Oncological Clearance Research Articles

Robot-assisted Müllerian compartment resection for cervical cancer.

Radical hysterectomy has been established as the standard treatment for early stage cervical cancers. Despite numerous efforts to standardize the technique for radical hysterectomy across varying extents of tumor invasion, success has been inconsistent. Total Müllerian Compartment Resection (TMCR), an ontogenetic compartment-based oncologic surgery initially developed for open procedures by Professor Höckel, offers a standardized approach applicable to all patients with locally confined tumors. This method holds promise for achieving thorough oncologic clearance while maintaining acceptable complication rates. Moreover, robotic-assisted surgery may further reduce morbidity compared to open surgery. In this context, we provide a detailed step-by-step description of robotically assisted Total Müllerian Compartment resection (R-TMCR) for cervical cancer and present feasibility data from a cohort of 20 patients. 20 patients with stage IA1-IB2 cervical cancer, robot-assisted resection of the Müllerian embryonic compartment was undertaken. Key metrics such as operative duration, intraoperative blood loss, and postoperative complication rates were meticulously recorded and analyzed. The duration of the surgery varied from 185 to 500 minutes, with intraoperative blood loss ranging between 5 mL and 300 mL. Postoperative hemoglobin levels dropped by -15 to 40 g/L from their preoperative values. Notably, there were no instances necessitating conversion to open surgery, and no intraoperative complications occurred. The rate of postoperative complications was 0%. Over the follow-up period, which averaged 18 months, there were no observed locoregional recurrences of cervical cancer, nor were there any deaths attributed to cervical cancer during this time. The application of robotic Müllerian compartment resection in the surgical treatment of cervical cancer is both safe and feasible. Utilizing robotic technology enables more precise and refined surgical outcomes. Combining embryonic compartment-based radical hysterectomy with the principles of membrane anatomy can standardize and optimize the surgical process, helping surgeons master radical hysterectomy more quickly and effectively.

Incidental Finding of Double Posterior Belly of Digastric Muscle in Head and Neck Cancer Patient.

The digastric muscles have important roles in swallowing, chewing, speech, and landmark identification during neck dissection. The posterior belly of the digastric muscle (PBDM) is often useful for defining boundaries in surgical neck dissection as it contributes to the carotid, submandibular, and submental triangles. The cadaveric prevalence rate of anatomic variations in the digastrics has been reported to be 31.4% of the population with most occurring in relation to the anterior belly of the digastric muscle (ABDM). Few reports describe variations in the PBDM. While anatomic variants of the digastric muscles do not present with clinical manifestations, they can be mistaken as neck masses and contribute to intraoperative complications. We present a case report of a 73-year-old male with a past medical history significant for Parkinson's Disease, who was incidentally found to have a duplicate PBDM intraoperatively while receiving surgical management of a left buccal squamous cell cancer. Nine months prior to surgery, the patient began experiencing trismus and some mild dysphagia that were eventually worked up to reveal left buccal squamous cell carcinoma (SCC). Prior to this, the patient did not have clinical symptoms demonstrating dysfunction that could be related to or indicative of this anatomical abnormality preceding symptoms related to left buccal SCC growth. The procedure included a wide local excision, left modified radical neck dissection and left submental artery island flap with suprahyoid neck dissection. The superior duplicate PBDM was found to be overlying the stylohyoid muscle. It is important for surgeons operating in the head and neck to be aware of the possibility of this rare variation, and to be conscientious when it is identified so that it does not prohibit or limit a thorough dissection of the neck structures where oncologic clearance is paramount.

Robotic Radical Cholecystectomy: Demonstrating Technical Equivalence to Open Surgery in Gallbladder Cancer

BackgroundOpen radical cholecystectomy is the current “gold standard” for the management of gallbladder cancer. In well-selected patients, robotic radical cholecystectomy (RRC) can be a suitable alternative offering immediate postoperative benefits, such as less blood loss, shorter hospital stay, and fewer complications, while being oncologically equivalent. However, it requires a longer learning curve.1MethodsThis video demonstrates the technical equivalence of the robotic approach when performing portal lymphadenectomy (station 8, 12, and 13) with emphasis on retraction techniques to emulate the open approach. In the case presented, a 40-year-old female patient had an intraluminal gallbladder mass with periportal nodes as revealed by computed tomography. Patient underwent a RRC with portal lymphadenectomy, performed on the DaVinci Xi robotic system. The surgery can be divided into five major steps: (1) Station 16b1 node sampling in the inter-aortocaval region; (2) Right portal lymphadenectomy (station 13, 12b, 12p); (3) Left portal lymphadenectomy (station 8a, 8p, 12a, 12p); (4) Anterior portal lymphadenectomy (station 12a, 12b); and (5) Cholecystectomy with liver wedge resection. The technical nuances of each of these steps is compared with its counterpart in the open approach to demonstrate equivalence. The key element in achieving a thorough oncological clearance is to replicate the retraction techniques of the open approach on the robotic platform by using vessel tapes for portal lymphadenectomy.ConclusionsThere remains little doubt regarding the feasibility and early postoperative benefits of RRC.2 This video demonstrates the equivalence of a standardized technique of robotic portal lymphadenectomy and liver wedge resection to the open approach. However, prospective studies are needed to further evaluate the long-term benefits of the procedure.

Clinical outcomes of left upper segmentectomy vs. lobectomy for early non-small-cell lung cancer: a nationwide database study in Japan

PurposeGiven that left upper lobe and right upper and middle lobes share a similar anatomy, segmentectomy, such as upper division and lingulectomy, should yield identical oncological clearance to left upper lobectomy. We compared the prognosis of segmentectomy with that of lobectomy for early stage non-small-cell lung cancer (NSCLC) in the left upper lobe.MethodsWe retrospectively examined 2115 patients who underwent segmentectomy or lobectomy for c-stage I (TNM 8th edition) NSCLC in the left upper lobe in 2010. We compared the oncological outcomes of segmentectomy (n = 483) and lobectomy (n = 483) using a propensity score matching analysis.ResultsThe 5-year recurrence-free and overall survival rates in the segmentectomy and lobectomy groups were comparable, irrespective of c-stage IA or IB. Subset analyses according to radiological tumor findings showed that segmentectomy yielded oncological outcomes comparable to those of lobectomy for non-pure solid tumors. In cases where the solid tumor exceeded 20 mm, segmentectomy showed a recurrence-free survival inferior to that of lobectomy (p = 0.028), despite an equivalent overall survival (p = 0.38).ConclusionSegmentectomy may be an acceptable alternative to lobectomy with regard to the overall survival of patients with c-stage I NSCLC in the left upper lobe.

Management of giant cell tumor of the distal end radius: extended curettage and adjuvant therapy versus wide resection and reconstruction: a systematic review and meta-analysis

Background Giant cell tumors (GCTs) in the distal end of the radius present unique challenges in balancing oncological clearance with preserving functional capabilities. This study aims to provide a comprehensive comparison between extended curettage with adjuvants and wide resection with reconstruction for GTCs of the distal radius, addressing outcomes such as recurrence rates, functional scores, and complications. Patients and methods A systematic review of the literature was conducted, involving databases such as MEDLINE, Cochrane library, and PubMed. Inclusion criteria comprised comparative cohort studies in English, comparing extended curettage with adjuvants versus wide resection with reconstruction in patients with GCTs of the distal end radius. Outcome measures included functional outcomes (Musculoskeletal Tumor Society, disabilities of the arm, shoulder, and hand), recurrence, metastasis, postoperative complications, and quality of life. Results The literature search identified 17 retrospective comparative cohort studies that met the inclusion criteria. The studies included 527 procedures, with an average participant age of 33.49 years and a mean follow-up of 7.1 years. The pooled estimate showed a significantly lower recurrence rate with wide resection (7.7%) compared with extended curettage with adjuvants (28.4%). Functional outcomes favored extended curettage in terms of visual analog scale pain scale and disabilities of the arm, shoulder, and hand score, with no significant difference in range of motion but higher grip strength in the curettage group. Complication rates were higher with wide resection. Conclusion While extended curettage with adjuvants may pose a higher risk of recurrence, it demonstrates promise for improved functional outcomes. The study suggests that extended curettage leads to reduced pain and disability scores compared with wide resection, with a higher grip strength. The findings contribute to the ongoing discussion on the optimal management of GCTs in the distal radius, highlighting the importance of balancing oncological considerations with functional outcomes. However, study limitations, including retrospective designs and potential selection bias, should be considered in interpreting the results.

The Role of Supraclavicular Flap in Reconstruction Following Resection in Buccal Mucosa Carcinoma.

Buccal mucosa is one of the common subsite for oral carcinoma. Following excision of the buccal mucosa tumor mass various pedicled and free flaps have been used to reconstruct the oral cavity defect. In this age of free flaps various locoregional pedicled flaps have been underrated and overlooked and supraclavicular flap is one of them. This flap meets the functional and cosmetic acceptance of the buccal mucosa defect reconstruction with minimal morbidity to the donor site. This paper presents author's experience of using supraclavicular flap in 10 patients of carcinoma buccal mucosa. In all cases surgical defect was completely covered by the flap, there was no necrosis of the flap. Functional and cosmetic outcome was acceptable in all the patients without compromising oncological clearance.

Robotic beyond total mesorectal excision (TME) for locally advanced or recurrent rectal cancer: a systematic review protocol

IntroductionThe surgical treatment for locally advanced or recurrent rectal cancer requires oncological clearance with a pelvic exenteration or a beyond total mesorectal excision (TME). The aim of this systematic review...

The Functional Outcome of Limb Salvage of Proximal Femur Tumors With Modular Endoprosthesis: A Prospective Study.

Introduction The proximal femur is a common siteforprimary bone sarcomas, includingEwing's sarcoma, chondrosarcoma, osteosarcoma, and giant celltumors (GCT). Extensive resections arechallengingto reconstruct because the size of the tumormay necessitate an extensive resection ofthefemur to achieve adequate oncologic clearance. The resection of the proximal femur can result inhip jointinstabilitydue totheloss of the strong native hipcapsule orhip abductor strength. With a wide range of reconstruction options,such asresection arthrodesis, allograft-prosthetic composite (APC),andendoprosthesis,we can achieve limb salvage with good functionaloutcomes. Objective The objective of this case series isto evaluate the clinical outcomes and complications associatedwith endoprosthesis replacement in patients with proximal femur tumors. Methods A prospective analysis was conducted with 32 patients who underwent modular endoprosthesis replacement for proximal femoral tumors at our institution. Patient data, tumor characteristics, surgicaldetails, and postoperative outcomes were collected and analyzed. Results The study involved 32 patientswho met theinclusion criteria.Theywere assessed usingthe MusculoskeletalTumor Society Score (MSTS), which showedgoodfunctional outcomesin72.84%of the patients. The study highlights the functionaloutcomes and potential complications associated with the use of modular prostheses. Conclusion Endoprosthesis replacement in proximal femur tumors is a viable treatment option, providinggood functional outcomes and an acceptable method for limb salvage, which enhances the quality of life.

Case Report of an Appendiceal Mucinous Neoplasm: A Rare Etiology for Appendicitis

An appendiceal mucinous neoplasm is a rare condition with a clinical picture that can resemble appendicitis. Published reports have documented an incidence of 0.07-0.3% of all appendicectomies. The ubiquitous use of computerized tomography scans has helped plan surgical strategies as these patients may often require a right hemicolectomy in order to ascertain oncological clearance. This helps the clinician to avoid the complication of pseudomyxoma peritonei with its attendant increased mortality. In this case report the presence of a normal appendix base allowed for a laparoscopic intervention without having to resect the right hemi-colon. All published case reports to date have documented the involvement of the entire appendix. This case report is unique in the sparing of the proximal appendix.

Standardized surgical procedure of conformal sphincter-preservation operation for low rectal cancer (2023 edition)

Conformal sphincter-preservation operation (CSPO) is considered the effective surgical technique for preserving the sphincter in cases of low rectal cancer. Accurate preoperative diagnosis and staging, reasonable selection of surgical approaches and technique, standardized perioperative management, and postoperative rehabilitation are the keys to ensuring the oncological clearance and functional preservation of CSPO. However, there is currently a lack of standardized surgical procedure for implementing CSPO in China. Therefore, the Colorectal Surgery Group of Surgery Branch of the Chinese Medical Association,along with the Colorectal Cancer Committee of the Chinese Medical Doctor Association and the Anorectal Branch of Chinese Medical Doctor Association, gathered experts in colorectal surgery to discuss and establish this standardized surgical procedure of CSPO. This standard, based on the latest evidence from literature, expert experiences, and China national condition, focuses on the definition, classification, pelvic anatomy, surgical techniques, postoperative complications, and perioperative care of CSPO. It aims to guide the standardized clinical practice of CSPO in China.

Hepatic Artery Anomalies in Pancreaticoduodenectomy: Outcomes from a High-Volume Center

Introduction: Hepatic artery anomalies (HAA) may have an impact on surgical and oncological outcomes of patients undergoing pancreaticoduodenectomy (PD). Methods: Patients who underwent PD at our institution between July 2015 and January 2020 were retrospectively reviewed and classified into two groups: group 1, with presence of HAA, and group 2, with no HAA. A weighted logistic regression model was employed to assess the association between HAA and postoperative complications, and to assess the association between HAA and R status in patients with pancreatic cancer. Results: 502 patients were considered for analysis, with 75 (15%) of them in group 1. They had either an accessory (n = 28, 40.8%) or replaced (n = 26, 36.6%) right hepatic artery. Most patients underwent surgery for a malignancy (n = 451; 90%); among them, vascular resection was performed in 69 cases (15%). The presence of a HAA was reported at preoperative imaging only in 4 cases (5%) and the aberrant vessel was preserved in 72% of patients. At weighted multivariable logistic regression analysis, HAA were not associated to higher odds of morbidity (odds ratio [OR]: 0.753, 95% confidence interval [CI]: 0.543–1.043) nor to R1 status in case of pancreatic cancer (OR: 1.583, 95% CI: 0.979–2.561). Conclusion: At our institution, the presence of HAA does not have an impact on postoperative outcomes or affects oncological clearance after PD. Hospitals’, surgeons’, volume and systematic review of preoperative imaging are all factors that help reduce possible adverse events.

Surgical templates for inguinal lymph node dissection in cN0 penile cancer: A comparative study.

Modified and superficial inguinal lymph node dissection (MILD and SILD) are the 2 widely used templates for surgical staging of clinically node negative (cN0) penile cancer (PeCa); however, no previous reports have compared their outcomes. We compared these 2 surgical templates for oncological outcomes and complications. We retrospectively reviewed records of cN0 PeCa patients who underwent MILD/SILD at our cancer care center from January 2013 to December 2019. Patients who developed a penile recurrence during follow up were excluded from analysis of oncological outcomes. The 2 groups (MILD and SILD) were compared for baseline clinico-pathological characteristics. The primary outcome was the groin recurrence free survival (gRFS). Secondary outcomes included the false negative rate (FNR) and disease free survival (DFS) for both templates and also the post-operative wound related complication. Of the 146 patients with intermediate and high risk N0 PeCa, 74 (50.7%) and 72 (49.3%) underwent MILD and SILD respectively. The 2 groups were comparable with regards to the distribution of T stage, tumor grade and the proportion of intermediate and high-risk patients. At a median follow up of 34 months (47 for SILD and 23 for MILD), a total of 5 groin recurrences were encountered; all of them occurred in the MILD group. The gRFS and DFS for the MILD group was 93.2% and 91.8% respectively; while that for the SILD group was 100% and 94.4% respectively. Too few events had occurred to determine any statistically significant difference. The FNR for MILD and SILD was 26.3% and 0% respectively. The overall complication rate was significantly higher in the SILD group (46% vs 20.3%, p=0.001), especially for Clavien Dindo 3A complications. MILD can fail to pick up micro-metastatic disease in a small proportion of cN0 PeCa patients, while SILD provides better oncological clearance with no groin recurrences. This oncological superiority comes at the cost of a higher incidence of wound-related complications.

191 Minimally Invasive General Surgery Landmark Trials and Lessons Learned - A Narrative Review

Abstract Aims The aim of this review is to explore the history of minimally invasive (MI) surgery and landmark trials that guide modern practice. Methods A narrative review was conducted according to the four steps outlined by Demiris et al. Results MI surgery has become the gold-standard for many operations. Laparoscopic surgery has equivalent operative outcomes to open surgery with reduced recovery time and hospital stay. Randomised controlled trials (RCTs) investigating complex laparoscopic upper gastrointestinal oncological resections demonstrate reduced blood loss and postoperative pain. Within colorectal surgery, the CLASSIC and COREAN trials described comparable mortality and oncological clearance in MI colorectal cancer resections versus open surgery. Conversely, ALaCaRT and ACOSOG raised concerns about oncological results. Robotic surgery provides a high degree of instrument freedom and stabilises hand tremors, however substantial associated costs remain a barrier. Robotic cholecystectomy (RC) is a safe and effective tool, and RC outcomes are comparable to laparoscopic surgery in the elective setting; although more evidence is required for more complex disease outcomes. For rectal cancer, the ROLARR trial found no difference in complications, conversion rate, or circumferential margin positivity for robotic-assisted versus laparoscopic surgery. Recently, the Smart Tissue Autonomous Robot performed the first autonomous intestinal anastomosis on porcupines, outperforming expert surgeons for both consistency and accuracy, demonstrating the potential future of robotic surgery. Conclusion This review gives an overview of MI general surgery; demonstrating the advantages as well as some concerns for the different surgical techniques, and raises suggestions for future uses.

Total portal vein replacement with peritoneal interposition graft during Whipple’s procedure for extrahepatic cholangiocarcinoma: a technical report

BackgroundAggressive surgical resection in locally advanced hepatopancreatobiliary (HPB) malignancies is frequently advocated as the only potentially curative treatment. In recent years, advances in chemotherapy regimens and surgical techniques have led to improved oncologic outcomes and overall survival, by increasing the rates of radical (R0) resections. Vascular resections are increasingly reported to further increase disease clearance rates. Within this perspective, the issue of vascular reconstruction has raised growing interest, drawing particular attention to vascular substitutes and surgical techniques for reconstruction.Case presentationA case of extrahepatic cholangiocarcinoma with high clinical suspicion of vascular infiltration of the portal trunk at preoperative assessment is reported. An autologous interposition graft, harvested from diaphragmatic peritoneum, was chosen as a vascular substitute leading to successful portal trunk reconstruction and overcoming all possible drawbacks associated with cadaveric and artificial grafts reconstructions.ConclusionThis solution was strategic to ensure complete oncologic clearance averting the risk of positive margins (R1) at final pathology.

LAPAROSCOPIC VERSUS ROBOTIC RESECTION WITHOUT SPLENIC FLEXURE MOBILIZATION FOR RECTAL CANCER: A SINGLE-INSTITUTION EVALUATION OF OUTCOMES.

Background Splenic flexure mobilization has been considered the standard of practice in cases of low anterior resection;however,it has been observed in southern Indian state population, splenic flexure mobilization is may not be necessary for all patients of Dravidian ethnicity. Methods We evaluated the 26 patientswho underwent Laparoscopic Reconstituting Subtotal cholecystectomy during July 2019 to Jan 2022. Preoperative parameters (Age, Gender, diagnosis,location of tumor and Neoadjuvant therapy) and postoperative parameters (Duration of surgery,Hospital Stay, complications, recurrence of malignancy) were compared.Aim of the study was to evaluate the outcome of Low anterior rection without splenic flexure mobilization. Results There was no statistically significant difference in terms of intraoperative,postoperative complications and oncological outcome when splenic flexure mobilization not done.The operative time was similar in the both groups (P>0.05).The Postop complication rate was lower after robotic than after laparoscopic (9% vs. 25.5%, P=0.07). Post operative complications observed in 6 patients (23%) including wound infection, wound dehiscence, anastomotic leak and anastomotic stricture. 5 post op complications were seen in laparoscopic cases;however,this was not statistically significant.On a median 24 month follow-up,the local recurrence rates did not differ significantly between the 2 groups (5 for LAP vs. 1 for Robotic). Conclusion Resection of rectal cancers by minimally invasive approach (Lap and Robotic) without the routine use of SFM do not increase postoperative morbidity or oncologic risk in our subset of patients all of whom belong to the same Dravidian ethnicity. Compared to robotic surgery, patients with laparoscopic surgery had more postoperative complications though the oncologic clearance was comparatively similar.Hence,we suggest that Splenic flexure mobilization need not be done for patients of Dravidian ethnicity as they possess small to medium stature, genetically. This needs to be validated by larger randomized studies.

Anatomical Description of Anterior Parametrium: AProbable Answer to Pelvic Recurrence Following Radical Hysterectomy.

A prospective analysis of a retrospective data of patients with cervix carcinoma treated by minimal invasive surgery at high-volume gynecology oncology center analyzing that minimal access surgery is an acceptable treatment modality in cervix carcinoma. The study included 423 patients who underwent laparoscopic/robotic radical hysterectomy after pre-operative evaluation after taking their consent and obtaining ethical approval from the IRB. Post-operatively, patients were followed up at regular intervals for clinical examination and ultrasonography for a median range of 36months. A PET scan was done only if there was any suspicious finding on clinical examination or ultrasonography. Patients with parametrial involvement, positive vaginal margins, and nodal involvement were treated with chemotherapy/radiotherapy. Four hundred twenty-three patients of cervix carcinoma were treated with minimal access surgery. Average duration of surgeries was 92min. Median range of duration of post-operative follow-up was 36months. None of the patients had positive resection margins indicating adequate parametrectomy with complete oncological clearance. On post-operative follow-up, only 2 patients had vaginal recurrence which is comparable to that observed in open surgery and no pelvic recurrence. With the understanding of the anatomical landmarks of the anterior parametrium and development of skills for adequate oncological clearance, minimal access surgery should be the preferred surgical modality in carcinoma of the cervix.

OGC P27 A Review of Minimally Invasive Oesophagogastric Cancer Surgery in a High-Volume UK Unit

Abstract Background Oesophagogastric (OG) cancer resections are technically challenging and associated with peri-operative morbidity. Practice has evolved from open to minimally invasive surgery (MIS), with ERAS has seen peri-operative outcomes improve. OG surgeons have not transitioned to MIS at the rate of others; 2021 NOGCA results showed that 17.6% of oesophagectomies and 17% of gastrectomies were performed as MIS. Concerns regarding the technical ability to perform safe anastomoses and appropriate oncological clearance have been cited as common reasons for surgeons not transitioning to MIS. GSTT is a high-volume OG unit which has transitioned from a fully open to predominantly MIS practice. The unit has performed over 100 minimally invasive Ivor Lewis oesophagectomies and 97 laparoscopic gastrectomies, it was therefore decided to analyse the unit's peri-operative outcomes to ensure that appropriate standards were maintained during this change in practice. The primary aim of this study was to examine a decade of peri-operative outcomes for Ivor Lewis oesophagectomy and gastrectomies, comparing parallel open and MIS cohorts. The secondary aim is to perform a sequential cumulative sum control chart (CUSM) analysis of the cohort to determine whether a learning curve effect for OG MIS can be demonstrated. Methods A retrospective analysis of a prospectively maintained comprehensive local database was performed. The results were cross-checked with NOCGA data, and a notes review was performed to capture any missing data.All Ivor Lewis oesophagectomy and gastrectomy (total, extended total and subtotal) performed for adenocarcinoma, squamous cell carcinoma, neuroendocrine tumours and high grade dysplasia at Guy's and St Thomas’ NHS Foundation Trust, London, UK over a ten-year period (January 2012- December 2021) were included. MIS for oesophagectomy was defined as an Ivor Lewis oesophagectomy performed with both laparoscopic and thoracoscopic phases. A hybrid (laparoscopic abdomen and open chest phase) oesophagectomy was grouped with a two-phase open procedure to create an open cohort. Laparoscopic gastrectomy (with a laparoscopic oesophago-jejunostomy or gastro-jejunostomy for sub-total gastrectomy) was used as the definition of MIS. The cohorts were compared for: age, sex, BMI and use of neoadjuvant therapy. Temporal trends in surgical approaches were compared as were Individual surgeon (n=4) volumes. Peri-operative clinical and oncological outcomes including length of stay, anastomotic leak, return to theatre, chest complications, resection margins and lymph node harvest were all examined. A CUSM analysis is currently being completed to further analyse surgeon performance over time. Results 596 patients underwent resection in well matched cohorts, 197 patients had an oesophagectomy (100 MIO), 339 had a gastrectomy (97 laparoscopic). MIS rates increased with no operations being performed as MIS in 2012 compared to 81% of oesophagectomy and 67% of gastrectomy performed as MIS in 2021. Two surgeons performed over 170 resections with MIS rate over 40%. OR of MIS performed by a high-volume surgeon was 3.01 (p<0.001). Lower volume MIS surgeons were more likely to have two consultants present, OR 1.4 (p=0.16). Anastomotic leak rates following gastrectomy were 2% in both groups (p=0.66), 9% following open oesophagectomy and 11% after MIO (p=0.77). 10% of laparoscopic gastrectomy patients experienced a chest complication, 26% after open surgery, 22% MIO and 24% open (p=0.65). Mean length of stay was significantly reduced after MIS. An R0 rate of 96% was seen after laparoscopic gastrectomy, 90% after open (p=0.08). 68% of MIO patients had R0 resection compared to 70% after open. Positive CRM was 29% after MIO. The mean lymph node harvest was 29 after laparoscopic gastrectomy and 26 after open (p=0.24), 29 following MIO, 30 after open oesophagectomy. 97% of MIO harvested over 15 nodes. Conclusions This study demonstrates that a transition from open to MIS practice is achievable in the UK. Outcomes demonstrated similar peri-operative clinical and oncological outcomes between MIS and open surgery which addresses the concerns that prohibited the widespread uptake of MIS in UK centres. Developing a reliable surgical technique for lymphadenectomy and anastomoses that transitioned from open to hybrid and now MIS allowed for appropriate outcomes to be maintained. Unit outcomes compare well to both NOGCA/ECCG data with complication rates following MIO being significantly lower when compared to ECCG. Lymph node harvests were significantly higher in unit MIOs when compared to NOGCA (p=0.01). Volume played an important role in surgeons performing independent MIS. This should be considered when planning unit workload or a transition to MIS. It will be further explored in the CUSM analysis. A positive CRM was seen in more cases (29%) when compared to NOGCA (24%) and may be related to the preferred neoadjuvant regime being chemotherapy over chemoradiotherapy. The future of OG is moving towards robotic surgery. It is proposed that the evolution from open to MIS will make a second transition to robotics less challenging as the strategies needed to perform MIS have been addressed.

HPB P19 Our experience comparing multi-visceral and single organ excision of retroperitoneal sarcomas from a HPB centre

Abstract Background Sarcomas are a heterogenous set of soft tissue cancers with an estimated incidence of up to 5.0 cases per 100,00 worldwide. Retroperitoneal sarcomas (RPS) account for up to 20% of these. The aetiology behind the pathogenesis is not truly understood, but to date, surgery remains the only curative treatment. Owing to resistance, systemic chemotherapy only plays a role in attempts to downstage the tumour, or in the palliative setting. RPS are slow growing and owing to the lack of symptoms have variable presentation. The ability to excise RPS traditionally was limited by vascular invasion, which increases the complexity of the resection and poses uncertainty about the long-term oncological benefit. Although small, emerging case series over the last couple of decades have established the feasibility of multi-visceral resection with vascular reconstruction. Here we present our outcomes comparing multi-visceral resections with single organ resections with vascular reconstructions. Methods All patients who underwent excision of a retroperitoneal sarcoma between January 2005 and April 2021 were included in the analysis. Patients were identified from a database which was prospectively completed by the operating surgeon. Data collected included patient demographics, clinicopathologic characteristics and intra-operative variables. Endpoints included perioperative morbidity and mortality, oncological clearance status, recurrence status, and survival. Complications were graded using the Clavien-Dindo classification. All patients were discussed in a local multi-disciplinary team meeting. When aortic/iliac artery involvement was suspected on pre-operative imaging (Computer Tomography or Magnetic Resonance Imaging), patients were referred appropriately to vascular for further pre-operative discussion regarding treatment and/or conduit plans. Continuous data was presented as medians (range) and compared using ANOVA (analysis of variance). Survival probabilities were calculated using the Kaplan-Meier method and log-rank test. Normally distributed data was assessed with the Student's t-test, and skewed data with Mann-Whitney test. A two-sided p value < 0.05 was considered significant. Results From January 2005 to April 2021, 122 patients underwent 170 operations for RPS resections. 112 (68.9%) underwent a visceral resection (90 (53.0%) multi-visceral (MVR) and 22 (15.9%) single organ (SOR)). In the MVR group, 23 (25.6%) involved a synchronous vascular resection with a complete resection margin in 94.7%. In the SOR group, 6 (27.3%) underwent a synchronous vascular resection with a 96.3% complete resection margin. Multi-visceral resections included 39 nephrectomies, 33 segmental colectomies, 16 liver resections, 16 splenectomies, pancreatic resections in 19, and partial gastrectomy in 12 cases. The inferior vena cava was resected in 17 and 5 cases in the MVR and SOR group, respectively. Aortic and iliac artery resection and reconstruction with Dacron graft took place in 4 cases. Histologically, leiomyosarcomas and dedifferentiated liposarcomas were the most common subtype, accounting for 33 and 30 (36.7% and 33.3%) in the MVR group and 10 and 6 (37.0% and 22.2%) in the SOR group, respectively. Overall 5-year survival for all resections was 60%. There was no significant difference in complication rate[HM1] [AR2], length of stay, 30-day mortality (2% and 1%) or 1- (71.1% and 77.8%) or 3-year (33.3% and 25.9%) survival between the MVR and SOR groups. Conclusions RPS are prone to localised invasion as well as into surrounding viscera. Although traditionally, these patients may not have been deemed suitable for surgical intervention, our case series shows multi-visceral resections with vascular resections can be undertaken safely with no impact on overall survival. The series also highlights the need for a multi-disciplinary surgical approach to address the technical complexities of the operation. In conclusion, the need for multi-visceral resection or vascular resection and reconstruction should not deter surgical treatment, and these cases should be managed within a MDT with appropriate surgical expertise.

Mediastinal Parathyroid Cancer.

Parathyroid cancer (PC) is rare, but its pre-operative recognition is important to choose appropriate access strategies and achieve oncological clearance. This study characterizes features of mediastinal parathyroid cancer (MPC) and explores criteria aiding in the pre-operative recognition of malignancy. We assembled data from 502 patients with mediastinal parathyroid neoplasms (MPNs) from a systematic review of the literature 1968−2020 (n = 467) and our own patient cohort (n = 35). Thirty-two of the 502 MPNs (6.4%) exhibited malignancy. Only 23% of MPC patients underwent oncological surgery. Local persistence and early recurrence at a median delay of 24 months were frequent (45.8%), and associated with a 21.7-fold (95%CI 1.3−351.4; p = 0.03) higher risk of death due to disease. MPCs (n = 30) were significantly larger than cervical PC (n = 330), at 54 ± 36 mm vs. 35 ± 18 mm (χ2 = 20; p < 0.0001), and larger than mediastinal parathyroid adenomas (MPA; n = 226) at 22 ± 15 mm (χ2 = 33; p < 0.01). MPC occurred more commonly in males (60%; p < 0.01), with higher calcium (p < 0.01) and parathyroid hormone (PTH) levels (p < 0.01) than MPA. Mediastinal lesions larger than 3.0 cm and associated with a corrected calcium ≥ 3.0 mM are associated with a more than 100-fold higher odds ratio of being malignant (OR 109.2; 95%CI 1.1−346; p < 0.05). The composite 3 + 3 criterion recognized 74% of all MPC with an accuracy of 83%. Inversely, no MPN presenting with a calcium < 3.0 mM and size < 3.0 cm was malignant. When faced with pHPT in mediastinal location, consideration of the 3 + 3 rule may trigger an oncological team approach based on simple, available criteria.

The effect of thymectomy during central neck dissection in papillary thyroid carcinoma: a case-controlled study.

Central lymph-node dissection (CND) as part of total thyroidectomy is recommended in the treatment of papillary thyroid cancer. CND with thymus resection for achieving more oncological clearance is suggested in guidelines, but the benefits of this technique are still unclear due to the risk of parathyroid glands injury and postoperative hypocalcemia. The aim of this study is to evaluate the risk and benefits of thymectomy in CND with total thyroidectomy. We retrospectively reviewed the records of 188 patients with total thyroidectomy and CND. Participants were divided into 110 patients with CND and thymus resection and 78 patients with thymus preservation. Oncological completeness was evaluated by measuring the postoperative thyroglobulin and hypocalcemia as a postoperative complication was measured by blood calcium level. Based on our findings, patients who underwent thymus resection had a higher incidence of hypocalcemia compared to patients with thymus preservation (56.4% vs. 39.2%; P = 0.027), but there was no significant difference in thyroglobulin levels between these two groups. (P = 0.115 and 0.185, respectively) The proportion of involved to total resected lymph nodes in our study was 28%, which did not statistically differ among the thymus groups. Routine thymus resection during the CND and total thyroidectomy is not recommended because of more postoperative hypocalcemia occurrence and minimal oncological benefit in PTC treatment.