Consensus conference statement on fluorescence-guided surgery (FGS) ESSO course on fluorescence-guided surgery.

BACKGROUND: Fluorescence-guided surgery (FGS) has emerged as an innovative technique with promising applications in various surgical specialties. However, clinical implementation is hampered by limited availability of evidence-based reference work supporting the translation towards standard-of-care use in surgical practice. Therefore, we developed a consensus statement on current applications of FGS. METHODS: During an international FGS course, participants anonymously voted on 36 statements. Consensus was defined as agreement ≥70% with participation grade of ≥80%. All participants of the questionnaire were stratified for user and handling experience within five domains of applicability (lymphatics & lymph node imaging; tissue perfusion; biliary anatomy and urinary tracts; tumor imaging in colorectal, HPB, and endocrine surgery, and quantification and (tumor-) targeted imaging). Results were pooled to determine consensus for each statement within the respective sections based on the degree of agreement. RESULTS: In total 43/52 (81%) course participants were eligible as voting members for consensus, comprising the expert panel (n = 12) and trained users (n = 31). Consensus was achieved in 17 out of 36 (45%) statements with highest level of agreement for application of FGS in tissue perfusion and biliary/urinary tract visualization (71% and 67%, respectively) and lowest within the tumor imaging section (0%). CONCLUSIONS: FGS is currently established for tissue perfusion and vital structure imaging. Lymphatics & lymph node imaging in breast cancer and melanoma are evolving, and tumor tissue imaging holds promise in early-phase trials. Quantification and (tumor-)targeted imaging are advancing toward clinical validation. Additional research is needed for tumor imaging due to a lack of consensus.

Microbiota-derived metabolites in colorectal cancer patients in preoperative period.

OBJECTIVE: Short-chain fatty acids (SCFAs) are microbial derived metabolites, which have multiple beneficial properties. The amount of SCFAs depends on several factors, such as age, diet (mainly intake of dietary fiber), and overall health condition. The normal proportion between SCFAs is 3:1:1 for acetate, proprionate and butyrate, respectively. In colorectal cancer (CRC) patients, microbiota alterations have been shown. Consequently, metabolome within the gut might change to a large extent. Therefore, the aim of this study was to analyse the content of SCFAs and the proportion between SCFAs in the stool obtained from CRC patients in preoperative period. PATIENTS AND METHODS: This study included 15 patients with CRC in preoperative period. The stool samples were taken and stored at -80°C in the Fahrenheit Biobank BBMRI.pl, Medical University of Gdansk, Poland. The analysis of SCFAs from stool samples was conducted by means of gas chromatography. RESULTS: This study included mainly males (66.67%, n=10). In all patients, there was abnormal proportion between SCFAs. The extremely higher concentration of butyrate was noted in 2 samples (13.33%) compared to the rest of patients. However, based on normal proportion between SCFAs, the results <1 for butyrate were noted in 93.33% of patients. CONCLUSIONS: SCFAs pool is altered in CRC patients, among others characterized by low level of butyrate. It should be considered to administer butyrate supplementation to CRC patients especially prior to surgery to support an appropriate preparation to this treatment.

The analysis of oral nutritional supplements related aspects among patients with digestive system cancer.

OBJECTIVE: Malnutrition-related disease particularly occur in patients with digestive system cancer. The administration of oral nutritional supplements (ONSs) is one of the methods of nutritional support recommended for oncological patients. The primary aim of this study was to assess the consumption-related aspects of ONSs among patients with digestive system cancer. The secondary aim was to assess the impact of ONSs consumption on the quality of life of these patients. PATIENTS AND METHODS: The current study included 69 patients with digestive system cancer. The assessment of ONSs-related aspects among cancer patients was conducted using a self-designed questionnaire, which has been accepted by Independent Bioethics Committee. RESULTS: Among all patients, 65% of participants declared that they consumed ONSs. Patients consumed various types of ONSs. However, the most common were protein products (40%) and standard products (37.78%). Only 4.44% of patients consumed products with immunomodulatory ingredients. Nausea was the most commonly (15.56%) observed side effect after ONSs consumption. Considering particular types of ONSs, side effects were the most commonly declared by patients who consumed standard products (p=0.157). The easy product availability in the pharmacy was noted by 80% of participants. However, 48.89% of patients assessed the cost of ONSs as not acceptable (48.89%). 46.67% of studied patients did not observe the improvement of quality of life after ONSs consumption. CONCLUSIONS: We have demonstrated that patients with digestive system cancer consumed various period, amount, and types of ONSs. Side effects after ONSs consumption occur rarely. However, the improvement of quality of life related to ONSs consumption was not noted in almost half of participants. ONSs are easily available in pharmacy.

European Society of Surgical Oncology's strategy for clinical research: Paving the way for a culture of research in cancer surgery.

As part of its mission to promote the best surgical care for cancer patients, the European Society of Surgical Oncology (ESSO) has been developing multiple programmes for clinical research along with its educational portfolio. This position paper describes the different research activities of the Society over the past decade and an action plan for the upcoming five years to lead innovative and high quality surgical oncology research. ESSO proposes to consider pragmatic research methodologies as a complement to randomised clinical trials (RCT), advocates for increased funding and operational support in conducting research and aims to enable young surgeons to be active in research and establish partnerships for translational research activities.

Meta-analysis of microsatellite instability in relation to clinicopathological characteristics and overall survival in gastric cancer.

BACKGROUND: Several associations between microsatellite instability (MSI) and other clinicopathological factors have been reported in gastric cancer, but the results have been ambiguous. This systematic review and meta-analysis investigated the relationship between MSI and overall survival and clinicopathological characteristics of patients with gastric cancer. METHODS: A systematic literature search of the PubMed, Cochrane and Ovid databases until 31 January 2016 was performed in accordance with the PRISMA statement. The articles were screened independently according to PICO (population, intervention, comparator, outcome) eligibility criteria. All eligible articles were evaluated independently by two reviewers for risk of bias according to the Quality In Prognosis Study tool. RESULTS: Overall, 48 studies with a total of 18 612 patients were included. MSI was found in 9·2 per cent of patients (1718 of 18 612), and was associated with female sex (odds ratio (OR) 1·57, 95 per cent c.i. 1·31 to 1·89; P < 0·001), older age (OR 1·58, 2·20 to 1·13; P < 0·001), intestinal Laurén histological type (OR 2·23, 1·94 to 2·57; P < 0·001), mid/lower gastric location (OR 0·38, 0·32 to 0·44; P < 0·001), lack of lymph node metastases (OR 0·70, 0·57 to 0·86, P < 0·001) and TNM stage I-II (OR 1·77, 1·47 to 2·13; P < 0·001). The pooled hazard ratio for overall survival of patients with MSI versus those with non-MSI gastric cancer from 21 studies was 0·69 (95 per cent c.i. 0·56 to 0·86; P < 0·001). CONCLUSION: MSI in gastric cancer was associated with good overall survival, reflected in several favourable clinicopathological tumour characteristics.

Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with T2 to T4, N0 and N1 breast cancer.

BACKGROUND: Histological status of axillary lymph nodes is an important prognostic factor in patients receiving surgery for breast cancer (BC). Sentinel lymph node (SLN) biopsy (B) has rapidly replaced axillary lymph node dissection (ALND), and is now the standard of care for axillary staging in patients with clinically node-negative (N0) operable BC. The aim of this study is to compare pretreatment lymphoscintigraphy with a post primary systemic treatment (PST) scan in order to reduce the false-negative rates for SLNB. METHODS: In this single-institution study we considered 170 consecutive T2-4 N0-1 M0 BC patients treated with anthracycline-based PST. At the time of incisional biopsy, we performed sentinel lymphatic mapping. After PST, all patients repeated lymphoscintigraphy with the same methodology. During definitive surgery we performed further sentinel lymphatic mapping, SLNB and ALND. RESULTS: The SLN was removed in 158/170 patients giving an identification rate of 92.9% (95% confidence interval (CI) = 88.0-96.3%) and a false-negative rate of 14.0% (95% CI = 6.3-25.8%). SLNB revealed a sensitivity of 86.0% (95% CI = 74.2-93.7%), an accuracy of 94.9% (95% CI = 90.3-97.8%) and a negative predictive value of 92.7% (95% CI = 86.1-96.8%). CONCLUSION: Identification rate, sensitivity and accuracy are in accordance with other studies on SLNB after PST, even after clinically negative node conversion following PST. This study confirms that diagnostic biopsy and neoadjuvant chemotherapy maintain breast lymphatic drainage unaltered.

Surgical management of advanced gastric cancer: An evolving issue.

Worldwide, gastric cancer represents the fifth most common cancer and the third leading cause of cancer deaths. Although the overall 5-year survival for resectable disease was more than 70% in Japan due to the implementation of screening programs resulting in detection of disease at earlier stages, in Western countries more than two thirds of gastric cancers are usually diagnosed in advanced stages reporting a 5-year survival rate of only 25.7%. Anyway surgical resection with extended lymph node dissection remains the only curative therapy for non-metastatic advanced gastric cancer, while neoadjuvant and adjuvant chemotherapies can improve the outcomes aimed at the reduction of recurrence and extension of survival. High-quality research and advances in technologies have contributed to well define the oncological outcomes and have stimulated many clinical studies testing multimodality managements in the advanced disease setting. This review article aims to outline and discuss open issues in current surgical management of advanced gastric cancer.

The pharmacokinetics of oral oxycodone in patients after total gastric resection.

OBJECTIVE: Oxycodone is a semi-synthetic opioid with a stronger analgesic effect than morphine and codeine. The efficacy of this opioid in the treatment of postoperative pain has been proved in different groups of patients. The drug has a favourable adverse reaction profile, which encourages doctors and patients to use it more and more widely. The drug is also used in the patients who underwent an abdominal surgery, e.g. stomach resection. Gastrectomy leads to pathophysiological changes within the gastrointestinal tract, which may cause changes in the drug absorption. In consequence this leads to a change in the pharmacokinetics and effect of the drug. The aim of the research was an analysis of the pharmacokinetics of oxycodone from prolonged release tablet in patients after total gastrectomy. PATIENTS AND METHODS: The research was carried out on patients after gastrectomy with Roux-en-Y reconstruction. The patients (n=24; mean [SD] age, 67.6 [9.8] years; weight, 69.1 [13.6] kg; and BMI, 25.2 [4.0] kg/m(2)) received oxycodone in a prolonged release tablet in a single orally administered dose of 10 mg. Blood samples were collected within 12 h after the drug administration. The plasma concentrations of oxycodone and noroxycodone were measured with validated high-pressure liquid chromatography coupled with triple tandem mass spectrometery method. RESULTS: The main pharmacokinetic parameters for oxycodone in men (n = 14) and women (n = 10) were as follows: Cmax, 14.40 (3.76) and 11.54 (6.98) ng/ml (p = 0.2066); AUC0-∞, 157.87 (56.89) and 106.44 (61.31) ng´h/ml (p = 0.0460); tmax, 2.18 (0.58) and 2.15 (0.58) h (p = 0.8008), respectively. CONCLUSIONS: Total gastrectomy did not affect the pharmacokinetics of oxycodone administered in prolonged release tablets, but the exposure to the drug was significantly lower in women.

Indocyanine green angiography for evaluation of gastric conduit perfusion during esophagectomy--first experience.

BACKGROUND: A complication of esophageal surgery is leakage at the anastomosis site and one of the factors involved in this complication is poor blood flow in the distal portion of the tube. The aim of this study was to evaluate the feasibility of indocyanine green fluorescence imaging as a method of determining the perfusion of the gastric conduit after esophagectomy. METHODS: We analysed 15 consecutive patients who underwent transhiatal esophagectomy (THE) due to cancer. All of the patients had reconstruction of the gastrointestinal tract using the gastric conduit. Before performing the anastomosis, the blood flow in the area of the tube was evaluated using intravenous indocyanine green and observing its vascular flow with a camera equipped with an infrared laser. RESULTS: In all cases it was possible to visualize the vascular flow of indocyanine green within the region of the gastric tube. The fluorescence imaging system showed vascular insufficiency of the distal gastric conduit in 4 patients--in all of these patients the anastomosis was performed end-to-side and there was no subsequent leak. Leakage at the anastomosis site was observed in 1 patient (6.66%). The leak was observed in the 9th postoperative day, despite visualization of a good vascular supply of the tube. CONCLUSIONS: Indocyanine green fluorescence imaging of gastric tube allows for intraoperative modifications, but it must be noted that the patient's comorbidities and general health may also increase the risk of anastomosis leakage.

Breast cancer sentinel lymph node mapping using near infrared guided indocyanine green and indocyanine green--human serum albumin in comparison with gamma emitting radioactive colloid tracer.

AIMS: Recently, a novel method of using near infrared (NIR) guided indocyanine green (ICG) and ICG conjugated with human serum albumin (ICG:HSA) for sentinel lymph node biopsy (SLNB) of breast cancer patients has shown true potential. The aim of this study was to compare the usefulness of NIR guided ICG and ICG:HSA against the gamma emitting radiocolloid (RC). METHODS: A group of 49 consecutive breast cancer patients underwent SLNB using RC. From this group, the first 28 patients were compared against ICG, while the next 21 patients were compared against ICG:HSA. The number of patients with visible fluorescent path was recorded. Furthermore, the number of SLNs detected by fluorophores percutaneously and total number of intraoperative SLNs detected by fluorophores and/or RC was noted. RESULTS: NIR guided real time lymphatic flow was observed in 47/49 patients (96%). In all cases except one, SLNs detected by the RC tracer were also detected by their respective fluorophore. Additionally, ICG detected 10 additional SLNs in 8 patients, while 3 additional SLNs were detected by ICG:HSA in 3 patients. Statistical analysis revealed no difference between the number of SLNs detected between ICG versus ICG:HSA and RC versus ICG:HSA. However, a significant statistical difference was observed between RC and ICG (p=0.0117), as well as between the combined NIR guided and RC method (p=0.0033). CONCLUSIONS: In conclusion, the use of either ICG or ICG:HSA with RC to obtain SLNB seems to be an effective alternative. Compared to RC alone, the use of ICG:HSA, more so than ICG alone, may provide additional benefits.

The effect of immediate breast reconstruction with Becker-25 prosthesis on the preservation of proper body posture in patients after mastectomy.

PURPOSE: This was a prospective study comparing coronal, sagittal and transverse plane body posture parameters in women after radical mastectomy and women after radical mastectomy with immediate breast reconstruction (IBR) for stage I and II breast cancer. METHODS: The three studied groups were one that underwent Madden's radical mastectomy (n = 38), a second with skin sparing mastectomy with IBR with expander-prosthesis Becker-25 (n = 38), and the control (n = 38). All the women were examined to determine their body posture in the coronal, sagittal and transverse planes using three-dimensional (3D) body surface analysis before and 6, 12, 18 and 24 months after surgery. RESULTS: There is a significant difference body posture in the coronal, sagittal and transverse planes between groups of patients after mastectomy with IBR comparing with patients after mastectomy alone. The women after radical mastectomy demonstrated the greatest postural changes in particular parameters of body posture in postsurgical months 18 and 24. The IBR group only demonstrated significant postural changes in one parameter, though as time after surgery increased, these changes decreased. CONCLUSIONS: IBR after mastectomy has an impact on proper body posture. Photogrammetric examination revealed important body posture disturbances only in the radical mastectomy group. It gives useful information on body posture parameters in the evaluation of quality of life in breast cancer survivors. It appears that immediate breast reconstruction helps to preserve proper body posture after mastectomy.

The role of sentinel node biopsy in ductal carcinoma in situ of the breast.

AIM: Sentinel node biopsy (SNB) is an accepted alternative to lymphadenectomy in the case of invasive breast carcinoma, although the sentinel node's role in ductal carcinoma in situ (DCIS) diagnosed on core needle biopsy has not been well defined nevertheless guidelines recommend this procedure. The purpose of this study was to determine the diagnostic value of sentinel nodes in female patients with primary DCIS using core needle stereotactic biopsy. MATERIAL AND METHODS: Between the years 2000 and 2005, 261 patients were diagnosed with DCIS by core needle biopsy. In this group, 183 patients underwent SNB to determine lymph node involvement. Those patients with metastases to the sentinel node underwent axillary lymphadenectomy. RESULTS: In the group of 183 patients that underwent SNB, 10 patients (5.5%) showed metastases to the sentinel lymph node. Histopathological studies of the primary lesions of these 10 patients revealed invasive ductal carcinoma in 6 cases (3.5%) and 1 case (0.5%) of invasive lobular carcinoma. Only 3 of the patients (1.5%) were given a final diagnosis of DCIS with metastases to sentinel lymph nodes, of which 2 cases were DCIS and 1 case was DCIS with microinvasion. Axillary lymphadenectomy performed on patients with abnormal SNB showed involvement of other axillary lymph nodes in 4 patients. CONCLUSIONS: SNB as a diagnostic tool in DCIS remains controversial as the number of cases of axillary lymph node metastases is minuscule. The biggest clinical challenge in this situation is a group of patients with primary diagnosis of DCIS in which invasive components are seen by mammotomic biopsy.