A Predictive Noninvasive Single-Nucleotide Variation-Based Biomarker Signature for Resectable Pancreatic Cancer: Protocol for a Prospective Validation Study.

BACKGROUND: Single-nucleotide variations (SNVs; formerly SNPs) are inherited genetic variants that can be easily determined in routine clinical practice using a simple blood or saliva test. SNVs have potential to serve as noninvasive biomarkers for predicting cancer-specific patient outcomes after resection of pancreatic ductal adenocarcinoma (PDAC). Two recent analyses led to the identification and validation of three SNVs in the CD44 and CHI3L2 genes (rs187115, rs353630, and rs684559), which can be used as predictive biomarkers to help select patients most likely to benefit from pancreatic resection. These variants were associated with an over 2-fold increased risk for tumor-related death in three independent PDAC study cohorts from Europe and the United States, including The Cancer Genome Atlas cohorts (reaching a P value of 1×10-8). However, these analyses were limited by the inherent biases of a retrospective study design, such as selection and publication biases, thereby limiting the clinical use of these promising biomarkers in guiding PDAC therapy. OBJECTIVE: To overcome the limitations of previous retrospectively designed studies and translate the findings into clinical practice, we aim to validate the association of the identified SNVs with survival in a controlled setting using a prospective cohort of patients with PDAC following pancreatic resection. METHODS: All patients with PDAC who will undergo pancreatic resection at three participating hospitals in Switzerland and fulfill the inclusion criteria will be included in the study consecutively. The SNV genotypes will be determined using standard genotyping techniques from patient blood samples. For each genotyped locus, log-rank and Cox multivariate regression tests will be performed, accounting for the relevant covariates American Joint Committee on Cancer stage and resection status. Clinical follow-up data will be collected for at least 3 years. Sample size calculation resulted in a required sample of 150 patients to sufficiently power the analysis. RESULTS: The follow-up data collection started in August 2019 and the estimated end of data collection will be in May 2027. The study is still recruiting participants and 142 patients have been recruited as of November 2023. The DNA extraction and genotyping of the SNVs will be performed after inclusion of the last patient. Since no SNV genotypes have been determined, no data analysis has been performed to date. The results are expected to be published in 2027. CONCLUSIONS: This is the first prospective study of the CD44 and CHI3L2 SNV-based biomarker signature in PDAC. A prospective validation of this signature would enable its clinical use as a noninvasive predictive biomarker of survival after pancreatic resection that is readily available at the time of diagnosis and can assist in guiding PDAC therapy. The results of this study may help to individualize treatment decisions and potentially improve patient outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54042.

Interventional treatment of biliodigestive anastomosis leaks with a modified percutaneous transhepatic cholangiodrainage.

INTRODUCTION: Biliodigestive leaks are typically caused by an insufficiency at the surgical anastomosis. Biliodigestive anastomosis (BDA) insufficiencies can lead to bilomas, abscesses and vascular erosion in chronic conditions. MATERIAL AND METHODS: We performed a retrospective analysis of the medical and radiological records of all patients with biliodigestive insufficiency who received interventional treatment between July 2015 and February 2021. Nine patients (three with unilateral drainage and six with bilateral drainage) were treated with a modified percutaneous transhepatic cholangiodrainage (PTCD). Clinical success was considered after complete resolution of the peribiliary collections, absence of bile within the surgical drains, radiological patency of the BDA (contrast medium flowing properly through the BDA and no signs of leakage) and haemodynamic stability of the patient without signs of sepsis. RESULTS: Clinical success was achieved in all nine patients. No patients required revision surgery to repair their BDA. The mean indwelling drainage time was 34.8±16.5 days. The mean number of interventional procedures performed per patient was 6.6±2.0. CONCLUSION: Patients who present with BDA insufficiency may benefit from interventional radiological techniques. Our modified PTCD resolved the BDA leak in all nine cases and should be considered as a valuable option for the treatment of patients with this complication. Our technique demonstrated to be feasible and effective.

Implementation of a Bundle of Care in Colorectal Surgery to Reduce Surgical Site Infections Successfully at Cantonal Hospital Lucerne: Study Protocol for a Prospective Observational Study.

BACKGROUND: Surgical site infections (SSIs) remain a relevant problem in colorectal surgery. The aim of this study is to implement a bundle of care in order to reduce SSIs in colorectal surgery. METHODS: All patients undergoing colorectal surgery between October 2018 and December 2021 will be included in a prospective observational study. Since our colorectal bundle has been established gradually, patients will be grouped in a pre-implementation (2018-2019), implementation (2019-2020) and post implementation phase (2021), in order to assess the effectiveness of the actions undertaken. Primary endpoint of this study will be surgical site infection (SSI) rate, while secondary endpoints encompass potential risk factors for SSIs. We assume that obesity, age, diabetes, alcoholism and smoking may lead to a higher risk for SSIs. DISCUSSION: This study aims to determine whether the colorectal bundle designed and implemented at Cantonal Hospital Lucerne, will lead to a significant reduction of SSIs. The impact of potential risk factors for SSIs will additionally be evaluated. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT04677686. Registered retrospectively 18 December 2020. HIGHLIGHTS: A bundle of care might reduce the occurence of surgical site infections after colorectal surgery.Analysis of risk factors may detect patient's with high probability of developing surgical site infections.

Challenges in the management of life-threatening complications caused by a rare case of sarcoid-lymphoma syndrome.

PURPOSE: The sarcoid-lymphoma syndrome is a rare condition where both entities co-exist in the same patient. Overlapping clinical manifestations, imaging findings, and pathological characteristics pose both a diagnostic as well as therapeutic challenge, especially in the setting of life-threatening complications. The objective of this case report is to highlight rare complications caused by abdominal sarcoidosis as well as a subsequently diagnosed non-Hodgkin lymphoma. METHODS: A 35-year-old man presented with massive upper gastrointestinal bleeding caused by a large retroperitoneal mass. Following several endoscopic and radiologic interventions, successful hemostasis could only be achieved by an emergency Whipple procedure. Biopsies of the mass showed an abdominal manifestation of sarcoidosis and corticosteroid therapy was started. The patient required several additional emergency surgeries due to a complicated bronchoperitoneal fistula, splenic abscess, perforation of the sigmoid colon, small bowel leakage, and repetitive intra-abdominal bleeding. RESULTS: Histopathological findings finally revealed a concurrent lymphoma, as clinically suspected earlier. Ultimately, polychemotherapy was administered. CONCLUSION: A concurrent lymphoma can lead to emergency surgery and should be considered when sarcoidosis treatment does not improve symptoms, lymphadenopathy occurs, or hematologic changes persist under therapy.

Gallbladder Retrieval From Epigastric Versus Umbilical Port in Laparoscopic Cholecystectomy: A PRISMA-Compliant Meta-Analysis.

Purpose. To date, no evidence supports the retrieval of the gallbladder through a specific trocar site, and this choice is left to surgeons' preference. The aim of this meta-analysis was to investigate the influence of the trocar site used to extract the gallbladder on postoperative outcomes. Methods. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Google Scholar, Cochrane Library, and EMBASE databases was performed. Terms used were: ("gallbladder" OR "cholecystectomy") AND "umbilical" AND ("epigastric" OR "subxiphoid"). Randomized trials comparing the gallbladder retrieval from different trocar sites were considered for further analysis. Results. Literature search revealed 145 articles, of which 7 matched inclusion criteria and reported adequate data about postoperative pain, operative time, port-site infections, and hernias. A total of 876 patients were included, and the gallbladder was extracted through epigastric or umbilical trocar site in 441 and in 435 patients, respectively. A statistically significant difference among groups was noted in terms of postoperative pain at 1, 6, 12, and 24 hours in favor of the umbilical trocar site (P < .001). No significant differences were noted in postoperative hernia and infection rate, nor in terms of operative time. Conclusions. This meta-analysis shows a statistically significant reduction in terms of postoperative pain at 1, 6, 12, and 24 hours after surgery when the gallbladder is extracted through the umbilical port. Retrieval time, infections, and hernias rate implicate no contraindication for the choice of a specific trocar site to extract specimens. Despite limitations of this study, the umbilical trocar should be favored as the first choice to retrieve the gallbladder.

A Life-Threatening Mediastinal Hematoma After Central Venous Port System Implantation.

BACKGROUND: We report a case of surgical central venous port system implantation using Seldinger's technique with a life-threatening mediastinal hematoma due to the perforation of the superior vena cava. CASE REPORT: A 68-year-old woman was admitted to our institution for port implantation. Open access to the cephalic vein and 2 punctures of the right subclavian vein were unsuccessful. Finally, the port catheter could be placed into the superior vena cava using Seldinger's technique. As blood aspiration via the port catheter was not possible, fluoroscopy was performed, revealing mediastinal contrast extravasation without contrasting the venous system. A new port system could be placed in the correct position without difficulties. After extubation, the patient presented with severe respiratory distress and required consecutive cardiopulmonary resuscitation and reintubation. The CT scan showed a significant hematoma in the lower neck and posterior mediastinum with tracheal compression. We assumed a perforation of the superior vena cava with the tip of the guidewire using Seldinger's technique. Long-term intensive treatment with prolonged ventilation and tracheotomy was necessary. The port system had to be subsequently explanted due to infection. CONCLUSIONS: Mediastinal hematoma is a rare but life-threatening complication associated with central venous catheterization using Seldinger's technique. Perforation occurs most often during central venous catheterization in critical care. Mediastinal hematoma is an example of a mechanical complication occurring after central venous catheterization, which has been described only a few times in the literature to date. This case highlights the importance of awareness of possible, rare, life-threatening complications during port implantation, mostly performed in multimorbid patients by surgeons in training.

One-stage cleft repair outcome at age 6- to 18-years -- a comparison to the Eurocleft study data.

The optimisation of the relation between quality of outcome and burden of care is difficult in the treatment of cleft lip and palate. We analysed long-term outcome after one-stage repair of clefts to assess the benefits and limitations of this form of treatment. Thirty-three patients aged 6-18 years who had had lip repair, two-flap palatoplasty, and corticocancellous alveolar bone grafts at 6 months of age were divided into three age groups (6-11, 12-14, and 15-18 years) and compared with mean outcome data from the Eurocleft centres and with cephalometric standards of healthy people. Fifteen of the 33 patients were assessed for nasalance. Maxillary protrusion (SNA) and intermaxillary relation (ANB) in the one-stage groups differed significantly from those of healthy people, but not from corresponding means in the Eurocleft study. In 61% the Bergland score for alveolar ossification was grade I or II, and in 15% it was grade III; 24% had secondary alveolar bone grafting. No palatal fistulas occurred and nasalance did not differ significantly from that of healthy controls. As each patient generally had a primary operation and one secondary procedure, they benefited from half the number of surgical steps of multistage procedures. However, one-stage procedures led to significant disturbance in growth, but the degree of this was similar to mean values of multistage procedures in the Eurocleft study. Primary alveolar bone grafting led to inconsistent alveolar ossification and was suspected to interfere with anterior maxillary growth so it has been abandoned.