Synchronous Resection Research Articles

Synchronous resection of primary colorectal cancer with liver metastases: two birds with one stone?

About one in every five patients with colorectal cancer presents with liver metastases at the time of diagnosis1. Logically, the mode of presentation drives the sequence of intervention. In patients with an urgent presentation and complications from the primary tumour, the management of intestinal obstruction, perforation or bleeding dictates treatment. Even if the acute episode is managed non-surgically, for example with use of a colonic stent for obstruction, the likelihood of advanced T category or node positivity of the primary tumour suggests that systemic chemotherapy should be the preferred treatment after resolution of the urgent issue2. Contrast-enhanced MRI of the liver and contrast-enhanced CT of the thorax after treatment of the emergency situation should be considered to document the extent of disease at baseline and before commencement of systemic chemotherapy. Patients with colorectal cancer and synchronous liver metastases may also present with either an asymptomatic or minimally/moderately symptomatic primary tumour. Should staging show metastases in more than one organ (in the context of liver metastases, this typically represents additional lung metastases), both North American and European oncology guidelines2,3 advocate systemic chemotherapy as first-line treatment. Thus, it is in the subset of patients with colorectal cancer and synchronous liver-limited metastatic disease with an asymptomatic presentation that synchronous surgery (resection of primary and liver metastases at a single operative procedure) is an option. In this setting, the practical management question of how to select patients for synchronous rather than staged surgery (resection of bowel tumour followed by hepatic resection) is an active issue (Fig. 1).

Spatially resolved transcriptomics deconvolutes histological prognostic subgroups in patients with colorectal cancer and synchronous liver metastases.

165 Background: Up to 50% of patients with Colorectal Cancer (CRC) will metastasise to the liver (CRLM). KRAS-mt liver metastases particularly when co-mutated with TP53 are associated with poor prognosis. We have used the Glasgow Microenvironment Score (GMS), a histological score performed on H+E slides utilising immune and stromal components of the microenvironment to robustly stratify outcome in primary CRC. The aim of the current study was firstly to determine the utility of GMS in metastatic CRC and secondly to employ the NanostringTM GeoMx Digital Spatial Profiler (DSP), a state-of-the art analysis platform enabling spatial transcriptomic characterisation while maintaining tumour microenvironment (TME) topographical features, to interrogate the functional biology underlying the GMS. Methods: FFPE specimens from primary and metastatic lesions from 44 patients undergoing synchronous resection of CRLM underwent GMS, IHC and panel genomic assessment. Primary endpoints were recurrence-free survival (RFS) and cancer-specific survival (CSS). In addition to bulk transcriptomic assessment, 4 matched pairs from the cohort were selected for GeoMx analysis: 2 samples were GMS0 (high-immune) and 2 were GMS1 (low-immune) with an equal distribution of KRASmt and wt. After multiplex IF staining (PanCK, CD45, DAPI, αSMA), 48 regions of interest were selected and Cancer Transcriptome Atlas Transcriptomic outputs (2000 genes) were analysed using Pathway enrichment analysis with immune deconvolution of the transcriptome performed. Results: GMS0 (high-immune) was associated with improved RFS (p=0.0048) and CSS (p=0.0012) remaining an independent predictor of survival on multivariate analysis (HR 2.90, 95% C.I 1.18-7.16 P=0.021). GMS0 lesions were enriched for adaptive immune (NES=2.20 p.adj<0.0005) and IL-10 (NES=1.9 p.adj<0.0005) pathways specifically at the invasive edge. In contrast, a poor prognostic KRAS/TP53 lesion demonstrated profound immunosuppression, upregulated NOTCH signalling (NES=2.13 p.adj<0.0005) and neutrophil degranulation (NES=1.99 p.adj<0.0005). Topographical Immune-cell deconvolution demonstrated significantly higher populations of CD4 (p=0.05) and CD8 (p=0.0003) cells in GMS0 leading edges. Conclusions: We have demonstrated that spatial transcriptomic analysis using the Nanostring GeoMx tool can reveal potential novel mechanisms underlying biologically relevant histological and mutational subgroups (KRAS-mt) of CRC, providing potential therapeutic targets requiring further investigation. Future studies will apply this technology to pre and post treatment biopsy samples.

Adjuvant Hepatic Arterial Infusion Pump Chemotherapy after Resection of Colorectal Liver Metastases; Surgical Complications, Toxicity, and Survival in a Prospective Study in the Netherlands

Background: Hepatic arterial infusion pump (HAIP) chemotherapy remains a promising treatment for patients with colorectal liver metastases (CRLM). The aim of this study was to investigate surgical complications, toxicity, and survival outcomes of patients who received adjuvant HAIP chemotherapy for CRLM. Methods: A single arm phase II study was performed in four centers. Patients with resectable CRLM without extrahepatic disease were eligible. An infusion pump was implanted after complete local treatment of CRLM followed by a maximum of 6 cycles of HAIP chemotherapy with floxuridine. Outcomes were 90 days pump-related major complications (Clavien Dindo grade ≥III), intra-arterial chemotherapy-related severe toxicity (CTCAE grade ≥III), and overall survival (OS). Results: Twenty-nine patients were included. Four patients (11.8%) had pump-related major complications, all requiring pump replacement; one for pump dysfunction, two for pump dislocation, and one for pump pocket infection. All patients started with HAIP chemotherapy. The median number of cycles was 5 (IQR 4-6), and the median cumulative dosage was 72% (IQR 55-85%). Ten patients (34%) required intra-arterial steroid treatment for biliary toxicity. Seven patients (24%) developed severe toxicity; five patients required stent-placement (three for biliary sclerosis/hyperbilirubinemia, two for persistent increase in liver enzymes without hyperbilirubinemia), one patient developed hepatic artery thrombosis, one patient required endoscopic extraction of an intrahepatic gallstone. Two-year OS was 93% (95%CI: 85-100%). Conclusion: Adjuvant HAIP chemotherapy for CRLM may result in major complications and severe toxicity; 1 in 7 patients required pump replacement and 1 in 6 patients required stent-placement for biliary sclerosis. Two-year OS was 93%.Tabled 1Patient and surgical characteristicsMedian [IQR] / n (%)Age at resection (years)57 [50-64]Clinical Risk Score (Fong score)2 [1-3]Preoperative systemic CTx9 (30)Major hepatectomy6 (21)Synchronous resection with primary CRC3 (10)Open ablation (with or without resection)11 (45)Surgery time (min)247 [204-300]Blood loss (mL)455 [187-762]Postoperative hospital stay (days)8 (6-9) Open table in a new tab

Cumulative Operative Time and Postoperative Complication Risk in Synchronous Resections of Colorectal Liver Metastases and Primary Tumors

Introduction: Synchronous resection of colorectal liver metastases (CLM) and primary colorectal cancers (CRC) is complex due to inherent complication rates. We investigated perioperative factors associated with morbidity after synchronous resection.

SP6.1.9 Colorectal Cancer and Synchronous Liver-limited Metastatic Disease: The final results of the CoSMIC Inception Cohort Study

Abstract Aims Currently, evidence is inadequate to inform the selection of optimal treatment for patients with colorectal cancer and synchronous liver-limited hepatic metastases. Options include synchronous or staged surgery integrated with systemic chemotherapy. CoSMIC is the first inception cohort study to follow patients from point of presentation in order to identify factors influencing treatment and outcome. Methods Patients were identified at presentation to the regional liver metastases MDT at Manchester Royal Infirmary between April 2015-2018. Data were collected on demographics, intervention and outcome. The study was approved by Regional Ethics Committee (REC reference: 14/NW/1397). Results Of 125 patients recruited, 109 underwent surgery with 18 (17%) liver-first, 75 (69%) bowel-first and 16 (14%) undergoing synchronous resection. There were no differences in baseline demographics or co-morbidity. Eighty-eight completed the intended surgical pathway, with highest failure in liver-first patients where 39% did not proceed to subsequent bowel resection. Critical care occupancy between staged and synchronous resections (5.6 versus 5.2 days; P = 0.92), and inpatient stay (16.5 versus 16.8 days; P = 0.92) was not significant. There was no 30-day mortality. Cox regression analysis identified surgical sequence as a significant covariate (Х2= 31.3; P < 0.001). Survival was similar between surgical groups (Log-rank test; P = 0.87). Conclusions CoSMIC is the first prospective inception cohort study of colorectal cancer and synchronous liver-limited metastasis. The study population is small and from a single centre and thus could be influenced by recruitment and sample bias. However, the important novel finding is that there is no survival difference between treatment pathways.

TP6.1.5 The Importance of the Patient Voice in Metastatic Colorectal Cancer: A Qualitative Study

Abstract Aims Colorectal cancer is the fourth commonest cancer in the UK with a third presenting with synchronous liver metastases. Although there is a large body of clinical cohort data, there is no research exploring patient perspectives of disease. This qualitative phenomenological study explores the lived experiences of patients following treatment for synchronous disease. Methods Qualitative interviews used pre-prepared prompts encouraging open dialogue and were transcribed for thematic analysis. Results Four major themes emerged. (1) Experience of Cancer The initial diagnosis was recalled in vivid detail, with delays perceived negatively particularly if clinicians were dismissive about their concerns. Caregiver participation was valued in consultations. Patients with recurrence perceived chemotherapy as a method of control. (2) Patient Autonomy Patients describe a paternalistic relationship with their clinician and were satisfied with their management despite any complications or recurrence. There was little perception of pathway equipoise with some questioning any real choice particularly those with a symptomatic bowel primary. (3) Treatment Strategy Patients preferred a bowel-first strategy as a method of control, perceiving the primary to continually seed the body with metastases. Chemotherapy offered little reassurance for disease control. Synchronous resection was preferred but the greater potential for complications was appreciated. (4) Research No patients expressed ethical concerns about potential studies randomising to different surgical strategies. However, patients would not want a liver-first strategy. Conclusions This is the first qualitative study exploring patient perceptions of metastatic colorectal cancer. The importance of the first consultation outlining management is emphasised as a simple but important message.

Elective minimally invasive surgery for sigmoid diverticulitis: operative outcomes of patients with complicated versus uncomplicated disease.

The aim of this work was to compare the results of elective minimally invasive surgery between patients with complicated sigmoid diverticulitis and those with uncomplicated disease. An institutional review board-approved database was searched for all consecutive patients who underwent elective minimally invasive surgery, including laparoscopic, hand-assisted and robotic sigmoidectomy, for diverticulitis between 2010 and 2017; they were classified according to the modified Hinchey classification as having complicated (abscess, fistula, stricture, obstruction, bleeding or previous perforation) versus uncomplicated disease. Data recorded included baseline demographics, indications for surgery, operative details and complications. Three hundred and twenty-five patients underwent elective sigmoidectomy for complicated (n=105) and uncomplicated (n=220) diverticulitis. Surgical indications for complicated disease were abscess (n=74), stricture (n=14), fistula (n=28) and bleeding (n=7). The two groups were statistically comparable for age, gender, body mass index and American Society of Anesthesiologists score. Patients with complicated disease had higher rates of concomitant loop ileostomy creation (9.5% vs. 0.9%, p<0.001) and synchronous resections (9.5% vs. 2.7%, p=0.01), higher volumes of blood loss (177±140 vs. 125±92ml, p<0.001), longer length of stay (5.6±3 vs. 4.8±2days, p=0.04) and longer operating time (218.2±59 vs. 185.8±63min, p<0.001). There were no significant differences in anastomotic leakage (3% vs. 1%, p=0.3), conversion to laparotomy (4.8% vs. 2.3%, p=0.3) or overall complications (36% vs. 25.9%, p=0.06) for complicated versus uncomplicated disease, respectively. Minimally invasive surgery for complicated diverticulitis resulted in higher rates of construction of proximal ileostomy and synchronous resections and longer operating times and length of hospital stay. Otherwise, it has outcomes that are not significantly different from the results recorded in patients with uncomplicated disease.

Survival of patients with bilateral renal cell cancer after nephro-preserving surgery

This article presents a systematic literature review to assess the survival outcomes of patients with bilateral renal cell carcinoma who underwent nephro-preserving surgery. Patients with bilateral renal neoplastic lesions represent a rare subpopulation, numbering, according to different authors, from 2 to 6 % of the total RCC group. Despite the increase in the number of cases of bilateral RCC, the number of works devoted to the study of the features of surgical intervention, prognosis factors, treatment outcomes and survival of this cohort of patients is limited, and a number of important questions regarding this problem remain unresolved. Currently, the only effective method of treating bilateral renal cancer is nephro-preserving surgery in the volume of bilateral renal resection / nephrectomy with resection of the contralateral kidney in case of synchronous lesion or resection of a single kidney in case of metachronous lesion. This strategy avoids or reduces the risk of developing renal failure and its consequences after surgery. Conclusion. Nephro-preserving surgery for bilateral renal cell carcinoma is the only effective method to achieve satisfactory oncological results with a low incidence of complications.

Mechanisms restraining break-induced replication at two-ended DNA double-strand breaks.

DNA synthesis during homologous recombination is highly mutagenic and prone to template switches. Two-ended DNA double-strand breaks (DSBs) are usually repaired by gene conversion with a short patch of DNA synthesis, thus limiting the mutation load to the vicinity of the DSB. Single-ended DSBs are repaired by break-induced replication (BIR), which involves extensive and mutagenic DNA synthesis spanning up to hundreds of kilobases. It remains unknown how mutagenic BIR is suppressed at two-ended DSBs. Here, we demonstrate that BIR is suppressed at two-ended DSBs by proteins coordinating the usage of two ends of a DSB: (i) ssDNA annealing proteins Rad52 and Rad59 that promote second end capture, (ii) D-loop unwinding helicase Mph1, and (iii) Mre11-Rad50-Xrs2 complex that promotes synchronous resection of two ends of a DSB. Finally, BIR is also suppressed when Sir2 silences a normally heterochromatic repair template. All of these proteins are particularly important for limiting BIR when recombination occurs between short repetitive sequences, emphasizing the significance of these mechanisms for species carrying many repetitive elements such as humans.

Outcomes following synchronous liver resection, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal liver and peritoneal metastases: A bi-institutional study

PurposeSynchronous liver resection, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal liver (CRLM) and peritoneal metastases (CRPM) has traditionally been contraindicated. However, latest practice promotes specialist, multidisciplinary-led consideration for select patients. This study aimed to evaluate the perioperative and oncological outcomes of synchronous resection in the management of CRLM and CRPM from two tertiary referral centres. MethodThis bi-institutional, retrospective, cohort study included patients undergoing simultaneous liver resection, CRS and HIPEC for metastatic colorectal cancer from 2013 to 2020. Patients treated with ablative liver techniques, staged operative approaches and extra abdominal disease were excluded. Overall survival (OS) and disease-free survival (DFS) rates were assessed. Univariate and multivariate analyses identified variables associated with survival and major morbidity (Clavien-Dindo grade III/IV). ResultsTwenty-three patients were included. The median peritoneal carcinomatosis index (PCI) was 9 (range 0–22). There were two major liver resections and 21 minor resections. CC-0 resections were achieved in all patients. Major morbidity occurred in 7 patients. There were no deaths at 90 days. PCI was independently associated with morbidity (p = 0.04). PCI >10 (p = 0.069), major morbidity (p = 0.083) and presence of KRAS mutation (p = 0.052) approached significance for poor OS. Median follow up was 21 months (4–54 months). Median OS was 37 months, 3-year survival 54%, and median DFS 18 months. ConclusionSynchronous liver resection, cytoreductive surgery and HIPEC is feasible in selected patients with low-volume CRPM and CRLM. Increasing PCI is associated with postoperative major morbidity, and should be considered during operative planning.

Hand-assisted Laparoscopic Surgery for Colorectal Liver Metastasis: Analysis of Short-term and Long-term Results.

There is scant data regarding the outcomes of hand-assisted laparoscopic surgery (HALS) for colorectal liver metastasis (CRLM). The aim of this study is to report our experience and analyze the short-term and long-term results. Retrospective study of patients undergoing HALS for CRLM in 2 university affiliated medical centers. Two hundred and thirty-eight liver procedures were performed on 145 patients including 205 parenchymal sparing resections and 33 anatomic resections. The median number of metastases was 1 (range: 1 to 8), 38 patients (26.2%) had 3 or more metastases, and 41 patients (28.3 had a bi-lobar disease. The tumor size was 20 (2 to 90) mm, and 52 patients (36.6%) had a tumor larger than 30 mm. Nighty-nine patients (67.8%) received neoadjuvant chemotherapy. In 8 patients (5.5%) the laparoscopic liver resection was combined with ablation, and 16 patients (11%) underwent a synchronous resection of colorectal cancer. The median operative time, blood loss during surgery, and postoperative hospital stay were 163 minutes, 300 mL, and 4 days, respectively. The median modified Iwate complexity score was 4 (0 to 10) and the conversion rate to open surgery was 5.5%. The overall and major complication rates were 23.8% and 3.6%, respectively. The mortality rate was 0.7%. R0 resections were achieved in 91% of patients. Median overall survival for all the cohort (intend to treat) was 59 months, and the 8- and 10-year overall survival rates were 47.3% and 24.9%, respectively. This study shows that HALS is a safe and efficacious treatment for selected patients with CRLM.

Transdiaphragmatic single-port video-assisted thoracoscopic surgery; a novel approach for pulmonary metastasectomy through laparotomy incision \u2013 case series

BackgroundPulmonary metastasectomy was performed in the early twentieth century and ever since, it has evolved to be one of the main treatment options for certain metastatic malignancies. The advancement of minimally invasive procedures enabled new techniques to minimize morbidity and improve patient quality of care and overall outcome.Cases presentationHerein we present three patients, aged 53, 48, and 27 years, known to have sigmoid, rectal, and non-seminomatous germ cell tumors respectively. All patients were diagnosed to have metastatic lung nodules and underwent laparotomy to excise abdominal tumors followed by trans-diaphragmatic single-port video-assisted thoracoscopic pulmonary metastasectomy. All patients achieved complete surgical tumor excision, and none had pulmonary related complications on follow-up.ConclusionOur prescribed novel trans-diaphragmatic single-port video-assisted thoracoscopic surgery (VATS) technique for synchronous pulmonary metastasectomy and intra-abdominal tumor resection is safe and can achieve complete resection with negative margins.

Synchronous resection of colorectal cancer primary and liver metastases: an outcomes analysis

BackgroundConcurrent resection of the primary cancer and synchronous colorectal cancer liver metastases (CRCLM) was evaluated for differences in outcomes following stratification of both the liver and colorectal resection. MethodsConsecutive cases of synchronous resection of both the CRC primary and CRCLM were reviewed retrospectively at a single, high-volume institution over a 17-year period (2000–2017). Results273 patients underwent simultaneous resection of CRCLM. The distribution of the primary lesion was similar between the colon (52.4%) and rectum (47.6%), while 46.9% of patients had bilobar liver disease. Major liver/major colorectal resection (n = 24) were significantly more likely to experience colorectal specific morbidity (OR 3.98, 95% CI 1.56–10.15, p = 0.004), liver specific morbidity (OR 7.4, 95% CI 2.22–24.71, p = 0.001), total morbidity (OR 2.91, 95% CI 1.18–7.18, p = 0.020) and 90-day mortality (OR 5.50, 95% CI 1.27–23.81, p = 0.023). Failure to receive adjuvant chemotherapy secondary to postoperative morbidity was associated with significantly worsened survival (HR for death 5.91, 95% CI 1.59–22.01, p = 0.008). ConclusionsPostoperative morbidity precluding the administration of adjuvant chemotherapy is associated with an increase in mortality. Combining a major liver with major colorectal resection is associated with a significant increase in major morbidity and 90-day mortality, and should be avoided.

Cumulative operative time and postoperative complication risk in synchronous resections of colorectal liver metastases and primary tumors

Presenter: Allison N Martin MD, MPH | The University of Texas MD Anderson Cancer Center Background: Selection of patients for synchronous resection of colorectal liver metastases (CLM) and primary colorectal cancers (CRC) is complex due to inherent complication rates. We sought to identify perioperative factors associated with postoperative morbidity after synchronous resection. Methods: Using a prospectively maintained quality improvement database, adult patients undergoing synchronous CLM and CRC resection from 1/1/2017-7/1/2020 were included, and 90-day postoperative outcomes were collected. The primary outcome of this study was to estimate effects of clinical covariates on the occurrence of grade 2 or worse (grade ≥2) complications as defined by the Accordion Severity Grading System. Univariate and sequential multivariable logistic regression models were used to estimate the impact of colorectal resection type, Kawaguchi-Gayet complexity grade of hepatectomy and perioperative risk factors on outcomes, including 90-day postoperative complications. Results: A total of 120 patients underwent synchronous CLM and CRC resection during this study period. Most patients (62%) underwent a low-complexity hepatectomy (Kawaguchi-Gayet 1 [KG1]), and the most common CRC resections were right colectomy (n=37, 31%) and proctectomy (n=40, 33%). The most common synchronous resection was a KG1 CLM resection with proctectomy (n=30, 25%). Nearly 40% (n=46) of patients experienced grade ≥2 complications, and 12% (n=14) experienced grade ≥3 complications. Grade ≥2 complication was associated with longer length of stay (median LOS 7.5 vs. 4 days, p506 minutes) had higher rates of grade ≥2 complications (37% vs. 15%, p=0.04) and were associated with a greater than 4-fold increased risk of grade ≥2 morbidity (OR 4.3, 95% CI 1.41-13.1, p=0.01). As an intraoperative surrogate for complexity of hepatectomy, Pringle inflow occlusion time above the median (33 minutes) was not significantly associated with increased risk of grade ≥2 morbidity (p=0.26). In multivariable analysis, increasing operative time was independently associated with grade ≥2 complications, especially for those resections in the highest quartile (OR 7.28, 95% CI 1.73-30.6, p=0.007; Table 1). Conclusion: In patients preoperatively selected for synchronous CLM and CRC resection, prolonged operative time is independently associated with grade ≥2 complications. Surgical teams should consider preoperative initiatives to address factors related to total operative time, including team dynamics, communication, and case selection, to accurately predict and reduce cumulative operative time as a strategy to mitigate complication risk. Operative time may also inform intraoperative decisions after the hepatectomy to continue with or delay the colorectal resection.

Surgical Treatment of Liver Metastases from Gastrointestinal Stromal Tumor

Introduction: Gastrointestinal stromal tumors (GISTs) are rare tumors which can arise within in most parts of gastrointestinal tract. Most common sites of metastatic spread are liver and the peritoneum. Thyrosinkinase inhibitors greatly improved prognosis of the locally advanced and metastatic disease allowing patients to gain several years of overall survival, yet majority of them will eventually develop progression and succumb to disease. The role of surgical therapy in metastatic setting still remains unclear. Methods: Within the years 2011 - 2020, we performed 29 surgical procedures on 24 patients with liver metastasis from GISTs. We monitored postoperative morbidity, DFI and overall survival in all patients. Results: We identified 24 patients (range 32-80 years), 17 men and 7 women. In 15 patients a metachronous occurrence of metastases was found, most often within the median 2 years after the primary resection (range 2 - 9 years). 9 patients had synchronous disease. 6 synchronous resections were performed (primary tumor and liver), 3 stage resection were performed. 6 large resections were performed, otherwise mainly extraanatomical resections, eventualy combined with RFA (4x) were performed. Only RFA was performed 5 times. The morbidity according to Clavien – Dindo cassification > 2 was 24 %. 20 patients (83%) received systemic treatment before the surgery, and 21 patients (88%) after the surgery. The 1-, 3- and 5-year survival rate was 91%, 86%, and 72%. Conclusion: Surgical treatment of liver metastases from GIST is a safe method. RO resection and a good therapeutic response to systemic thyrosinkinase inhibitors therapy is an important predictive factor of reccurrence. A multidisciplinary approach for treatment of liver metastases from GISTs is necessary. We need further studies to determine the benefits of surgical treatment.

Experience of synchronous thoracic and gastric carcinoma resection: a case report

Experience of synchronous thoracic and gastric carcinoma resection: a case report

Can Patients with Pancreatic Cancer and Liver Metastases Obtain Survival Benefit from Surgery? A Population-Based Study.

Background: Surgery for pancreatic cancer with liver metastases (PCL) is not recommended in the international guidelines, and investigation of its clinical significance in patients with PCL is very limited. This study explored whether surgery, especially synchronous resection of the primary tumor and liver metastases (SPL), could improve survival in PCL.Methods: Data of 14,248 patients with PCL from Surveillance, Epidemiology, and End Results database was analyzed. Patients were divided into following groups: SPL, synchronous primary site, and other resection (SPO), single resection of the primary site (SPS), and no resection (NR).Results: In this study, only 93 (0.7%) underwent SPL, 88 (0.6%) for SPO, and 232 (1.6%) for SPS. Multivariate Cox analysis showed surgical procedures of both the primary site and other sites were independent protective prognostic factors for pancreatic cancer cause-specific survival (PCSS) (all P < 0.001). Patients in the SPL group showed the most survival benefit, with a significant and gradually increased difference as compared with the SPO, SPS, and NR groups (median survival: 54, 34, 15, and 3 months, respectively, all P < 0.001). Compared with the NR group, mortalities were significant and gradually declining in the SPS, SPO, and SPL groups, with hazard ratio 0.329 (95% confidence interval [CI], 0.281 to 0.386), 0.220 (95% CI, 0.164 to 0.294), and 0.162 (95% CI, 0.118 to 0.222), respectively (all P < 0.001).Conclusions: Surgical procedures for both primary site and other sites improved survival. SPL, particularly, showed a considerable survival benefit in well-selected patients with PCL.

Crohn's Disease Complicated by IleosigmoidFistula - Synchronous Resection or PrimarySigmoid Repair, One or Two-stage Procedure?A systematic review of the literature andprospective case series.

Although ileosigmoid fistulas (ISFs) in Crohn's disease (CD) are rare they can be quite challenging, especially for the inexperienced surgeons. Furthermore, current guidelines offer no clear recommendation regarding the surgical strategy in such cases. A systematic review of the literature to determine the best surgical strategy and a prospective case series are presented herein. The systematic review was performed according to PRISMA guidelines. A single-center prospective data-base from January 1, 2014 to August 20, 2019 is presented. Age, duration of CD, and the rates of ISF, emergency, preoperative diagnosis, type of surgery, type of stoma, and complications were analyzed and a prospective case series. Eleven of 69 papers with a total of 505 patients were included in the systematic analysis. The rate of ISF was 3-5% of all CD patients. The combined preoperative detection rate of all modalities was 71%. Primary repair was performed in 42% of the cases; the rate of stoma was 31.5% with a similar proportion in primary repair and sigmoid resection.In the presented series, 35 of 176 patients with CD were operated (51% in an emergency setting). There were 7 cases with ISFs (4% of all and 20% of the operated patients). Preoperative diagnosis was made at 57%. Primary repair was performed in 71%, and a two-stage intervention with a stoma - in 58% of patients. Primary repair should be attempted in all cases in which the sigmoid colon is disease-free or is not involved in the adja-cent abscess. The synchronous resections are not a mandatory indication for the stoma, but rather a tailored approach is recommended with an evaluation of the risk factors. Based on the available literature, no clear recommendation regarding the type of stoma can be made.

Oncologic outcomes after resection of para-aortic lymph node metastasis in left-sided colon and rectal cancer.

The optimal surgical management strategy for para-aortic lymph node (PALN) metastasis has not attracted as much attention as surgery for liver or lung metastasis. The purpose of this retrospective study was to evaluate the oncologic outcomes after synchronous resection of PALN metastasis in left-sided colon and rectal cancer. Between January 1986 and August 2016, 29 patients with pathologically positive PALN metastases who underwent curative resection at our hospital were retrospectively reviewed. We examined clinicopathological characteristics, long-term oncologic outcomes, and factors related to favorable prognosis in these patients. The 3-year overall survival and recurrence-free survival (RFS) rates were 50.5% and 17.2%, respectively. In total, 6 (20.7%) patients experienced no recurrence in the 3 years after surgery, while postoperative complications were seen in 9 (31.0%) patients. The 3-year RFS rate was significantly better in the pM1a group than in the pM1b/pM1c group (26.3% and 0.0%, respectively, p = 0.032). PALN dissection for patients without other organ metastases in left-sided colon or rectal cancer is a good indication as it is for liver and lung metastasis.

Feasibility of pancreaticoduodenectomy with synchronous liver metastasectomy for oligometastatic pancreatic ductal adenocarcinoma - A case-control study

BackgroundResection of pancreatic ductal adenocarcinoma (PDAC) with synchronous liver metastasectomy is still a matter of debate. We aimed to evaluate the feasibility of synchronous resection of PDAC and liver metastases for curative intent at a high-volume surgical center. MethodsPatients who underwent pancreaticoduodenectomy (PD) with synchronous liver metastasectomy (M1 resection group, n = 50) were matched 1 : 1 based on tumor and nodular stage, age, gender, body mass index and concomitant disease with two control groups (M0 resection and M1 no resection). The M0 resection group included patients who underwent PD without metastases. The M1 no resection group included patients with liver metastases who underwent palliative bypass or exploratory laparotomy without resection followed by palliative and adjuvant therapies. ResultsM1 resection group had a longer operation time, larger intraoperative blood loss, and longer postoperative hospital stay than other two groups. R0 resection rate of M1 resection group was similar to that of M0 resection group (92% vs. 94%, p = 1.000). Postoperative complications were comparable between the groups. The overall median survival in M1 resection, M0 resection, and M1 no resection group was 16, 30, and 6 months, respectively. Cumulative survival rates for 1-, 2-, and 3-year of the M1 resection, M0 resection, and M1 no resection group were 63.8%, 29.0%, and 6.7%; 94.0%, 74.4%, and 25.1%; 24.0%, 2.0%, and 0%, respectively. The survival of M1 resection group was worse than that of M0 resection group (p = 0.009), however significantly much better than that of M1 no resection group (p = 0.001). Univariate analysis showed carcinoembryonic antigen >8 ng/ml and non-R0 resection were associated with death. Multivariate analysis revealed that M1 resection group had improved survival compared with M1 no resection group. ConclusionsPD with synchronous liver metastasectomy for oligometastatic PDAC is safe and feasible, it might provide survival benefits for selected patients.