent tumor. A total of 22,465 immune and non-immune cells were analyzed. Compared to the initial, the recurrent tumor tended to have decreased numbers of T cells and T cells had lower expression of CD2 and GZMA. Pathway analysis for DE genes in TAMs demonstrated enrichment of genes associated with NTRK signaling, while pathways related to aerobic respiration and mitochondrial translation were decreased suggesting a less inflammatory phenotype. Tumor cells at recurrence demonstrated decreased expression of CD274 (PD-L1) and of the chemokine CXCL14, previously identified as a factor driving an anti-tumor CD8+ T cell response. In a cohort of 5 patients with paired initial and recurrent tumors, we observed increased numbers of CD163+ TAMs. Together these data suggest changes in the tumor-associated immune response at recurrence that may be relevant to therapy. Using murine models for the disease we are investigating the factors that regulate these changes.

ANGI-01. EXTRANEURAL METASTATIC EPENDYMOMA: DISTANT METASTASIS TO THE PLEURA, LUNGS, LYMPH NODES, AND BONE

Abstract Ependymomas are neuroepithelial tumors arising from ependymal cells surrounding the cerebral ventricles that account for 1.6-1.8% of primary CNS tumors. They rarely metastasize to extraneural structures, with one study reporting an incidence of 6.2% with a mean time from diagnosis to extraneural metastasis of 75.6 months. This spread, when it does occur, has been reported to occur to the lungs, lymph nodes, liver, and bone. We describe the case of a patient with recurrent WHO Grade III ependymoma, ZFTA::RELA fusion positive, with extraneural metastatic disease to the thoracic spine, lungs, and pelvic bones. He was treated with multiple surgical resections, radiation therapy, and salvage chemotherapy for his extraneural metastasis to the lungs, bone, pleural space, and lymph nodes. His functional and respiratory statuses declined until he ultimately developed pneumonia, status epilepticus, then spontaneous respiratory arrest, which resulted in his passing away. Salvage chemotherapy for ependymoma has unclear mortality benefit and more research must be done to determine how best to treat patients with extraneural metastases, particularly those who fail traditional treatment with resection and radiation therapy.

QLTI-02. THE ROLE OF REOPERATION IN PAEDIATRIC PILOCYTIC ASTROCYTOMA

Abstract INTRO Cerebellar pilocytic astrocytomas (cPAs) in childhood have long been recognized to have a good prognosis after total resection, but the outcome after incomplete resective surgery remains largely unpredictable, with the incidence of radiological progressive disease ranging from 18-100%. It has been traditionally thought that gross-total resection was required for long-term survival, and small residuals were classically resected in a subsequent operation. OBJECTIVE To determine the role of reoperation in residual or recurrent cerebellar pilocytic astrocytoma. METHODS The authors analyzed their pediatric low-grade clioma (PLGG) database for cases treated between 1985-2020 and filtered for intracranial PAs, to determine what clinical or radiological factors precipitated revisional resective surgery in their single quaternary care center cohort. RESULTS Using the PLGG database, 283 patients <18 years of age were identified to have a histopathological diagnosis or intracranial PA between 1985-2020, of which, 200 were within the cerebellum (70.7%). The majority of patients with cPA were between 1 and 10 years of age (n=145, 72.5%) without gender preponderance (M/F=99:101) usually presenting with 1 lesion (n=197, 98.5%). Gross total resection was achieved in 74.5% (n=149) of initial surgeries for cPA. In patients with subtotal resection, the mean largest diameter of the postoperative residual tumor was 1.06cm (range 0-2.95cm). Seven patients with subtotal resection did not require a second resective intervention. In 31 patients the neuro-oncology multi-disciplinary team recommended a second resection at a mean time interval of 22.9 months (range 0.13-81.6 months) from the initial surgery. Proportionally, the children who underwent multiple resections were also more likely to receive adjuvant chemo/radiotherapy. Functionally, the children in the multiple operation cohort experienced more complications of therapy including ongoing endocrinopathy, treatment-associated hearing deficit, and neuro-cognitive deficits. CONCLUSION Residual disease in cPA should be maintained under clinico-radiological surveillance postoperatively with adoption of a more conservative approach when residual disease is not significantly changing over time.

Outcomes Associated With Stereotactic Radiosurgery After Multiple Resections of Nonfunctioning Pituitary Macroadenomas: An International, Multicenter Case Series.

Stereotactic radiosurgery (SRS) represents an effective treatment for nonfunctioning pituitary adenomas (NFPAs). However, no data have yet been published regarding results of SRS on NFPAs after multiple previous resections. Retrospective multicentric data of patients diagnosed with NFPA and who underwent multiple resections (≥2) before SRS were reviewed and analyzed. The treatment interval spanned the period of 1992 to 2022. Cox regression and Kaplan-Meier curves were used to assess predictive factors and the probability of tumor control and hypopituitarism. Among the 311 patients (median age: 50.2 [IQR: 18.0] years), 226 (72.7%) had undergone ≥2 previous resections. The median margin dose was 14 Gy (IQR: 4.0 Gy), and the median tumor volume 3.6 cm3 (IQR: 4.8). Overall, the probability of tumor control after SRS was 93.3% (CI 95%: 89.9-96.9) and 86.7% (CI 95%: 81.1-92.6) at 5 and 10 years, respectively. A margin dose >14 Gy was associated with a decreased risk of tumor progression (hazard ratio = 0.33, CI 95% = 0.15-0.75, P = .008). At a last clinical follow-up of 4.1 (IQR 6.1) years, 10.1% (30/296) developed at least 1 new hormone deficiency after SRS. The cumulative probability of new hormone deficiency was 6.1% (95% CI: 3.0-9.1), 10.3% (95% CI: 5.8-14.6), and 18.9% (95% CI: 11.5-25.8) at 3, 5, and 10 years after SRS, respectively. The average latency between SRS and development of new hormone deficiencies was 3.3 years (IQR 4.1). A maximum point dose to the pituitary stalk >10 Gy was associated with a new deficiency (hazard ratio = 4.06, CI 95% = 1.57-10.5, P-value = .004). For patients with NFPA with multiple previous resections, SRS offers effective local tumor control and a low risk of delayed hypopituitarism for managing these challenging adenomas. SRS should be strongly considered in patients with NFPA with 2 previous resections compared with considering a third resection.

CRTC1::TRIM11-fusion tumor with rare sinonasal presentation and locally aggressive disease course

Abstract Introduction/Objective Cutaneous melanocytic tumor with CRTC1::TRIM11 fusion (CMTCT) is a rare dermatological neoplasm that has not yet been formally recognized by the World Health Organization. At present, our knowledge of this disease is limited to single reports and a series 41 cases with limited follow-up information. It is typically described as a skin lesion expressing melanocytic makers, often leading to its misdiagnosis as melanoma or clear cell sarcoma. CMTCT is regarded as an indolent tumor with infrequent recurrence after complete surgical excision. However, we present a case with uncommon sinonasal presentation and metastasis after multiple resections. Methods/Case Report A 23-year-old woman presented with a right nasal vestibule mass, requiring partial rhinectomy in a foreign country, where she subsequently received chemoradiation. Her tumor at the time was diagnosed as a mucosal melanoma. Eleven years following initial presentation, she demonstrated a recurrent right nasal tumor, as well as neck mass, cervical lymphadenopathy, and lung nodules. The patient then underwent a nasal endoscopic resection and modified neck dissection, which demonstrated a high-grade neoplasm with intersecting fascicles of medium-to-large monomorphic cells; whole exome and whole transcriptome sequencing performed on the resected neck mass identified a pathogenic TERT c.-146C>T alteration and CRTC1 exon 1::TRIM11 exon 2 fusion. The patient is currently alive and undergoing post-surgical chemoradiation. Results (if a Case Study enter NA) NA Conclusion This case expands our understanding of CMTCT and emphasizes its potentially aggressive behavior. The sinonasal presentation contrasts the tumor’s typical appearance on the skin and could mimic mucosal melanoma. Of note, our patient developed recurrent disease and distant metastases, thereby emphasizing the possible role of systemic therapy and suggesting that simple surgical excision may not be curative in all cases. Our case illustrates that CMTCT is an uncommon and potentially misidentified neoplasm, but that its proper diagnosis is essential for treatment selection and follow up.

Locally Aggressive and Recurrent Facial Inflammatory Myofibroblastic Tumor in a Pediatric Patient

Inflammatory myofibroblastic tumor (IMT) is a rare tumor type with a prognosis ranging from benign to locally aggressive. Initially described as a reactive lesion most commonly of the lungs, cases of IMT have now been reported in rare instances in the head and neck, which may be more aggressive than other tumor locations. IMT frequently afflicts children and adolescents, but pediatric cases of IMT in the head and neck region are rare. This report serves to describe a rare presentation of a recurrent and locally aggressive facial IMT in a pediatric patient that required multiple surgical resections alongside medical management.

Huge and Multiple Xanthomas Misdiagnosed as Rheumatoid Nodules and Mistreated with Multiple Surgical Excisions over 4 Years, A Case Report

Background: Xanthoma is the iceberg of familial hypercholesterolemia; it’s resemblance to other cutaneous lesions such as rheumatoid nodules might lead to misdiagnosis. We emphasize in this case report the importance of comprehensive clinical and investigatory approach to cutaneous lesions as they could be the only manifestation of systemic diseases, and this helps to avoid delayed management and unnecessary interventions. Aim: Xanthomas as a possible diagnosis for multiple skin nodules, as it can be easily supported by performing simple noninvasive blood tests; the lipid panel. Case report: Female patient, presented with multiple skin lesions and a strong family history of premature coronary artery disease. She was firstly managed with multiple surgical resections as having benign masses, and later was misdiagnosed as having rheumatoid nodules and referred to rheumatology clinic for evaluation, wherein a clinical suspicion of xanthomas originated, and was supported by the severely elevated serum LDL level and a tissue diagnosis of xanthoma. She has been started on statins with regular clinic. Conclusion: The purpose of this case study is to explain the importance of including xanthomas within the differential diagnosis of recurrent skin lesions. Whereas the tissue diagnosis is the gold-slandered investigation, simple noninvasive blood test, serum lipid measurement can be the clue for diagnosis of the hidden fatal but easily controllable disease; familial hypercholesterolemia.

A modern approach to multiple pulmonary resections in children with recurrent metastatic pulmonary disease.

Implications of repeated resections of pulmonary metastasis (PM) are not well documented in the modern era. Fifteen children underwent two (n=8), three (n=3), or four or more (n=3) resections (total=38 procedures), most commonly for osteosarcoma (71%). Operative approach included muscle-sparing thoracotomy (71%), non-muscle-sparing thoracotomy (18%), and video-assisted thoracoscopy (11%). Median resected nodules per procedure was four (range = 1-95). Prolonged air leaks were the most common postoperative complication (29%). Median hospital stay was 4days, and no children were discharged with or have required oxygen. Event-free survival is 67% at median follow-up time of 54months, with an overall survival rate of 64%. Repeat resection of PM appears to be well tolerated, without prolonged hospital stays or compromised pulmonary function.

Use of Glucagon-like peptide 2 (GLP-2) analogs in inflammatory bowel disease

Introduction: Inflammatory bowel disease (IBD) is a chronic condition that involves long-term treatment and chronic idiopathic inflammation within the gastrointestinal tract. The predominant forms of IBD are: Crohn's disease and ulcerative colitis. These diseases cause significant physical as well as psychological dysfunction - patients with this condition are thought to have an increased risk of depression as well as anxiety. Standard treatment for IBD most commonly includes aminosalicylates, corticosteroids, immunomodulatory drugs, and biologic therapy. In some cases, particularly when it comes to Crohn's disease, it is necessary to remove a portion of the inflamed bowel. Multiple segmental bowel resections can result in the rare but serious complication of short bowel syndrome, which leads to intestinal failure and necessitates parenteral nutrition. Glucagon-like peptide-2 exhibits intestinotropic properties and also acts as a growth factor in the gastrointestinal tract, thereby increasing intestinal perfusion, causing increased absorption of nutrients, and enhancing proliferative mechanisms while inhibiting apoptotic processes. Methods: We carefully reviewed the medical literature on inflammatory bowel disease, short bowel syndrome and the potential treatment of this condition with GLP-2 and its analogs. The materials for the analysis we presented came from the PubMed database. Conclusions: Glucagon-like peptide 2 (GLP-2) analogs may prove to be new treatments for short bowel syndrome (SBS). They exhibit growth-stimulating effects on the intestinal membrane and promote normal function.

A huge retroperitoneal liposarcoma mimicking ovarian teratoma: A case report

Retroperitoneal liposarcoma is a malignant, primitive, and rare mesenchymal tumor. It can grow usually asymptomatic until large enough to compress the surrounding organs. We report an observation of a retroperitoneal liposarcoma mimicking an ovarian tumor. A 50-year-old, P1+0 postmenopausal female, presented to our Department of Obstetrics and Gynecology, with abdominopelvic mass and pressure symptoms for 2 months. Her magnetic resonance imaging abdomen and pelvis, ULTRASOUND-guided fine needle aspiration cytology, and tumor markers were done to make the provisional diagnosis after which, the patient underwent exploratory laparotomy. Complete removal of mass along with the right ovary was done in spite of mass encasing the right iliac vessels and the right ureter. Along with this, a hysterectomy with the left salpingo-oophorectomy and the right salpingectomy were done. A very huge ovarian tumor 22×15×28 cm weighing 5.5 kg was removed. Histopathological examination showed myxoid/well-differentiated liposarcoma with heterologous differentiation. Retroperitoneal liposarcomas are rare; however, they require an aggressive surgical approach, including multi-organ resection, if necessary, or multiple resections in the case of recurrence.

Serial Transverse Enteroplasty (STEP) versus Longitudinal Intestinal Lengthening and Tailoring (LILT): Systematic Review and Meta-Analysis of Outcomes and Complications

Abstract Background The prevalence of SBS is 3-4 per million. It occurs in about 15% of adult patients who undergo intestinal resection, with 3/4th of these cases resulting from massive intestinal resection and 1/4th from multiple sequential resections. About 70% of patients in whom SBS develops are discharged from the hospital and a similar percentage remain alive a year later. This improved survival rate has been achieved primarily by the ability to deliver long-term nutritional support. Objective To compare between Serial Transverse Enteroplasty (STEP) and Longitudinal Intestinal Lengthening and Tailoring (LILT) in the incidence of complications and clinical prognosis regarding morbidity and mortality in patients with Short Bowel Syndrome (SBS). Patients and Methods The search was carried out using the electronic national library of medicine PubMed database, Cochrane library and manual reference of articles published on serial transverse enteroplasty (STEP) versus longitudinal intestinal lengthening and tailoring (LILT) in management of patients with SBS. Conclusive search was done and duplicate studies were excluded. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available on the Internet till 2022. Results LILT and STEP are both valuable treatment strategies used in the management of pediatric SBS. However, currently, it is not possible to advise surgeons on accurate patient selection and to predict the result of either intervention. There is very limited published data on bowel lengthening procedure exclusively in adults. Most reported series exclusively or predominantly discuss the pediatric population with some adults included in one series and two additional single case reports. Conclusion Both STEP and LILT are potentially safe and effective methods for the treatment of SBS, under the conditions that the surgical techniques required have been mastered and the indications for surgery are observed. This review should be a gateway to open the scope on the field of Autologous Intestinal Reconstruction Surgeries (AIRS) and plan for a more detailed prospective studies with close monitoring of the data regarding outcomes, complications and follow up.

When synchronous mucinous metaplasia and neoplasia of the female genital tract and peutz-jeghers syndrome meet: a case report and literature reviews

BackgroundPeutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous polyps in the gastrointestinal tract and mucocutaneous pigmentation on the lips, oral mucosa, nose, fingers, and toes. Synchronous mucinous metaplasia and neoplasia of the female genital tract (SMMN-FGT) refers to the occurrence of multifocal mucinous lesions in at least two sites, including the cervix, uterus, fallopian tubes, and ovaries, in the female genital tract. SMMN-FGT and PJS are rare diseases with a very low incidence, especially when occurring simultaneously.Case presentationWe report a case in which a woman with a large mass on the left ovary underwent a gynecological surgery and was diagnosed with cervical gastric-type adenocarcinoma and mucinous lesions in the endometrium, bilateral fallopian tubes, and ovary, i.e., SMMN-FGT, by postoperative paraffin pathology. The patient sought medical attention for abdominal distension and enlargement. A gynecological ultrasound revealed a multilocular cystic mass in the pelvis, while serum tumor markers were within normal limits, with mildly elevated carbohydrate antigen 199 and carbohydrate antigen 125 levels. Cervical thin-prep cytology test result was negative. The patient had a family history of PJS with black spots on her skin and mucous membranes since the age of 8 years. She underwent multiple partial small bowel resections and gastrointestinal polypectomy owing to intestinal obstruction and intussusception. She underwent left adnexectomy, hysterectomy, right salpingectomy, greater omental resection, appendectomy and right ovary biopsy, and received six courses of adjuvant chemotherapy with Lopressor plus Carboplatin. Genetic testing revealed a heterozygous serine threonine kinase 11 germline mutation and there were no signs of recurrence during the 18-month follow-up period after treatment.ConclusionsThis is a rare case in which PJS was complicated by SMMN-FGT. Owing to its extreme rarity, there are no guidelines, but reported cases appear to indicate a poor prognosis. We retrospectively reviewed all cases of collisions between PJS and SMMN-FGT and explored the clinical features, pathological characteristics, diagnosis, treatment methods, and prognosis when the two diseases coexisted. The aim is to deepen the clinicians’ understanding of this disease for early detection, diagnosis and treatment.

Combined Pubic Arch and Ischial Bone Resection for Metachronous and Frequent Local Recurrences of Rectal Cancer.

Complete surgical resection with negative margins remains the cornerstone for curative treatment of rectal cancer; however, local recurrence can pose a significant challenge. Herein, we aimed to introduce a novel surgical technique for combined resection of the pubic arch and ischial bone in the context of treating recurrent rectal cancer. We present a case of a patient with a fourth local recurrence of rectal cancer, with no evidence of distant metastasis. The tumor directly invaded the posterior wall of the pubic arch. To achieve complete tumor resection, an osteotomy was performed using a thread wire saw at the bilateral pubic rami and ischial bones. Intraoperative frozen section analysis (rapid tissue examination) was conducted on tissue samples from the lateral margins of the planned osteotomy line. Samples were negative for adenocarcinoma (cancerous cells). The combined resection of the pubic arch and ischial bone was successfully performed with negative margins for adenocarcinoma, as confirmed by frozen section analysis. Mastery of the surgical technique for combined resection of the pubic arch and ischial bone may be clinically significant for achieving complete resection in cases of multiple resections for locally recurrent rectal cancer.

LGG-28. THE ROLE OF REOPERATION IN PEDIATRIC CEREBELLAR PILOCYTIC ASTROCYTOMA

Abstract BACKGROUND Cerebellar pilocytic astrocytomas (cPAs) in childhood have long been recognized to have a good prognosis after total resection but the outcome after incomplete resective surgery remains largely unpredictable with the incidence of radiological progressive disease ranging from 18-100%. Traditionally thought that GTR was required for long-term survival, small residuals were classically resected in a subsequent operation. METHODS We analyzed our Pediatric Low-Grade Glioma (PLGG) database, between 1985 and 2020, and filtered for intracranial pilocytic astrocytomas to determine what clinical or radiological factors precipitated revisional resective surgery in our single quaternary center cohort. RESULTS Using our Pediatric Low-Grade Glioma (PLGG) database, 283 patients were identified to have a histopathological diagnosis of intracranial pilocytic astrocytoma between 1985-2020 of which 202 were within the cerebellum (68.2%). The majority of patients with cerebellar PA were between 1-10 years of age (n=147, 73.5%) without gender predominance (M:F=99:101), usually presenting with 1 lesion (n=197, 98.5%). Gross total resection (GTR) was achieved in 74.5% (n=149) of initial surgeries for cerebellar PA. In patients with NTR or STR, the mean largest diameter of the post-operative residual was 1.1cm (0.2-3.7cm). Seven patients with STR did not require a second resective intervention. In 31 patients the neuro-oncology multidisciplinary team (MDT) recommended a second surgical resection at a mean time interval of 22.9 months (0.13-81.6 months) from the initial surgery. Proportionally, the children who underwent multiple resections were also more likely to receive adjuvant chemo/radiotherapy. Functionally, the children in the multiple operation cohort experienced more complications of therapy including ongoing endocrinopathy, treatment-associated hearing deficit, and neurocognitive deficits. CONCLUSION Residual disease in cPA should be maintained under clinocoradiological surveillance post-operatively with adoption of a more conservative approach when residual disease is not significantly changing over time.

The role of reoperation in pediatric cerebellar pilocytic astrocytoma.

Cerebellar pilocytic astrocytomas (cPAs) in childhood have long been recognized to have a good prognosis after total resection, but the outcome after incomplete resective surgery remains largely unpredictable, with the incidence of radiological progressive disease ranging from 18% to 100%. It has been traditionally thought that gross-total resection was required for long-term survival, and small residuals were classically resected in a subsequent operation. The authors analyzed their pediatric low-grade glioma (PLGG) database for cases treated between 1985 and 2020 and filtered for intracranial PAs, to determine what clinical or radiological factors precipitated revisional resective surgery in their single quaternary care center cohort. Using the pediatric low-grade glioma database, 283 patients were identified to have a histopathological diagnosis of intracranial PA between 1985 and 2020, of which 200 lesions were within the cerebellum (70.7%). The majority of patients with cPA were between 1 and 10 years of age (n = 145, 72.5%) without gender predominance (M/F = 99:101), usually presenting with 1 lesion (n = 197, 98.5%). Gross-total resection was achieved in 74.5% (n = 149) of initial surgeries for cPA. In patients with subtotal resection, the mean largest diameter of the postoperative residual tumor was 1.06 cm (range 0-2.95 cm). Seven patients with subtotal resection did not require a second resective intervention. In 31 patients the neuro-oncology multidisciplinary team recommended a second resection at a mean time interval of 22.9 months (range 0.13-81.6 months) from the initial surgery. Proportionally, the children who underwent multiple resections were also more likely to receive adjuvant chemo/radiotherapy. Functionally, the children in the multiple operation cohort experienced more complications of therapy including ongoing endocrinopathy, treatment-associated hearing deficit, and neurocognitive deficits. Residual disease in cPA should be maintained under clinicocoradiological surveillance postoperatively with adoption of a more conservative approach when residual disease is not significantly changing over time.

Primary cutaneous mucinous carcinoma in a periorbital lesion: two case reports and literature review.

Primary cutaneous mucinous carcinoma (PCMC) is a rare malignancy of the sweat glands that most commonly affects the periorbital area. It is characterized by slow growth over a prolonged period, and its morphology can be easily confused with a benign tumor, such as an epidermal cyst. Consequently, many patients experience recurrence after undergoing multiple resections. However, there are few reports concerning the surgical management of PCMC. We present two cases of PCMC originating in the periorbital area. The first case involved a 76-year-old man with a mass measuring 3.0× 1.5 cm that had been increasing in size. The second case was a 61-year-old man with two masses, each measuring 1.0× 1.0 cm, that were also growing. Both patients underwent wide excision with a 5-mm safety margin, which was determined based on the widest view of the cross-section of the mass on the magnetic resonance imaging. Subsequently, based on the intraoperative frozen biopsy results, both patients underwent additional excision with a 5-mm safety margin in only one direction. This report shows that, when determining the surgical margin of PCMC in periorbital area, employing imaging modalities and intraoperative frozen biopsies can be helpful for narrowing the surgical margin.

Comprehensive management of challenging recurrent aortoiliac and lower extremity occlusive disease with simultaneous modified-covered endovascular reconstruction of the aortic bifurcation, inferior mesenteric artery snorkel, and lower extremity bypass.

Despite recent advancements in endovascular technology and proven durability of open surgeries, managing extensive aortoiliac occlusive disease (AIOD) with concurrent severe lower extremity (LE) arterial occlusion remains a formidable challenge. This paper introduces a comprehensive approach to addressing recurrent AIOD and LE occlusive diseases by employing modified-CERAB, inferior mesenteric artery (IMA) snorkel, and LE bypass in a challenging case. A 56-year-old male patient presented with subacute bilateral lower extremity rest pain with dry gangrene in the left great toe and a complex medical history. His history included a hostile abdomen stemming from past ischemic bowel episodes and multiple bowel resections through laparotomies. Furthermore, the patient had a persistent left ventricular thrombus (LVT), stage-2 chronic kidney disease (CKD), diabetes, and was currently experiencing bilateral LE rest pain and dry gangrene in the left great toe, accompanied by severe dermatitis in both LEs. He successfully underwent modified-CERAB with a concurrent snorkel technique for IMA preservation, along with an LE bypass to resolve bilateral LE critical ischemia. This comprehensive management approach, combining simultaneous modified-CERAB, IMA snorkel, and LE bypass, provides an effective alternative for addressing complex AIOD and LE occlusive disease patients with hostile abdomen.

Modified Graham Patch Repair of Small Bowel Anastomotic Leak.

The modified Graham patch repair is a well-established technique for management of perforating foregut injuries, often learned by surgeons during general surgery training. There is, however, little to no data regarding the utilization of this technique for perforation of the distal midgut or in the re-operative field. We present two cases of midgut anastomotic complications successfully managed with modified graham patch repair at our institution. The first case is a 79-year-old female who underwent an emergent right hemicolectomy at an outside institution for management of an iatrogenic perforation during endoscopic polypectomy. Over the course of two years she underwent numerous abdominal operations, due to various complications, ultimately resulting in multiple resections and end ileostomy creation. She then had her ileostomy reversed by laparoscopic single incision (SILS) technique at our institution. This was also complicated by anastomotic leak. Intraoperatively, adequate mobilization of the anastomosis for resection was deemed not safe due to dense fibrosis and adhesions in the re-operative field; therefore, she underwent a SILS modified Graham patch repair of an ileocolic anastomotic defect with diverting loop ileostomy. Post-operatively, she had no radiographic evidence of leak from the repaired anastomosis, which facilitated successful loop ileostomy reversal five months later. Our second case is a 64-year-old male referred to our institution for management of his stage IV colon cancer. He underwent an open right hemicolectomy and hepatic metastectomy, which was complicated by anastomotic leak. The small defect was repaired via a SILS modified Graham patch technique. Five months postoperatively, he had neither radiographic nor endoscopic evidence of a leak; therefore, he successfully underwent ileostomy reversal without complication. We encourage further investigation and reporting of the role of the modified graham patch repair in management of midgut anastomotic complications, particularly when resection and re-anastomosis is unsafe due to a hostile re-operative field.

Multiple snares-assisted endoscopic full-thickness resection of a giant submucosal tumor at the esophagogastric junction.

Multiple snares-assisted endoscopic full-thickness resection of a giant submucosal tumor at the esophagogastric junction.