A systematic review and meta-analysis of mediastinoscopy-assisted transhiatal esophagectomy (MATHE).

BACKGROUND: Transhiatal esophagectomy (THE) avoids thoracotomy but sacrifices mediastinal lymphadenectomy. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) allows for visualisation and en-bloc dissection of mediastinal lymph nodes while retaining the benefits of THE. However, given its novel inception, there is a paucity of literature. This study aimed to conduct the first meta-analysis to explore the efficacy of MATHE and clarify its role in the future of esophagectomy. METHODS: Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to May 1, 2023. Studies were included if they reported outcomes for patients with esophageal cancer who underwent MATHE. Meta-analyses of proportions and pooled means were performed for the outcomes of intraoperative blood loss, lymph node (LN) harvest, mean hospital length of stay (LOS), mean operative time, R0 resection, conversion rates, 30-day mortality rate, 5-year OS, and surgical complications (anastomotic leak, cardiovascular [CVS] and pulmonary complications, chyle leak and recurrent laryngeal nerve palsy [RLN]). Sensitivity analyses were performed for outcomes with substantial statistical heterogeneity. RESULTS: The search yielded 223 articles; 28 studies and 1128 patients were included in our analysis. Meta-analyses of proportions yielded proportion rates: 30-day mortality (0 %, 95 %CI 0-0), 5-year OS (60.5 %, 95 %CI 47.6-72.7), R0 resection (100 %, 95 %CI 99.3-100), conversion rate (0.1 %, 95 %CI 0-1.2). Among surgical complications, RLN palsy (14.6 %, 95 %CI 9.5-20.4) were most observed, followed by pulmonary complications (11.3 %, 95 %CI 7-16.2), anastomotic leak (9.7 %, 95 %CI 6.8-12.8), CVS complications (2.3 %, 95 %CI 0.9-4.1) and chyle leak (0.02 %, 95 %CI 0-0.8). Meta-analysis of pooled means yielded means: LN harvest (18.6, 95 %CI 14.3-22.9), intraoperative blood loss (247.1 ml, 95 %CI 173.6-320.6), hospital LOS (18.1 days, 95 %CI 14.4-21.8), and operative time (301.5 min, 95 %CI 238.4-364.6). There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses. CONCLUSION: MATHE is associated with encouraging post-operative mortality and complication rates, while allowing for radical mediastinal lymphadenectomy with reasonable lymph node harvest.

Integration of Genomic Biology Into Therapeutic Strategies of Gastric Cancer Peritoneal Metastasis.

The peritoneum is a common site of metastasis in advanced gastric cancer (GC). Diagnostic laparoscopy is now routinely performed as part of disease staging, leading to an earlier diagnosis of synchronous peritoneal metastasis (PM). The biology of GCPM is unique and aggressive, leading to a dismal prognosis. These tumors tend to be resistant to traditional systemic therapy, and yet, this remains the current standard-of-care recommended by most international clinical guidelines. As this is an area of unmet clinical need, several translational studies and clinical trials have focused on addressing this specific disease state. Advances in genomic sequencing and molecular profiling have revealed several promising therapeutic targets and elucidated novel biology, particularly on the role of the surrounding tumor microenvironment in GCPM. Peritoneal-specific clinical trials are being designed with a combination of locoregional therapeutic strategies with systemic therapy. In this review, we summarize the new knowledge of cancer biology, advances in surgical techniques, and emergence of novel therapies as an integrated strategy emerges to address GCPM as a distinct clinical entity.

Resistance to systemic immune checkpoint inhibition in the peritoneal niche.

Immune checkpoint inhibition (ICI) is an established therapeutic option for patients with deficient mismatch repair or high levels of microsatellite instability tumors. Yet, response to ICI among this group is varied, with nearly one-third of patients exhibiting primary resistance. Initial efforts in studying mechanisms of resistance to ICI have focused on intrinsic tumor factors. Host factors such as metastatic niches have unique biological properties that may mediate resistance to ICI but have been less studied date. Patients with metastatic d-MMR/MSI-H gastrointestinal cancers and peritoneal metastases (PM) who had concurrent ascites have been recently shown to have worse outcomes with ICI therapy compared with patients with PM without ascites and patients with non-PM metastases. The juxtaposition of tumors with an intrinsic sensitivity to ICI failing to respond by virtue of the presence of ascites within the peritoneum, brings to the forefront the critical role of the metastatic niche. In this commentary, we discuss mechanisms for ICI resistance that may arise from the immunoprivileged state of the peritoneal cavity, paracrine factors within malignant ascites or tumor-peritoneum interactions. An improved understanding of the peritoneal microenvironment and the use of peritoneal-directed therapies may ameliorate the modest benefit of ICIs in this unique clinical entity.

Lymphocyte-White Cell Ratio Is a Novel Marker of Morbidity Following Colorectal Cancer Surgery.

BACKGROUND: A preoperative marker for morbidity in patients with colorectal cancer would help to risk stratify patients and allow for timely intervention to avert poor outcomes. We conducted this study to evaluate preoperative lymphocyte-white blood cell ratio (LWR) as a marker of postoperative morbidity. METHODS: A prospective cohort of patients who underwent elective surgery for colorectal cancer was reviewed. Three morbidity-related outcomes were described-overall morbidity, multiple morbidities, and severe morbidity, defined as Clavien-Dindo Class ≥3. Univariable and multivariable analyses of presurgical predictors of these three outcomes were performed. Preoperative variables included hemoglobin levels, neoadjuvant therapy, albumin levels, white blood cell count, lymphocyte count, LWR, neutrophil-lymphocyte ratio, and prognostic nutritional index. RESULTS: Of 177 patients, 31.6% (56/177) suffered at least one morbidity, 15.3% (27/177) had multiple morbidities, 7.9% (14/177) suffered severe morbidity. On multivariate analysis, only LWR <0.180 (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.15-5.55) and neoadjuvant therapy (OR 2.49, 95% CI 1.16-5.24) were associated with overall morbidity. For multiple morbidities and severe morbidity, only LWR <0.180 was significantly associated on multivariate analysis with an OR of 2.92 (95% CI 1.19-7.13) and 4.62 (95% CI 1.45-14.73), respectively. CONCLUSIONS: LWR is a preoperative marker which can be conveniently applied using standard preoperative blood tests. LWR is an independent risk factor for overall morbidity, multiple morbidities, as well as severe morbidity when used with a cut-off of LWR<1.80.

Age is an independent risk factor for increased morbidity in elective colorectal cancer surgery despite an ERAS protocol.

INTRODUCTION: Elderly patients with colorectal cancer are high-risk surgical candidates. ERAS protocols have been developed to mitigate against these risks. We performed this study to quantify the risks which elderly patients face and then to determine independent risk factors for short-term ERAS-specific outcomes. METHODS: An analysis of a prospectively collected audit database of all patients who underwent elective colorectal cancer resection within an ERAS framework from January 2018 to December 2018 was performed. Elderly was defined in our study as age ≥ 65 years. RESULTS: There were 172 elective colorectal cancer resections performed. Ninety-seven (56.4%) were elderly. Elderly patients were at increased risk of developing post-operative complications (33.0% vs 16.0%, p = 0.011), longer time to diet (3.4 vs 2.2 days, p = 0.001), and longer hospital stay (10.9 vs 6.7 days, p = 0.007). Independent risk factors were determined for the abovementioned three outcomes. Elderly status was the only risk factor for increased complications (OR 2.61 95% CI (1.05-6.51), p = 0.040). For delayed time to soft diet, male gender (OR 6.67(1.92-20.0), p = 0.002), open approach (OR 9.06(2.26-36.30), p = 0.002), and increased operative time (OR 1.01(1.00-1.01) p = 0.014) were risk factors. Finally, elderly age (OR 5.53(1.82-16.84), p = 0.003), leucocyte count (OR 1.39(0.76-2.57), p = 0.038), open approach (OR 5.26(1.41-19.62), p = 0.013), operative time (OR 1.01(1.00-1.01), p = 0.021), and Clavien-Dindo classification (OR 7.97(1.27-49.88), p = 0.027) were risk factors for prolonged length of stay. CONCLUSION: Elderly patients are intrinsically at risk for increased complications, longer time to soft diet and longer hospital stay. ERAS protocols may need to be specifically tailored for elderly patients.

Patient-Reported Outcomes and Long-Term Results of a Randomized Controlled Trial Comparing Single-Port Versus Conventional Laparoscopic Inguinal Hernia Repair.

BACKGROUND: Surgical techniques for inguinal hernia repair have evolved rapidly from open methods to conventional laparoscopic totally extra-peritoneal (CTEP) and recently single-port TEP (STEP). As there is currently no randomized controlled trial (RCT) reporting long-term patient-reported outcomes between CTEP and STEP, we reviewed patients who were randomized to CTEP or STEP 5 years after surgery. METHODS: Telephone interviews were administered to patients with primary unilateral inguinal hernia recruited for the RCT comparing CTEP and STEP in 2011. The modified Body Image Questionnaire was used to measure long-term patient-reported outcomes. RESULTS: Forty-two out of forty-nine of the STEP group and forty-one out of fifty of the CTEP group responded to phone interviews. Median follow-up time, demographic data and clinical outcomes were comparable between both groups. The Body Image Score (5-20: 5-least dissatisfied, 20-most dissatisfied; BIS score ± SD, STEP vs. CTEP, 5.33 ± 0.90 vs. 7.17 ± 1.87, p < 0.001) and Cosmetic Score (2-20: 2-least satisfied, 20-most satisfied; CS score ± SD, STEP vs. CTEP, 19.05 ± 1.31 vs. 15.87 ± 1.57, p < 0.001) were superior in the STEP group. Similarly, self-reported scar perception (1-cannot be seen, 2-can barely be seen, 3-visible; scar perception score ± SD, STEP vs. CTEP, 1.29 ± 0.51 vs. 2.55 ± 0.64, p < 0.001) and overall experience score (1-least satisfied, 10-most satisfied; overall satisfaction score ± SD, STEP vs. CTEP, 9.57 ± 0.67 vs. 8.22 ± 0.94, p < 0.001) were superior in the STEP group. CONCLUSION: Patients who underwent STEP reported superior cosmetic and satisfaction scores and comparable surgical outcomes 5 years after surgery compared to the CTEP group. STEP should be strongly considered in patients who are concerned about long-term cosmetic outcomes and should be offered if surgical expertise is available. Trial registration NCT02302937.

Correction to: Prevalence of colorectal cancer in acute uncomplicated diverticulitis and the role of the interval colonoscopy.

The original version of this article, unfortunately, contained errors. The first and family names of the authors were interchanged. The correct author names are now correctly presented in this article. The original article has been corrected.].

Prevalence of colorectal cancer in acute uncomplicated diverticulitis and the role of the interval colonoscopy.

PURPOSE: Although computed tomography (CT) is the imaging modality of choice for diagnosing colonic diverticulitis today, there remains a risk of colorectal cancer mimicking diverticulitis due to overlapping imaging features. Current practice guidelines recommend interval colonoscopy after diverticulitis to exclude occult malignancy. Some authors have suggested that this may be unnecessary in patients with uncomplicated diverticulitis. The aim of our study was to examine the prevalence of occult colorectal cancer in patients with CT-proven acute uncomplicated diverticulitis in an Asian population. METHODS: This was a retrospective study of all patients admitted for CT-proven acute uncomplicated diverticulitis between 2007 and 2011 in a single institution. Colonoscopy and histopathology reports were reviewed for patients who underwent interval colonic evaluation. For patients who defaulted follow-up, national health records were reviewed for any subsequent diagnoses of colorectal cancer. The primary outcome was prevalence of colorectal cancer in the cohort. Secondary outcome was prevalence of advanced adenomas. RESULTS: A total of 227 patients with acute uncomplicated diverticulitis were included in our study. One hundred and thirty-five patients (59.5%) underwent follow-up colonic evaluation. The overall prevalence of colorectal cancer was 1.8%, with half these patients presenting with acute colonic obstruction after defaulting follow-up evaluation. Of the patients, 1.5% who underwent colonoscopy had advanced adenomas. CONCLUSION: Prevalence of colorectal cancer in patients with CT-proven acute uncomplicated diverticulitis may not be as low as previously suggested. We recommend that patients with acute uncomplicated diverticulitis continue to be offered interval colonoscopy until larger studies demonstrate the safety of omission.

ALPPS for Hepatocellular Carcinoma Is Associated with Decreased Liver Remnant Growth.

BACKGROUND: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been widely described for colorectal liver metastases with insufficient future liver remnant (FLR). However, its role in hepatocellular carcinoma (HCC) remains poorly defined and not widely accepted. METHODS: A retrospective comparison of clinical data, liver volumetry, histological characteristics, and surgical outcomes between nine HCC and four non-HCC patients who underwent ALPPS was performed. RESULTS: Patients with HCC were more likely to have histological evidence of hepatic fibrosis (HCC vs. non-HCC, 66.7 vs. 0%, p = 0.049). Baseline demographic and disease characteristics were otherwise comparable between both groups. FLR growth after ALPPS-Stage 1 was significantly less in HCC patients (HCC vs. non-HCC, 154.5 vs. 251.0 ml, p = 0.012). FLR growth was also significantly decreased in patients with hepatic fibrosis (fibrosis vs. non-fibrosis, 157.5 vs. 247.5 ml, p = 0.033). There was no difference in post-hepatectomy liver failure (HCC vs. non-HCC, 28.6 vs. 25%, p = 0.721) or 90-day mortality (HCC vs. non-HCC, 11.1 vs. 0%, p = NS). DISCUSSION: In our study, HCC patients demonstrated significantly less FLR growth after ALPPS-Stage 1 compared to non-HCC patients. Hepatic fibrosis was also found to negatively impact FLR growth. When considering suitability for ALPPS, patients with HCC may benefit from additional pre-operative assessment of fibrosis.