Multiple Resections Research Articles

Dietetic advocacy for long-term use of exclusive enteral nutrition resulted in high-risk surgical avoidance for complicated fibrotic Crohn's disease – A case report

Surgery is often the only therapeutic option for the management of fibrotic Crohn's disease (FCD). Exclusive Enteral Nutrition (EEN), a nutritionally complete liquid formula, is an effective, safe, short-term treatment for Crohn's Disease. No cases were found internationally of adults with FCD on long-term EEN. We report on clinical outcomes and self-reported quality of life (QoL) after longer-term EEN provision in a patient with complex FCD. "Billie", a 54-year-old female, was admitted with ileal FCD diagnosed in 1985. Previous treatments were unsuccessful, including multiple bowel resections. Billie was chronically bedbound with pain and depression. CDAI (Crohn's disease activity index) score was 640 (<150) with ∼3-20 liquid stools/day, and recurrent partial bowel obstructions. Radiological findings were so severe surgeons reluctantly considered surgery but "one more resection will result in short bowel syndrome". Billie trialled EEN given her QoL was "non-existent". Unable to tolerate the taste, EEN was administered via nasogastric tube. After two months, EEN was administered ongoing via percutaneous endoscopic gastrostomy given patient preference and dietetic advocacy. After eight weeks on EEN, Billie's pain predominantly resolved, with bowel motions of ∼1-2/day, and nil bowel obstructions. Twelve months after EEN commencement, Billie's CDAI was 52, with 'no indication for surgical intervention' and was self-reporting that "life is good". After 18 months, Billie remains asymptomatic, and in clinical remission. This unique case is a wonderful example of dietetic advocacy and showcases the positive impact long-term EEN may have on surgical avoidance, clinical outcomes and self-reported QoL.

Clinical Observations and Outcomes in Advanced Low-Grade Serous Carcinoma of the Ovary: Case Series from a Tertiary Cancer Center.

Low-grade serous carcinoma (LGSC) is a rare histologic subtype of ovarian cancer. We present detailed management of 15 cases of advanced LGSC from a tertiary cancer center of India. Fifteen cases of advanced LGSC who underwent cytoreductive surgery (CRS) were analyzed from a prospectively maintained database. Baseline demographic characteristics, surgical details, and chemotherapy details were recorded. Descriptive statistics were summarized, and progression-free survival (PFS) and overall survival (OS) were estimated. The median age was 37years. Nine patients had received NACT. All cases were FIGO stage III. Mean PCI was 15. Eleven patients had a completeness of cytoreduction score of 0-1. The median surgical time was 7.5h; nine patients required multiple gastrointestinal resections. Median blood loss was 2500ml. Median postoperative ventilation, ICU stay, and hospital stays were 1, 2, and 16days, respectively. One patient had a grade III complication. Four patients received adjuvant chemotherapy. There was no postoperative mortality at the end of 90days of surgery. All the patients except one were offered hormonal maintenance therapy. At a median follow-up of 43months, 4 patients were disease-free, 9 had a recurrence, one died of disease progression, and one was lost to follow-up. Most recurrences were locoregional in the peritoneal cavity or pelvis. Four-year OS and PFS were 71.8% and 29.7%, respectively. Advanced LGSCs occur mostly in young premenopausal women with favorable oncologic outcomes. Optimal CRS is the mainstay of treatment. Relative chemo-resistance and hormone receptor positivity provide an excellent therapeutic opportunity for endocrine therapy.

Treatment of De-Differentiated Liposarcoma in the Era of Immunotherapy.

Well-differentiated/de-differentiated liposarcoma (WDLPS/DDLPS) is one of the most common histologic subtypes of soft tissue sarcoma (STS); however, treatment options remain limited. WDLPS and DDLPS both exhibit the characteristic amplification of chromosome region 12q13-15, which contains the genes CDK4 and MDM2. DDLPS exhibits higher amplification ratios of these two and carries additional genomic lesions, including the amplification of chromosome region 1p32 and chromosome region 6q23, which may explain the more aggressive biology of DDLPS. WDLPS does not respond to systemic chemotherapy and is primarily managed with local therapy, including multiple resections and debulking procedures whenever clinically feasible. In contrast, DDLPS can respond to chemotherapy drugs and drug combinations, including doxorubicin (or doxorubicin in combination with ifosfamide), gemcitabine (or gemcitabine in combination with docetaxel), trabectedin, eribulin, and pazopanib. However, the response rate is generally low, and the response duration is usually short. This review highlights the clinical trials with developmental therapeutics that have been completed or are ongoing, including CDK4/6 inhibitors, MDM2 inhibitors, and immune checkpoint inhibitors. This review will also discuss the current landscape in assessing biomarkers for identifying tumors sensitive to immune checkpoint inhibitors.

Symptomatic Neuroma Development following En Bloc Resection of Skeletal and Soft-Tissue Tumors: A Retrospective Analysis of 331 Cases.

Although symptomatic neuroma formation has been described in other patient populations, these data have not been studied in patients undergoing resection of musculoskeletal tumors. This study aimed to characterize the incidence and risk factors of symptomatic neuroma formation following en bloc resection in this population. The authors retrospectively reviewed adults undergoing en bloc resections for musculoskeletal tumors at a high-volume sarcoma center from 2014 to 2019. The authors included en bloc resections for an oncologic indication and excluded non-en bloc resections, primary amputations, and patients with insufficient follow-up. Data are provided as descriptive statistics, and multivariable regression modeling was performed. The authors included 231 patients undergoing 331 en bloc resections (female, 46%; mean age, 52 years). Nerve transection was documented in 87 resections (26%). There were 81 symptomatic neuromas (25%) meeting criteria of Tinel sign or pain on examination and neuropathy in the distribution of suspected nerve injury. Factors associated with symptomatic neuroma formation included age 18 to 39 [adjusted OR (aOR), 3.6; 95% CI, 1.5 to 8.4; P < 0.01] and 40 to 64 (aOR, 2.2; 95% CI, 1.1 to 4.6; P = 0.04), multiple resections (aOR, 3.2; 95% CI, 1.7 to 5.9; P < 0.001), preoperative neuromodulator requirement (aOR, 2.7; 95% CI, 1.2 to 6.0; P = 0.01), and resection of fascia or muscle (aOR, 0.5; 95% CI, 0.3 to 1.0; P = 0.045). The authors' results highlight the importance of adequate preoperative optimization of pain control and intraoperative prophylaxis for neuroma prevention following en bloc resection of tumors, particularly for younger patients with a recurrent tumor burden. Risk, III.

Major hepatectomy in elderly patients: possible benefit from robotic platform utilization.

Robotic surgery has been increasingly utilized, yet its application for hepato-pancreato-biliary (HPB) procedures remains low due to technical complexity, perceived financial burden, and unproven clinical benefits. We hypothesized that the robotic approach would be associated with improved clinical outcomes following major hepatectomy compared with the laparoscopic approach among elderly patients who would benefit from the advantages of minimally invasive surgery. A retrospective review of consecutive patients who underwent major hepatectomy between January 2010 and December 2021 at Carolinas Medical Center was performed. Inclusion criteria were age ≥ 65years and major hepatectomy of three segments or more. Patients who underwent multiple liver resections, vascular/biliary reconstruction, or concomitant extrahepatic procedures (except cholecystectomy) were excluded. Categorical variables were compared using Chi-square or Fisher's exact test when more than 20% of cells had expected frequencies less than five, and Wilcoxon two-sample or Kruskal-Wallis tests were used for continuous or ordinal variables. Results are described as median and interquartile range (IQR). Multivariate analyses were used on postoperative admission days. There were 399 major hepatectomies performed during this time period, of which 125 met the criteria and were included. There were no differences in perioperative demographics among patients who underwent robotic hepatectomy (RH, n = 39) and laparoscopic hepatectomy (LH, n = 32). There was no difference in operative time, blood loss, or major complication rates. However, RH had lower rates of conversion to an open procedure (2.6% versus 31.3%, p = 0.002), shorter length of hospital stay [LOS, 4 (3-7) versus 6 (4-8.5) days, p≤0.0001], cumulative LOS [4 (3-7) versus 6 (4.5-9) days, p≤0.0001], and lower rates of intensive care unit (ICU) admission (7.7% versus 75%, p≤0.001), with a trend toward fewer rehabilitation requirements. Robot major hepatectomy shows clinical advantages in elderly patients, including shorter hospital and ICU stays. These advantages, as well as reduced rehabilitation requirements associated with minimally invasive surgery, could overcome the current perceived financial disadvantages of robotic hepatectomy.

Multidisciplinary management for primary uterine osteosarcoma, including gene panel testing: case report and literature review.

Primary osteosarcoma of the uterus (uOS) is rare, and its standard treatment has not yet been established. Herein, we present the case of a 50-year-old woman with uOS who demonstrated an improved prognosis after multiple surgeries to the metastatic sites. After the initial diagnosis of uOS, the patient showed recurrence and distant metastasis and hence expected to exhibit a poor prognosis. The patient underwent multiple surgical resections of the metastatic as well as primary tumors, which enabled the patient to survive for 24months after the initial surgery. Considering that the median survival time of patients with uOS is approximately 6months, the survival rate of our patient is noteworthy. Based on our observations, it is suggested that the resection of the primary and metastatic tumors might contribute to the extension of the survival period of the patient with chemo-resistant uOS.

Artificial intelligence (AI) in the management of colorectal cancer: on the horizon?

In the era of personalized medicine, an ever increasing emphasis is being placed on prognostication and prediction of surgical outcomes and treatment responses in colorectal cancer (CRC).1 Recent advances in information technology have allowed AI integration into clinical practice. Machine learning (ML) is a subfield of AI in which algorithms iteratively ‘learn’ from data to make predictions based on discerned patterns, without being explicitly programmed to do so. Deep learning (DL) is a further subfield of ML, whereby artificial neural networks (ANN) loosely modelled on the human brain structure, are exposed to large or ‘deep’ datasets, deriving predictive capacity from learned patterns in the data.2 Computer vision (CV) refers to the training of computers to read and interpret images, a field closely involved in the last half-decade with DL approaches. Within Radiomics, AI is making an impact in CRC staging.1 DL platforms have demonstrated the ability to distinguish between T2 and T3 rectal cancer on MRI with 90% accuracy,3 and to detect lymph node disease with a higher accuracy than radiologists.4 The combination of histopathological outcomes with MRI and CT imaging shows promise. It allows models to predict a complete pathological response in rectal cancer patients treated with neoadjuvant therapy and the identification of systemic therapy responders with metastatic CRC.1 Colonoscopy is an area in which AI is already being used. AI algorithms designed to aid polyp detection have been shown to increase adenoma detection rates, even amongst experienced endoscopists,5 thus providing a cost effective method of reducing CRC during population screening.6 DL models can both detect and classify polyps with high sensitivity and specificity.7 The development of AI-assisted clinical tools that can provide decision support such as future endoscopic surveillance intervals are ongoing.5 Such tools can also enhance endoscopy training through improved polyp pattern recognition identification.5 Support systems which provide evidence-based clinical decision making tools for CRC are already available. The Watson for Oncology (WFO) program developed by IBM and the Memorial Sloan Kettering Cancer Centre has been trained to follow the U.S. National Comprehensive Cancer Network guidelines.8 Treatment recommendations suggested by the WFO have shown concordance rates of 80%–90% for CRC management compared to a multidisciplinary team (MDT).8, 9 Although not designed to supplant the MDT, AI tools can become an adjunct for clinicians to increase workload time efficiency, and decrease the risk of errors.8 Though still in its infancy, the utilization of AI tools is becoming increasingly relevant within colorectal surgery, through the intraoperative use of CV10 for operative precision and training. Using laparoscopic image data from multiple rectal resections, DL models have been able to recognize the correct phase of the operation, and also act as an intra-operative guide in the identification of complex anatomical structures, such as the total mesorectal excision plane of dissection.10, 11 A recent pilot study has demonstrated the utilization of DL-based software to automate the surgical skill assessment of various steps within a laparoscopic rectal resection, paving its way for future applications in surgical training.12 Despite these exciting developments, many limitations remain. Significant financial investment and creation of regulatory and legal frameworks will be required to integrate AI into existing healthcare systems.13 Furthermore, AI is constrained by the quality and quantity of available data used to train them. As the majority of relevant studies come from only a few geographical locations, AI models are susceptible to inherent biases related to differing patient cohorts.14 AI has the potential to revolutionize the management of CRC. However, there are many challenges to be addressed before AI programs can become embedded into routine care for CRC. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians. Matthew Y. K. Wei: Conceptualization; writing – original draft; writing – review and editing. Junyao Zhang: Writing – review and editing. Reuben Schmidt: Validation; writing – review and editing. Andrew S. Miller: Writing – review and editing. Justin M. C. Yeung: Supervision; validation; writing – review and editing.

Muscle strength and functional recovery for soft-tissue sarcoma of the thigh: a prospective study.

This study aimed to investigate changes in muscle strength and functional outcome before and after surgery for soft-tissue sarcoma of the thigh and to examine the timing of recovery. From 2014 to 2019, 15 patients who underwent multiple resections of the thigh muscle for soft-tissue sarcoma of the thigh were included in this study. The muscle strength was measured with an isokinetic dynamometer for the knee joint and with a hand-held dynamometer for the hip joint. The functional outcome assessment was based on the Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D), and maximum walking speed (MWS). All measurements were conducted preoperatively and at 3, 6, 12, 18, and 24months postoperatively, and the ratio of postoperative to preoperative value was used. A repeated-measures analysis of variance was performed to compare changes over time and to investigate the recovery plateau. Correlations between changes in muscle strength and functional outcomes were also examined. The muscle strength of the affected limb, MSTS score, TESS, EQ-5D, and MWS were significantly decreased at 3months postoperatively. The recovery plateau was subsequently reached at 12months postoperatively. The changes in muscle strength of the affected limb and functional outcome showed a significant correlation. The estimated postoperative recovery for soft-tissue sarcoma of the thigh is 12months after surgery.

Abstract #1405536: Hyponatremia After Placement of an External Lumbar Drain Following Transsphenoidal Surgery in a Patient with Preoperative Diabetes Insipidus

Hypernatremia due to diabetes insipidus (DI) is perhaps the most anticipated electrolyte abnormality after transsphenoidal surgery (TSS), but hyponatremia is more common and occurs in over 15% of patients undergoing TSS. Postoperative placement of an external lumbar drain (ELD) is a well-known risk factor for hyponatremia following TSS. We present an unusual case of refractory hyponatremia occurring after ELD placement in a patient with preoperative DI. A 68-year-old male underwent TSS for resection of a recurrent sella meningioma. History was notable for multiple recurrences and resections of the tumor, and the patient was treated for longstanding central DI and hypopituitarism (>10 y). Surgery was complicated by bleeding, requiring placement of an ELD. Preoperative serum sodium levels were in the reference range (136-145 mM), but within 48 h of ELD placement, serum sodium level fell to 127 mM. Spot urine sodium level and osmolality were <10 mM and 162 mOsm/kg, respectively. The patient received stress dose glucocorticoids after surgery, and free T4 level was in the reference range (0.5-1.3 ng/dL). Other causes of hyponatremia and pseudohyponatremia, including hyperglycemia, renal tubular acidosis, paraproteinemia, and hyperlipidemia were excluded. While the lumbar drain was in place, serum sodium levels remained 125-129 mM despite decreasing the amount and frequency of DDAVP doses for treatment of preoperative central DI. After the ELD was removed, hyponatremia resolved within 48 h, and the patient was discharged home with a serum sodium level of 140 mM on oral DDAVP (0.1 mg BID) prescribed prior to surgery. In a series of over 300 adults undergoing TSS, placement of an ELD accounted for almost half of hyponatremia cases. Cerebral salt wasting syndrome (CSWS) and syndrome of inappropriate antidiuretic hormone (SIADH) are identified as the most common causes of ELD-induced hyponatremia, though undetectable urine sodium level in this case excludes CSWS. Spot urine osmolality was surprisingly high (>100 mOsm/kg) for the patient’s longstanding central DI, appearing to indicate SIADH as the etiology of hyponatremia. The patient likely had partial central DI, and persistent hyponatremia after placement of the ELD despite significant reductions of DDAVP doses appears to be best explained by release of endogenous ADH by surviving magnocellular neurons of the supraoptic nucleus in the hypothalamus superimposed on treatment with DDAVP. This case demonstrates that ELD-induced hyponatremia is possible in patients treated for central DI prior to TSS and likely indicates only a partial deficit of endogenous ADH secretion.

Multiple Intestinal Atresia with Combined Immunodeficiency, a New Gene Arises

We present here a single case report of a 2-day-old female born to a 29-year-old G4P3→4 Swartzentruber Amish mother at 35 weeks gestation that presented with abdominal distension and failure to pass meconium.Family history was positive for a cousin born with multiple intestinal atresia (MIA) and combined immunodeficiency (CID) who died in his first month of life. A primary immune deficiency targeted gene panel was done, covering TTC7A, in addition to 206 other genes, with no known mutations identified.An exploratory laparotomy was performed on DOL4 with MIA observed, as well as malrotation without volvulus. Repair of pyloric atresia and multiple small bowel resections and anastomosis were performed. She was kept NPO with TPN and NG suctioning of gastric contents for bowel rest.Immunologic profiling revealed low CD3+ cells (578/µL), very low CD8+ T cells (23/µL), low CD4+ T cells (485/µL), normal NK and B cell counts, low levels of serum IgM (< 10 mg/dL) with normal levels of IgG (likely maternal) and IgA. Mitogen stimulation testing was normal. Sanger sequencing showed a homozygous c.4867 T>G (p.Tyr1623Asp) mutation in PIK4A confirming the diagnosis of Gastrointestinal Defects and Immunodeficiency Syndrome 2 (GIDID2). Despite surgery, the patient continued to have large volume NG output without return of bowel function. Other treatment options, including long term TPN, potential small bowel and liver transplants, and HSCT were discussed, but the family elected for hospice given the poor prognosis. She passed away on DOL 28. PI4KIIIα, encoded by PI4KA, catalyzes the conversion of phosphatidyl inositol to phosphatidyl inositol-4-phosphate while using TTC7A as a scaffolding protein. This process is critical for development of enterocyte polarity and actomyosin contractility in multiple cell types. PI4KA mutations have only recently been implicated in causing MIA with CID and can be missed in many genetic screens. GIDID2 is a devastating disease in which intestinal surgery provides only an immediate mechanical fix, without improving mortality. Further research on the molecular mechanisms that govern GIDID2 is critically needed to identify new treatment modalities. Furthermore, awareness of PI4KA mutations in newborns with MIA with CID is critical, particularly in Amish populations.

44. Symptomatic Neuroma Formation following Skeletal and Soft Tissue Tumor Resection

PURPOSE: While symptomatic neuroma formation has been described in other patient populations, these data have not been studied in patients undergoing resection of musculoskeletal tumors. This study aims to characterize the incidence and risk factors of symptomatic neuroma formation following en bloc resection in this population. METHODS: We retrospectively reviewed adults undergoing en bloc resections for musculoskeletal tumors at a high-volume sarcoma center from 2014-2019. We included en bloc resections for an oncologic indication and excluded non-en bloc resections, primary amputations, and patients with insufficient follow-up. Data are provided as descriptive statistics and multivariable regression modeling was performed. RESULTS: We included 231 patients undergoing 331 en bloc resections (46% female; mean age 52 years). Nerve transection was documented in 87 resections (26%). There were 81 symptomatic neuromas (25%) meeting criteria of Tinel sign or pain on exam and neuropathy in the distribution of suspected nerve injury. Factors associated with symptomatic neuroma formation included age 18-39 (aOR, 3.6; 95% CI, 1.5-8.4; p < 0.01) and 40-64 (aOR, 2.2; 95% CI, 1.1-4.6; p = 0.04), multiple resections (aOR, 3.2; 95% CI, 1.7-5.9; p < 0.001), preoperative neuromodulator requirement (aOR, 2.7; 95% CI 1.2-6.0; p = 0.01) and resection of fascia or muscle (aOR, 0.5; 95% CI, 0.3-1.0; p = 0.045). CONCLUSION: Our results highlight the importance of adequate preoperative optimization of pain control and intraoperative prophylaxis for neuroma prevention following en bloc resection of tumors, particularly for younger patients with a recurrent tumor burden.

Robotic liver surgery: A new reality. Descriptive analysis of 220 cases of minimally invasive liver surgery in 182 patients

IntroductionThe level of recommendation of the robotic approach in liver surgery is controversial. The objective of the study is to carry out a single-center retrospective descriptive analysis of the short-term results of the robotic and laparoscopic approach in liver surgery during the same period. MethodsDescriptive analysis of the short-term results of the robotic and laparoscopic approach on 220 resections in 182 patients undergoing minimally invasive liver surgery. ResultsBetween April 2018 and June 2022, a total of 92 robotic liver resections (RLR) were performed in 83 patients and 128 laparoscopic (LLR) in 99 patients. The LLR group showed a higher proportion of major surgery (P < .001) and multiple resections (P = .002). The two groups were similar in anatomical resections (RLR 64.1% vs. LLR 56.3%). In the LLS group, the average operating time was 212 min (SD 52.1). Blood loss was 276.5 mL (100–1000) and conversion 12.1%. Mean hospital stay was 5.7 (SD 4.9) days. Morbidity was 27.3% and 2% mortality. In the RLS group, the mean operative time was 217 min (SD 53.6), blood loss 169.5 mL (100.900), and conversion 2.5%. Mean hospital stay was 4.1 (SD 2.1) days. Morbidity was 15%, with no mortality. ConclusionMinimally invasive liver surgery is a safe technique, and in particular, RLS allows liver resections to be performed safely and reproducibly; it appears to be a non-inferior technique to LLS, but randomized studies are needed to determine the minimally invasive approach of choice in liver surgery.

Customized External Cranioplasty for Management of Syndrome of Trephined in Nonsurgical Candidates.

Craniectomies represent a lifesaving neurosurgical procedure for many severe neurological conditions, such as traumatic brain injury. Syndrome of trephined (SoT) is an important complication of decompressive craniectomy, and cranial reconstruction is the definitive treatment. However, many patients cannot undergo surgical intervention because of neurological status, healing of the primary surgical wound, or the presence of concurrent infection, which may prevent cranioplasty. To offer a customized external cranioplasty option for managing skull deformities for patients who could not undergo surgical intervention for definitive cranioplasty. We describe the design and clinical application of an external cranioplasty for a patient with a medical history of intractable epilepsy, for which she underwent multiple right cerebral resections with a large resultant skull defect and SoT. The patient had resolution of symptoms and restoration of a symmetrical skull contour with no complication at 17 months. Customized external cranioplasty can improve symptoms associated with SoT for patients who cannot undergo a definitive cranioplasty. In addition, inset monitoring options, such as electroencephalography or telemetric intracranial pressure sensors, could be incorporated in the future for comprehensive monitoring of the patient's neurological condition.

Abstract 5934: Tracking T cell clonal dynamics across time and space in metastatic colorectal cancer

Abstract Here we tracked T cell dynamics in 15 metastatic colorectal cancer (mCRC) patients who had multiple resections (median: 3, range: 2-7) over a period of &amp;gt;7 years (median: 10 years, range: 7-16 years), using a novel T cell receptor sequencing (TCRseq) method. These samples had been previously characterized for DNA and methylation alterations and gene expression, enabling an integrated analysis to determine potential cellular and molecular drivers and consequences of immune dynamics. This multi-region, multi-timepoint dataset presents a unique opportunity to study the co-evolution of mCRC and the T cell response over time, across metastatic sites and in response to therapy. T cell antigen specificity is defined by the TCR - a highly diverse sequence that enables tracking of specific T cell expansions across time and space. TCRseq quantifies the abundance of T cell clones and maps the dynamics of the TCR repertoire, however little is known about how these are altered in different metastatic sites, and post-chemotherapy. We developed and validated a new FFPE-compatible TCRseq method and sequenced 216 longitudinal samples representing the mCRC cohort described above. We detected a median of 348 unique TCRs per sample (range 69-9700), and revealed high levels of intra-tumor spatial heterogeneity. No significant difference was detected in the number of T cell clones or the TCR clonality between primary tumors (n=40), lung metastases (n=30) and liver metastases (n=50). Furthermore, these were not significantly different between tumor regions (n=139) and surrounding stroma (n=38). We found that compared to chemo-naïve tumors (n=36), those that had been exposed to recent chemotherapy (n=41) had a significant increase in both the number of unique T cell clones and Simpson’s evenness, likely reflecting a broad T cell response to DNA-damaging agents. After more than a year had passed without chemotherapy (n=64) these returned to pre-chemotherapy levels. In most cases the 10 most abundant TCR sequences in the primary tumor represented 15-40% of the total repertoire. We tracked these expanded clones through metastases, identifying ubiquitous clones which persisted across metastatic sites and through therapy. We found other expanded clones which were no longer present in metastases lesions, although some of these were found to expand again in later metastases. Finally, we examined correlations with tumor genomics, finding evidence in some patients that the TCR repertoire tracks closely with tumor clones even through metastasis and chemotherapy. In summary, this project represents the first comprehensive analysis of T cell dynamics through colorectal cancer metastasis, highlighting the changing T cell landscape post-chemotherapy and correlating the TCR repertoire with tumor genomics. Our results could have important clinical implications for mCRC immunotherapy and the design of personalized T cell-based therapy. Citation Format: Ann-Marie Baker, Alison Berner, Tahel Ronel, Nick Trahearn, Barbara Bravi, John Bridgewater, Benny Chain, Trevor A. Graham. Tracking T cell clonal dynamics across time and space in metastatic colorectal cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5934.

159 Neuroplastic Changes Across Multiple Brain Resections in Glioma Patients: Identification of Patterns that Predict Beneficial Repeat Resection

INTRODUCTION: The brain displays degrees of functional reorganization, i.e., neuroplasticity, that enable interventions that were previously thought to be impossible (e.g., resection of “Broca’s area”). Studies have described the static, single-point in time neuroplastic potential in diffuse low-grade gliomas (DLGG) following one surgery. METHODS: We studied n=103 patients with a DLGG that underwent multiple brain resections achieved up to critical neural networks identified under awake mapping by means of direct cortical and subcortical electrostimulation. We used normalized postoperative images to generate probability overlap, atlas-based cortical and subcortical parcellation, and functional compensation maps for both surgeries. We performed statistical analysis correcting for multiple comparisons across all cortical parcels and tracts to determine differences at the cortical and subcortical levels between surgeries. RESULTS: We show for the first time the dynamics of neuroplastic changes occurring in DLGG that undergo multiple awake resections. We created residual and resection cavity overlap probability maps; cortical parcel damage and subcortical tract disconnection maps and the difference between surgeries; and functional compensation maps and subcortical volumes. We discovered the following four main patterns that constrain how and to what degree this dynamic reorganization occurs between surgeries: cortical vs subcortical, superficial vs deep, unimodal vs multimodal, and left vs right. We found greater plasticity at the cortical level, superficial terminations of white matter tracts, multimodal networks, and left ventral and right dorsal networks. CONCLUSIONS: These newly discovered patterns of reorganization provide a unifying model to understand the dynamics of neuroplasticity in DLGG patients undergoing multiple resections. These dynamics with its patterns that constrain mechanisms of neuroplasticity, can help guide neurosurgeons to predict which patients are likely to benefit from a repeat resection.

A case series of 10 patients undergone linear cutter/stapler guiding device-led overlapped esophagojejunostomy: a preliminary study.

In laparoscopic total gastrectomy with overlap esophagojejunostomy (EJS), esophageal 'false track' is easily formed during EJS. In this study, a linear cutter/stapler guiding device (LCSGD) was used in EJS, so that the linear cutting stapler can complete the technical action with high speed and high efficiency in a narrow space, while avoiding the formation of 'false passage', optimizing the quality of common opening and shortening the anastomosis time. The LCSGD is safe and feasible in laparoscopic total gastrectomy overlap EJS, and the clinical effect is satisfactory. A retrospective, descriptive design was adopted. The clinical data of 10 gastric cancer patients admitted to the Third Department of Surgery of the Fourth Hospital of Hebei Medical University from July 2021 to November 2021 were collected. The cohort comprised 8 males and 2 females aged 50-75 years. (I) The intra-operative conditions: 10 patients received LCSGD-guided overlap EJS after radical laparoscopic total gastrectomy. Both D2 lymphadenectomy and R0 resection were achieved in these patients. No combined multiple organ resection was performed. There was neither conversion to an open thoracic or abdominal procedure nor conversion to other EJS approaches. The average time from the entry of the LCSGD into the abdominal cavity to the completion of the firing of the stapler was 1.8±0.4 minutes, the average time for manual suturing of the EJS common opening was 14.4±2.1 minutes (mean: 18±2 stitches), and the average operative time was 255±52 minutes. (II) The postoperative outcomes: the time to the first ambulation was 1.9±1.4 days, the average time to the first postoperative exhaust/defecation was 3.5±1.3 days, the average time to a semi-liquid diet was 3.6±0.7 days, and the average postoperative hospital stay was 10.4±4.1 days. All patients were smoothly discharged, without any secondary surgery, bleeding, anastomotic fistula, or duodenal stump fistula. (III) Follow-up: The telephone follow-up lasted 9-12 months. No eating disorders or anastomotic stenosis was reported. One patient experienced Visick grade II heartburn, and the condition of the remaining 9 patients was Visick grade I. Application of the LCSGD in overlap EJS after laparoscopic total gastrectomy is safe and feasible, with satisfactory clinical effectiveness.

A STUDY ON RETROSPECTIVE ANALYSIS OF GASTROINTESTINAL STROMA TUMOURS.

Introduction:.Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal (GI) tract. They are believed to originate from the interstitial cells of Cajal (ICCs) or from the precursors of ICCs. Most GISTs show an activating mutation in either the c-kit or platelet-derived growth factor receptor alpha (PDGFRA) gene. Tumor size, mitotic rate, and anatomic location correlate with potential malignancy and recurrence rate. The aim of our study is to Aim &amp; Objectivesobserve the demographic and clinical characteristics of GIST in our clinical environment.Method- 30 patients who are diagnosed with GIST managed during the period from Jun 2017 to July 2022 were reviewed in terms of demographics, clinical presentation, location of tumor, characteristics, management, histopathology, IHC analysis, post op follow up &amp; recurrence.The risk stratication in terms of size, mitotic index, site of tumour was observed &amp; classied using modied NIH classication. Results- Out of 30 cases male patient's- 73% (n- 22); female patients27%(n-8). Mean age was 60 years with a range of 44-81 years. Most common clinical presentation was abdominal mass, Abdominal pain. Commonly involved sites are stomach and small bowel.4 cases who underwent multiple organ resection 2 cases developed recurrence in which 1 underwent palliative Whipple's procedure and one was medically managed. GIST Conclusion- s are rare entities with a variety of clinical features, Common sites for GIST are stomach &amp; small intestine. Surgery is the main stay of management in GIST. Neo adjuvant therapy will help in down staging the tumour. Wedge resection &amp; resection &amp;anastomosis will be adequate for stomach in small bowel GIST. En-bloc resection should be considered if adjacent structures are involved. Overall GIST has favourable prognosis if diagnosed early

Multiple colorectal liver metastases resection can offer long-term survival: The concept of a chronic neoplastic disease.

Resection for colorectal liver metastases has evolved significantly and, currently, there are no limits to the number of resected nodules. This study aimed to evaluate the outcomes and prognostic factors after liver resection for patients with ≥4 colorectal liver metastases, emphasizing long-term survival. The study population consisted of 137 patients with ≥4 colorectal liver metastases out of a total of 597 patients with colorectal liver metastases who underwent curative intent liver resection from January 2010 to July 2019 in a single hepatobiliary center. The probability of overall and disease-free survival at 1, 3, and 5 years was 90.8%, 64.5%, 40.6%, and 37.7%, 19.3%, 18.1%, respectively. In a multivariate analysis for overall survival, the size of the largest metastatic nodule was the only unfavorable factor (P= .001). For disease-free survival, complete pathological response was a favorable factor (P= .04), and the following were negative factors: number of nodules ≥7 (P= .034), radiofrequency ablation during surgery (P= .04), positive primary tumor lymph nodes (P= .034), R1 resection (P= .011), and preoperative carcinoembryonic antigen >20 ng/mL (P= .015). After the first and second years of follow-up, 59 patients (45.3%) and 45 patients (34.6%), respectively, were not receiving chemotherapy. After 5 years of follow-up, 21 (16.1%) multimetastatic patients were chemotherapy-free. A significant number of patients with multiple colorectal liver metastases will present long-term survival and should not be denied surgery. The long-term survival rates, even in the presence of recurrence, characterize a chronic neoplastic disease.

Incomplete Currarino triad in an adult woman

Introduction: Currarino Syndrome (CS) is a rare entity characterized by a triad of sacral agenesis, anorectal malformations, and pre-sacral masses. CS is typically diagnosed during the first decade of life.&#x0D; Case Description: We present a rare case of incomplete Currarino syndrome manifesting in a 36-year-old lady who presented with back pain, urinary retention, anal paresthesia, and lower limb weakness. The patient underwent multiple laminectomies and partial resection of an epidermoid cyst and regained function.&#x0D; Conclusion: Although rare, the possibility of Currarino syndrome should be entertained in adult patients with lower lumbosacral symptoms and a pre-sacral mass. A thorough physical examination and strategic pre-operative planning are mandatory to maximize patient outcomes.

Surgical Resection of Vulvar Labial Venous Malformations: A Single Center Experience

BackgroundVenous malformations (VMs) involving the vulva are rare but often cause debilitating pain, aesthetic concern, and functional impairment. Treatment with medical therapy, sclerotherapy, operative resection, or a combination thereof may be considered. The optimal therapeutic approach remains unclear. We report our experience resecting labial VMs in a large cohort of patients. MethodsA retrospective review of patients who underwent partial or complete resection of a labial VM was conducted. ResultsThirty-one patients underwent forty-three resections of vulvar VMs between 1998 and 2022. Physical examination and imaging demonstrated: 16% of patients had focal labial lesions, 6% had multifocal labial lesions, and 77% had extensive labial lesions. Indications for intervention included pain (83%), appearance (21%), functional impairment (17%), bleeding (10%), and cellulitis (7%). Sixty-one percent of patients underwent a single resection, 13% multiple partial resections, and 26% a combination of sclerotherapy and operative resection(s). Median age was 16.3 years at first operation. All patients requiring multiple operations had extensive VMs. Median blood loss was 200 mL. Postoperative complications included wound infection/dehiscence (14%), hematoma (2%), and urinary tract infection (2%). The median follow-up assessment was 14 months: 88% of patients had no complaints and 3 patients were experiencing recurrent discomfort. ConclusionsSurgical resection is a safe and effective approach to treating vulvar labial VMs. Patients with focal or multifocal VMs can be successfully treated with a single resection, whereas patients with an extensive VM may require multiple partial resections or combined sclerotherapy and resection(s) to achieve long-term control. Type of studyRetrospective Study. Level of evidenceIV.