Role of Diagnostic Laparoscopy During Pancreatic Cancer Surgery in the Modern Era.

INTRODUCTION: Despite improvements in preoperative image resolution, approximately 10% of curative-intent resection attempts for pancreatic ductal adenocarcinoma are aborted at the time of operation. To avoid nontherapeutic laparotomy, many surgeons perform intraoperative diagnostic laparoscopy (DL) to identify radiographically occult metastatic disease. There are no consensus guidelines regarding DL in pancreatic cancer. The goal of this study is to investigate the efficacy of same-procedure DL at avoiding nontherapeutic laparotomy. METHODS: A single-institution retrospective review was performed from 2016 to 2022, identifying 196 patients with pancreatic ductal adenocarcinoma who were taken to the operating room for open curative-intent resection. Patient demographic, tumor characteristic, treatment, and outcome data were abstracted. Univariate and multivariate Cox hazard ratio analysis was performed to investigate risk factors for overall survival and recurrence-free survival. Number needed to treat (NNT) was calculated to identify number of DLs necessary to avoid one nontherapeutic laparotomy. RESULTS: Curative-intent resection was achieved in 161 (82.1%) patients. One hundred twenty six (64.0%) patients received DL prior to resection and DL identified metastatic disease in three (2.4%) patients with an NNT of 42. NNT of DL in a subgroup analysis performed on clinically high-risk patients (defined by preoperative or preneoadjuvant therapy carbohydrate antigen 19-9 > 500 U/mL) is 11. Receipt of DL did not prolong operative times in patients receiving pancreaticoduodenectomy when accounting for completed versus aborted resection. CONCLUSIONS: Although intraoperative DL is a short procedure with minimal morbidity, these data demonstrate that same-procedure DL has potential efficacy in avoiding nontherapeutic laparotomy only in a subgroup of clinically high-risk patients. Focus should remain on optimizing preoperative patient selection and further investigating novel diagnostic markers predictive of occult metastatic disease.

Peritoneal Metastases After Intraductal Papillary Mucinous Neoplasm Resection: How Common are They?

INTRODUCTION: Peritoneal metastases (PMs) following resection of pancreatic intraductal papillary mucinous neoplasms (IPMNs) are rare. Consequently, prevalence, risk factors, and prognosis are not well known. We reviewed our institution's experience and published literature to further characterize the scope of this phenomenon. METHODS: All pancreatectomy cases (556 patients) performed at a tertiary care center between 2010 and 2020 were reviewed to identify IPMN diagnoses. Patients with adenocarcinoma not arising from IPMN, or a history of other malignancies were excluded. RESULTS: Seventy-eight patients underwent pancreatectomy with IPMN on final pathology at our institution; 51 met inclusion criteria. Of these, there were five cases of PMs (4:1 females:males). Four had invasive carcinoma arising from IPMN and one had high-grade dysplasia at the index operation. Female sex and invasive histology were significantly associated with PM (P < 0.05). PM rates by sex were 3% (95% confidence interval [CI]: 0.5-15) in males and 22% (95% CI: 9-45) in females. Rates by histology were 2.9% (95% CI: 0.5-15) for noninvasive IPMN, and 23.5% (95% CI: 9.5-47) for invasive carcinoma arising from IPMN. Median interval from surgery to PMs was 7 mo (range: 3-13). CONCLUSIONS: PMs following IPMN resection are rare but may be more common in patients with invasive histology. Although rare, PMs can arise in patients with noninvasive IPMNs. Further studies on pathophysiology and risk factors of PM following IPMN resection are needed and may reinforce adherence to guidelines recommending long-term surveillance.

A National-Level Validation of the New American Joint Committee on Cancer 8th Edition Subclassification of Stage IIA and B Anal Squamous Cell Cancer.

INTRODUCTION: The 8th edition of the American Joint Committee on Cancer (AJCC) updated the staging system of anal squamous cell cancer (ASCC) by subdividing stage II into A (T2N0M0) and B (T3N0M0) based on a secondary analysis of the RTOG 98-11 trial. We aimed to validate this new subclassification utilizing two nationally representative databases. MATERIALS: The National Cancer Database (NCDB) [2004-2014] and the Surveillance, Epidemiology, and End Results (SEER) database [1988-2013] were queried to identify patients with stage II ASCC. RESULTS: A total of 6651 and 2579 stage IIA (2-5 cm) and 1777 and 641 stage IIB (> 5 cm) patients were identified in the NCDB and SEER databases, respectively. Compared with stage IIB patients, stage IIA patients within the NCDB were more often females with fewer comorbidities. No significant differences were observed between age, race, receipt of chemotherapy and radiation, and mean radiation dose. Demographic, clinical, and pathologic characteristics were comparable between patients in both datasets. The 5-year OS was 72% and 69% for stage IIA versus 57% and 50% for stage IIB in the NCDB and SEER databases, respectively (p < 0.001). After adjustment for available demographic and clinical confounders, stage IIB was significantly associated with worse survival in both cohorts (hazard ratio 1.58 and 2.01, both p < 0.001). CONCLUSION: This study validates the new AJCC subclassification of stage II anal cancer into A and B based on size (2-5 cm vs. > 5 cm) in the general ASCC population. AJCC stage IIB patients represent a higher risk category that should be targeted with more aggressive/novel therapies.

Complications and survival associated with operative procedures in patients with unresectable pancreatic head adenocarcinoma.

BACKGROUND: Unresectable tumors of the pancreatic head are encountered in up to 20% of patients taken for resection. The objective of this study was to evaluate the complications and outcome associated with palliative surgical procedures to help guide management decisions in these patients. METHODS: Patients with pancreatic head adenocarcinoma taken to the operating room with curative intent who did not undergo pancreatectomy were evaluated. RESULTS: From 1997 to 2013, 50 patients were explored and found be unresectable due to M1 disease (n = 27, 54.0%) or vascular invasion (n = 23, 46.0%). Among unresectable patients, 34 (68.0%) had a palliative procedure performed including double bypass (n = 13), biliary bypass (n = 7), gastrojejunostomy (n = 5), or cholecystectomy (n = 9). Complications occurred in 22 patients (44.0%), and patients who had a palliative operation had a longer hospital stay and more major complications. Overall survival was reduced in patients treated with a palliative operation. CONCLUSIONS: Despite advancements in endoscopic palliation, operative bypasses are still commonplace in patients with unresectable pancreatic head cancer. In this study, patients treated with operative procedures had a high rate of complications without a notable improvement in outcome. These findings highlight the importance of identifying unresectable disease prior to surgery and support a selective approach to palliative operations.

Management of Gastric Adenocarcinoma for General Surgeons.

Gastric cancer is one of the most common cancers in the world, despite declining incidence of the disease in the United States. Because of the rare occurrence of the disease in the United States, there is significant treatment variance in use of diagnostic modalities, neoadjuvant/adjuvant therapies, and surgical techniques. The survival of patients with gastric cancer in the United States is significantly lower than those of Asian countries where the diagnosis is made at an earlier stage and uniform high-quality treatment is delivered. This article reviews pearls and pitfalls of multidisciplinary management of the gastric adenocarcinoma for best outcomes.

Epidermal growth factor receptor expression correlates with histologic grade in resected esophageal adenocarcinoma.

Activation of the epidermal growth factor receptor (EGFR) has a role in oncogenesis and may correlate with prognosis. The aim of this study was to examine EGFR expression in esophageal adenocarcinoma and correlate EGFR status with pathologic and clinical prognostic features. An exploratory retrospective review of 38 patients with surgically resected esophageal adenocarcinoma was performed. All patients underwent an esophagogastrectomy with regional lymphadenectomy; 24 patients underwent primary resection and 14 patients had surgery after preoperative chemoradiation therapy. Immunohistochemical analysis was performed on paraffin-embedded tissue samples using an EGFR monoclonal antibody. Low- and moderate-grade tumors were positive for EGFR expression in 2 of 15 patients; poorly differentiated tumors were positive for EGFR expression in 13 of 23 patients (p=0.02). The median survival was 35 months (confidence interval [CI]: 29-40) for EGFR negative patients (n=23) and 16 months (CI: 10-22) for EGFR positive patients (n=13) (p=0.10). Disease recurred in 3 of 21 EGFR negative patients and 6 of 13 EGFR positive patients (p=0.06). Poorly differentiated adenocarcinomas of the esophagus demonstrated higher EGFR expression compared to low-grade tumors based upon immunohistochemical analysis. A trend toward improved disease-free and overall survival was seen in EGFR negative patients.

Standard D2 and modified nodal dissection for gastric adenocarcinoma.

The quality of surgical treatment is a major determinant of cancer treatment outcomes; however, controlling surgical quality is a difficult task. Surgical treatment of gastric cancers, and especially the benefits of nodal dissection, has been a topic of debate and no consensus has been reached to date. The D2 nodal dissection defined, standardized, and practiced in Japan is a technically challenging procedure but carries better locoregional disease control. This article reviews the current definition of D1, D1 plus, and D2 nodal dissections, as well as the nodal dissection technique, indications for its modification, and the learning curve.

Resources and rewards for clerkship directors: how surgery compares.

BACKGROUND: Clerkship directors (CDs) are key educators and active clinicians. In 2003, the Alliance for Clinical Education published standards for CD resources and responsibilities, but how reality compares is unknown. METHODS: Representatives from each core clinical disciplines' CD organizations created an electronic survey that CDs received in 2006-2007. RESULTS: More than 500 CDs responded, including 71 surgeons. Surgeons reported spending approximately 27% of professional time on education. Most have codirectors, so total CD effort approximates the greater than 50% Alliance for Clinical Education guidelines. No disciplines' CDs have more than one support staff as recommended. Surgeons have the least clinic time, but the most inpatient weeks and many publications. Surgery CD concerns are curricula and simulation; few believe being a CD impairs academic advancement and more than 95% believe it enhances work satisfaction. CONCLUSIONS: Surgery CDs are clinically active and academically productive. Although few surgery CDs have the recommended support staff, more than 95% report being a CD enhances work satisfaction.

Gallbladder cancer: Defining the indications for primary radical resection and radical re-resection.

BACKGROUND: The role of radical resection for gallbladder cancer is an ongoing area of debate. In this review, we present our experience managing gallbladder cancer at a tertiary center by using an aggressive surgical approach for T2 or greater disease, reserving simple cholecystectomy only for T1 lesions. METHODS: Seventy-six patients with histologically confirmed gallbladder cancer were identified from our cancer registry. Estimated survival distributions were calculated by the Kaplan-Meier method, and comparisons were made by using the log-rank test. The Cox proportional hazards model was used to determine the effect on survival of T stage, nodal status, age, and margins. RESULTS: Sixty-four patients were assessable for this study. Simple cholecystectomy was the only procedure performed in 10 T2 and 15 T3 cases. Radical cholecystectomy was performed as the primary procedure in two T2, two T3, and six T4 cases. Radical re-resection was accomplished in seven T2 and two T3 cases. Excluding the T4 group, there was a significant survival advantage (P = .007) for the radical resection group (n = 13; median survival not yet reached) compared with the simple cholecystectomy group (n = 25; median survival, 17 months; 95% confidence interval, 7-27 months). Analysis of the 13 T2 and T3 patients who underwent radical resections revealed that the radical re-resection group (n = 9) had an overall survival similar to that of the primarily resected group (n = 4). All T2N(+) and T3N(-) patients are still alive and disease free after 5 years of follow-up, whereas none of the T3N(+) or T4 patients survived beyond 24 months. Increasing T stage and age (>65 years) were independent predictors of a poor prognosis. CONCLUSIONS: Radical resection for T2 and T3 disease resulted in a significant survival advantage compared with simple cholecystectomy. Patients who undergo radical re-resection after an incidentally discovered gallbladder cancer experience the same survival benefit as primarily resected patients. Radical resection for T2N(-), T2N(+), and T3N0 cases can achieve long-term survival. Conversely, the prognosis for T3N(+) and T4 patients is poor, and improved outcome for this group will likely depend on the development of multi-institutional neoadjuvant clinical trials that can identify effective systemic regimens.