Vascular Resection Research Articles

Vascular Resection in Perihilar Cholangiocarcinoma: How Much Is Two Much

Introduction: Surgery for perihilar cholangiocarcinoma is demanding. Frequently, vascular invasion occurs. Vascular resection correlates with worse perioperative outcomes. The authors aim to discuss the limits of vascular resection.

Laparoscopic pancreatectomies for borderline tumors with major venous resections.

Resection of the portal vein or superior mesenteric vein infiltrated by the pancreatic cancer is currently a standard during open pancreatic surgery for cancer. When found intraoperatively it often leads to conversion. Nowadays, research data for laparoscopic pancreatectomies with major venous resections and reconstructions are scarce. To present our own results of laparoscopic total pancreatectomies, pancreaticoduodenectomy and distal pancreatectomies (RAMPS) performed for cancer with major venous resection and reconstructions of the portal system. This is a retrospective study of our own clinical material of consecutive patients treated for adenocarcinoma of pancreas who underwent laparoscopic pancreatectomies with major venous resection and reconstruction in 2020 and 2021. The study included 6 females and 2 males in median age of 68 years (56-77). 6 tumors were located in the pancreatic head, 1 in the pancreatic neck and 1 in the pancreatic body. Surgical procedures included 5 total pancreatectomies, 2 RAMPS and 1 Whipple pancreaticoduodenectomy. There were no conversions. Median time of vascular closure was 55.5 (41-70) min. Median blood loss was 500 (250-900) ml. Median length of hospital stay (LOS) was 18.5 (11-34) days. We observed no complications related directly to vascular resection. Laparoscopic approach for pancreatectomies with portal or superior mesenteric vein resections could be a safe and feasible approach in the hands of an experienced surgeon.

Venous Resection for Locally Advanced Pancreatic Cancer: Time Trend and Outcome Analysis of 80 Consecutive Resections at a High-Volume Center

Introduction: Locally advanced pancreatic cancer (LAPC) is a highly malignant carcinoma with an extremely poor prognosis. Vascular venous invasion is a frequent finding in patients with pancreatic cancer. The aim of this study was to investigate the morbidity, mortality, and survival of patients with advanced pancreatic cancer. Methods: We retrospectively reviewed our experience of 80 consecutive pancreatic surgeries with venous resection for pancreatic cancer in three hospitals: Ramon y Cajal (Madrid, Spain) from 2002 to 2004, Monteprincipe University Hospital (Madrid, Spain) from 2005 to 2006 and Sanchinarro University Hospital (Madrid, Spain) from 2007 to December 2020. Prognostic factors were analyzed by the log-rank test and a multivariate proportional hazard regression analysis. Results: Major venous reconstruction was performed by primary lateral venorrhaphy in 17% of patients, primary end-to-end anastomosis in 70.7% and reconstruction with a Gore-Tex® patch (W.L. Gore & Associates, Inc., Flagstaff, AZ) in 12.3% of patient. In 58% of the patients, the pathological examination showed infiltration of the vascular specimen. About 85% of the procedures performed were R0. The perioperative morbidity rate with Dindo-Clavien classification = III was 21.5%. Tumor size and nodal status were the only prognostic variables, which significantly decreased survival by a multivariate analysis. Conclusions: Major vascular resection to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. Nevertheless, it is justified only in carefully selected cases.

Survival after Pancreatic Resection in Older Patients with Pancreatic Malignancy

Introduction: Pancreatic malignancies have among the highest mortality rates of solid organ cancers, and there has been a global trend towards an increasing incidence. In the context of an aging population, more older patients will present for consideration of curative resection. Although mortality and morbidity associated with pancreatic resection has improved, there are mixed outcomes reported in the literature regarding survival outcomes for older patients undergoing pancreatectomy. Methods: A retrospective cohort study was performed including patients ≥75 years of age undergoing pancreatic resection for primary pancreatic malignancy, identified using a prospectively maintained database of a single surgeon’s experience. The primary outcomes were median survival and 5-year overall survival. Secondary outcomes included hospital length of stay, peri-operative morbidity and mortality, patterns of recurrence and disease-free survival. Results: 41 patients aged ≥75 years were identified from a total of 497 major pancreatic resections for malignancy between 2007 and 2020. The mean age was 80.6 (range 75 - 88) Of these patients, patients underwent pancreacitoduodectomy (n=36), distal pancreatectomy (n=3), total pancreatectomy (n=2) for pancreatic adenocarcinoma (n=34), ampullary adenocarcinoma (n=5), pancreatic acinar carcinoma (n=1) and invasive microcystic cystadenoma (n=1). 21 patients (51%) had concurrent major vascular resection. The median survival was 24 months, and the 5-year overall survival rate 37%. 30-day and 90-day mortality was 0% and 4.9% (n=2), respectively. Conclusion: Pancreatic resection for malignancy in appropriately selected older adults is safe and confers comparable survival outcomes to the general population. Age alone should not be a contraindication to pancreatectomy.

Surgical and Oncological Outcomes of Extremity soft Tissue Sarcoma following en bloc Resection of the Neurovascular Bundle

Purpose: Vascular involvement is a major limitation in attaining limb salvage with negative margins for managing softtissue sarcomas (STS). The study evaluated surgical and oncological outcomes of vascular resection and reconstructionduring the management of extremities STS.

Duct-to-Mucosa Pancreaticojejunostomy with Less Serosal Stitches: A Different Approach to Well-known Problem.

To describe a new approach (duct-to-mucosa pancreaticojejunostomy with less serosal stiches) for postoperative pancreatic fistula (POPF) in pancreaticoduodenectomy. An observational study. Tepecik Training and Research Hospital, Izmir, Turkey, between January 2019 and May 2020. Medical records of 45 patients, who underwent pancreaticoduodenectomy by the same general surgeon between January 2019 and May 2020, were reviewed retrospectively. Pylorus-preserved pancreaticoduodenectomy was performed for all patients. Duct-to-mucosa PJ with less serosal suture technique was used for all patients in reconstruction after pancreaticoduodenectomy. Definition of the ISGPS was used for the POPF and only grade B and C fistulas were accepted as clinically relevant POPF. Here, the descriptive measures were reported. Seventeen (17) of the forty-five (45) patients were females and median age was sixty- six (66) years. The majority of the underlying disease was pancreatic adoneocarcinoma. Hyperbilirunemia was seen in 15 patients. Median operation time was 360 minutes. Number of patients with pancreatic duct size <3 mm was five. Rate of soft pancreas texture was 33.3%. Lastly, the number of patients that underwent vascular resection or additional organ resection were 6 (13.3%) and 8 (17.8%), respectively. Clinically relevant POPF according to ISGPS was seen in 6 patients (grade B:4 and grade C:2). The most prevalent postoperative complication was surgical site infection at a rate of 40%. There was no POPF related mortality. Two-layer duct-to-mucosa pancreaticojejunostomy with less serosal stitches technique has acceptable pancreatic fistula rates. This technique could be used by surgeons who are faced with challenges with the duct-to-mucosa anastomosis due to aforementioned causes. Large multi-centre randomised future studies are required to confirm these findings. Key Words: Postoperative pancreatic fistula, Surgical technique, Duct-to-mucosa pancreaticojejunostomy, Less serosal stiches.

Portal Vein Reconstruction Using Cryopreserved Veins in Pancreatoduodenectomy for Advanced Pancreatic Head Carcinoma

Introduction: For advanced pancreatic head carcinoma, removal and reconstruction of the portal vein and/or the superior mesenteric vein are sometimes necessary to achieve R0 resection. Our institute has Tissue-Bank stocking the cryopreserved venous allografts donated based on the voluntary wish after the cardiac death. We have utilized these grafts to various surgeries with combined vascular resection. Methods: We retrospectively reviewed medical records of the 23 cases undergoing pancreatoduodenectomy with the combined resection of the portal venous systems and reconstructed it using the venous grafts for advanced pancreatic carcinoma between January 2002 and December 2019. Results: There were 12 male and 11 female, aged 73 (31-81), (median and range, same applies hereafter). Operative time was 749 (610-1148) min, estimated blood loss was 1305 (690-4350) gram. The type of portal vein resection consisted of 13 cases of circumferential segmental resection, 10 cases of wedged resection. Median postoperative hospital stay was 30 (18-105) days. There was no surgical complication greater than Clavien-Dindo IIIb. Five cases of postoperative occlusion of the allografts were observed. Graft patency rate in six months after the surgery was 75.0% and no occlusion later than 6 months were detected. Overall survival rate in one, three, and five years were 71.9%, 36.0%, 30.0% respectively. Conclusions: Reconstruction of portal vein using cryopreserved venous allografts is safe and its therapeutic effects is feasible for the pancreatoduodenectomy for advanced pancreatic carcinoma. Our techniques will be shown with a short videoclip.

Alveolar Echinococcosis-A Challenging Task for the Hepatobiliary Surgeon.

(1) Background: Alveolar echinococcosis (AE) is an ultimately fatal disease, whose only curative treatment is surgery. Due to its late presentation extended liver resections are often necessary. The true benefit of extensive surgery has yet to be established; (2) Methods: We present a single center experience of 33 cases of Echinococcus multilocularis that have been treated at a high-volume hepatobiliary surgery center between 2004 and 2021. (3) Results: Of the 33 patients 24 patients underwent major liver resection (73%). In addition to the liver resection patients frequently underwent complex extrahepatic procedures such as lymphadenectomy (n = 21, 61%), vascular resections and reconstructions (n = 9, 27%) or resections and reconstruction of the extrahepatic bile duct (n = 11, 33%). Seven patients suffered from ≥ grade III complications (21%). Complete resection was achieved in 17 patients. Fourteen patients had R1 resections and two had macroscopic parasitic remnant (R2). Progressive disease was reported in three patients (The two R2 patients and one R1 resected patient). At a median follow-up of 54 months no mortality has occurred in our cohort; (4) Conclusions: Liver resection remains the gold standard for AE. Even in extensive disease the combination of complex resection and perioperative benzimidazoles can achieve favorable long-term outcomes.

Vascular Proximity Increases the Risk of Local Recurrence in Soft-Tissue Sarcomas of the Thigh-A Retrospective MRI Study.

Simple SummaryProximity to major vessels increases risk of local recurrence in soft tissue sarcomas of the thigh. When major vessels were observed to be surrounded by the tumor on preoperative MRI, vascular resection and by-pass reconstruction offered a better local control.The aim of this study was to establish the prognostic effects of the proximity of the tumor to the main vessels in patients affected by soft tissue sarcomas (STS) of the thigh. A total of 529 adult patients with deeply seated STS of the thigh and popliteal fossa were included. Vascular proximity was defined on MRI: type 1 > 5 mm; type 2 ≤ 5 mm and >0 mm; type 3 close to the tumor; type 4 enclosed by the tumor. Proximity to major vessels type 1–2 had a local recurrence (LR) rate lower than type 3–4 (p < 0.001). In type 4, vascular by-pass reduced LR risk. On multivariate analysis infiltrative histotypes, high FNLCC grade, radiotherapy administration, and type 3–4 of proximity to major vessels were found to be independent prognostic factors for LR. We observed an augmented risk of recurrence, but not of survival as the tumor was near to the major vessels. When major vessels were found to be surrounded by the tumor on preoperative MRI, vascular resection and bypass reconstruction offered a better local control.

P-P35 Textbook outcomes after pancreaticoduodenectomy in high risk patients: results from a high volume UK centre

Abstract Background Textbook Outcome (TO) after pancreaticoduodenectomy (PD) is a quality metric that may be used to compare outcomes between centres, but the effect of casemix on TO is unknown. The aim of this study was to determine if TO after PD is affected by casemix. Methods TO was evaluated in a prospectively maintained database of 830 consecutive patients who underwent PD between 2009-2019 in a high volume centre. TO was defined as an absence of POPF, bile leak, haemorrhage, Clavien III+ complications, readmission and hospital mortality. Frequency of TO was compared between high and low risk cases. High risk was defined as any of the following: age ≥ 75 years, significant comorbidity (Charlson index ≥5), vascular resection or additional procedures. Multivariable analysis using binary logistic regression analysis was performed to assess factors associated with TO. Results Overall, 599/830 patients (72%) had TO after PD. There has been no change during the study period (2009-2013 v 2014-2018: 70% v 75%; p = 0.148). There was no difference in TO in elderly patients (p = 0.774), severe comorbidity (p = 0.483), vascular resection (p = 0.187) or additional procedures (p = 0.189). On multivariable analysis, cardiac disease (OR 0.47, 95%CI 0.28-0.81; p = 0.006), pancreatic adenocarcinoma (OR 1.55 95%CI 1.02-2.35; p = 0.039) and hard gland (OR 3.12, 95%CI 2.06-4.736; p &amp;lt; 0.001) were independently associated with TO. Conclusions Acceptable Textbook Outcomes can be achieved in high risk patients and those undergoing complex surgery, when performed in high volume specialist centres with appropriate patient selection.

Pancreaticoduodenectomy in octogenarians: The importance of “biological age” on clinical outcomes

IntroductionWith the prolongation of life expectancy, an increasing number of elderly patients are evaluated for pancreatic surgery. However, the influence of increasing age on outcomes after pancreaticoduodenectomy (PD) is still unclear, especially in octogenarians. Aim of this study is to evaluate the perioperative characteristics and outcomes of octogenarians undergoing PD. MethodsData for 812 patients undergoing PD between 2019 and 2020 in 10 referral centers in Italy were reviewed. Patients aged 80 years or older were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients younger than 80 years. Propensity scores were calculated using 7 perioperative variables including gender, ASA score, neoadjuvant treatment (NAT), biliary stent positioning, type of surgical approach (open, laparoscopic, robot-assisted), associated vascular resections, type of lesion. Perioperative characteristics and short-term postoperative outcomes were compared before and after matching. ResultsOverall, 81 (10%) patients had 80 years or more. Before matching, octogenarians had a higher rate of ASA score≥ 3 (n = 35, 43.2% vs. n = 207, 28.3%; p = 0.005) and less frequently underwent NAT (n = 11, 13.6% vs. n = 213, 29.1%; p = 0.003). Matching was successfully performed for 70 octogenarians. After matching, no differences in preoperative and intraoperative characteristics were found. Postoperatively, ICU admission was more frequent in octogenarians (50% vs 30%; p = 0.01). Although in-hospital mortality was higher in octogenarians before matching (7.4% vs 2.9% in the younger cohort; p = 0.03), no difference was noted between the matched cohorts (p = 0.36). Postoperative morbidity was comparable between groups in the whole and selected populations. At the multivariate analysis, chronological age was not recognized as a prognostic factor for cumulative major complications, while ASA ≥3 was the only confirmed influencing feature (OR 2.98; 95%CI: 1.6–6.8; p = 0.009). ConclusioIn high-volume centers, PD in octogenarians shows similar outcomes than younger patients. Age itself should not be considered an exclusion criterion for PD, but a focused preoperative assessment is essential for adequate patient selection.

Categorization of Differing Types of Total Pancreatectomy

Comparability of morbidity and mortality rates after total pancreatectomy (TP) reported by different surgical centers is limited. Procedure-specific differences, such as the extent of resection, including additional vascular or multivisceral resections, are rarely acknowledged when postoperative outcomes are reported. To evaluate postoperative outcomes after TP and categorize different types of TP based on the extent, complexity, and technical aspects of each procedure. This single-center study included a retrospective cohort of 1451 patients who had undergone TP between October 1, 2001, and December 31, 2020. Each patient was assigned to 1 of the following 4 categories that reflect increasing levels of procedure-related difficulty: standard TP (type 1), TP with venous resection (type 2), TP with multivisceral resection (type 3), and TP with arterial resection (type 4). Postoperative outcomes among the groups were compared. Categorization of different types of TP based on the procedure-related difficulty and differing postoperative outcomes. Of the 1451 patients who had undergone TP and were included in the analysis, 840 were men (57.9%); median age was 64.9 (IQR, 56.7-71.7) years. A total of 676 patients (46.6%) were assigned to type 1, 296 patients (20.4%) to type 2, 314 patients (21.6%) to type 3, and 165 patients (11.4%) to type 4 TP. A gradual increase in surgical morbidity was noted by TP type (type 1: 255 [37.7%], type 2: 137 [46.3%], type 3: 178 [56.7%], and type 4: 98 [59.4%]; P < .001), as was noted for median length of hospital stay (type 1: 14 [IQR, 10-19] days, type 2: 16 [IQR, 12-23] days, type 3: 17 [IQR, 13-29] days, and type 4: 18 [IQR, 13-30] days; P < .001), and 90-day mortality (type 1: 23 [3.4%], type 2: 17 [5.7%], type 3: 29 [9.2%], and type 4: 20 [12.1%]; P < .001). In the multivariable analysis, type 3 (TP with multivisceral resection) and type 4 (TP with arterial resection) were independently associated with an increased 90-day mortality rate. The findings of this study suggest there are significant differences in postoperative outcomes when the extent, complexity, and technical aspects of the procedure are considered. Classifying TP into 4 different categories may allow for better postoperative risk stratification as well as more accurate comparisons in future studies.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

IntroductionThe main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. MethodDescriptive, retrospective and single-center study, corresponding to the period 2006−2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. Results631 patients were analyzed. The values ​​obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02). ConclusionsThe experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.

Surgery for pancreatic cancer: current controversies and challenges.

Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy doesnot offer any advantage over standard lymphadenectomy. Althoughminimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.

Application of Biological Glue in Orthopedics and Traumatology

The purpose of the study was to investigate the method of osteosynthesis using glues. Materials and methods. The simplest and most effective method in the treatment of traumatological patients is a plaster fixing bandage of different variations. This is a conservative type of treatment. Also, a very common method in the treatment of orthopedic and traumatological patients is the surgical method. Modern high-tech methods of osteosynthesis require a thorough preoperative examination of the patient, conducting a 3D tomographic examination for intra-articular fractures, clear planning of the course of surgical intervention, electro optical probing techniques during the operation, the availability of tool kits for installing retainers, the ability to choose a retainer intraoperative in the size range. An orthopedic-traumatologist and the entire operating team need appropriate training. All operational fixation methods must provide adequate stability to maintain axis length and rotation. Results and discussion. In the world practice, biological glues are used in such areas as abdominal surgery, neuro- and cardiac surgery, plastic and pediatric surgery, orthopedics and traumatology. Cyanocrylate glues have undergone extensive experimental clinical testing. Positive characteristics of cyanoacrylate glues are the ability to glue living tissues in a humid environment, polymerization rate, autosterility, bactericidal, absence of histotoxicity, hemostatic effect. Another glue in the review is sulfacrylate. It can be used in patients of any age, starting from newborns, regardless of the pathogenesis of the disease. Venaseal glue, used by many authors to treat fistulas of the gastrointestinal tract. Widely used fibrin glues, such as Evicel, are used to achieve hemostasis and sealing in surgery, for example, in vascular operations, kidney resection and neurosurgical interventions, in the surgical treatment of distal hypospadias in children. BioGlue glue is designed to seal surgical sutures, thereby preventing fluids (exudate, lymph, urine, gastric juice) and / or air from leaking through them. It is also used in liver surgery. At the moment, the use of bone cement is the most common auxiliary method for surgical interventions. But its side effects are very clear. Bone cement can cause the patient to die on the operating table or, in the postoperative period, in intensive care. This is due to an immediate or rapid allergic reaction. This situation is dangerous for humans. Biological glues are not so toxic and do not cause such allergic reactions Conclusion. The search for new materials and techniques for consolidating bone fragments is one of the most important problems of modern medical science, namely orthopedics and traumatology. Substances that are included in the biological glue must be bioinert, contain elements of strength (for holding fragments), looseness of the structure (for germination of capillaries between fragments), natural antibiotic (for antibiotic prevention), activators of hematopoiesis processes (for the fastest callus), organic and inorganic substances (for the building material of bone tissue). Therefore, the desire to improve treatment and improve its results, in particular in orthopedics and traumatology, is the key to the development of modern medicine

Clinical Correlates of Portal Venous or Superior Mesenteric Vein Thrombosis Following Neoadjuvant Therapy with Dose Escalated Radiation for Borderline Resectable or Locally Advanced Pancreatic Adenocarcinoma

Neoadjuvant regimens for borderline resectable and locally advanced pancreatic adenocarcinoma (PDAC) are incorporating radiation dose escalation through conventional external beam radiation (EBRT), intraoperative radiation therapy (IORT), and stereotactic body radiation (SBRT). We conducted a retrospective review of patients treated with and without IORT dose escalation to identify risk factors for portal vein and superior mesenteric vein thrombosis (PVT/SMVT).We identified 96 patients with locally advanced or borderline-resectable PDAC treated at our institution with neoadjuvant therapy followed by exploratory laparotomy between 2009 and 2014. Patients considered at risk for close or positive surgical margins based on preoperative imaging were treated with dose escalated RT consisting of EBRT with or without IORT boost to a biological equivalent dose (BED) greater than 100. Prognostic factors for PVT/SMVT were evaluated using the Wilcoxon rank-sum test, Fisher exact test, and Cox proportional hazards model.Median follow-up was 23 months. Fifty-six patients received IORT (58%). Twenty-nine patients (30%) developed PVT/SMVT, fifteen of which (52%) occurred in the setting of local recurrence (LR). Median time to PVT/SMVT was 10 months for patients with and without LR. On multivariate analysis, local recurrence and venous resection and repair with vascular interposition grafts were significantly associated with PVT/SMVT. IORT dose escalation and history of diabetes were not associated with PVT/SMVT. Six patients underwent both IORT and vascular repair, one with vascular interposition graft, of whom 50% developed PVT/SMVT. While the fourteen patients who developed PVT/ SMVT in the absence of LR did not experience a decrease in overall survival, there was significant morbidity associated with PVT/SMVT in this setting, with ten patients developing ascites requiring frequent paracenteses and additional interventions.Approximately 30% of patients who underwent neoadjuvant chemoradiation for PDAC developed PVT/SMVT a median of 10 months following surgery. This was significantly associated with local recurrence and vascular resection with reconstruction with vascular grafts, but not with escalating RT dose. PVT/SMVT in the absence of LR was associated with significant morbidity.

Role of Adjuvant Chemoradiotherapy in Perihilar Bile Duct Cancer: A Single Institutional Long-Term Follow Up Analysis

The role and indication of adjuvant therapy in perihilar cholangiocarcinoma remains to be elucidated. The aim of this analysis was to identify the effects of concurrent chemoradiotherapy (CCRT) and define the clearance cut-off of various margins in perihilar cholangiocarcinoma.A retrospective analysis was performed on 290 patients who received definitive resection from January 2000 through December 2015. The exclusion criteria were as follows: (a) palliative resection (n = 91), (b) multiple primary cancer diagnosis within 5 years (n = 30), (c) adjuvant therapy at outside institution (n = 19). Treatment result analysis for various end-points including overall survival (OS), disease-free survival (DFS), locoregional-recurrence free survival (LRRFS), and distant-metastasis free survival (DMFS) was performed using the Kaplan-Meier method.Among 150 patients of analyzed cohort, adjuvant therapy was performed in 112 (74.7%) patients: chemotherapy alone (n = 6), radiotherapy (n = 6), and CCRT (n = 100). Number of patients with nodal and margin involvement were 45 (31.9%) and 58 (38.7%), respectively. Median follow-up duration was 24.3 months. In univariate analysis, nodal involvement (HR = 1.7, 95% CI: 1.1-2.4, P = 0.009), lymphatic invasion (HR = 1.6, 95% CI: 1.1-2.3, P = 0.011) were adverse prognostic factors for OS. In multivariate analysis, margin involvement (HR = 1.8, 95% CI: 1.1-2.8, P = 0.019) was an adverse prognostic factor for OS. CCRT was associated with better overall survival (HR = 0.5, 95% CI: 0.3-0.9, P = 0.012). On subgroup analysis for patients with nodal and/or margin involvement, survival gain was found with use of CCRT in both OS and LRRFS (P = 0.02 and P = 0.02, respectively). Not only margin involvement but, close resection margin was related with poor treatment results. Clearance cut-off for vascular and radial resection margin was 0.1cm and 0.2cm, respectively (P = 0.0192).Negative surgical margins and CCRT as adjuvant treatment were statistically significant prognostic factors. Treatment result was improved with CCRT for patients with margin and/or nodal involvement. Suggested clearance for vascular and radial margin from current analysis was 0.1cm and 0.2cm, respectively.

Vascular Resection in Perihilar Cholangiocarcinoma.

Simple SummaryIn perihilar cholangiocarcinoma with vascular involvement, vascular resection to achieve margin-free status is being performed with increasing frequency despite controversial results. Morbidity, mortality, and overall survival are widely variable throughout the world. Vascular resections can include the portal vein alone, the hepatic artery alone, or combined resections. In some cases of locally advance disease, extended resections, such as hepatopancreatoduodenectomy or liver transplant, may be performed to achieve R0 status or a change to cure. The neoadjuvant treatment could help to achieve it. This article reviews and updates all treatment options in this setting.Among the cholangiocarcinomas, the most common type is perihilar (phCC), accounting for approximately 60% of cases, after which are the distal and then intrahepatic forms. There is no staging system that allows for a comparison of all series and extraction of conclusions that increase the long-term survival rate of this dismal disease. The extension of the resection, which theoretically depends on the type of phCC, is not a closed subject. As surgery is the only known way to achieve a cure, many aggressive approaches have been adopted. Despite extended liver resections and even vascular resections, margins are positive in around one third of patients. In the past two decades, with advances in diagnostic and surgical techniques, surgical outcomes and survival rates have gradually improved, although variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Extended hepatectomies and portal vein resection, or even right hepatic artery reconstruction for the left side tumors are frequently needed. Salvage procedures when arterial reconstruction is not feasible, as well as hepatopancreatoduodenectomy, are still under evaluation too. In this article, we discuss the aggressive surgical approach to phCC focused on vascular resection. Disparate results on the surgical treatment of phCC made it impossible to reach clear-cut conclusions.

Surgery With Arterial Resection for Hilar Cholangiocarcinoma: Protocol for a Systematic Review and Meta-analysis.

BackgroundIn light of recent advances in multimodality treatment, an analysis of vascular resection outcomes in surgery for hilar cholangiocarcinoma is lacking.ObjectiveThe aim of this meta-analysis is to summarize the currently available evidence on outcomes of patients undergoing arterial resection for the treatment of hilar cholangiocarcinoma.MethodsA systematic literature search in the databases PubMed/MEDLINE, Cochrane Library, and CINAHL, and the trial registries ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform will be carried out. Predefined outcomes are mortality (100-day and in-hospital), morbidity (Clavien-Dindo classification, any type of complication), vascular complications (thrombosis or stenosis of the portal vein or hepatic artery, pseudoaneurysms), liver failure, postoperative bleeding, duration of surgery, reoperation rate, length of hospital stay, survival time, actuarial survival (2-, 3-, and 5-year survival), complete/incomplete resection rates, histologic arterial invasion, and lymph node positivity (number of positive lymph nodes and lymph node ratio).ResultsDatabase searches will commence in December 2020. The meta-analysis will be completed by December 2021.ConclusionsOur findings will enable us to present the current evidence on the feasibility, safety, and oncological effectiveness of surgery for hilar cholangiocarcinoma with arterial resection. Our data will support health care professionals and patients in their clinical decision-making.Trial RegistrationPROSPERO 223396; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=223396International Registered Report Identifier (IRRID)DERR1-10.2196/31212

Resectable, borderline, and locally advanced pancreatic cancer-"the good, the bad, and the ugly" candidates for surgery?

The possibility of surgical resection strongly overrules medical oncologic treatment and is the only modality, causa sine qua non, long-term survival can be achieved in patients with pancreatic cancer. For this reason, the clinical classification of local resectability, subdividing tumors into resectable, borderline resectable, and locally advanced cancer, that is very technical in nature, is the one most widely used and accepted. As multimodality treatment with potent agents, particularly in the neoadjuvant setting, seems to be stepping forward as the new standard of treatment of pancreatic cancer, the established technical surgical landmarks tend to get challenged. This review aims to highlight the grey zones in the current classifications for local tumor involvement with respect to the observed patient outcome in the current multimodality treatment era. It summarizes the latest reported series on the outcome of resected primary resectable, borderline and locally advanced pancreatic cancer, and particularly vascular resections during pancreatectomy, in the background of different types of neoadjuvant therapy. It also hints what the new horizons of cancer biology tend to reveal whenever the technical hinders start being pushed aside. The current calls for the necessity of re-classification of the clinical categories of pancreatic cancer, from technically oriented to biology-focused individualized approach, are being elucidated.