The Frailty Based on the Memorial Sloan Kettering Frailty Index for Prediction of Surgical Outcome in Advance Epithelial Ovarian Cancer-Experience of a Single Center in Mexico.

Retrospective impact evaluation of frailty as measured by the Memorial Sloan Kettering Frailty Index (MSK-FI) on outcomes in older women surgically treated for advanced epithelial ovarian cancer (EOC). Women ≥ 60 years with stage IIIC/IV EOC who underwent primary debulking surgery (PDS) or interval debulking surgery (IDS) were included. Medical records were reviewed for patients' characteristics and outcomes. We retrospectively applied the MSK-FI which included 10 comorbidities and functional assessment that were extracted from medical records. The MSK-FI ranges from 0 to 11; a score of ≥ 3 was considered frail. Associations were assessed using logistic regression and Cox proportional hazards regression. We identified 79 patients treated with PDS (n = 36, 45.5%) or IDS (n = 43, 54.4%) with complete data. The prevalence of frailty based on MSK-FI was 25%. Almost half of the frail patients (47.3%) were admitted to the ICU compared to 16% of non-frail patients (p = 0.006). In univariable analysis, the MSK-FI was associated with postoperative complications [OR 1.57 (95% CI 1.04-2.37), p = 0.03] and ICU admission [OR 2.05 (95% CI 1.30-3.23), p = 0.002], but not with readmission rate [OR 1.29 (95% CI 0.65-2.59), p = 0.5], postoperative mortality [OR 1.02 (95% CI 0.51-2.00), p = 0.9], and hospital stay [ß 0.60 (95% CI - 1.19-2.41)]. In multivariable analysis, the frailty index was independently associated with postoperative complications [OR 1.54 (95% CI 1.02-2.34), p = 0.04] and ICU admissions [OR 1.97 (95% CI 1.23-3.16), p = 0.004]. Frailty, based on the Memorial Sloan Kettering Frailty Index, is associated with adverse postoperative outcomes in older women with advanced ovarian cancer, suggesting that MSK-FI can improve the predictive ability of current surgical assessment tools.

Predictors of anastomotic leak after total gastrectomy in patients with adenocarcinoma.

BACKGROUND: Esophagojejunal anastomotic leakage (EJAL) is among the most feared complications after gastric cancer surgery; they entail an uncertain prognosis and relate with increased morbidity and mortality. Factors associated with their development are not well determined, and their diagnosis and treatment vary between institutions. MATERIAL AND METHODS: Retrospective case-control study of patients operated of total gastrectomy with Roux-en-Y esophagojejunostomy from January 2002 to December 2018. We divided our sample into two groups based on the presence of EJAL, and compared demographic, clinical, and histologic variables. We performed a logistic regression model to search risk factors associated with EJAL and described the management offered in our center. RESULTS: We included 58 patients of which 8 (13.7%) presented clinically relevant EJAL. On the comparative analysis, albumin levels and diffuse histology presented a statistically significant difference between groups and presented association with EJAL in the logistic regression model. Regarding treatment of EJAL, ten patients (55.5%) required only conservative measures, whereas eight patients (44.4%) warranted an endoscopic or surgical intervention. CONCLUSION: Our retrospective analysis identified some factors that may be associated with the development of EJAL after gastric cancer surgery. High suspicion and prompt identification of this complication is essential to improve postoperative outcomes in this group.

INTRODUCCIÓN: Las fugas de la anastomosis esófago-yeyunal se encuentran entre las más temidas complicaciones de la cirugía para cáncer gástrico. Estas conllevan un mal pronóstico con una alta mortalidad y morbilidad. Los factores asociados a su desarrollo no están bien determinados y su diagnóstico, y tratamiento varían ampliamente entre instituciones. MATERIAL Y MÉTODOS: Estudio retrospectivo de casos y controles en pacientes operados de gastrectomía total con esófago-yeyuno anastomosis en Y de Roux en el periodo de enero 2002 a diciembre 2018. Nuestra muestra fue dividida en dos grupos con base al desarrollo de fuga de anastomosis en el postoperatorio. Se realizó un análisis comparativo de características demográficas, clínicas y histológicas. Se realizó además una regresión logística para identificar factores de riesgo asociados al desarrollo de fuga de anastomosis en nuestra serie. RESULTADOS: Incluimos a 58 pacientes de los cuales 8 (13.7%) presentaron fuga de anastomosis clínicamente relevante. En el estudio comparativo: Niveles disminuidos de albúmina e histología difusa fueron significativamente mayores en el grupo de fuga y se asociaron en el modelo de regresión logística. En cuanto al tratamiento, diez pacientes (55%) requirieron únicamente tratamiento conservador, mientras que ocho pacientes (44.4%) fueron sometidos a maniobras endoscópicas o quirúrgicas. CONCLUSIÓN: Nuestro análisis retrospectivo identifico factores asociados al desarrollo de fuga de anastomosis posterior a cirugía de cáncer gástrico. Una alta sospecha diagnóstica es esencial para mejorar el pronóstico de estos pacientes.

Risk Factors Associated to Residual Tumor in Re-excision for Positive Margins in Breast Conservative Surgery.

BACKGROUND: Breast conservative surgery (BCS) is an adequate treatment for patients with early breast cancer. Local recurrence is associated with diverse factors. Our objective was to evaluate risk factors associated with finding residual tumor in patients with positive margins in BCS. METHODS: Observational retrospective study, including patients diagnosed with breast cancer undergoing BCS between 2000 and 2016. Clinicopathological and treatment variables were collected. Main outcome was the finding of residual tumor on re-excision. Positive margins were defined as tumor present on ink. RESULTS: Three hundred and six patients underwent BCS. Mean age was 57 ± 12.2 years. Positive margins were found in 84 (27.4%) patients, 15 (4.9%) had unknown margin status, and 207 (67.6%) had negative margins. Seventy-eight patients from the positive margin group and 23 patients from the unknown/negative margin group were reintervened. Residual tumor was present in 41% of patients with positive margins and in 45% of patients with negative margins (P = .192). In univariate analysis, overweight (P = .04) and positive axillary lymph nodes (P = .02) were associated with residual tumor on re-excision. In multivariate analysis, postmenopausal status was a protective factor (HR .047, P = .30). Mean follow-up was 58.4 months and mean local recurrence-free survival (LRFS) was 56.4 months (.1-203.2), with no difference regarding margin status or residual tumor. DISCUSSION: Postmenopausal status was associated with a decreased rate of residual tumor in patients with positive margins. The presence of residual tumor on re-excision was not associated with a lower LRFS. These factors must be considered when positive margins are present in BCS.

Exenteración pélvica para cáncer de recto localmente avanzado y recurrente: resultados a largo plazo y factores pronósticos.

OBJETIVO: El objetivo de este trabajo fue analizar los resultados perioperatorios y a largo plazo de los pacientes sometidos a exenteración pélvica para cáncer de recto en un centro de referencia en la Ciudad de México. MÉTODO: Se incluyeron todos los pacientes que se sometieron a exenteración pélvica por cáncer de recto entre 1995 y 2019. Se analizaron variables demográficas, clínicas, quirúrgicas y patológicas. RESULTADOS: Se incluyeron 18 pacientes operados por cáncer de recto (16 localmente avanzados y 2 recurrentes). La relación hombre: mujer fue de 1:3.5. La morbilidad mayor fue del 27.7%. El sangrado intraoperatorio ≥ 1000 ml se asoció con morbilidad (80 vs. 20%; p = 0,029) y mortalidad posoperatoria (100 vs. 0; p = 0.043). La mediana de sobrevida global fue 102 meses. Las sobrevidas global y libre de enfermedad a los 5 años fueron del 44.4% y el 38.8%, respectivamente. La invasión linfovascular fue un factor de mal pronóstico para sobrevida libre de enfermedad (p = 0.017). CONCLUSIONES: La exenteración pélvica para el cáncer de recto es un procedimiento quirúrgico con altas morbilidad y mortalidad. La invasión linfovascular es un factor de mal pronóstico para la sobrevida libre de enfermedad. INTRODUCTION: Pelvic exenteration is a radical treatment for locally advanced and recurrent pelvic tumors. The aim of this study was to analyze the perioperative and long-term outcomes of patients undergoing pelvic exenteration for rectal cancer at a referral center in Mexico City. METHOD: We included all patients who underwent pelvic exenteration due to rectal cancer between 1995 and 2019. Demographic, clinical, surgical and pathological variables were analyzed. RESULTS: 18 patients were included (16 locally advanced and 2 recurrent). The male-female ratio was 1:3.5. The highest morbidity was 27.7%. Intraoperative bleeding ≥ 1000 ml was associated with postoperative morbidity (80 vs. 20%; p = 0.029) and mortality (100 vs. 0; p = 0.043). The median overall survival was 102 months. Overall survival and disease free survival at 5 years after exenteration were 44.4% and 38.8%, respectively. Lymphovascular invasion of the tumor was a poor prognostic factor for disease free survival (p = 0.017). CONCLUSIONS: Pelvic exenteration for rectal cancer is a surgical procedure with high morbidity and mortality. Lymphovascular invasion is a poor prognostic factor for disease-free survival.

Frailty index as a predictive preoperative tool in the elder population undergoing major abdominal surgery: a prospective analysis of clinical utility.

PURPOSE: The geriatric population has increased considerably in the last decades. Such increases come along with new challenges for surgical practitioners, who now face a risen number of frail patients in need of major operations. The value of frailty indexes in this setting has been discussed recently. This study assessed the modified Rockwood frailty index (mRFI) as a predictive tool for postoperative complications in older adults subjected to major abdominal operations and correlated it with other scores widely utilized for this purpose. METHODS: We performed a prospective study utilizing the mRFI including all patients older than 65 years subjected to major abdominal surgery between May 2017 and May 2019 in a third-level academic center. A comparison between frail (mRFI >0.25) and non-frail patients (mRFI <0.25) was performed. We performed logistic regression to identify predictors of postoperative complications and 30-day mortality. We analyzed the correlation between mRFI and ACS-NSQIP, P-POSSUM, PMP, and Charlson score risk calculators. RESULTS: One hundred forty patients were included in our study, of whom 49 (35%) were identified as frail. Frail patients demonstrated significantly prolonged hospital stay (p<.0001), ICU admission rates (p=0.004), hospital readmissions (p=0.007), and higher mortality rates (p=0.02). Our univariate analysis associated frailty (mRFI>0.25), ASA >III, increased age, and BMI with postoperative complications. In our multivariate analysis, frailty remained an independent predictor for postoperative complications (OR 6.38, 95% CI [2.45-16.58], p<0.001). Frailty was also associated with length of stay (LOS) regardless of the type of surgery (OR 3.35, 95% CI [0.37-6.33], p= 0.03). mRFI>0.25 demonstrated a sensitivity (Se) of 70% and specificity (Sp) 67% with area under the curve (AUC) 0.75 for perioperative complications, Se 69% and Sp 70% with AUC 0.74 for ICU admissions, and Se 83% and Sp 68% with AUC 0.83 for mortality. CONCLUSION: Frail patients demonstrated significantly prolonged hospital stay, ICU admission rates, hospital readmissions, and higher mortality rates. mRFI is an independent predictor for perioperative complications with a Se of 70% and Sp 67% and AUC 0.75.

Non-epithelial ovarian carcinoma: what is the optimal staging surgery?

Non-epithelial ovarian neoplasms are a group of infrequent, heterogenous clinical and histological tumors that account from 6% to 10% of ovarian malignancies, the two most common non-epithelial ovarian neoplasms are germ cell tumors and sex cord-stromal cell tumors, each of these classifications is divided in multiple histologic subtypes. In the case of epithelial ovarian tumors comprehensive surgical staging has remained as the gold standard for staging, nonetheless for non-epithelial ovarian neoplasms the use of staging surgery has remained debatable and controversial throughout the years in order to correctly stage non-epithelial ovarian carcinomas. Despite the fact that the role of surgery remains critical in the adequate management of all ovarian tumors, there are several manners to surgically approach an ovarian tumor depending on the type of tumor, risk factors and staging of disease. There are multiple reasons why the use of surgery in non-epithelial ovarian tumors is still debatable nowadays, for instance the main reason relies in the low prevalence of this disease, therefore there are few studies that actually offer a clear and sufficient overview to this issue. The objective of this manuscript is to present a comprehensive review of the non-epithelial carcinoma and to focus in the latest information, evidence and recommendations about the optimal treatment and staging surgery for these tumors.

Clinical characteristics and surgical treatment of schwannomas of the esophagus and stomach: A case series and systematic review.

BACKGROUND: Gastrointestinal schwannomas are slow-growing benign mesenchymal neoplasms that originate from Schwann cells of the nerve sheath of Auerbach´s plexus or less frequently from Meissner´s plexus. The main differential diagnosis of gastric schwannomas are the gastrointestinal stromal tumors (GISTs), which are classified by their immunohistochemistry. The treatment of choice for gastric schwannomas is surgery where laparoscopy plays an important role. Wedge resection, subtotal or total gastrectomy can be done. In its counterpart, esophageal schwannomas are benign tumors of the esophagus that are very uncommon since they comprise less than 2% of all esophageal tumors. The main differential diagnosis is the leiomyoma which corresponds to the most common benign esophageal tumor, followed by GIST. The treatment consists on tumoral enucleation or esophagectomy. AIM: To review the available literature about gastrointestinal schwannomas; especially lesions from de stomach and esophagus, including diagnosis, treatment, and follow up, as well as, reporting our institutional experience. METHODS: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. The following databases were used for reviewing process: PubMed, Ovid, MEDLINE, and Scopus. Only English language manuscripts were included. All gastrointestinal schwannomas specifically located in the esophagus and stomach were included. Cases that did not report long-term follow-up were excluded. RESULTS: Gastric localization showed a higher prevalence in both, the literature review and our institution: 94.95% (n = 317) and 83% (n = 5) respectively. With a follow-up with disease-free survival greater than 36 mo in most cases: 62.01% (n = 80) vs 66.66% (n = 4). In both groups, the median size was > 4.1 cm. Surgical treatment is curative in most cases. CONCLUSION: Schwannoma must be taken into account in the differential diagnosis of gastrointestinal mesenchymal tumors. It has a good prognosis, and most are benign. A disease-free survival of more than 36 mo can be achieved by surgery.

Acute cholecystitis in neutropenic patients.

BACKGROUNDS/AIMS: The frequency of acute cholecystitis reported in neutropenic patients is between 0.4-1.65%. Clinical manifestations differ from general population as well as clinical approach, diagnosis and treatment. The aim of this work is to describe clinical characteristics, diagnostic approach, and outcomes of patients with hematological diseases that presented with neutropenia and fever associated with acute cholecystitis in a tertiary referral hospital. METHODS: We performed a retrospective analysis of patients with diagnosis of neutropenia and fever associated with acute cholecystitis in the period between January 2000 and January 2017. Quantitative variables were analyzed with mean and standard deviation, and qualitative variables with frequency and percentage. RESULTS: During the study period, 2007 patients presented with neutropenia and fever. Twelve of them (0.59%) had associated acute cholecystitis. The most common hematologic disease among these patients was lymphoblastic leukemia. Acute acalculous cholecystitis was diagnosed in 6 cases (50%). Eleven patients (91.6%) had a severe presentation and cholecystostomy was performed in 9 (75%) cases. The main cause of mortality was septic shock (33.3%). CONCLUSIONS: Treatment of acute cholecystitis in patients with neutropenia must be individualized. Cholecystostomy should be considered as a bridge therapy for an interval cholecystectomy.

II. The research ethics involving vulnerable groups

Abstract Vulnerability in research occurs when the participant is incapable of protecting his or her interests and therefore, has an increased probability of being intentionally or unintentionally harmed. This manuscript aims to discuss the conditions that make a group vulnerable and the tools and requirements that can be used to reduce the ethical breaches when including them in research protocols. The vulnerability can be due either to an inability to understand and give informed consent or to unequal power relationships that hinder basic rights. Excluding subjects from research for the only reason of belonging to a vulnerable group is unethical and will bias the results of the investigation. To consider a subject or group as vulnerable depends on the context, and the investigator should evaluate each case individually.

Randomized Controlled Trial to Reduce Bacterial Colonization of Surgical Drains with the Use of Chlorhexidine-Coated Dressings After Breast Cancer Surgery.

BACKGROUND: Breast surgery is considered a clean surgery. However, surgical-site infection (SSI) rates are currently higher than predicted. Postoperative drains remain in situ for several days, with inevitable bacterial colonization and increased SSI risk. METHODS: This randomized controlled trial from October 2016 to January 2018 analyzed patients undergoing breast cancer surgery. The patients were randomized to either the standard drain care group or the antiseptic dressing group (3M® Tegaderm® CHG). Drain samples taken on postoperative days (PODs) 7 and 14 were cultured as standardized in the laboratory. Colonization rates and SSI were compared between the two groups. RESULTS: The study enrolled 104 patients with 167 surgical drains. The patients' clinical characteristics were similar in the two groups, with no statistically significant differences. Bulb fluid cultures at postoperative week (POW) 1 were positive for 42.9% of the control group and 28.9% of the antiseptic group (p = 0.06). Cultures from the POW 2 assessment were positive for 79.7% of the control group versus 54.9% of the antiseptic group (p = 0.001). Cultures from drain tubes were positive for 79.8% of the control group and 50.7% of the antiseptic group (p = < 0.001). In 11 patients, an SSI developed, 3 (5.8%) from the intervention and 8 (15.4%) from the control procedure (p = 0.11). CONCLUSION: The study findings demonstrated that the use of antiseptics at the drain exit site significantly reduced bacterial colonization of the closed drainage system in breast cancer surgery. Semi-permeable occlusive chlorhexidine-impregnated dressings provide an opportunity to test simple, safe, and low-cost interventions that may reduce drain bacterial colonization and SSI after breast surgery.

I. The role of research ethics committees in observational studies: epidemiological registries, case reports, interviews, and retrospective studies

Abstract It is often unclear to the clinical investigator whether observational studies should be submitted to a research ethics committee (REC), mostly because, in general, no active or additional interventions are performed. Moreover, obtaining an informed consent under these circumstances may be challenging, either because these are very large epidemiological registries, or the subject may no longer be alive, is too ill to consent, or is impossible to contact after being discharged. Although observational studies do not involve interventions, they entail ethical concerns, including threats such as breaches in confidentiality and autonomy, and respect for basic rights of the research subjects according to the good clinical practices. In this context, in addition to their main function as evaluators from an ethical, methodological, and regulatory point of view, the RECs serve as mediators between the research subjects, looking after their basic rights, and the investigator or institution, safeguarding them from both legal and unethical perils that the investigation could engage, by ensuring that all procedures are performed following the international standards of care for research. The aim of this manuscript is to provide information on each type of study and its risks, along with actions to prevent such risks, and the function of RECs in each type of study.

Soft tissue angiosarcoma of the breast in a patient with Klippel-Trenaunay-Weber syndrome.

Angiosarcomas are neoplasms of blood or lymphatic vessels with aggressive behavior. We report the coexistence of this malignancy within soft tissue of the breast in a 49-year-old woman who was diagnosed with Klippel-Trenaunay-Weber syndrome (KTW-S) during childhood. The patient has no previous history of radiation therapy on the chest and does not have any known risk factor for developing angiosarcoma, except for her congenital disease. To the best of our knowledge, the association between soft tissue angiosarcoma of the breast and KTW-S has never been previously reported.

Los angiosarcomas son neoplasias de los vasos sanguíneos y linfáticos con comportamiento agresivo. Reportamos la coexistencia de esta malignidad dentro del tejido blando de la mama en una mujer de 49 años que fue diagnosticada de síndrome de Klippel-Trenaunay-Weber desde la infancia. La paciente no tiene antecedentes de radioterapia en el tórax ni factores de riesgo conocidos para desarrollar angiosarcoma, a excepción de su enfermedad congénita. A nuestro saber, la asociación entre el angiosarcoma del tejido blando de la mama y el síndrome de Klippel-Trenaunay-Weber no había sido reportada previamente.

Neoadjuvant chemotherapy and interval debulking surgery for advanced ovarian cancer, an alternative with multiple advantages.

Ovarian cancer, which is mostly diagnosed in advanced stages, is a disease with high mortality among women. Until now, no screening strategies have been accepted and are currently under study because although they help in the diagnosis at early stages, they do not increase survival. The gold standard treatment for advanced ovarian cancer is based on primary debulking surgery (PDS) follow by adjuvant chemotherapy (ACT) with paclitaxel and carboplatin. Recently, treatment alternatives have been proposed: neoadjuvant chemotherapy (NAC) with interval debulking surgery (IDS). This approach has been controversial due to the lack of clinical data on the validity as a safe and successful procedure and because of the high morbidity and mortality associated to this disease. The most important prognostic factor for survival is no residual tumor after surgery; despite of this, numerous tumors do not fulfill the criteria for performing a PDS and associated morbidity is unacceptable high. Based on selected clinical features, NAC-IDS could be a reasonable alternative to those patients with reversible contraindications to primary surgery with the only objective of improving survival and quality of life (QOL). Although, several papers have reported that NAC could induce ACT resistance, neither randomized controlled trials nor meta-analyses have demonstrated this fact. The true is that more advantages have been reported: NAC groups trend toward higher QOL and lower rates of postoperative adverse events. This has been confirmed by two randomized clinical trials, but further studies are needed to support the role of NAC. Meanwhile, patients should receive the best opportunities and the best option for treating this type of cancer.