Palliative Surgery Research Articles

To study the survival outcomes of uncommon recurrences among patients with cervical cancer compared with loco-regional and nodal recurrences at a tertiary care center in North East India – Bridging the knowledge gap in the existing literature.

BackgroundRecurrence rates of FIGO stage IB-IIA and IIB-IVA cervical cancer 28–64 respectively. There is a scarcity of data on the recurrence recurrence pattern for unusual sites and theirrecurrence pattern for unusual sites and its association with survival and prognosis. ObjectiveTo study overall survival in patients with distant metastasis compared to local and regional nodal metastasis. MethodsA retrospective study was done from 1/1/2017 to 30/12/22. Cervical cancer patients post primary treatments were included. Survival was analyzed with respect to 3 groups local, regional nodalconducted from 1/1/2017 to 30/12/22. Cervical cancer patients who had received primary post-primary treatments were included. Survival was analyzed with respect to three groups: local, regional nodal, and distant metastasis. Results225 patients had recurrences post-completion of primary treatment, of which 105 (46.6%)(46.6 %) had local, 46 (20.4%)(20.4 %) had regional nodal, and 74 (33.3%) had distant recurrences. The median time for recurrence in local, regional nodal, and atypical recurrences were 9, 9, and 13 months (p value - <0.05), respectively. Treatment included systemic chemotherapy 122 (54.2%), metronomic therapy 19 (8.4%), palliative radiotherapy 44 (19.5%), palliative surgery 8 (3.5%) and best supportive care 30 (13.3%) patients. Median Time to treatment-death of patients after recurrence in local, nodal and distant recurrences was 17.0 months, 18.0 months and 10.0 months respectively (p value - < 0.05). Overall Survival of patients after primary treatment with local, nodal and distant recurrences was 35.0 months, 47.0 months and 50.0 months respectively (p value <0.05). ConclusionLocal recurrence is most common, followed by regional, nodal, and distant recurrences. Overall survival post recurrence was lowest for distant recurrences and highest for local recurrences however overall survival after primary treatment completion was highest for distant recurrence due to the late presen; however, tation of distant recurrences.

The Language of Palliative Surgery: A Scoping Review

BackgroundDespite an identified need for palliative surgery to have a clear definition and well-defined therapeutic goals, comprehensive assessment of the word palliative has not been performed in the surgical literature. The objective of this scoping review is to characterize use of the word palliative in reference to surgery performed for adult general surgery patients. MethodsFour electronic databases were searched for peer-reviewed articles published from January 2000 to April 2023. Two independent reviewers extracted data and conducted a qualitative thematic synthesis of included studies. Representative analytic themes were generated and agreed upon by all authors. Results6,906 studies were identified and 222 met inclusion criteria. 96.4% of studies were performed in oncology patient populations. Thematic synthesis revealed two domains: the language of palliative surgery and the evaluation of palliative surgery, each with associated themes. There was wide variability in the use and meaning of the term palliative. Many researchers reported survival as the sole outcome measure and very few studies utilized a validated instrument to quantify post-operative outcomes related to palliation. There was often a misalignment between the patient population, study objectives, study design, and conclusions drawn. ConclusionsDisparate definitions of palliative surgery and poor study design compromise the validity of studies investigating palliative-intent surgery. Patient-reported and patient-centered outcomes are not routinely measured and lead to unwarranted conclusions. Consistent and accurate use of medical terminology, in addition to proper study design, is required to inform surgeons who counsel patients and families regarding the potential benefits of palliative-intent surgical interventions.

Pediatric palliative epilepsy surgery: a report from the Pediatric Epilepsy Research Consortium (PERC) Surgery Database

Pediatric palliative epilepsy surgery: a report from the Pediatric Epilepsy Research Consortium (PERC) Surgery Database

Clinical benefits of symptom resolution after palliative surgery in advanced cancer: A single-center experience

BackgroundPalliative surgery (PS) is defined as any surgical procedure aimed at improving quality of life or relieving symptoms caused by an advanced or metastatic cancer. The involvement of patients, caregivers, and other professional figures is crucial for obtaining optimal symptom relief and avoiding complications. This study aims to evaluate the short-term outcome and related factors in patients undergoing PS. Patients and methodsA retrospective analysis was performed in consecutive patients who underwent palliative gastrointestinal surgery at our surgical unit during the period June 2018 to May 2023. Demographic, clinical, pathological and follow-up data were collected from a prospectively maintained department database. The main outcomes were complications, symptoms palliation, symptoms recurrence and return to systemic chemotherapy. Standard statistical analysis was performed. ResultsDuring the study period, 127 patients underwent palliative surgery. The Clavien-Dindo 3–5 complication rate and mortality rate were 19.7 % and 6 %, respectively. The resolution of symptoms was achieved in 109 patients (89 %). Successful symptom palliation was significantly related to the possibility of returning to systemic chemotherapy (SC) (OR 9.30 95 % CI 0.1.83–47.18, p 0.007). The only factor related to survival in multivariate analysis was the return to systemic chemotherapy (HR 0.25 95 % CI 0.15–0.42 0.001). ConclusionPS in selected patients is effective for symptom resolution and improving overall survival, if the result is making anticancer therapy possible. Prospective data collection is in any case warranted in every institution performing PS for the purpose of monitoring appropriateness and quality of surgical care.

Results of patient survival after surgical interventions for complicated forms of colon cancer performed in general surgical hospitals

The aim of the study: to evaluate the 1- and 3-year survival of patients operated for complicated forms of colon cancer (СC) in general surgical hospital. Materials and methods. The study group included 71 (100 %) patients with complicated forms of СС. Acute intestinal obstruction was detected in 49 (69.1 %) patients, tumor perforation – in 13 (18.3 %), acute colonic bleeding – in 3 (4.2 %) patients, a combination of acute intestinal obstruction with tumor perforation – in 4 (5.6 %) and intestinal obstruction with bleeding – in 2 (2.8 %) operated patients. Radical operations were performed in 48 (67.6 %) patients, palliative operations – in 18 (25.4 %), symptomatic operations – in 5 (7.0 %) patients. II stage of the disease was diagnosed in 15 (21.1 %), III stage – in 32 (45.1 %), IV stage – in 24 (33.8 %) operated patients. 19 (30.2 %) patients underwent specific chemotherapy after surgery. Results. Among patients with the II stage of the oncological process 1-year survival was 76.9 ± 11.7 %, 3-year – 53.8 ± 13.8 %; with stage III, 1-year survival was 65.6 ± 8.4 %, 3-year – 50.0 ± 8.8 %; in persons with IV stage of СC – 29.2 ± 9.3 % and 8.3 ± 2.6 % respectively (χ2 = 21.8, p = 0.0001). Among male patients, 1-year survival was 51.4 ± 8.5 %, 3-year – 31.4 ± 7.9 %; women – 61.1 ± 8.1 % and 44.4 ± 8.3 %, respectively (χ2 = 2.3, p = 0.1302). Better indicators were found in the case of cancer of the left sections of the large intestine than the right sections – the 1-year survival rate was 60.4 ± 7.1 % and 43.5 ± 10.3 % respectively; 3-year – 39.6 ± 7.1 % and 30.4 ± 9.6 % (χ2 = 0.74, p = 0.3906). Conclusions. The conducted analysis indicates a clear dependence of the survival results on the stage of the disease, gender and localization of the tumor process.

Determining a multidisciplinary intraoperative strategy in emergency surgery for bowel obstruction and its impact on outcomes.

Bowel obstruction accounts for around 50% of all emergency laparotomies. A multidisciplinary (MDT) standardized intraoperative model was applied (definitive, palliative, or damage control surgery) to identify patients suitable for a one-step, definitive surgical procedure favoring anastomosis over stoma, when undergoing surgery for bowel obstruction. The objective was to present mortality according to the strategy applied and to compare the rate of laparoscopic interventions and stoma creations to a historic cohort in surgery for bowel obstruction. In a retrospective cohort study, we included patients undergoing emergency surgery for bowel obstruction during a 1-year period at two Copenhagen University Hospitals (2019 and 2021). The MDT model consisted of a 30- and 60-min time-out with variables such as functional and hemodynamic status, presence of malignancy, and surgical capabilities (lap/open). Pre-, intra-, and postoperative data were collected to investigate associations to postoperative complications and mortality. Stoma creation rates and laparoscopies were compared to a historic cohort (2009-2013). Three hundred sixty-nine patients underwent surgery for bowel obstruction. Intraoperative surgical strategy was definitive in 77.0%, palliative in 22.5%, and damage control surgery in 0.5%. Thirty-day mortality was significantly lower in the definitive patient population (4.6%) compared to the palliative population (21.7%) (p < 0.000). Compared to the historic cohort, laparoscopic surgery for bowel obstruction increased from 5.0 to 26.4% during the 10-year time span, the rate of stoma placements was reduced from 12.0 to 6.1%, p 0.014, and the 30-day mortality decreased from 12.9 to 4.6%, p < 0.000. An intraoperative improvement strategy can address the specific surgical interventions in patients undergoing surgery for bowel obstruction, favoring anastomosis over stoma whenever resection was needed, and help adjust specific postoperative interventions and care pathways in cases of palliative need.

Posterior-only 2-level vertebrectomy and fusion in a medically complex patient with lumbar metastasis: illustrative case.

Spinal metastases are commonly seen in patients with cancer and often indicate a poor prognosis. Treatment can include curative or palliative surgery, chemotherapy, and radiation therapy. The surgical approach varies widely on the basis of the affected region of the spine, the location of the tumor (anterior versus posterior), the goal of surgery, the health of the patient, and surgeon preference. The authors present a case of a 68-year-old male with intractable lower-back pain and substantially diminished ambulation. Diagnostic imaging revealed a lumbar metastasis from a cholangiocarcinoma primary at L2-3 (4.5 cm anteroposterior × 5.7 cm transverse × 7.0 cm craniocaudal). The patient underwent a 2-level vertebrectomy with expandable cage placement and T10 to S2 fusion via a posterior-only approach. The patient regained much of his mobility and quality of life after the surgery. Although this was a high-risk surgery, the authors show that a posterior-only approach can be used for lumbar vertebrectomies and fusion when necessary. Palliative surgeries carrying a high risk, especially in the setting of a limited prognosis, should include multidisciplinary deliberations and a thorough discussion of the risks and outcome expectations with the patient.

Increased Survival and Symptom Relief Following Palliative Cerebrospinal Fluid Diversion for Neoplastic Leptomeningeal Disease: A Case Series and Systematic Review

INTRODUCTION: Leptomeningeal disease (LMD) indicates widespread or advanced cancer and can lead to symptomatic hydrocephalus, for which palliative cerebrospinal fluid (CSF) diversion may be indicated. METHODS: We analyzed survival and symptom relief outcomes from a 10-year period at a single institution of patients with LMD secondary to cancer, symptoms of obstructive hydrocephalus, and documented date of death. We also searched PubMed, Embase, and Web of Science from database inception until 8/20/2022, using search terms including ‘cancer’, ‘hydrocephalus’, and ‘shunt’. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. RESULTS: In our series of 50 patients, 30 (60%) underwent CSF diversion surgery after LMD diagnosis with comparable median age in both surgery (58.4 ± 14.4 years) and non-surgery (57.8 ± 14.5 years) groups. Twenty-three patients (76.7%) achieved symptom relief. The surgery group lived longer after LMD diagnosis than patients in the non-surgery group (6.6 ± 6.0 vs. 1.3 ± 4.3 months, p &lt; 0.001) and had higher likelihood of survival (hazard ratio 2.49, 95% confidence interval 1.37-4.52, p = 0.002). Median survival after surgery was 2.8 ± 3.8 months. Out of 23 articles reporting outcomes for 2895 patients, 995 (34.3%) presented with LMD. Postoperative complication rates were 0-37.7% with no cases of extraneural metastases. Symptom relief rates were 50-100%. Three studies reported median survival after surgery for LMD (2-3.3 months). CONCLUSIONS: A rare entity with dismal prognosis, LMD can present as symptomatic hydrocephalus in patients with cancer. Symptom relief can be achieved with palliative surgery for permanent CSF diversion with relatively low complication rates. Prospective studies are needed to further assess outcomes and needs of this patient population.

Early outcome of palliative limb salvage surgery in patient with right proximal humerus osteosarcoma Enneking III at Dr. Soetomo Academic General Hospital: A case report

Introduction: Osteosarcoma is a type of bone cancer that commonly affects the long bones, including the proximal humerus. This case report aims to investigate the clinical outcomes of patients with osteosarcoma of the proximal humerus enneking III. Follow-up assessments were conducted to evaluate post-operative outcomes. Case Presentation: This was a case report of a 33-year-old man who came to an outpatient clinic referred from another island with a chief complaint huge lump in his right shoulder 6 years ago. The patient got several examinations and was diagnosed with osteosarcoma of proximal humerus enneking III accompanied by lung metastases. From the Clinical Pathological Conference (CPC) patient decided to do neoadjuvant chemotherapy followed by restaging and amputation, but the patient refused amputation. Since it was found that the neurovasculature was not encased, limb salvage palliative surgery was performed, in the form of wide resection surgery, reconstruction with bone cement and spacers, and also shoulder reconstruction with prolene mesh, then followed by adjuvant chemotherapy. Follow-up 15 months post-op showed there were no recurrences, stable lung metastases, and improvement in complications, Musculoskeletal Tumor Society (MSTS) score 26 out of 30 and Disabilities of the Arm, Shoulder and Hand (DASH) scores 37.9 out of 100. Conclusion: In this case, the decision to undergo palliative limb salvage surgery is not an ordinary decision. Even though the outcome is not good, the patient is satisfied with the results, and with routine physiotherapy, we can assess the improvement and progressivity of the results of the operation.

[Comparison of the efficacy of different surgical strategies in the treatment of patients with initially resectable gastric cancer liver metastases].

Objective: To examine the impact of varied surgical treatment strategies on the prognosis of patients with initial resectable gastric cancer liver metastases (IR-GCLM). Methods: This is a retrospective cohort study. Employing a retrospective cohort design, the study selected clinicopathological data from the national multi-center retrospective cohort study database, focusing on 282 patients with IR-GCLM who underwent surgical intervention between January 2010 and December 2019. There were 231 males and 51 males, aging (M(IQR)) 61 (14) years (range: 27 to 80 years). These patients were stratified into radical and palliative treatment groups based on treatment decisions. Survival curves were generated using the Kaplan-Meier method and distinctions in survival rates were assessed using the Log-rank test. The Cox risk regression model evaluated HR for various factors, controlling for confounders through multivariate analysis to comprehensively evaluate the influence of surgery on the prognosis of IR-GCLM patients. A restricted cubic spline Cox proportional hazard model assessed and delineated intricate associations between measured variables and prognosis. At the same time, the X-tile served as an auxiliary tool to identify critical thresholds in the survival analysis for IR-GCLM patients. Subgroup analysis was then conducted to identify potential beneficiary populations in different surgical treatments. Results: (1) The radical group comprised 118 patients, all undergoing R0 resection or local physical therapy of primary and metastatic lesions. The palliative group comprised 164 patients, with 52 cases undergoing palliative resections for gastric primary tumors and liver metastases, 56 cases undergoing radical resections for gastric primary tumors only, 45 cases undergoing palliative resections for gastric primary tumors, and 11 cases receiving palliative treatments for liver metastases. A statistically significant distinction was observed between the groups regarding the site and the number of liver metastases (both P<0.05). (2) The median overall survival (OS) of the 282 patients was 22.7 months (95%CI: 17.8 to 27.6 months), with 1-year and 3-year OS rates were 65.4% and 35.6%, respectively. The 1-year OS rates for patients in the radical surgical group and palliative surgical group were 68.3% and 63.1%, while the corresponding 3-year OS rates were 42.2% and 29.9%, respectively. A comparison of OS between the two groups showed no statistically significant difference (P=0.254). Further analysis indicated that patients undergoing palliative gastric cancer resection alone had a significantly worse prognosis compared to other surgical options (HR=1.98, 95%CI: 1.21 to 3.24, P=0.006). (3) The size of the primary gastric tumor significantly influenced the patients' prognosis (HR=2.01, 95%CI: 1.45 to 2.79, P<0.01), with HR showing a progressively increasing trend as tumor size increased. (4) Subgroup analysis indicates that radical treatment may be more effective compared to palliative treatment in the following specific cases: well/moderately differentiated tumors (HR=2.84, 95%CI 1.49 to 5.41, P=0.001), and patients with liver metastases located in the left lobe of the liver (HR=2.06, 95%CI 1.19 to 3.57, P=0.010). Conclusions: In patients with IR-GCLM, radical surgery did not produce a significant improvement in the overall prognosis compared to palliative surgery. However, within specific patient subgroups (well/moderately differentiated tumors, and patients with liver metastases located in the left lobe of the liver), radical treatment can significantly improve prognosis compared to palliative approaches.

Study on the optimal elastic modulus of flexible blades for right heart assist device supporting patients with single-ventricle physiologies.

Patients with single-ventricle physiologies continue to experience insufficient circulatory power after undergoing palliative surgeries. This paper proposed a right heart assist device equipped with flexible blades to provide circulatory assistance for these patients. The optimal elastic modulus of the flexible blades was investigated through numerical simulation. A one-way fluid-structure interaction (FSI) simulation was employed to study the deformation of flexible blades during rotation and its impact on device performance. The process began with a computational fluid dynamics (CFD) simulation to calculate the blood pressure rise and the pressure on the blades' surface. Subsequently, these pressure data were exported for finite element analysis (FEA) to compute the deformation of the blades. The fluid domain was then recreated based on the deformed blades' shape. Iterative CFD and FEA simulations were performed until both the blood pressure rise and the blades' shape stabilized. The blood pressure rise, hemolysis risk, and thrombosis risk corresponding to blades with different elastic moduli were exhaustively evaluated to determine the optimal elastic modulus. Except for the case at 8,000 rpm with a blade elastic modulus of 40 MPa, the pressure rise associated with flexible blades within the studied range (rotational speeds of 4,000 rpm and 8,000 rpm, elastic modulus between 10 MPa and 200 MPa) was lower than that of rigid blades. It was observed that the pressure rise corresponding to flexible blades increased as the elastic modulus increased. Additionally, no significant difference was found in the hemolysis risk and thrombus risk between flexible blades of various elastic moduli and rigid blades. Except for one specific case, deformation of the flexible blades within the studied range led to a decrease in the impeller's functionality. Notably, rotational speed had a more significant impact on hemolysis risk and thrombus risk compared to blade deformation. After a comprehensive analysis of blade compressibility, blood pressure rise, hemolysis risk, and thrombus risk, the optimal elastic modulus for the flexible blades was determined to be between 40 MPa and 50 MPa.

Abstract 2759: Transcriptional intra-tumoral heterogeneity of putative therapeutic targets in colorectal cancer peritoneal metastases

Abstract Background: The poor prognosis of peritoneal metastasis (PM) in colorectal cancer (CRC) is typically attributed to, and characterized by, resistance to systemic chemotherapy and immunotherapy. The evolutionarily conserved plasma-peritoneal barrier as well as reduced tumor tissue vascularity contributes to poorer responses to systemically administered antineoplastic therapy. Beyond these, we sought to understand transcriptomic variations of important therapeutic targets implicated in peritoneal organotropism and by extension, resistance to systemic regimens in CRC PM. Methodology: FFPE tissue samples from CRC patients were collected during oncological surgical resection of the synchronous PM (cytoreductive surgery [CRS] with or without hyperthermic intra-peritoneal chemotherapy [HIPEC]), or exploratory laparotomy for palliative surgery, with the majority of patients receiving systemic therapy prior to surgery. Samples were sequenced with whole transcriptomic sequencing. Paired and unpaired T-tests between PT and PM samples were undertaken with log2(fragments per kilobase of exon per million mapped [FPKM]) gene expression values. Results: Fifty-six (22 primary tumor [PT], 34 peritoneal metastases [PM]) samples from 35 patients, comprising 21 paired PT-PM samples, were included in this analysis. TEAD1 (unpaired T-test, p=0.087; paired T-test, p=0.041), FGFR1 (unpaired T-test, p=0.003; paired T-test, p&amp;lt;0.001), PIK3CA (unpaired T-test, p=0.034; paired T-test, p=0.003), SMAD4 (unpaired T-test, p=0.095; paired T-test, p=0.010), and HAVCR2 (unpaired T-test, p=0.009; paired T-test, p=0.007) were found to be upregulated in the PM. Conversely, MET was found to be downregulated in PM samples (unpaired T-test, p=0.004; paired T-test, p=0.002). There were no significant differences in gene expression profiles of BRAF, RHOA, CD274, CTLA4, PDCD1 and TIGIT between PT-PM (all p&amp;gt;0.05). Conclusion: Through CRC PT-PM comparisons, we identify potential therapeutic targets implicated in transcoelomic metastasis and provide rationale for development of immunotherapeutic biology and drug discovery for CRC PM. These findings underscore an exigent need to develop intra-peritoneal therapeutic strategies to overcome resistance to systemic regimens. Citation Format: Joseph J. Zhao, Johnny CA Ong, Daryl Kai Ann Chia, Melissa Ching Ching Teo, Qiu Xuan Tan, Gillian Ng, Joey Wee-Shan Tan, Haoran Ma, Xuewen Ong, Su Ting Tay, Patrick Tan, Raghav Sundar. Transcriptional intra-tumoral heterogeneity of putative therapeutic targets in colorectal cancer peritoneal metastases [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2759.

Prognostic factors for surgical site infection in patients with spinal metastases and following surgical treatment.

There were few articles reviewed prognostic factors of surgical site infection (SSI) in patients with spinal metastases following surgery. The purpose of the present study was to systematically: (1) investigate the incidence rates of SSI following spinal metastases surgery; (2) identify the factors which were independently associated with postoperative wound infection. One hundred sixty-seven consecutive adult patients with spinal metastases and underwent surgical treatment were retrospectively enrolled from January 2011 to February 2022. Demographic data, disease and operation-related indicators were extracted and analyzed. Univariate and multivariate logistic analysis model were performed respectively to determine independent risk factors of SSI. 17 cases infection were collected in this study. The overall incidence of SSI after surgery of spinal metastases patients was 10.2%. Univariate regression analysis showed that age (P = .028), preoperative ALB level (P = .024), operation time (P = .041), intraoperative blood loss (P = .030), Karnofsky Performance Status score (P = .000), body mass index (P = .013), American Society of Anesthesiologists > 2 (P = .010), Tobacco consumption (P = .035), and number of spinal levels involved in surgical procedure (P = .007) were associated with wound infection. Finally, the multivariate logistic model demonstrated that body mass index (P = .043; OR = 1.038), preoperative ALB level (P = .018; OR = 1.124), and number of spinal levels (P = .003; OR = 1.753) were associated with SSI occurrence. Surgery on multiple vertebral levels for spinal metastases significantly increases the risk of SSI and weight management, nutritional support and palliative surgery have the positive significance in reducing wound complications. Orthopedist should focus on identifying such high-risk patients and decrease the incidence of wound infection by formulating comprehensive and multi-disciplinary care strategy.

Fontan-Associated Liver Disease: A Review.

Fontan-associated liver disease (FALD) is a chronic complication of the Fontan procedure, a palliative surgery for patients with congenital heart disease that results in a single-ventricle circulation. The success of the Fontan procedure has led to a growing population of post-Fontan patients living well into adulthood. For this population, FALD is a major cause of morbidity and mortality. It encompasses a spectrum of hepatic abnormalities, ranging from mild fibrosis to cirrhosis and hepatocellular carcinoma. The pathophysiology of FALD is multifactorial, involving hemodynamic and inflammatory factors. The diagnosis and monitoring of FALD present many challenges. Conventional noninvasive tests that use liver stiffness as a surrogate marker of fibrosis are unreliable in FALD, where liver stiffness is also a result of congestion due to the Fontan circulation. Even invasive tissue sampling is inconsistent due to the patchy distribution of fibrosis. FALD is also associated with both benign and malignant liver lesions, which may exhibit similar imaging features. There is therefore a need for validated diagnostic and surveillance protocols to address these challenges. The definitive treatment of end-stage FALD is also a subject of controversy. Both isolated heart transplantation and combined heart-liver transplantation have been employed, with the latter becoming increasingly preferred in the US. This article reviews the current literature on the epidemiology, pathophysiology, diagnosis, and management of FALD, and highlights knowledge gaps that require further research.

The changing landscape of palliative epilepsy surgery for Lennox Gastaut Syndrome.

Lennox Gastaut Syndrome (LGS) is characterized by drug-resistant epilepsy that typically leads to decreased quality of life and deleterious neurodevelopmental comorbidities from medically refractory seizures. In recent years there has been a dramatic increase in the development and availability of novel treatment strategies for Lennox Gastaut Syndrome patient to improve seizure. Recent advances in neuromodulation and minimally invasive magnetic resonance guided laser interstitial thermal therapy (MRgLITT) have paved the way for new treatments strategies including deep brain stimulation (DBS), responsive neurostimulation (RNS), and MRgLITT corpus callosum ablation. These new strategies offer hope for children with drug-resistant generalized epilepsies, but important questions remain about the safety and effectiveness of these new approaches. In this review, we describe the opportunities presented by these new strategies and how each treatment strategy is currently being employed. Next, we will critically assess available evidence for these new approaches compared to traditional palliative epilepsy surgery approaches, such as vagus nerve stimulation (VNS) and open microsurgical corpus callosotomy (CC). Finally, we will describe future directions that would help define which of the available strategies should be employed and when.

Local Excision Versus Radical Resection for Grade 2 Rectal Neuroendocrine Tumors: A Multicenter Propensity Score-Matched Analysis.

Studies on the grade 2 rectal neuroendocrine tumors are limited and the optimal treatment for these tumors is not well established. To compare the oncologic results of local excision versus radical resection for the treatment of grade 2 rectal neuroendocrine tumors. Retrospective multicenter propensity score-matched study to minimize heterogeneity between groups and focus on the difference between surgery strategies. Seventeen Chinese large-scale medical centers participated in this study. A total of 144 patients with pathologically confirmed grade 2 rectal neuroendocrine tumors were retrospectively analyzed. Cancer-specific survival and relapse-free survival were assessed to compare surgery strategies. A total of 144 patients with grade 2 rectal neuroendocrine tumors were enrolled in this study. Twenty-seven patients underwent endoscopic resection, 55 underwent transanal excision, 50 underwent radical resection, and 12 underwent palliative surgery or biopsy for distant metastasis. Of the 50 patients who underwent radical resection, 30 (60.0%) had clinically positive lymph nodes based on the histopathology results. The optimal cutoff value for tumor size to predict cancer-specific survival was 1.5 cm. In patients with grade 2 rectal neuroendocrine tumors ≤ 1.5 cm, there were no significant differences in cancer-specific survival and relapse-free survival between local excision and radical resection groups (P >0.05). In patients with grade 2 rectal neuroendocrine tumors > 1.5 cm, relapse-free survival was significantly lower in the local excision group than in the radical resection group (P = 0.04). The nature of retrospective review and relatively short follow-up period are limitations of this study. Grade 2 rectal neuroendocrine tumors have a nonnegligible rate of lymph node metastasis. Local excision is a feasible choice for tumors ≤ 1.5 cm without metastasis, while radical resection is more beneficial in those > 1.5 cm. See Video Abstract.

Perioperative outcomes after open biliary bypass for malignant biliary obstruction (MBO) in resource-limited setups; a multicenter prospective cohort study, 2023

IntroductionObstructive jaundice is the most common symptom of malignant diseases of the extrahepatic biliary system and necessitates either non-operative or operative biliary bypass. Because of percutaneous and endoscopic approaches, the use of palliative surgical procedures has decreased in recent years. However, in resource-limited situations, open biliary bypasses remain a viable option. This study aimed to identify factors associated with adverse perioperative outcomes following open biliary bypass. MethodsFrom June 2022 to May 2023, 69 patients underwent open biliary bypass for malignant biliary obstruction. Postoperative morbidity and mortality within 30 days of surgery were assessed. A Kaplan-Meier was used for categorical variables, and a log-rank test was used to determine the statistically significant difference between variables. A Cox regression analysis was conducted to identify factors associated to time to develop complications. ResultsThe hazard of developing complications among those with preoperative cholangitis was 2.49 times higher than those without preoperative cholangitis (HR 2.49, 95% CI [1.06, 5.84]). For every hour increment in the length of surgery, the hazard of getting complications increased by 2.47 times (HR 2.47, 95% CI [1.28, 4.77]). As serum bilirubin increased by 1 mg/dl, the hazard of developing complications increased by 14% (HR 1.14, 95% CI [1.03, 1.17]). ConclusionPatients who had long operation times, preoperative cholangitis, and elevated total bilirubin levels are at increased risk for poor perioperative outcomes. Clinicians may use these results to optimize these patients to decrease their elevated risk of serious morbidity and mortality.

Palliative surgery: state of the science and future directions.

Palliative surgical procedures are operations that aim to alleviate symptoms in a patient with serious, life-limiting illness. They are common, particularly within the field of surgical oncology. However, few high-quality studies have attempted to measure the durability of improvements in symptoms and quality of life after palliative surgery. Furthermore, many of the studies that do exist are outdated and employ highly inconsistent definitions of palliative surgery. Consequently, the paucity of robust and reliable evidence on the benefits, risks, and trade-offs of palliative surgery hampers clinical decision-making for patients and their surgeons. The evidence for palliative surgery suggests that, with effective communication about goals of care and careful patient selection, palliative surgery can provide symptomatic relief and reduce healthcare burdens for certain seriously ill patients.

Quantification of ventricular stress in univentricular hearts during early childhood using age-independent zlog-NT-proBNP

BackgroundChildren with univentricular hearts (UVH) undergo up to three palliative surgical procedures to achieve complete circulatory separation (Fontan circulation). As a marker of cardiac wall stress, NT-proBNP is a promising tool to assess systemic ventricular load in these patients. However, different reference intervals (RI) apply to each stage, as NT-proBNP is highly age-dependent. MethodsChildren undergoing systemic-to-pulmonary (SP) shunt placement (stage 1), bidirectional cavopulmonary shunt (BCPS, stage 2) or total cavopulmonary connection (TCPC, stage 3) between 2011 and 2021 with NT-proBNP measurement within 7 days before surgery were included. Furthermore, outpatients after TCPC with NT-proBNP measurement were enrolled. Biomarker levels were evaluated using its age-adjusted z-score (“zlog-NT-proBNP”; age-independent RI, −1.96 to +1.96), allowing comparison between different stages and revealing changes in systemic ventricular load independent of the marked physiological decline in RI with age. ResultsOverall, 289 children (227 before, 62 after TCPC) met the eligibility criteria. Median time between blood sampling and surgery (SP shunt/BCPS/TCPC) was 2 [1–3] days and 3.2 [2.0–4.5] years after TCPC. Age-adjusted zlog-NT-proBNP levels were 3.47 [2.79–3.93] in children with native UVH (before SP shunt), 3.10 [1.89–3.58] at stage 1 (before BCPS), 1.08 [0.51–1.88] at stage 2 (before TCPC), and 1.09 [0.72–1.75] at stage 3 (after TCPC/Fontan completion). Consequently, BCPS revealed the strongest decrease (median − 2.02 logarithmized standard deviations, p < 0.001). ConclusionsIn children with UVH undergoing staged Fontan palliation, zlog-NT-proBNP is a highly promising tool for course assessment of systemic ventricular load, independent of the age-related decline in physiological NT-proBNP concentration.

Assessment of the Surgical Oncology Case Volume Within the Public Sector in Tanzania.

Surgery provides vital services to diagnose, treat, and palliate patients suffering from malignancies. However, despite its importance, there is little information on the delivery of surgical oncology services in Tanzania. Operative logbooks were reviewed at all national referral hospitals that offer surgery, all zonal referral hospitals in Mainland Tanganyika and Zanzibar, and a convenience sampling of regional referral hospitals in 2022. Cancer cases were identified by postoperative diagnosis and deidentified data were abstracted for each cancer surgery. The proportion of the procedures conducted for patients with cancer and the total number of cancer surgeries done within the public sector were calculated and compared with a previously published estimate of the surgical oncology need for the country. In total, 69,195 operations were reviewed at 10 hospitals, including two national referral hospitals, five zonal referral hospitals, and three regional referral hospitals. Of the cases reviewed, 4,248 (6.1%) were for the treatment of cancer. We estimate that 4,938 cancer surgeries occurred in the public sector in Tanzania accounting for operations conducted at hospitals not included in our study. Prostate, breast, head and neck, esophageal, and bladder cancers were the five most common diagnoses. Although 387 (83%) of all breast cancer procedures were done with curative intent, 506 (87%) of patients with prostate and 273 (81%) of patients with esophageal cancer underwent palliative surgery. In this comprehensive assessment of surgical oncology service delivery in Tanzania, we identified 4,248 cancer surgeries and estimate that 4,938 likely occurred in 2022. This represents only 25% of the estimated 19,726 cancer surgeries that are annually needed in Tanzania. These results highlight the need to identify strategies for increasing surgical oncology capacity in the country.