<h2>ABSTRACT</h2><h3>Background</h3> Retroperitoneal sarcoma (RPS) has high local recurrence rates and poor outcomes, with complete surgical resection being the only curative treatment. Over the past two decades, there has been a trend towards multivisceral resection (MVR). This systematic review sought to evaluate the role of MVR compared with simple resection in patients with primary RPS. <h3>Methods</h3> A systematic review was conducted following PICO methodology. Adult patients with primary localized RPS undergoing MVR were compared to those receiving simple resection. Primary outcomes included abdominal recurrence-free survival, overall survival, and perioperative morbidity. <h3>Results</h3> Twenty-three retrospective studies were identified, with patient cohorts ranging from 23 to 1007 participants. Results demonstrated conflicting evidence regarding MVR's impact on survival outcomes. The highest quality study showed MVR significantly reduced 3-year abdominal recurrence rates (10% vs 47%, HR 1.99, p=0.04) compared to simple resection. However, MVR did not significantly improve overall survival across most studies. Analysis of perioperative morbidity consistently demonstrated that MVR does not significantly increase complications compared to simple resection. <h3>Conclusions</h3> Current evidence suggests MVR may reduce abdominal recurrence in primary RPS without significantly increasing perioperative morbidity, though overall survival benefits remain unproven. MVR could be considered for RPS subtypes at high risk of local recurrence, particularly liposarcoma, to maximize local control without significantly increasing perioperative morbidity. Given that complete surgical resection remains the only curative therapy for RPS, the decision for MVR should be individualized with input from a sarcoma multidisciplinary team.

Radionuclide dimercaptosuccinic acid (DMSA) renal imaging is considered a standard pre-operative assessment for renal function before multi-visceral resection (MVR) with en bloc nephrectomy in retroperitoneal sarcoma (RPS), according to Transatlantic Retroperitoneal Sarcoma Working Group guidelines. DMSA scans assess split renal function (SRF) to evaluate both the ipsilateral kidney's contribution and the remaining kidney's function post-surgery. However, limited evidence supports routine DMSA use. This study aimed to evaluate the impact of DMSA on surgical planning. This retrospective cohort study, performed in a UK high volume specialist sarcoma centre, included 312 patients considered for MVR of RPS between 2010 and 2023. Phase 1 represented pre 2019 surgical practice with phase 2 representing the period which included more selective DMSA guideline implementation. DMSA SRF was correlated with other imaging, comorbidities, renal tests, and clinical decisions. A significant SRF difference (≥10%) was the threshold for this study, with p<0.05 deemed significant for eGFR and ipsilateral versus contralateral SRF. 217 patients were referred for DMSA imaging, of which 165 patients (76%) underwent surgery. 18 patients (8%) were excluded due to insufficient data and 34 patients (16%) did not undergo surgery. Of the 165 patients who underwent surgery, 19 (12%) had a contralateral SRF ≤45%, with the lowest at 28%. Post-operatively, eGFR insignificantly declined from 77.1 to 63.9 and slightly improved to 65.5 after 2-5 years. Unfavourable DMSA SRF did not correlate to additional poorer long term renal function or factor in those failing to progress to surgery; pre-operative death (10/34 patients; 29%) and inoperable RPS (10/34 patients; 29%) being the primary reasons for failing to progress to surgery. In only two cases were unfavourable DMSA results cited in pre-operative planning clinic letters and did not prevent resection. From 2010 to 2019, 87.2% (164/188) of patients underwent pre-operative DMSA scans. Given paucity of departmental evidence related to the utility of DMSA in surgical planning the department of sarcoma moved away from routine DMSA requests unless perceived risk factors for poor renal function were apparent. Thus after 2019, DMSA usage significantly reduced to 28.6% (8/28) in 2020, further decreasing significantly (p<0.001) to 4.5% (1/22), 8.5% (3/35), and 2.5% (1/39) from 2021 to 2023. Only 13 DMSA scans were performed out of 124 resections between 2020 and 2023, saving £63,270, reducing patient disruption and preserving resources. Pre-operative DMSA had minimal impact on MVR decision-making for RPS. Reflective guideline adaptations streamlined the patient assessment pathway for consideration of MVR for RPS surgery.

PurposeThis study aimed to evaluate surgical outcomes, identify complications, and analyze recurrence in patients undergoing surgery for primary retroperitoneal tumors (RPTs), which pose significant therapeutic challenges.MethodsWe retrospectively reviewed the medical records of 59 patients who underwent surgery for primary RPTs at Ajou University Hospital between January 2015 and December 2024. Patients were divided into a multivisceral resection (MVR) group (n = 25) and a non-MVR group (n = 34) to compare demographics, clinical characteristics, pathological findings, and postoperative outcomes.ResultsCompared to the non-MVR group, the MVR group had a significantly higher rate of open surgery (96.0% vs. 73.5%, P = 0.034), longer operative times (237.6 minutes vs. 188.8 minutes, P = 0.032), more frequent R2 resections (32.0% vs. 8.8%, P = 0.018), and longer hospital stays (13.1 days vs. 7.0 days, P = 0.007). Malignant tumors comprised 67.7% of cases, with sarcoma being the most common. Recurrence rates were highest in well-differentiated liposarcoma (50.0%) and dedifferentiated liposarcoma (22.2%). While univariate analysis showed MVR was associated with severe morbidity (Clavien-Dindo grade ≥III; odds ratio, 6.200; P = 0.029), this was not sustained as an independent predictor in multivariable analysis.ConclusionAlthough MVR was associated with severe complications in univariate analysis, it was not an independent predictor in multivariable analysis. This suggests the increased risk reflects overall surgical complexity. Therefore, MVR should be pursued when oncologically necessary, as it presents an acceptable morbidity profile.

Surgical management of metastatic adrenocortical carcinoma: Is there a role for multivisceral resection?

Reportedly, in laparoscopic surgeries for colorectal cancer, surgeries performed or supervised by Endoscopic Surgery Skills Qualification System (ESSQS)-certified surgeons yield favorable outcomes. However, the impact of ESSQS-certification on the prognosis of multivisceral resection (MVR) surgery remains unclear. The aim of this study was to examine the impact of MVR surgery performed by ESSQS-qualified surgeons on patient prognosis. We retrospectively reviewed 226 consecutive colorectal cancer patients who underwent MVR between 2016 and 2024. The patients were divided into two groups: surgery performed by ESSQS-certified surgeons (expert group, n=88) and those performed by ESSQS-uncertified surgeons (non-expert group, n=138). Propensity score matching for baseline patient and surgical characteristics identified 65 patients in each group. Groups were compared for clinicopathological and surgical features, and 5-year relapse-free survival (RFS), overall survival (OS) and local recurrence free survival (LRFS) were assessed using Kaplan Meier methods and log-rank tests. Before matching, the incidence of rectal cancer was higher (33.0% vs. 8.7%, p<0.001) and laparoscopic surgery was more often performed (89.8% vs. 79.7%, p=0.043) in the expert group. Five-year RFS (74.8% vs. 63.1%, p=0.056), OS (83.3% vs. 64.4%, p=0.062), and LRFS (3.5% vs. 11.4%, p=0.078) tended to be better in the expert group. The results of this multicenter study indicated better short- and long-term outcomes of MVR performed by ESSQS-qualified surgeons.

PurposeHigh-risk colon cancer may benefit from preoperative chemotherapy (preCHT), but evidence on its short-term safety and outcome is limited. Population-based evidence before its incorporation into national guidelines is lacking.MethodsPatients with final weighted stage II–III colon cancer undergoing elective resection between 2007 and 2017 were identified in the Swedish Colorectal Cancer Registry. Patients planned for preCHT, irrespective of intention, were compared with those undergoing upfront surgery. Primary outcomes were 30- and 90-day mortality and 30-day major morbidity, defined as all medical and surgical complications classified as Clavien-Dindo (CD) ≥ 3 grade. Subgroup analyses examined cT4 disease, and multivariable logistic regression was performed.ResultsAmong 20,185 eligible patients, 299 (1.5%) received preCHT. Postoperative mortality was comparable (1.7% vs. 1.7%, p = 1.00 at 30 days and 3.0% vs. 2.8%, p = 0.82 at 90 days). Overall and surgical postoperative morbidity (CD ≥ 3) was higher in the preCHT group (34.1 vs. 25.0%, p < 0.001 and 17.4% vs. 13.1%, p < 0.001), rates of anastomotic leakage were similar (3.3% vs. 3.6%, p = 0.85). Compared to upfront surgery, the preCHT group was more likely to undergo multivisceral resections (53.9% vs. 13.6%, p < 0.001), with a higher rate of R1 resections (6.4% vs. 3.2%, p < 0.001), reflecting more advanced disease (cT4: 59.5% vs. 10.5%, p < 0.001; cN1-2: 54.9% vs. 28.6%, p < 0.001). In the cT4 subgroup, short-term outcomes were comparable, and regression analyses found no independent association between preCHT and mortality or major morbidity.ConclusionPreCHT appeared feasible in cT4N0-2M0 colon cancer, with short-term outcomes comparable to upfront surgery despite more advanced primary tumour and greater surgical extent.

RECIST Responses to Radiation in Retroperitoneal Soft Tissue Sarcoma: When and How Often Do They Occur?

To conduct a systematic review of literature data on robot-assisted multivisceral resections for locally advanced rectal cancer and to present own immediate results of these interventions. Request "robotic OR," "robotic ORs," "robot-assisted OR," "robot-assisted" and «(Robotic OR robot-assisted) AND rectal AND (T4 OR multivisceral)» in PubMed and E-library databases resulted in 268 publications. Of these, 12 articles were included. Surgery time, intraoperative complications, including blood loss, conversion rate, postoperative complications, and extent of resection (R0, R1) were studied. Meta-analysis enrolled the incidence of complications and R0 resections. In addition, own results of 5 robot-assisted combined rectal resections for the period August - December 2024 are presented. Rectal resections were combined with bladder resection in three cases, and left-sided adnexectomy was performed in one case. One surgery was combined with anterior abdominal wall resection. Treatment outcomes were analyzed in 891 people. The conversion rate was 11%, incidence of R0 resections - 76.2-100%, overall morbidity - 20.7-78%. Locoregional recurrences occurred in 4-9.3% of cases. Own results of treating 5 patients with locally advanced rectal cancer are summarized. There were R0 resections in all cases. There were no intraoperative complications. Severe postoperative complications (Clavien-Dindo ³ III) were observed in one case. Mean surgery time was 5 hours. Our experience of robot-assisted combined rectal resections for locally advanced cancer demonstrates feasibility of such operations. Own data are comparable with results of previous studies. Systematization of available results is complicated by high heterogeneity of data. However, available data are favorable and confirm the need for prospective accumulation of experience.

Abstract Background &amp; Aim Gastrointestinal stromal tumours (GISTs) require individualised surgical strategies based on tumour biology and anatomical complexity. We assessed real-world outcomes from a high-volume tertiary centre, including the use of minimally invasive approaches and complex resections. Method A retrospective study of 152 primary GIST resections performed between 2012 and 2024 was conducted. Demographics, tumour characteristics, surgical approach, recurrence, and survival outcomes were analysed. A Subgroup analysis of the multi-visceral resections was also analysed. SPSS v24 was used for statistical analysis, with significance set at p&amp;lt;0.05. Results Most tumours were gastric 75%, spindle-cell type 77.6%, and &amp;gt;5 cm in 63.8%. Minimally invasive surgery (MIS) was performed in 48% of cases, including one-third of large tumours. R0 resection was achieved in 96.1%, with an overall 5-year survival of 91.4% and recurrence in 9.9%. In multi-visceral resections (n =18), recurrence was significantly higher (27.8%, p =0.020), although 5-year survival remained high (94.4%). Postoperative complication rates were acceptable in the entire cohort: VTE, 9.5%; leak, 3.3%; reoperation, 2.6%; readmission rate, 2.6%; and surgical site infections (SSIs), 2%, with higher rates in multi-visceral cases. Conclusions This is one of the largest regional GIST series evaluating MIS use in GIST &amp;gt;5cm. Post op complications, namely leaks and SSI, are within the globally accepted range. Multi-visceral resections were shown to predict recurrence. Recurrence and 5-year disease free survival reflects favourable outcomes in a well-managed tertiary setting. These findings, along with other data, support the importance of effective multidisciplinary management in GIST; evident in our high-volume centre.

Abstract Aim To identify risk factors for recurrence and survival in primary GIST resection. Method A retrospective analysis of 152 primary GIST resections performed at a tertiary centre between 2012 and 2024 was conducted. The final follow-up date was May 1, 2025. Univariate analyses identified associations between clinical-pathological variables and recurrence or survival. Variables with p&amp;lt;0.05 were included in multivariable logistic regression to identify independent predictors. Kaplan–Meier (KM) estimated recurrence-free survival (RFS) by risk classifications (Fletcher, NIH, Miettinen) and significant independent multivariate predictors. Overall survival (OS) KM analysis was performed for significant multivariate predictors only. Log-rank test compared survival. SPSS 24 was used with significance: p&amp;lt;0.05. Results Recurrence occurred in 12.5% of patients. Univariate predictors included age &amp;gt;50 (p=0.049), tumour size (p=0.038), non-gastric location (p=0.031), high mitotic rate (p=0.021), multivisceral resection(p=0.041), IHC markers (p=0.007), death during follow-up (p=0.002), and failure to reach five-year survival (p=0.021). On multivariate analysis, high mitotic rate was the only factor independently predictive of recurrence(p=0.006). KM analysis showed lower RFS in high mitotic index and non-gastric tumours. Risk models stratified recurrence effectively. Overall mortality was significantly associated with male gender (p=0.002), tumor size (p=0.024), non-gastric site (p=0.001), high mitotic index (p=0.040), R1/R2 resection (p=0.024), metastasis (p=0.002), and recurrence(p=0.049). On multivariate analysis, male gender(p=0.011) and recurrence (p=0.006) independently predicted mortality. KM analysis showed lower OS with high mitotic index, non-gastric tumours, and epithelioid histology. Conclusions Recurrence and survival in GIST are influenced by mitotic activity, tumour location, and surgical factors. Early risk identification supports individualised management approaches.

To evaluate short-term outcomes and identify predictors of morbidity and mortality following multivisceral oncologic resections involving the pancreas. Multivisceral resections including the pancreas are required for locally advanced abdominal malignancies but are associated with considerable perioperative risk. While smaller series suggest acceptable outcomes in selected patients, large-scale international data are lacking to guide surgical decision-making and risk stratification. This was a retrospective cohort study of 1,283 patients from 31 international centers who underwent multivisceral oncologic resections involving the pancreas. Patient demographics, tumor characteristics, operative details, and 90-day postoperative outcomes were analyzed. The cohort had a mean age of 64.7years, and 54.7% were male. Distal pancreatectomy was the most frequent procedure (60.5%), and R0 resection was achieved in 60.9% of cases. Ninety-day mortality was 6.9%, highest in patients with gastric adenocarcinoma (16.7%). Major complications (Clavien-Dindo grade III-V) occurred in 34.4% of patients. Higher ASA classification and open surgical approach were independently associated with increased morbidity and mortality. Prolonged operative time was associated with morbidity only. Female gender and treatment at high-volume centers were protective. In patients with pancreatic tumors, resection involving the colon (OR 1.78, p<0.001), stomach (OR 1.33, p=0.042), or three or more organs (OR 1.75, p=0.006) significantly increased complication rates. Multivisceral resections involving the pancreas are associated with relevant perioperative risk. Optimizing patient selection, favoring minimally invasive techniques when feasible in selected patients, and centralizing care to high-volume centers may help improve outcomes for these complex surgical procedures.

This study was aimed to evaluate the impact of multivisceral resection (MVR) on the oncologic outcomes of patients with locally advanced colorectal cancer. We conducted a retrospective review of patients who underwent surgical resection between 2011 and 2020. Patients were divided into two groups: the MVR group and the standard resection group. Prognostic factors were compared, and the effect of MVR on oncologic outcomes was assessed. Among 625 patients, 108 underwent MVR. The MVR group showed a significantly lower rate of lymph node metastasis (51.9% vs. 72.5%, p < 0.001), lymphovascular invasion (25.9% vs. 42.8%, p = 0.001), and perineural invasion (45.4% vs. 73.2%, p < 0.001) compared to the standard resection group. Postoperative complications were more frequent in the MVR group (57.4% vs. 26.9%, p < 0.001). Three-year disease-free survival (68.6% vs. 62.7%, p = 0.743) and overall survival (OS) (80.9% vs. 85.0%, p = 0.290) were comparable between the two groups. Multivariable analysis identified lymph node metastasis, perineural invasion, R2 resection, and absence of adjuvant chemotherapy as independent poor prognostic factors for OS. The MVR group showed a significantly lower rate of lymph node metastasis and comparable oncologic outcomes. Therefore, when adjacent organ invasion is suspected, an aggressive en-bloc MVR should be considered to achieve radical resection.

Postoperative pancreatic fistula (POPF) is the most important complication after left pancreatectomy. Superiority of hand-sewn closure or stapler closure of pancreatic stump in terms of short-term outcomes is not established. The aim of this study was to compare short-term surgical outcomes between the two modalities after left pancreatectomy. International multicenter retrospective cohort study was performed, including patients undergoing left pancreatectomy. Patients with multivisceral resection other than splenectomy were excluded. POPF as defined by the International Study Group for Pancreatic Surgery was the main outcome. Patients undergoing hand-sewn closure were matched to stapler patients in 1:1 fashion using propensity-score matching. Altogether 2183 patients were included, and 219 (10.0%) underwent hand-sewn closure. The overall POPF incidence was 470 (21.5%). In the matched cohort of 438 patients (219 per group), POPF incidence was significantly higher in the hand-sewn group (72 [32.9%] vs. 46 |21.0%], p=0.007). In addition, the reoperation rate was higher, and the length of hospital stay longer in the hand-sewn group. These results were reproducible in most of the different subgroups defined by, for example pancreatic thickness, duct diameter and histology. Hand-sewn closure is associated with worse short-term outcomes, mainly increased POPF incidence, compared to stapler closure.

Clinically significant delayed gastric emptying after multivisceral resection for retroperitoneal sarcoma: A retrospective cohort study.

Delayed Gastric Emptying Following Multivisceral Resections for Retroperitoneal Sarcoma: Incidence, Risk Factors, and Clinical Impact

Predictors of quality-of-life following liver resection for malignancy.

Evolution of the Indications and Outcomes of Total Pancreatectomy

A standardized surgical approach to multifocal locoregionally recurrent left-sided adrenocortical carcinoma.

BackgroundPost-hepatectomy liver failure (PHLF) is a serious complication after liver resection and is associated with increased morbidity and mortality. The current International Study Group of Liver Surgery (ISGLS) definition relies on laboratory values from postoperative day (POD) 5 onwards, which may potentially delay diagnosis and intervention. This study aimed to evaluate whether early postoperative liver function parameters can predict the development of PHLF.MethodsAll patients who underwent elective liver resection between April 2019 and May 2023 were included in the study. Exclusion criteria were emergency or multivisceral resections and incomplete laboratory data. Bilirubin, international normalized ratio (INR), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were measured on POD 1, 3, and 5. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of PHLF. Receiver operating characteristic (ROC) analysis was performed, and optimal cutoffs on POD3 were determined using the Youden index.ResultsOut of 445 included patients, 38 (8.5%) developed PHLF. Bilirubin, INR, AST, and ALT levels were significantly higher in patients with PHLF from POD 1 onwards. On POD 3, bilirubin ≥1.8 mg/dl (AUC 0.79; sensitivity 93.3%, specificity 62.4%), INR ≥ 1.18 (AUC 0.83; sensitivity 80.6%, specificity 68.8%), AST ≥ 179 U/L (AUC 0.75; sensitivity 68.4%, specificity 74.9%), and ALT ≥ 258 U/L (AUC 0.70; sensitivity 68.8%, specificity 69.8%) demonstrated predictive value. In multivariate analysis, major hepatectomy, bilirubin on POD 3, INR on POD 3, and persistently elevated AST and ALT were confirmed as independent predictors of PHLF.ConclusionBilirubin and INR on POD 3 were the strongest independent predictors of PHLF. Elevated AST and ALT on POD 3 were also valuable prognostic indicators. Relying solely on ISGLS criteria from POD 5 onward may therefore delay diagnosis and intervention. Persistently elevated transaminases should be acknowledged as early indicators of liver dysfunction and considered in future revisions of PHLF definitions.

IntroductionSurgical management of patients with peritoneal surface malignancies (PSM) via multivisceral resection is associated with increased morbidity and mortality in the immediate postoperative period, rendering intensive care therapy critically important. We aimed to determine whether intensive care unit (ICU) course and scoring systems predict not only short-term but also long-term outcomes.MethodsWe retrospectively analyzed the medical records of all patients who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal surface malignancies (PSM) between 2008 and 2015 at a university cancer center. Upon postoperative ICU admission, Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores were recorded. Complications during the ICU stay and overall hospitalization were documented, and patients were followed according to a standardized protocol after discharge.ResultsA total of 251 patients were included. The mean Peritoneal Cancer Index (PCI) was 14 ± 9.1 and correlated significantly with both ICU stay duration (p = 0.002) and total hospital stay (p = 0.001). In-hospital mortality was 2%, and the reoperation rate was 16.7%. SOFA scores on the day of surgery, postoperative days 1, 2, and 7 demonstrated strong correlations with ICU length of stay (all p ≤ 0.001) and with overall hospital stay (p = 0.001 for the day of surgery and day 7; p ≤ 0.001 for days 1 and 2). In multivariate analysis, SOFA score on postoperative day 7 [hazard ratio (HR) 1.261; 95% confidence interval (CI) 1.120–1.421; p ≤ 0.001] and SAPS II on the day of surgery (HR 1.042; 95% CI 1.017–1.068; p ≤ 0.001) emerged as independent predictors of overall survival.DiscussionIn conclusion, SAPS II and SOFA scores not only predict ICU and hospital lengths of stay but also independently forecast overall survival in patients undergoing CRS and HIPEC for PSM.