Pancreatoduodenectomy after Ivor-Lewis Santi oesophagectomy with gastric tube reconstruction. An European multicentre experience.

BACKGROUND: Pancreaticoduodenectomy (PD) is the standard surgery to treat tumors and other conditions affecting the head of the pancreas. PD involves the division of the gastroduodenal artery (GDA) and its branches, to allow for complete dissection of lymph nodes. However, PD in patients with prior esophageal resection presents challenges due to altered anatomy and risks compromising gastric tube vascularization. GDA preservation becomes crucial to avoid ischemia, although this may pose oncological risks by potentially leaving behind regional lymph nodes. This article reviews European surgical center experiences and techniques for PD in patients with prior esophageal surgery, focusing on short-term outcomes. METHODS: We have collected all the experiences carried out in European surgical centers and evaluated the techniques applied for PD in patients who had prior esophageal surgery while analyzing short-term outcomes. RESULTS: Eight patients from 5 European centers were identified. Six patients were diagnosed with pancreatic adenocarcinoma, including one borderline case. Intraoperatively, the gastroduodenal artery (GDA) was preserved in all cases, with portal vein reconstruction required in only one instance due to tumor invasion. No ischemia or venous congestion of the gastric tube was observed during the surgical procedure. Post-operative complications that occurred included POPF type C in 1 (12.5 %), PPH type C in 1 (12.5 %). The median number of harvested lymph nodes was 21 [14-24]. with a median of 1.5 positive lymph nodes. R1 resection was present in 62.5 % of cases. CONCLUSION: Performing pancreaticoduodenectomy subsequent to Ivor Lewis esophagectomy is a technical challenge, but seems feasiable and safe in selected patients. GDA-preserving pancreaticoduodenectomy emerges as a valuable and time-efficient variation of the conventional procedure, it can be considered oncologically appropriate, but studies confirming its long-term impact on radicality are still needed.

Prognostic nutritional index as a predictor of surgical complications in women with gynecological cancer.

OBJECTIVE: To analyze the association between the prognostic nutritional index and surgical morbidity in women with gynecologic cancers. METHODS: This is a retrospective cohort study of women with ovarian, endometrial, or cervical cancer who underwent surgery between January 2013 and December 2020 at a cancer center. Demographic and clinical data were extracted from electronic medical records. The prognostic nutritional index was calculated during the immediate pre-operative period. Binomial logistic regression was conducted to identify the association of the prognostic nutritional index with the outcome of surgical complications after Clavien-Dindo classification, adjusting for confounding variables. RESULTS: A total of 1000 women were included: 114 (11.4%) were diagnosed with cervical cancer, 551 (55.1%) with ovarian cancer, and 335 (33.5%) with endometrial cancer. Patients with a prognostic nutritional index >40 had a decreased possibility of surgical complications (OR=0.39, 95% CI 0.29 to 0.52); basal blood hemoglobin, volume of surgical bleeding, operative time, and length of hospital stay were also explanatory factors. The prognostic nutritional index has a significant effect on patients with endometrial and cervical cancer, but conversely is not significant in patients with ovarian cancer. CONCLUSION: The prognostic nutritional index is associated with surgical morbidity in endometrial and cervical cancers and thus can be a useful tool for predicting morbidity and guide pre-operative interventions in patients with gynecological cancers.

Roles of pediatric surgeons in palliative pediatric oncology.

Pediatric surgeons engaged in oncology will inevitably treat patients receiving palliative care, but their role in this context is poorly described. This article identifies some of the challenges and opportunities of surgical involvement in pediatric oncology palliative care, underscoring how the surgeon's expertise can be exploited to significantly benefit children with cancer. Specific examples of skills (procedural, communication, and coordination) that surgeons can provide to the multidisciplinary palliative care teams are described and the importance of collaboration is highlighted.

Surgical and safety outcomes in patients with non-small cell lung cancer receiving neoadjuvant chemoimmunotherapy versus chemotherapy alone: A systematic review and meta-analysis.

Neoadjuvant immune checkpoint blockade (ICB) combined with chemotherapy has improved survival outcomes in locally-advanced non-small cell lung cancer (NSCLC). However, its impact on surgery has not been fully elucidated. We performed a systematic review and meta-analysis to compare surgical outcomes between neoadjuvant chemoimmunotherapy and chemotherapy alone in resectable NSCLC. PubMed and Embase were searched to select randomized controlled trials (RCTs) evaluating neoadjuvant ICB therapy for resectable NSCLC. The risk difference (RD) and odds ratio (OR) of outcomes such as surgical and R0 resection rates, overall complication rates, treatment-related adverse events (TRAEs), and AEs leading to cancellation of surgery were pooled using the random-effect model meta-analysis. We also evaluated the correlations between overall survival (OS) and surgical and safety outcomes. Eight RCTs with 3,387 patients were analyzed. Neoadjuvant chemoimmunotherapy was associated with improved surgical resection (RD 4.52 %, 95 % confidence interval [CI] 0.95 %-8.09 %, p = 0.01) and R0 resection (RD 4.04 %, 95 % CI 1.69 %-6.40 %, p = 0.0008) without increasing overall complications (RD -0.13 %, 95 % CI -5.14 %-4.88 %, p = 0.96), but an increase in surgery cancellation due to AEs (RD 1.15 %, 95 % CI 0.25 %- 2.05 %; p = 0.01) and grade 3-4 TRAEs (RD 3.42 %, 95 % CI 0.33 %-6.52 %, p = 0.03). OS did not show a direct significant correlation with surgical outcomes or TRAEs. Neoadjuvant chemoimmunotherapy improves resection rates but increases high-grade TRAEs and AEs leading to surgery cancellation. Nevertheless, incorporating ICB into neoadjuvant approach appears reasonable by improving surgical outcomes, potentially leading to improved survival in patients with locally-advanced NSCLC.

Preoperative Identification of Adamkiewicz Artery in Pediatric Posterior Thoracic Tumors: Fact or Fiction? A Systematic Review From the International Society of Pediatric Surgical Oncology (IPSO).

BACKGROUND AND AIMS: We aimed to review current literature on the impact of Preoperative Identification (POI) of the Adamkiewicz Artery (AKA) in solid pediatric Posterior Thoracic Tumors (PTT), comprising a spectrum of neuroblastic tumors and neuroblastoma, with particular focus on Complete Macroscopic Excision (CME) and Neurologic Complications/Sequelae (NCS). METHODS: A systematic review in accordance with PRISMA guidelines was undertaken. The study included reports on pediatric patients providing available data on POI of the AKA in PTT. RESULTS: Among 838 records screened, 33 full-texts underwent evaluation, and 8 papers were included. Among 49 tumors (N = 49 patients), 30 were neuroectodermic tumors. Spinal angiography (SA) was undertaken in four studies for 32 (65%) patients. No SA-related morbidity was recorded. Otherwise, a combination of CT and/or MRI imaging was described. The lack of detailed reporting on CT/MRI imaging, hindered a feasible detailed comparative analysis among non-SA imaging modality techniques. The overall success rate of AKA POI was 65%, 71% with SA and 33% with non-SA studies. CME was achieved in 73% of SA and 80% non-SA groups. Overall, 5 children experienced NCS, 60% of those who had dumbbell tumors. All NCS occurred in patients without successful POI of the AKA. Furthermore, no SA patient had NCS, while 33% of the non-SA sustained NCS. CONCLUSIONS: Successful POI of the AKA may play a key role in prevention of NCS. SA showed the utility of deploying POI, without added morbidity. Furthermore, SA appeared to have a preventive impact on NCS. SA may have a key role on CME which may also be operator dependent.

Early non-compliance to ERAS in gynecological open surgery for malignancies, and post-operative complications: a multicenter, prospective, observational, cohort study.

BACKGROUND: Open surgical procedures for gynecological malignancies have a potential risk of post-operative complications and hence prolonged hospitalization, despite adherence to an Enhanced Recovery After Surgery (ERAS) protocol. PRIMARY OBJECTIVE: To investigate the relationship between non-compliance to an ERAS protocol in the post-operative setting and the rate of post-operative complications, in women who underwent open surgery for gynecological malignancies. STUDY HYPOTHESIS: Early non-compliance with the ERAS protocol increases the risk of post-operative complications. TRIAL DESIGN: Multicenter, prospective, observational, cohort study. MAJOR INCLUSION CRITERIA: Patients with histologically proven gynecological cancer (endometrial, uterine, tubo-ovarian, and cervical) undergoing elective open surgery and managed according to ERAS guidelines. EXCLUSION CRITERIA: Patients with post-operative recovery in an intensive care unit, undergoing anterior or total pelvic exenteration or intraperitoneal chemotherapy. Previous radiotherapy or previous non-gynecological major abdominal surgery. PRIMARY ENDPOINT: Association of non-compliance with the ERAS protocol using five selected indicators on post-operative day 2 with the rate of 30-day post-operative complications. SAMPLE SIZE: 600 patients will be enrolled in the study. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: At present, 106 patients have been recruited. Based on this, the accrual should be completed in 2025. Results should be presented at the end of 2025. TRIAL REGISTRATION: NCT05738902.

An Enhanced Recovery Program for Pediatric, Adolescent, and Young Adult Surgical Oncology Patients Improves Outcomes After Surgery.

BACKGROUND: Enhanced Recovery after Surgery (ERAS®) is a standardized perioperative approach that utilizes a multidisciplinary team to reduce physiologic stress and improve postoperative recovery. The purpose of our study is to evaluate outcomes in pediatric, adolescent, and young adult (AYA) patients undergoing major oncologic operations before and after the implementation of an enhanced recovery program (ERP). METHODS: All patients ≤23 years old who underwent major oncologic surgery between 1/2017-2/2022 were identified. ERP was implemented on 6/7/2021, with all patients enrolling on ERP after that date. Pre-ERP patients were selected based on similar age, diagnosis, and operations. The Mann-Whitney U-test was used to compare continuous variables, and the chi-squared test or Fisher exact test as appropriate to compare categorical variables between Pre-ERP and ERP patients. RESULTS: A total of 47 patients were included (28 Pre-ERP, 19 ERP). The median age was 14 years (range, 1-23). 18 underwent thoracotomy, 26 laparotomy, and 3 chest wall resections. Results suggest that ERP patients had significantly shorter time to ambulation (25 h; p = 0.004) and postoperative length of stay (LOS; 3 days; p < 0.001). Two patients in the ERP group required zero narcotics after operation. CONCLUSION: We found initial evidence that the implementation of an ERP for pediatric, AYA patients resulted in positive postoperative outcomes - a decrease in postoperative LOS and promoted early mobility without an increase in readmission rates. Enhanced recovery programs should be incorporated into the care of pediatric, AYA oncology patients undergoing oncologic surgery. LEVEL OF EVIDENCE: Retrospective Comparative Study - Level III.

Travel burden and bypassing closest site for surgical cancer treatment for urban and rural oncology patients.

PURPOSE: We examined the relationship between travel burden for surgical cancer care and rurality, geographic bypass of the nearest surgical facility, cancer type, and mortality outcomes. METHODS: Using Medicare claims and enrollment data (2016-2018) from beneficiaries with cancer of the colon, rectum, lung, or pancreas, we measured travel times to: the nearest surgical facility and facility used. For those who bypassed the nearest, we examined travel time and rurality in relation to surgical rates. Using multivariable regression modeling, we estimated associations of bypass with 90-day postoperative- and one-year mortality; rurality was examined as an effect modifier. FINDINGS: Among 211,025 beneficiaries with cancer, 25.5% resided in non-metropolitan areas. About 66% of metropolitan/micropolitan, and 78% of small town/rural patients bypassed their closest facility. Increasing rurality was significantly associated with increased likelihood of bypass (Referent = metropolitan, OR; 95%CI: micropolitan 1.10; 1.04-1.16, small town/rural 2.08; 1.96-2.20. Bypassing the nearest facility was associated with decreased likelihood of both 90-day postoperative mortality (OR = 0.79; 95%CI 0.74-0.85) and 1-year mortality (OR = 0.81; 95%CI 0.77-0.86). The greatest decrement in 1-year mortality was for pancreatic cancer across all rural-urban categories (OR; 95%CI: metropolitan 0.63; 0.53-0.76; micropolitan 0.53; 0.29-0.97); small town/rural 0.46; 0.25-0.86). CONCLUSIONS: Most Medicare beneficiaries with lung, colon, rectal, or pancreatic cancer bypassed the closest facility providing surgical cancer care, especially rural patients. Bypassing was associated with a lower likelihood of 90-day postoperative, and 1-year mortality. Understanding determinants of bypassing, particularly among rural patients, may reveal potential mechanisms to improve cancer outcomes and reduce rural cancer disparities.

Fertility outcomes in stage I ovarian immature teratomas.

OBJECTIVE: To evaluate the impact of adjuvant chemotherapy, type of ovarian surgery, and the surgical approach on fertility in patients with stage I immature teratoma of the ovary. METHODS: Clinicopathologic data were retrospectively collected and analyzed from a cohort of 47 patients with childbearing desire treated for a stage I immature teratoma of the ovary at IRCCS San Gerardo dei Tintori Hospital, Monza, Italy. Multivariate logistic regression was used to address the influence of chemotherapy and type of surgery on the outcome. RESULTS: Among the patients included, 78.7% (37/47) were able to get pregnant, with a live birth rate of 80.9% (51/63 pregnancies). These rates were not different between adjuvant chemotherapy versus surveillance group (62.5% (5/8) and 82.0% (32/39), respectively; p=0.22) nor between the type of ovarian surgery (cystectomy vs unilateral salpingo-oophorectomy; p=0.57) and surgical approach (laparotomy or laparoscopy; p=0.18). A statistically significant difference was found for stage of disease (a decrease in pregnancy rate from 86.5% (32/37) for stage IA to 50.0% for stage IC (5/10); p=0.02), but it was not confirmed in the multivariate analysis. After relapse diagnosis and management, a total of 62.5% (5/8) of patients conceived and had at least one live birth baby. CONCLUSIONS: The fertility-sparing approach is feasible in this population, and fertility does not depend on surgical approach or post-operative treatment. However, adjuvant chemotherapy should be carefully evaluated in this setting.

Link between isolated para-aortic lymph node metastasis and intrauterine cancer site in early stage endometrial cancer.

OBJECTIVE: Missing occult para-aortic lymph node metastasis is one of the primary concerns of sentinel lymph node biopsy in endometrial cancer. Our study aimed to evaluate the relationship between intrauterine cancer site and isolated para-aortic lymph node metastasis to tailor treatment and reduce the false negative rate of the sentinel lymph node procedure. METHODS: A retrospective, multicenter, case control study was performed in four international centers. All patients with positive lymph nodes who had complete surgical staging with pelvic and para-aortic lymphadenectomy, between January 2013 and December 2023, were included. Detailed descriptions of the cancer location within the uterine cavity on the cranio-caudal plane and the myometrial wall involvement on the cranio-caudal and ventro-dorsal planes were collected, as were clinical data and cancer histological features. Patients with isolated para-aortic lymph node metastasis were allocated to group 1; patients with pelvic lymph node metastasis and those with both pelvic and para-aortic lymph node metastasis were allocated to group 2. The groups were compared according to the variables collected. RESULTS: 200 preoperative early stage endometrial cancer patients with postoperative International Federation of Gynecology and Obstetrics 2009/2023 stage IIIC1/IIIC2 were included in our study: 42 patients (21%) with isolated para-aortic lymph node metastasis were allocated to group 1 and the remaining patients to group 2. The two groups had comparable clinical and pathological characteristics (p>0.05): mean age was 66.5±10.3 (group 1) and 63.5±11.9 (group 2); endometrioid histotype was the predominant one for both groups (50%); most patients had myometrial infiltration >50% (80.9% and 79.7%), grade 3 (61.9% and 63.9%), and lymph vascular space invasion (78.5% and 82.2%). Cancers involving the fundal uterine cavity, the fundal myometrial wall, or the anterior myometrial wall were 3.11 (1.04-9.27), 3.03 (1.12-8.21), and 2.12 (0.77-5.80) times more likely to metastasize only to para-aortic lymph nodes compared with cancers located in other uterine sites. CONCLUSIONS: In this study, the intrauterine location of the cancer determined the site of lymph node metastasis. When the tumor involved the fundus (cavity or wall) and infiltrated exclusively the anterior wall, the baseline risk of spreading only into the para-aortic area increased significantly in selected patients at risk of nodal disease.

Treatment of left tenth rib haemangioma vascularised by a costal artery giving the artery of Adamkiewicz.

Haemangioma of the ribs is considered an extremely rare benign tumour. Here, we present a case of a young male with left tenth rib haemangioma vascularised by a costal artery giving the artery of Adamkiewicz presented as chronic cough. This was successfully treated through preoperative embolisation and surgical resection. A preoperative angiogram was performed to identify the origin of the artery of Adamkiewicz. The final diagnosis was confirmed histopathologically. There were no complications in the postoperative course and no recurrence during 12 months of follow-up.

Developing a non-cadaveric brain tumour surgery lab in resource-constrained settings.

OBJECTIVE: To develop the country's first brain tumour surgery lab in resource-constrained settings, for training young neurosurgeons and residents. METHODS: A workshop was developed using mixed-fidelity models for assessing and training a participant's psychomotor skills, hand-eye coordination, and teaching the principles of brain tumour surgery. Affordable noncadaveric models were used to compare and contrast the benefit of each teaching model. Within the existing space for wet labs at our institution, 8 different dissection stations were set up with adequate space for 2 people to work at a time. Each station was equipped with an operating room-Caliber microscope, a lighting system and a camera linked to a screen and high-powered electric drills and basic surgical equipment. RESULTS: Our team was able to develop and use 3D-printed skull models and animal brain models for training in complex approaches and craniotomy. CONCLUSIONS: Surgical simulation training, in a cost-effective manner, provides the benefit of training residents and students in neurosurgical techniques in a safe, controlled environment leading to improvement in skills and technique.

Unresectable squamous cell carcinoma in a patient with spina bifida.

Spina bifida is a congenital malformation of foetal neural structures which may present as a skin fold or sac containing cerebrospinal fluid and neural structures with a variety of neurological deficits. Surgical repairs of spina bifida may not ensure complete functions, neural improvement or recovery. We present this palliative report of an adult male in his early 40s with a medical history of meningocele repair in his infancy, with long-standing Marjolin ulcers, fractures, contractures, diverting ileostomy and urostomy and a fungating mass externally measuring 33×25 cm. The mass involved the buttocks, perineum and scrotum with a tumour overlying the meningocele and extending into the thigh through an internally draining tract. Factors such as immobility, pressure injuries and poor social support in the setting of chronic disability led to a conservative approach in the management of this unresectable carcinoma.

Population-based survival analysis of primary spinal chordoma in the US from 2000 to 2020.

PURPOSE: Chordomas are rare malignant tumors that occur primarily in the axial skeleton. We seek to analyze trends affecting five-year overall survival (5y OS) among patients with primary spinal chordomas (PSC) of the vertebrae and sacrum/pelvis. METHODS: The Surveillance, Epidemiology, and End Results (SEER) Program was used to identify patients with PSC (ICD-O-3 histology codes 9370/3, 9371/3, and 9372/3) of the spine or sacrum/pelvis. Multivariate and univariate survival analyses were conducted to assess demographic, disease, or treatment characteristic trends. RESULTS: Eight-hundred-ninety-six patients diagnosed with PSC were identified. Patients 0-54 years at diagnosis had improved 5y OS compared to those either 55-69 years (HR = 1.78; p = 0.046) or those between 70 and 85 + years (HR = 3.92; p < 0.001). Histology impacted 5y OS: Cox regression demonstrated variance among the three histologies assessed (p < 0.001), while univariate analysis demonstrated patients with dedifferentiated chordoma (1.0% of cohort; 33.3% [1.9,64.7]) and chondroid chordoma (2.0% of cohort; 52.5% [26.1,78.9]) had decreased 5y OS compared to those with general chordoma (72.2% [68.8,75.6]; p < 0.001). Nonmarried patients had decreased 5y OS on univariate analysis (65.2% [59.4,71.0] versus 76.2% [72.0,80.4]), with widowed patients being the primary driver of this on subanalysis. Treatment with gross total resection was associated with increased 5y OS (HR = 0.22, p < 0.001), as was treatment with radiotherapy (HR = 0.69, p = 0.030). CONCLUSION: Patient age and marital status were significant demographic factors associated with changes in 5y OS among those with PSC. PSC histology is a potentially important prognostic factor in the management of disease.

Comparative overall survival analysis of chordomas of the base of the skull from the Surveillance, Epidemiology, and End Results (SEER) program between 2000 and 2020.

Chordomas of the skull base are rare, slow growing, locally invasive cancers with limited long-term survival analysis reported in the literature. We seek to provide comparative survival analysis of patients on a long-term (20-year) basis using population-level data. The Surveillance, Epidemiology, and End Results (SEER) program was queried for cases of chordoma relegated to the base of the skull, diagnosed between 2000 and 2020. Demographic, disease, and treatment information were analyzed using Cox proportional hazards and log-rank comparisons. 630 patients with chordoma of the skull base were identified. Age ≤ 49 years at diagnosis was associated with increased five-, 10-, and 20-year overall survival (hazard ratio (HR) = 0.39, 0.33, and 0.30, respectively; p < 0.001 for all). Treatment with surgery and adjuvant radiotherapy was associated with increased five-, 10-, and 20-year survival (HR = 0.71, 0.79, and 0.79, respectively; p < 0.001 for all). On univariate analysis, widowed patients had decreased survival (20-year overall survival = 34.8% [15.3%-34.8%] compared to married patients (74.4% [68.1%-80.8%]. Surgery remains the primary treatment associated with increased survival among patients with chordoma of the skull base, with adjuvant radiotherapy serving a complimentary role. Demographic factors such as marital status are also associated with changes in survival.

Jejunogastric intussusception after pancreaticoduodenectomy in a patient with HIV.

The incidence of jejunogastric intussusception (JGI) after gastric surgery is 0.1%. We report a case of JGI after pancreaticoduodenectomy in a patient with HIV. After presenting to the hospital with abdominal pain and emesis, a CT abdomen/pelvis showed evidence of gastrojejunal anastomosis intussusception into the stomach. Oesophagogastroduodenoscopy was performed, but endoscopic reduction was unsuccessful. Exploratory laparotomy was subsequently performed with a successful reduction of the intussusception and resection of a portion of the small bowel. With only five previously reported cases of JGI after pancreaticoduodenectomy, our case is novel in that it describes JGI in a patient with HIV on highly active antiretroviral therapy, which has been associated with an increased risk of intussusception. While rare, we highlight the importance of having high clinical suspicion for intussusception in patients with risk factors who present with abdominal pain after pancreaticoduodenectomy. Timely diagnosis is critical to optimise patient outcomes.

Surgical management of rare hepatobiliary sarcomas in a regional teaching hospital: a collaborative model for optimal care with case studies.

Sarcomas are challenging and conventionally referred to sarcoma specialist centres. In select cases with required surgical expertise, collaboration with a quaternary sarcoma centre rather than an upfront transfer of care may reduce logistic challenges without compromising patient care.We present a case series of three rare tumours of hepatobiliary origin-two cases of undifferentiated embryonal liver sarcoma in adults and one case of follicular dendritic sarcoma of the cystic lymph node.All three patients underwent surgery in a non-sarcoma specialist centre by hepatobiliary specialist surgeons with concurrent remote referrals to a sarcoma specialist quaternary centre. Both centres belong to the same cluster. R0 resection and no significant postoperative morbidity were achieved. All three patients currently remain disease-free.The unique and integrated healthcare systems within Singapore render cross-institution management possible. This case series suggests that an established setup for cross-centre collaboration facilitates wholistic patient care with good outcomes.