Selective survival advantage associated with primary tumor resection for metastatic gastric cancer in a Western population.

BACKGROUND: The prognosis of metastatic gastric cancer (GC) remains dismal, with a median survival of 10 months. Historically, primary tumor resection was not thought to confer any survival benefit. Although high-level data exist guiding treatment of metastatic GC for patients in the East, no such data exist for Western patients despite inherent ethnic differences in GC biology. METHODS: The 2006-2012 National Cancer Database was queried for adult patients with metastatic gastric adenocarcinoma. Patients were classified into those who underwent primary tumor resection and chemotherapy (PTRaC) and those who received chemotherapy only. Groups were propensity score matched, and survival was compared using advanced statistical modeling. RESULTS: A total of 7026 patients met the inclusion criteria: 6129 (87%) patients were treated with chemotherapy alone and 897 (13%) patients were treated with PTRaC. After multivariable adjustment, patients who underwent PTRaC had a significantly better overall survival (OS) than patients who received systemic therapy only (HR, 0.60; 95% CI, 0.56-0.64; p < 0.001). Following full bipartite propensity score-adjusted analysis, 2-year OS for patients who received chemotherapy only was 12.6% (95% CI, 11.7-13.5%), whereas it was 34.2% (95% CI, 31.3-37.5%) for patients who underwent PTRaC (HR for resection: 0.52; 95% CI, 0.47-0.57; p < 0.001). CONCLUSION: Our data suggest that there exists a subset of patients with metastatic GC for which PTRaC may improve OS. As significant uncertainty still remains, our results support the need for further prospective trials investigating the influence of palliative gastrectomy on survival among Western patients.

Bariatric metabolic surgery eliminates body mass index as a risk factor for unemployment.

BACKGROUND: The effects of bariatric metabolic surgery (BMS) on health and comorbidities are well-known. Socioeconomic factors have been increasingly in focus in recent investigations. OBJECTIVE: The aim of this study was to analyze the effects of BMS on predictive variables for unemployment. SETTING: This study as performed in one reference center for BMS. Patients were treated between 2011 and 2017. METHODS: The study design was a retrospective cohort study. Inclusion criteria were Roux-en-Y gastric bypass surgery, follow-up of 60 months, and complete data on employment rate. Exclusion criteria were secondary BMS, secondary referral, loss of follow-up, or patients aged 60 years and above. Patients were stratified as employed independent of part-time work and as unemployed if the patient had no current employment at the time of the visit. Follow-up visits were performed after 6, 12, 24, 48, and 60 months. RESULTS: This study included 623 patients; prior to BMS, 239 (38.36%) patients were employed and 384 (61.64%) unemployed. Risk factors for baseline unemployment included increased body mass index (BMI) (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01 to 1.05; P = .010) and increased American Society of Anesthesiology (ASA) score (OR, 3.55; 95% CI, 2.56 to 4.90; P < .001). Unemployment rate dropped to 32.4% after 24 months (P < .001) and increased to 62.8% after 60 months. The BMI continuously decreased. Following BMS, the unemployment rate was no longer associated with BMI (24 months: OR, 0.97; 95% CI, 0.95 to 1.01; P = .220; 60 months: 1.04; 95% CI, 0.97 to 1.11; P = .269). The initial ASA status remained associated with unemployment (OR, 2.20; 95% CI, 1.60 to 3.01; P < .001). CONCLUSION: BMI showed some association with the unemployment rate prior to BMI. The unemployment rate significantly decreased 24 months after BMS but increased to baseline values after 60 months. Following BMS, BMI was no longer associated with unemployment.

An ileo-colic intussusception reaching down to the descending colon - A case report.

INTRODUCTION AND IMPORTANCE: Intussusception in healthy adults is rare and often associated with oncologic diseases. This case report presents a case of an ileo-colic intussusception reaching down to the descending colon in a healthy adult that required ileo-colic resection. CASE PRESENTATION: We present a case of a 78-year-old male patient with acute onset unspecific abdominal pain. The medical history was unremarkable. Preoperative radiologic assessments showed an invagination of the small intestine into the colon without any signs of polyps or tumours. An emergency laparotomy with resection of the affected intestine was performed. The pathologist described a 49 cm length of intussuscepted colon and an additional 7 cm intussusception of the terminal ileum. A circular area with multiple polyps extending over 8 cm in the colon could be identified. The microscopic findings showed a low-grade dysplasia within this area. Following surgery, the patient was discharged to rehabilitation after a ten-day hospitalization. CLINICAL DISCUSSION: Intussusception in adults is rare and the clinical presentation includes unspecific symptoms making the diagnosis challenging. In 90% of the cases, a pathologic lesion is found (two-thirds are neoplasms). An intussusception involving the colon should be treated surgically without prior reduction due to the high incidence of a neoplasm and the risk for perforation and tumour dissemination. CONCLUSION: In the literature, neoplastic disease represents the major cause for intussusception in adults. This report presents a rare case of an ileo-colic intussusception reaching down to the descending colon treated successfully with a subtotal colectomy.

The implementation of physicians assistant in a surgical ward improves continuity in daily clinical work and increases comprehensibility of nurses and physicians.

INTRODUCTION: Physician Assistant (PA) have been deployed to increase the capacity of a team, supporting continuity and medical cover. The goal of this study was to assess the implementation of PAs on continuity of surgical rounds, on the collaboration of nurses and physicians and on support of administrative work. METHODS: This cross-sectional survey was performed on nurses and physicians who work full-time at a surgical ward in a Swiss reference center. PAs were introduced in our institution in 2019. Participants answered a self-developed questionnaire 6 and 12 months after the implementation of PAs. Administrative work, teamwork, improvement of workflow, and training of physicians has been assessed. Participants answered questions on a 5-point Likert scale and were stratified according to profession (nurse, physician). RESULTS: Participants (n = 53) reported a positive effect on the regular conduct of rounds (2.9, SD 1.1 points after 6 weeks and 3.5, SD 1.1 points after 12 weeks, p = 0.05). A significant improvement of nurse-doctor collaboration has been reported (3.6, SD 1.0 and 4.2, SD 0.8, p = 0.05). Nurses (n = 28, 52.8%) reported the that PAs are integrated in the physicians team rather than the nurses team (4.0, SD 0.0 points and 4.4, SD 0.7 points, p = 0.266) and a significant beneficial effect on the surgical clinic (3.7, SD 1.0 points and 4.4, SD 0.8 points, p = 0.043). Improved overall management of surgical cases was reported by the physicians (n = 25, 47.2%) (4.8, SD 0.4 and 4.3, SD 0.6, p = 0.046). CONCLUSION: The implementation of PA has improved the collaboration of physicians and nurses substantially. Continuity of rounds has improved and the administrative workload for residents decreased substantially. Overall, the implementation of PA was reported to be beneficial for the surgical clinic.

Computer planned, image-guided combined resection and ablation for bilobar colorectal liver metastases.

For patients with extensive bilobar colorectal liver metastases (CRLM), initial surgery may not be feasible and a multimodal approach including microwave ablation (MWA) provides the only chance for prolonged survival. Intraoperative navigation systems may improve the accuracy of ablation and surgical resection of so-called "vanishing lesions", ultimately improving patient outcome. Clinical application of intraoperative navigated liver surgery is illustrated in a patient undergoing combined resection/MWA for multiple, synchronous, bilobar CRLM. Regular follow-up with computed tomography (CT) allowed for temporal development of the ablation zones. Of the ten lesions detected in a preoperative CT scan, the largest lesion was resected and the others were ablated using an intraoperative navigation system. Twelve months post-surgery a new lesion (Seg IVa) was detected and treated by trans-arterial embolization. Nineteen months post-surgery new liver and lung metastases were detected and a palliative chemotherapy started. The patient passed away four years after initial diagnosis. For patients with extensive CRLM not treatable by standard surgery, navigated MWA/resection may provide excellent tumor control, improving longer-term survival. Intraoperative navigation systems provide precise, real-time information to the surgeon, aiding the decision-making process and substantially improving the accuracy of both ablation and resection. Regular follow-ups including 3D modeling allow for early discrimination between ablation zones and recurrent tumor lesions.