Surveillance after Total Neoadjuvant Therapy: What to do for Near-Complete Responders.

A proportion of patients who undergo total neoadjuvant therapy for rectal cancer will achieve what is classified as a near-complete response. Significant debate exists as to the optimal management strategy for these patients with large heterogeneity in management. This article will examine the therapeutic and surveillance options for these patients as well as the relevant outcomes data.

The Current of Consciousness: Neural Correlates and Clinical Aspects.

PURPOSE OF REVIEW: In this review, we summarize the current understanding of consciousness including its neuroanatomic basis. We discuss major theories of consciousness, physical exam-based and electroencephalographic metrics used to stratify levels of consciousness, and tools used to shed light on the neural correlates of the conscious experience. Lastly, we review an expanded category of 'disorders of consciousness,' which includes disorders that impact either the level or experience of consciousness. RECENT FINDINGS: Recent studies have revealed many of the requisite EEG, ERP, and fMRI signals to predict aspects of the conscious experience. Neurological disorders that disrupt the reticular activating system can affect the level of consciousness, whereas cortical disorders from seizures and migraines to strokes and dementia may disrupt phenomenal consciousness. The recently introduced memory theory of consciousness provides a new explanation of phenomenal consciousness that may explain better than prior theories both experimental studies and the neurologist's clinical experience. Although the complete neurobiological basis of consciousness remains a mystery, recent advances have improved our understanding of the physiology underlying level of consciousness and phenomenal consciousness.

Robotics for Acute Care in Colorectal Surgery.

Robotic surgery is growing exponentially in elective colorectal procedures, but utilization of robotics in urgent and emergency procedures remains low. Robotic surgery can be safely utilized for the management of several acute colorectal operations such as anastomotic leaks, perforated diverticulitis, and more. This chapter discusses safe access principles and planning, as well as technical aspects of these complex procedures, and the pathway to building a 24/7 robotic access culture.

Anti-NMDA receptor encephalitis presenting as a progression of disease in a patient with underlying congenital leukodystrophy: Case report.

Anti-NMDA Receptor (NMDAR) Encephalitis (NMDARE) is an autoimmune disorder that is often debilitating and difficult to diagnose. Patients, especially those with underlying neuropsychiatric disorders, may experience delayed or misdiagnosis of NMDARE. Here, we report on a patient with known congenital leukodystrophy (CLD) and epilepsy with a challenging diagnosis of NMDARE. The patient first presented with progressive behavior changes and seizure-like episodes. Initial workup, including video EEG and brain MRI, were mostly unremarkable, and the patient's symptoms were resistant to treatment with multiple anti-epileptic drugs. Given the patient's complicated clinical history, his presentation was initially thought of as progression or exacerbation of his chronic disease. With continued lack of improvement, autoimmune encephalitis was considered. The patient was started on immunotherapy and autoimmune encephalitis panels were sent, which came back positive. He continued to improve over the next weeks and months. Despite a growing body of literature, our knowledge on confirmed risk factors for NMDAR remains limited outside of young age, ovarian teratomas, and herpes encephalitis. We know that maintenance of the blood brain barrier is key to preventing autoimmune disorders of the central nervous system (CNS), and multiple congenital leukodystrophies exhibit pathology in the neurovascular unit. This is the first described case of anti-NMDA receptor encephalitis in a patient with an underlying congenital leukodystrophy, which may reflect an underreported NMDAR encephalitis risk factor. With limited known risk factors and time to diagnosis and treatment so important, this case may reflect an important and underreported risk factor for NMDAR.

The role of the cancer center when using lymph node count as a quality measure for gastric cancer surgery.

IMPORTANCE: Cancer center recognition, offered as accreditation by the American College of Surgeons Commission on Cancer or the National Cancer Institute, and quality measure reporting purport to improve the quality of cancer care. For surgically resectable gastric cancer, removal of 15 or more lymph nodes has been associated with improved outcomes and has been endorsed as a gastric cancer quality measure. OBJECTIVES: To determine whether cancer center classification is associated with compliance with the lymph node-count quality measure and the effect of compliance with the measure on overall survival. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of prospectively collected population-based data from the Surveillance, Epidemiology, and End Results Cancer Registry of Greater California and California Cancer Registry was conducted. Participants included patients who underwent surgery for stage I to III gastric adenocarcinoma between January 1, 2004, and December 31, 2010. MAIN OUTCOMES AND MEASURES: Compliance with removal of 15 or more lymph nodes and overall survival. RESULTS: Of 3321 gastric cancer cases, 42.3% had a minimum of 15 lymph nodes removed. Hospitals with cancer program recognition treated 69.9% of the cases. In hospitals without cancer program approval, 34.8% of the patients had 15 or more lymph nodes removed compared with 45.5% in the facilities with cancer program approval. Logistic regression analysis demonstrated that patients undergoing gastrectomy had significantly higher odds of having 15 or more lymph nodes removed if they were younger (trend P < .001), Asian/other race/ethnicity (adjusted odds ratio [AOR], 1.24; 95% CI, 1.03-1.50), or non-Hispanic black (AOR, 1.37; 95% CI, 1.03-1.82) compared with non-Hispanic white, received diagnosis at a progressively higher stage (trend P < .001), or received diagnosis in a more recent year (trend P < .001). Removal of 15 or more lymph nodes was associated with cancer program recognition (vs no recognition) (odds ratio, 1.48; 95% CI, 1.25-1.74). Cox proportional hazards regression showed that improved survival was predicted by removal of 15 or more lymph nodes (hazard ratio [HR], 0.70; 95% CI, 0.63-0.78) but not by cancer program recognition (HR, 1.03; 95% CI, 0.92-1.15). CONCLUSIONS AND RELEVANCE: Although adequate lymph node retrieval is more likely in hospitals with a recognized cancer program, survival outcome is associated with the lymph node count rather than with cancer program classification. Less than half of the cases reviewed in this study met the minimum lymph node-count guideline, indicating the need for process improvement for all hospitals.

Laparoscopic management of obstructed gastric conduit after minimally invasive esophagectomy.

We describe a novel, minimally invasive method of managing an obstructed gastric conduit after minimally invasive esophagectomy. In addition, we briefly review the management of obstructed gastric conduit in patients status-post minimally invasive esophagectomy. On literature review, it was noted that gastrojejunostomy after esophagectomy was exceptionally rare. Only one other reported case of gastrojejunostomy after esophagectomy was found in the literature. This is the first reported case to our knowledge of laparoscopic gastrojejunostomy after minimally invasive esophagectomy (MIE). Laparoscopic gastrojejunostomy after minimally invasive esophagectomy for obstructed gastric conduit is technically feasible, and it effectively managed the obstruction in our patient.

Alcohol fat clearing increases lymph node yield after surgery for colorectal cancer.

Lymph node (LN) yield is associated with oncologic outcome in patients who undergo surgery for colorectal adenocarcinoma (CRC). Standards to maximize LN yield have been initiated to enhance treatment of patients with CRC. This study evaluates the impact of a simple alcohol-based preparation protocol on LN yield. Surgical specimens from patients with CRC were prepared using either the alcohol protocol or standard formalin fixation and LN yield was compared. In total, 80 consecutive patients (n = 40 formalin, n = 40 alcohol) were examined. Overall, median LN yield increased from 17 to 29 (P < 0.01) with the alcohol fat clearance protocol. For patients with rectal adenocarcinoma who underwent proctectomy after neoadjuvant chemoradiotherapy, LN yield increased from 15 to 23 (P = 0.02). The frequency of need for additional sampling to achieve a minimum 12 LN count was also reduced. Initiation of a standardized alcohol fat-clearing protocol increased LN yield after surgery for CRC. This simple, cost-effective measure may improve the efficiency of LN assessment and accurate staging, which may impact oncologic outcomes.