Management of malignant Gastric Outlet Obstruction (mGOO) due to pancreatic cancer in the era of EUS-Gastrojejunostomy: an international practice survey and case vignette study by Pancreas 2000 from the European Pancreatic Club.

BACKGROUND: Malignant Gastric Outlet Obstruction (mGOO) has been standardly treated by surgical Gastrojejunostomy (S-GJ) or Endoscopic Stenting (ES). Recently, EUS-Gastrojejunostomy (EUS-GJ) has emerged as an alternative, despite its worldwide diffusion is heterogeneous. The aim of this survey was to assess clinical decision-making around mGOO and to explore current opinions regarding EUS-GJ. METHODS: An online survey, spread through social networks and EPC newsletter, was created exploring opinions regarding indications, contraindications, benefits/risks, availability of mGOO treatments; 2 case vignettes explored clinical decision-making in different scenarios. RESULTS: Overall, 290 pancreatologists from 44 countries responded, of whom 35% surgeons and 65% gastroenterologists. The most common treatment for mGOO was ES (86%), followed by laparoscopic GJ (76%). EUS-GJ was accessible to 59% of respondents, with 10% proficient in this technique. Gold-standard treatment for mGOO varied by specialty; 45% of gastroenterologists preferred ES, 20% EUS-GJ, and 10% surgical GJ, while among surgeons, these were 24%, 8%, and 25%, respectively. A higher annual volume of mGOO treated correlated with increased EUS-GJ adoption and reduced surgical advice. For 51%, EUS-GJ will become the primary treatment for mGOO, notably higher among gastroenterologists and high-volume centers. For 14%, EUS-GJ spread will be limited in the future, or used only when ES fails (19%). Life expectancy, disease stage and patient's frailty are the main decision driver in therapeutic choice, whereas future surgical resectability does not contraindicate any treatment for 75%. EUS-GJ's main advantages were its minimally invasive nature and clinical efficacy, offset by its steep learning curve. CONCLUSIONS: This survey revealed significant differences in the management of mGOO, depending on specialties, local expertise and treatment volume, suggesting the lack of standardized algorithms. Life expectancy and patients' frailty are the main decision drivers. Regarding EUS-GJ, its availability remains suboptimal, with learning curve as the main perceived barrier.

External Validation of a Nomogram Developed for Predicting Overall Survival in Gastric Cancer Patients with Insufficient Number of Examined Lymph Nodes.

Objectives: Nomograms and scoring systems in gastric cancers have been mainly developed based on adequate lymph node (lN) dissections. This study aimed to perform external validation of a nomogram developed for predicting overall survival (OS) in gastric cancer patients with insufficient number of examined LNs (eLNs) and to evaluate its usability as compared with the 8th American Joint Committee on Cancer (AJCC)'s Tumor-Node-Metastasis staging system. Methods: Medical records of 262 patients undergoing complete surgical resection for gastric cancers and having pathologically confirmed diagnosis were retrospectively reviewed. The study included 104 (39.7%) patients (82 males, median age, 60.3 years) with insufficient number of eLNs (<16). The 5-year OS rate was calculated using the nomogram and according to the AJCC system. Results: The median follow-up period was 37.4 months (range: 0.9-122.9). Of the patients, 69 (66.3%) died and 35 (33.7%) achieved 5-year survival within the follow-up period. The nomogram and the AJCC system predicted OS were significantly lower in patients who died than in those who achieved 5-year survival (p<0.001 for both). According to the receiver operative characteristics-curve, the area under the curve for the nomogram (0.801; 95% CI, 0.715-0.887; p<0.001) was larger than that for the AJCC system (0.754; 95% CI, 0.659-0.849; p<0.001). Conclusion: The nomogram developed for gastric cancer patients with insufficient number of eLNs (<16) was effective in predicting 5-year OS in our cohort and was superior to the AJCC system.

Genetic landscape of pancreatic cancer: a narrative review.

BACKGROUND AND OBJECTIVE: Pancreatic cancer is an aggressive disease with an impaired survival despite improvements in clinical management. Thus, understanding disease biology is of vital importance in order to overcome therapeutic challenges and achieve better prognosis. The purpose of this review is to outline the genetic landscape of pancreatic cancer along with its clinical implications. METHODS: We reviewed existing literature using electronic databases to outline the genetic landscape in pancreatic cancer. KEY CONTENT AND FINDINGS: This review mainly contains information on the genetic background of pancreatic cancer, mainly KRAS, CDKN2A, TP53 and SMAD4, with emphasis on the importance of understanding disease biology. CONCLUSIONS: The genetic aspects of pancreatic cancer have been well described especially with the introduction of next generation sequencing techniques. Future studies focusing on translation of these alterations in clinical application might pave the way for personalized surveillance and therapy.

Does Albumin Level Change the Strength of the Memorial Sloan Kettering Cancer Center Nomogram Used to Predict 5-year Survival in Patients with Colon Cancer?

OBJECTIVE: To test the efficacy of including albumin in the Memorial Sloan Kettering Cancer Center (MKSCC) nomogram (MSKCC+A) on predicting the overall survival. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Ankara Training and Research Hospital & Ataturk Training and Research Hospital, Turkey, in 2020, on patients who were operated between 2009 and 2014 to confirm the 5-year survival results. METHODOLOGY: Patients who underwent R0 resection for colon cancer were evaluated. For each patient in the cohort, the 5-year probability of survival was calculated and compared with actual, using the AJCC (American Joint Committee on Cancer), MSKCC and MSKCC+A estimation systems obtained using logistic regression. The performance of the estimation methods was evaluated by the ROC analysis. RESULTS: Two hundred and thirty-nine patients were studied. When the patients with more than 5-year overall survival were compared, the AJCC, MSKCC, and enhanced MSKCC survival scores were significantly higher. AUC = 0.699 for the AJCC staging system, AUC = 0.702 for the MKSCC nomogram, and AUC = 0.777 when the albumin level was added to the MKSCC system. CONCLUSIONS: The use of the MSKCC overall survival nomogram in patients with colon cancer appears useful for both clinicians and patients. The prognostic power of this calculator was found to be further enhanced by including the preoperative serum albumin level as an extra variable in the nomogram. KEY WORDS: Nomograms, Neoplasm grading, Survival, Colon cancer, Serum albumin.

Gossypiboma mistaken for a hydatid cyst: case report.

Although considered a rare complication, gossypiboma continues to be a clinically important and probably more frequently encountered than reported situation. This study aimed to report a case of gossypiboma that was mistaken for a hydatid cyst in the preoperative evaluation. A 34-year-old male patient with a history of Nissen Fundoplication presented with a large mass palpable in the epigastrium and both the left upper and lower quadrants of the abdomen. Computerized tomography was reported to show a 20x18 cm cystic mass with a collapsed germinative membrane inside it. Laparotomy, which was performed with a suggested diagnosis of type 3 hydatid cyst, revealed that the mass was caused by a 30x30 cm surgical abdominal compress. We believe gossypiboma should be kept in mind in the differential diagnosis of abdominal hydatid cysts in the presence of a former abdominal operation, especially when the result of indirect hemagglutination test is negative.

Synthetic mesh placement in the presence of abdominal infection: An experimental study of feasibility.

BACKGROUND: There are varying opinions on the feasibility of the placement of synthetic materials in contaminated surgical fields. The aim of this study was to investigate the outcomes of the use of a commercially available composite mesh in the presence of abdominal infection. METHODS: Twenty-four hours after the induction of experimental peritonitis, 20 rats were randomized into 2 groups of 10 subjects. After abdominal cleansing with a second laparotomy, the abdomen was closed with running sutures in the control group and the composite mesh was applied in the experimental group before closure. The rats were followed up for findings of sepsis, mortality, and wound infection. On the 28th day, the rats were sacrificed and evaluated for abdominal infection, abdominal adhesions, and bacterial growth in the mesh and tissue cultures. RESULTS: The mortality rate was 0% and 30% in the control and mesh groups, respectively (p=0.21), and the wound infection rate was 20% and 57.1% (p=0.162). In the mesh group, the adhesions were significantly more intense (p=0.018) and significantly more microorganisms proliferated in the tissue cultures (p=0.003). CONCLUSION: The significant increase in the intensity of adhesions and bacterial proliferation, as well as the higher rate of mortality and wound infection in the mesh group indicated that this composite mesh cannot be used safely in the repair of abdominal defects in the presence of abdominal infection.

Surgeons' approach toward clinical nutrition: A survey-based study.

OBJECTIVE: Although many surgical patients face postoperative problems due to a poor nutritional status, there is evidence that many cases of malnutrition still go unnoticed and untreated in surgical wards. This study aims to define the current attitudes of surgeons toward nutritional screening and support. MATERIAL AND METHODS: A questionnaire with 13 questions was e-mailed to 1500 surgeons. Cross-queries were made over the responses. RESULTS: The response rate was 20.9%. Most of the respondents (89.5%) implemented nutritional screening. However, only 24.6% of these surgeons screened every patient for malnutrition. The time to initiate nutritional support varied among respondents, and only 25.5% started nutritional support early enough prior to surgery. Only 9.9% of respondents implemented evidence based practices for preoperative fasting, and 21.2% preferred immunonutrition products for patients undergoing major abdominal surgery for cancer. The responses of surgeons, who participated in at least one scientific meeting on nutrition per year, were more coherent with the nutrition guidelines. CONCLUSIONS: The results of this study reveal that the awareness and knowledge of clinical nutrition need improving amongst surgeons. To increase this awareness and knowledge, continuous learning throughout their career seems essential.

The effects of enoxaparin on the liver in experimental pneumoperitoneum model

ABSTRACT PURPOSE: To investigate the potential protective effects of enoxaparin against the adverse events of carbon dioxide (CO2) pneumoperitoneum. METHODS: Thirty four rats were divided into three groups: Group 1 (sham) underwent insertion of Veress needle into the abdomen and 90 min of anesthesia with no gas insufflation. The animals in control and enoxaparin groups were subjected to 90 min of 14 mmHg CO2 pneumoperitoneum. Enoxaparin (100 u/kg) was administered subcutaneously to the rats in enoxaparin group one hour before the operation. After 90 min of pneumoperitoneum, the rats were allowed for reperfusion through 60 min. Blood and liver samples were obtained for biochemical and histopathological examination. RESULTS: Treatment with enoxaparin decreased the histopathological abnormalities when compared with the control group. The highest levels of oxidative stress parameters were found in control group. The use of enoxaparin decreased the levels of all oxidative stress parameters, but the difference between the control and enoxaparin groups was not statistically significant. CONCLUSION: Enoxaparin ameliorated the harmful effects of high pressure CO2 pneumoperitoneum on the liver.

Liver schwannoma incidentally discovered in a patient with breast cancer.

BACKGROUND: Benign schwannomas, also referred to as neurilemomas, neurinomas, and perineural fibroblastomas, are encapsulated nerve sheath tumors. Primary schwannomas of the liver are extremely rare. We present a case of liver schwannoma, incidentally found in a patient with breast cancer. CASE: A 66-year-old female consulted her physician for a mass she palpated on her left breast. The abdominal ultrasonography (USG) revealed a 44 x 28 mm mass in the medial segment of the left lobe of her liver suspicious of a metastasis. An USG-guided biopsy was performed and the histo-pathological examination revealed a "peripheral nerve sheath tumor". Positron emission tomography (PET-CT) revealed a pathologic FDG uptake in the lesion that was previously defined in the liver. The tumor resected from the liver was 5 x 4 x 3 cm, yellowish, soft, and capsulated tumor. Microscopic examination revealed that the mass consisted of bundles of spindle cells with hypercellular and hypocellular areas. In immunohistochemistry, there was a strong positive staining for S-100. The tumor was diagnosed as benign liver schwannoma. CONCLUSION: Schwannomas are benign, encapsulated neoplasms. Symptoms and signs vary depending on the anatomical site and the size of the neoplasm; however, most schwannomas present as an asymptomatic or painless mass. Recurrence is unusual, despite of an incomplete removal, and malignant transformation is exceedingly rare (Fig. 4, Ref. 8). Full Text (Free, PDF) www.bmj.sk.