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OBJECTIVE: To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research. SUMMARY BACKGROUND DATA: HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed. METHODS: The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of ten expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies. RESULTS: Fifty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering five sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing however the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics. CONCLUSION: The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.
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OBJECTIVE: The ISGPS aims to develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally-invasive pancreatoduodenectomy (MIPD). BACKGROUND: Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis towards appropriate patient selection according to adequate surgeon and center experience. METHODS: The ISGPS developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions. RESULTS: The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomical (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cut-offs 40 and 80) and center annual MIPD volume (cut-offs 10 and 30), all also incorporated in an A-B-C classification. CONCLUSION: This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcome between centers and countries.
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OBJECTIVE: This study aimed to clarify the molecular mechanism of remnant pancreatic cancer (PC) development after primary PC resection. SUMMARY BACKGROUND DATA: Molecular mechanisms of the development of remnant PCs following primary PC resection are largely unknown. METHODS: Forty-three patients undergoing remnant PC resection after primary PC resection between 2001 and 2017 at 26 institutes were retrospectively analyzed. Clinicopathological features and molecular alterations detected by targeted amplicon sequencing of 36 PC-associated genes were evaluated. RESULTS: These patients showed significantly lower body mass indices and higher hemoglobin A1c values at remnant PC resection than at primary PC resection. A comparison of the molecular features between primary and remnant PCs indicated that remnant PCs were likely to develop via three different molecular pathways: successional, showing identical and accumulated alterations (n=14); phylogenic, showing identical and distinct alterations (n=26); and distinct, showing independent distinctive alterations (n=3). The similarity of gene alterations was associated with time to the remnant PC development (r=ï¼0.384, P=0.0173). Phylogenic pathways were significantly associated with the intraductal spread of carcinoma (P=0.007). Patient survival did not differ significantly depending on these molecular pathways. CONCLUSION: Molecular profiling uncovered three pathways for the development of remnant PCs, namely, successional, phylogenic, and distinct pathways. The vast majority of remnant PCs are likely to be molecularly associated with primary PCs either in the successional or phylogenic way. This information could impact the design of a strategy for monitoring and treating remnant PCs.
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Reducing recurrence following radical resection of colon cancer without over- or under-treatment remains a challenge. Postoperative adjuvant chemotherapy (Adj) is currently administered based solely on pathological tumor, node, and metastasis (TNM) stage. However, prognosis can vary significantly among patients with the same disease stage. Therefore, novel classification systems in addition to the TNM are necessary to inform decision-making regarding postoperative treatment strategies, especially stage II and III disease, and to minimize overtreatment and undertreatment with Adj. We developed a prognostic prediction system for colorectal cancer by using a combined convolutional neural network (CNN) and support vector machine (SVM) approach to extract features from hematoxyling and eosin staining (HE) images. We combined the TNM and our AI-based classification system into a TNM-AI (mTNM-AI) classification system with high discriminative power for recurrence-free survival (RFS). Furthermore, the cancer cell population recognized by this system as low risk of recurrence exhibited the mutational signature SBS87 as a genetic phenotype. The novel AI-based classification system developed here is expected to play an important role in prognostic prediction and personalized treatment selection in oncology.
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BACKGROUND: Complete mesocolic excision with central vascular ligation is a standard method for managing colon cancer. However, there is no consensus on its procedure, especially for cancer in the splenic flexure of the transverse colon. This is because various types of variational arteries are distributed to the region, and their running course below and near the pancreas leads to difficulty in ligating the artery. OBJECTIVE: To clarify the arterial distribution to the splenic flexure of the transverse colon using cadavers. DESIGN: The arteries in the transverse mesocolon distributed to the colon were dissected in cadavers, and their route was quantitatively visualized using drawing software. SETTINGS: This study was conducted at the Department of Anatomy, Tokyo Medical University. PATIENTS: Sixty cadavers donated to Tokyo Medical University in 2017-2021 were used. MAIN OUTCOME MEASURES: The arterial courses to the splenic flexure of the transverse colon in the mesocolon and their patterns were evaluated. RESULTS: We found 34 variational arteries distributed to the splenic flexure of the transverse colon. Most originated from the superior mesenteric artery and the middle colic artery, with their typical course below the pancreas. We identified another arterial course, crossing the mesocolon away from the pancreas toward the splenic flexure of the transverse colon. Furthermore, the origin of these arteries was not behind the pancreas and can be found in the caudal region of the pancreas. LIMITATIONS: We cannot discuss how the arteries within the transverse mesocolon are observed by CT examination. CONCLUSIONS: This study showed 2 types of arterial courses (below the pancreas and within the mesocolon) toward the splenic flexure of the transverse colon for the first time. In the latter case, the complete mesocolic excision with central vascular ligation is likely performed more easily than in the former. See Video Abstract. DOS TIPOS DE RECORRIDO VARIACIONAL DE LA ARTERIA DESDE LA ARTERIA MESENTRICA SUPERIOR PARA IRRIGAR EL NGULO ESPLNICO ESTUDIO ANATMICO MACROSCPICO: ANTECEDENTES:La escisión mesocólica completa con ligadura vascular central es un método estándar para el cáncer de colon. Sin embargo, no hay consenso sobre su procedimiento, especialmente para el cáncer en el ángulo esplénico del colon transverso. Esto se debe a que varios tipos de arterias variacionales se distribuyen en la región, y su recorrido por debajo y cerca del páncreas dificulta la ligadura de la arteria.OBJETIVO:Este estudio tuvo como objetivo aclarar la distribución arterial al SF del colon transverso utilizando cadáveres.DISEÑO:Las arterias en el mesocolon transverso distribuidas al colon fueron disecadas en cadáveres, y su ruta fue visualizada cuantitativamente utilizando un software de dibujo.AJUSTES:Este estudio se realizó en el Departamento de Anatomía de la Universidad Médica de Tokio.PACIENTES:Se utilizaron sesenta cadáveres donados a la Universidad Médica de Tokio en 2017-2021.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los cursos arteriales al ángulo esplénico del colon transverso en el mesocolon y sus patrones.RESULTADOS:Encontramos 34 arterias variacionales distribuidas al ángulo esplénico del colon transverso. La mayoría se originaron en la arteria mesentérica superior y la arteria cólica media, con su trayecto típico por debajo del páncreas. Identificamos otro curso arterial, cruzando el mesocolon alejándose del páncreas hacia el ángulo esplénico del colon transverso. Además, el origen de estas arterias no estaba detrás del páncreas y se pueden encontrar en la región caudal del páncreas.LIMITACIONES:No podemos discutir cómo se observan las arterias dentro del mesocolon transverso mediante un examen de tomografía computarizada.CONCLUSIONES:Este estudio mostró por primera vez dos tipos de trayectos arteriales (por debajo del páncreas y dentro del mesocolon) hacia el ángulo esplénico del colon transverso. En el último caso, es probable que la escisión mesocólica completa con ligadura vascular central se realice más fácilmente que en el primero. (Traducción-Dr. Aurian Garcia Gonzalez ).
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Colo Transverso , Neoplasias do Colo , Humanos , Colo Transverso/cirurgia , Artéria Mesentérica Superior , Neoplasias do Colo/cirurgia , Cadáver , Estudos RetrospectivosRESUMO
BACKGROUND: D3 is unaffected by anatomic factors even when the ileocolic artery runs along the dorsal side of the superior mesenteric vein. Complete "true D3" lymph node dissection in minimally invasive surgery for right-sided colon cancer could be beneficial for certain patients with lymph node metastases. IMPACT OF INNOVATION: The study aimed to determine the safety and feasibility of robotic true D3 lymph node dissection for right-sided colon cancer using a superior mesenteric vein-taping technique. TECHNOLOGY, MATERIALS, AND METHODS: The superior mesenteric vein was slowly and gently separated from the surrounding tissues and taped. Lifting the tape with the robotic third arm and fixing it in place using rock-stable tractions provides a good surgical view, which cannot otherwise be obtained. As a result, the ileocolic artery that branches from the superior mesenteric artery can be accurately exposed. Handling of the taping then enables expansion to a different surgical view. As the lymph nodes are originally concealed on the dorsal side of the superior mesenteric vein, this technique provides a good view for lymph node dissection. The root of the ileocolic artery was clipped and separated, and true D3 was thus completed. PRELIMINARY RESULTS: Fourteen patients underwent robotic true D3 lymph node dissection for right-sided colon cancer. No Clavien-Dindo classification grade II or higher intraoperative or postoperative complications were observed. The 30-day mortality rate was 0%. CONCLUSIONS: Our robotic true D3 lymph node dissection with superior mesenteric vein-taping technique is considered safe and feasible; it might be a promising surgical procedure for treating advanced right-sided colon cancer. FUTURE DIRECTIONS: Even when the ileocolic artery runs along the dorsal aspect of the superior mesenteric vein, the technique seems promising for facilitating robotic D3 lymph node dissection.
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Neoplasias do Colo , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Humanos , Neoplasias do Colo/cirurgia , Neoplasias do Colo/patologia , Veias Mesentéricas/cirurgia , Veias Mesentéricas/patologia , Procedimentos Cirúrgicos Robóticos/métodos , Colectomia/métodos , Laparoscopia/métodos , Excisão de Linfonodo/métodos , Linfonodos/patologiaRESUMO
BACKGROUND/PURPOSE: In colorectal cancer, the morphological categorization of fibrotic cancer stroma in the invasive frontal zone of the primary tumor is well reflected in the prognosis. Conversely, the histological characteristics of pancreatic cancer (PC) reveal fibrotic hyperplasia of stroma known as desmoplasia; however, its characterization is unknown. Therefore, this study aimed to evaluate the prognostic factors according to the histological categorization of desmoplastic reactions in PC. METHODS: We retrospectively enrolled 167 patients who underwent curative resection for PC. The desmoplastic pattern was histologically classified as mature, intermediate, or immature. Clinicopathological features were evaluated, and disease-free and overall survival (OS) were analyzed in the three groups. Prognostic factors were assessed using univariate and multivariate analyses. RESULTS: In total, 19 mature, 87 intermediate, and 61 immature desmoplastic patterns were evaluated. Jaundice decompression, white blood cell count, and platelet/lymphocyte ratio were significantly different among the groups. The mature group had a better disease-free survival (DFS) prognosis than the other two groups; however, OS did not differ between the groups. Desmoplastic patterns showed significant differences between the three groups for DFS. CONCLUSIONS: Desmoplastic patterns are a prognostic factor of DFS for PC, with mature desmoplastic reactions associated with good prognosis. Thus, they may aid in individualized therapeutic approaches in patients with PC.
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Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/cirurgia , Masculino , Feminino , Estudos Retrospectivos , Idoso , Pessoa de Meia-Idade , Prognóstico , Adulto , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Pancreatectomia , FibroseRESUMO
BACKGROUND: Recently, robot-assisted minimally invasive esophagectomy (RAMIE) has gained popularity worldwide. Some studies have compared the long-term results of RAMIE and minimally invasive esophagectomy (MIE). However, there are no reports on the long-term outcomes of RAMIE in Japan. This study compared the long-term outcomes of RAMIE and MIE. METHODS: This retrospective study included 86 patients with thoracic esophageal cancer who underwent RAMIE or MIE at our hospital from June 2010 to December 2016. Propensity score matching (PSM) was employed, incorporating co-variables such as confounders or risk factors derived from the literature and clinical practice. These variables included age, sex, body mass index, alcohol consumption, smoking history, American Society of Anesthesiologists stage, comorbidities, tumor location, histology, clinical TNM stage, and preoperative therapy. The primary endpoint was 5-year overall survival (OS), and the secondary endpoints were 5-year disease-free survival (DFS) and recurrence rates. RESULTS: Before PSM, the RAMIE group had a longer operation time (min) than the MIE group (P = 0.019). RAMIE also exhibited significantly lower blood loss volume (mL) (P < 0.001) and fewer three-field lymph node dissections (P = 0.028). Postoperative complications (Clavien-Dindo: CD ≥ 2) were significantly lower in the RAMIE group (P = 0.04), and postoperative hospital stay was significantly shorter than the MIE group (P < 0.001). After PSM, the RAMIE and MIE groups consisted of 26 patients each. Blood loss volume was significantly smaller (P = 0.012), postoperative complications (Clavien-Dindo ≥ 2) were significantly lower (P = 0.021), and postoperative hospital stay was significantly shorter (P < 0.001) in the RAMIE group than those in the MIE group. The median observation period was 63 months. The 5-year OS rates were 73.1% and 80.8% in the RAMIE and MIE groups, respectively (P = 0.360); the 5-year DFS rates were 76.9% and 76.9% in the RAMIE and MIE groups, respectively (P = 0.749). Six of 26 patients (23.1%) in each group experienced recurrence, with a median recurrence period of 41.5 months in the RAMIE group and 22.5 months in the MIE group. CONCLUSIONS: Compared with MIE, RAMIE led to no differences in long-term results, suggesting that RAMIE is a comparable technique.
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Neoplasias Esofágicas , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Esofagectomia/métodos , Estudos Retrospectivos , Pontuação de Propensão , Resultado do Tratamento , Neoplasias Esofágicas/patologia , Procedimentos Cirúrgicos Robóticos/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodosRESUMO
The patient was a 54-year-old male at the time of initial examination. He was aware of numbness and weakness in the left hemisphere of his body and came to see the hospital. He was diagnosed with brain metastasis of lung cancer and started treatment(cT2N0M1[Brain]). He underwent gamma knife for the head lesion and nivolumab for the lung lesion. The patient's lesions shrank with the success of the medical treatment, but recurred with small intestinal metastasis. He underwent a partial resection of the small intestine and was treated again with nivolumab, which resulted in a complete response. He is currently alive without recurrence. We have experienced a very rare case of recurrence-free survival after treatment for brain metastasis and small intestinal metastasis of lung cancer.
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Neoplasias Encefálicas , Neoplasias Intestinais , Neoplasias Pulmonares , Humanos , Masculino , Neoplasias Pulmonares/secundário , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Pessoa de Meia-Idade , Neoplasias Encefálicas/secundário , Neoplasias Encefálicas/terapia , Neoplasias Intestinais/cirurgia , Neoplasias Intestinais/patologia , Neoplasias Intestinais/secundário , Neoplasias Intestinais/terapia , Terapia Combinada , Fatores de Tempo , Recidiva , Radiocirurgia , Nivolumabe/uso terapêutico , Intestino Delgado/patologia , Antineoplásicos Imunológicos/uso terapêuticoRESUMO
INTRODUCTION: Elderly patients requiring surgical treatment is increasing in Japan, and while surgical treatment is expected to be effective even in the very elderly, there is a lack of evidence for the safety and efficacy of surgical resection due to problems with perioperative management and operative tolerance. We therefore retrospectively examined the short-term and long-term outcomes of colorectal cancer surgery for the very elderly at our hospital. SUBJECTS: The study included 14 cases of colorectal cancer in the very elderly who underwent radical resection at our hospital between January 2010 and March 2020. RESULTS: The mean age was 92 years, PS; 1/2=8/6, ASA-PS; 2/3/4=8/4/2, primary site was C/A/T/S/R= 2/5/2/2/3, pStage; 1/2/3=1/9/4, and only 1 case of decompression with ileus tube due to obstructive symptoms was treated before surgery. All patients underwent radical surgery. Median blood loss was 61 mL, median operation time was 190.5 min, and median postoperative hospital stay was 16 days. 5 patients had CD≥2 complications. All patients did not receive adjuvant chemotherapy, and recurrence in was observed 3 patients. CONCLUSION: Surgical treatment of very elderly patients seems to be acceptable under appropriate patient selection.
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Neoplasias Colorretais , Procedimentos Cirúrgicos do Sistema Digestório , Humanos , Idoso , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Neoplasias Colorretais/cirurgia , JapãoRESUMO
The case is a 78-year-old male. The chief complaint was melena and weight loss. After careful examination, the patient was diagnosed with advanced rectal cancer, and 3 courses of capecitabine plus oxaliplatin therapy were performed as preoperative chemotherapy. He underwent robot-assisted laparoscopic rectal resection, D3 lymphadenectomy, lateral lymphadenectomy, and temporary colostomy, and was discharged on hospital day 15. Postoperative pathological diagnosis showed only ulcerative lesions in the rectum, and malignant cells could not be confirmed. After postoperative adjuvant chemotherapy, the patient is alive without recurrence on an outpatient basis. There are many reports that it is slightly lower than radiotherapy. Therefore, it is important to select a more appropriate preoperative treatment, and the concentration of future cases is recognized.
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Protectomia , Neoplasias Retais , Masculino , Humanos , Idoso , Reto/patologia , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Oxaliplatina/uso terapêutico , Quimioterapia Adjuvante , Resposta Patológica CompletaRESUMO
BACKGROUND: Based on the Japan Adjuvant Study Group of Pancreatic Cancer 01 study, the standard duration of adjuvant chemotherapy with S-1 (an oral 5-fluorouracil prodrug consisting of tegafur, gimeracil, and oteracil) in patients with resected pancreatic ductal adenocarcinoma (PDAC) was considered to be 6 months, but the impact of increasing its duration on postoperative survival was unknown. Here, the authors investigated this question by reviewing real-world data from a large cohort of patients with PDAC. METHODS: In total, 3949 patients who underwent surgery for PDAC during the study period followed by S-1 adjuvant chemotherapy in board-certified institutions were included. Based on the duration of S-1 chemotherapy, two subgroups were defined: a standard-duration group that included patients who were treated for 180 ± 30 days and a longer duration group that included patients who received treatment for >210 days. RESULTS: The median duration of S-1 chemotherapy was 167 days, with a mean ± standard deviation of 200 ± 193 days. After excluding patients who had a recurrence within 210 days after the initiation of adjuvant chemotherapy, postoperative recurrence-free survival (RFS) and overall survival (OS) in the standard-duration group (n = 1473) and the longer duration group (n = 975) were compared. RFS and OS did not differ significantly between the standard-duration and longer duration groups (5-year RFS: 37.8% vs. 36.2% respectively; p = .6186; 5-year OS: 52.8% vs. 53.4%, respectively; p = .5850). The insignificant difference was verified by multivariate analysis and propensity-score matching analysis. CONCLUSIONS: The current findings suggest that extending S-1 adjuvant chemotherapy beyond 6 months has no significant additional effect on survival in patients with PDAC. This could be useful in determining whether to extend S-1 chemotherapy in patients who have completed the standard 6-month treatment.
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Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Humanos , Tegafur/uso terapêutico , Ácido Oxônico/uso terapêutico , Japão/epidemiologia , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/cirurgia , Neoplasias Pancreáticas/patologia , Quimioterapia Adjuvante , Carcinoma Ductal Pancreático/tratamento farmacológico , Carcinoma Ductal Pancreático/cirurgia , Carcinoma Ductal Pancreático/patologia , Pâncreas/patologia , Estudos Retrospectivos , Neoplasias PancreáticasRESUMO
OBJECTIVE: The aim of this study was to investigate the safety and survival benefits of portal vein and/or superior mesenteric vein (PV/SMV) resection with jejunal vein resection (JVR) for pancreatic ductal adenocarcinoma (PDAC). SUMMARY BACKGROUND DATA: Few studies have shown the surgical outcome and survival of pancreatic resection with JVR, and treatment strategies for patients with PDAC suspected of jejunal vein (JV) infiltration remain unclear. METHODS: In total, 1260 patients who underwent pancreatectomy with PV/ SMV resection between 2013 and 2016 at 50 facilities were included; treatment outcomes were compared between the PV/SMV group (PV/ SMV resection without JVR; n = 824), PV/SMV-J1 V group (PV/SMV resection with first jejunal vein resection; n = 394), and PV/SMV-J2,3 V group (PV/SMV resection with second jejunal vein or later branch resection; n = 42). RESULTS: Postoperative complications and mortality did not differ between the three groups. The postoperative complication rate associated with PV/ SMV reconstruction was 11.9% in PV/SMV group, 8.6% in PV/SMV-J1 V group, and 7.1% in PV/SMV-J2,3V group; there were no significant differences among the three groups. Overall survival did not differ between PV/SMV and PV/SMV-J1 V groups (median survival; 29.2 vs 30.9 months, P = 0.60). Although PV/SMV-J2,3 V group had significantly shorter survival than PV/SMV group who underwent upfront surgery ( P = 0.05), no significant differences in overall survival of patients who received preoperative therapy. Multivariate survival analysis revealed that adjuvant therapy and R0 resection were independent prognostic factors in all groups. CONCLUSION: PV/SMV resection with JVR can be safely performed and may provide satisfactory overall survival with the pre-and postoperative adjuvant therapy.
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Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Humanos , Pancreatectomia , Veia Porta/cirurgia , Veia Porta/patologia , Veias Mesentéricas/cirurgia , Pancreaticoduodenectomia , Resultado do Tratamento , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Neoplasias PancreáticasRESUMO
OBJECTIVE: To develop a prediction model for major morbidity and endocrine dysfunction after CP which could help in tailoring the use of this procedure. SUMMARY BACKGROUND DATA: Central pancreatectomy (CP) is a parenchyma-sparing alternative to distal pancreatectomy for symptomatic benign and pre-malignant tumors in body and neck of the pancreas CP lowers the risk of new-onset diabetes and exocrine pancreatic insufficiency compared to distal pancreatectomy but it is thought to increase the risk of short-term complications including postoperative pancreatic fistula (POPF). METHODS: International multicenter retrospective cohort study including patients from 51 centers in 19 countries (2010-2021). Primary endpoint was major morbidity. Secondary endpoints included POPF grade B/C, endocrine dysfunction, and the use of pancreatic enzymes. Two risk model were designed for major morbidity and endocrine dysfunction utilizing multivariable logistic regression and internal and external validation. RESULTS: 838 patients after CP were included (301 (36%) minimally invasive) and major morbidity occurred in 248 (30%) patients, POPF B/C in 365 (44%), and 30-day mortality in 4 (1%). Endocrine dysfunction in 91 patients (11%) and use of pancreatic enzymes in 108 (12%). The risk model for major morbidity included male sex, age, BMI, and ASA score≥3. The model performed acceptable with an area under curve (AUC) of 0.72(CI:0.68-0.76). The risk model for endocrine dysfunction included higher BMI and male sex and performed well (AUC:0.83 (CI:0.77-0.89)). CONCLUSIONS: The proposed risk models help in tailoring the use of CP in patients with symptomatic benign and premalignant lesions in the body and neck of the pancreas and are readily available via www.pancreascalculator.com.
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Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
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Gastroenterologia , Neoplasias Pancreáticas , Humanos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Japão , Terapia Neoadjuvante/métodos , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/cirurgiaRESUMO
BACKGROUND: Improving oncological curability and preserving urinary function must be established in robotic total mesorectal excision (TME) for rectal cancer. To achieve this, it is important to avoid nerve injury by sharp dissection of the avascular plane by the monopolar device and thermal spread. The aim of this study was to improve the robotic TME quality by focusing on the theory of fundamental use of surgical energy (FUSE) of the monopolar device and investigating the surgical procedure. METHODS: In this single-center retrospective study, 26 consecutive patients who underwent robotic TME for rectal cancer at Tokyo Medical University Hospital between June 2022 and August 2022 were included. All surgeries were performed by FUSE-certified surgeons in accordance with FUSE theory, which was, thermal effect = current density (current/area) squared × tissue resistance × contact time. RESULT: The median age of the patients was 64 years (range 40-79 years), and 17 patients were male. The median operative time was 287 min (range 229-430 min); median bleeding volume, 22 ml (range 5-223 ml); and the median number of harvested lymph nodes, 17 (range 4-40). The conversion rate to open surgery was 0%. A breakdown of Clavien-Dindo classification Grade ≥ II post-operative complications was as follows: surgical site infection, one patient (3.8%); ileus, one patient (3.8%); and urinary dysfunction, one patient (3.8%). No surgery-related or in-hospital deaths occurred. The pathological positive resection margin was not observed. CONCLUSIONS: Robotic TME for rectal cancer based on the theory of FUSE can be safely performed, making it a promising surgical procedure. It is suggested that robotic surgeons acquire surgical operation skills with monopolar devices based on the principles of FUSE, which may lead to an increased quality of robotic TME.
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Laparoscopia , Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Feminino , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento , Estudos Retrospectivos , Laparoscopia/métodos , Neoplasias Retais/cirurgia , Neoplasias Retais/patologiaRESUMO
PURPOSE: The importance of lateral pelvic lymph node dissection (LLND) for advanced low rectal cancer is gradually being recognized in Europe and the USA, where some patients were affected by uncontrolled lateral pelvic lymph node (LLNs) metastasis, even after total mesorectal excision (TME) with neoadjuvant chemoradiotherapy (CRT). The purpose of this study was thus to compare robotic LLND (R-LLND) with laparoscopic (L-LLND) to clarify the safety and advantages of R-LLND. METHODS: Sixty patients were included in this single-institution retrospective study between January 2013 and July 2022. We compared the short-term outcomes of 27 patients who underwent R-LLND and 33 patients who underwent L-LLND. RESULTS: En bloc LLND was performed in significantly more patients in the R-LLND than in the L-LLND group (48.1% vs. 15.2%; p = 0.006). The numbers of LLNs on the distal side of the internal iliac region (LN 263D) harvested were significantly higher in the R-LLND than in the L-LLND group (2 [0-9] vs. 1 [0-6]; p = 0.023). The total operative time was significantly longer in the R-LLND than in the L-LLND group (587 [460-876] vs. 544 [398-859]; p = 0.003); however, the LLND time was not significantly different between groups (p = 0.718). Postoperative complications were not significantly different between the two groups. CONCLUSION: The present study clarified the safety and technical feasibility of R-LLND with respect to L-LLND. Our findings suggest that the robotic approach offers a key advantage, allowing significantly more LLNs to be harvested from the distal side of the internal iliac region (LN 263D). Prospective clinical trials examining the oncological superiority of R-LLND are thus necessary in the near future.
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Laparoscopia , Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Humanos , Estudos Retrospectivos , Estudos Prospectivos , Excisão de Linfonodo/métodos , Linfonodos/cirurgia , Linfonodos/patologia , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Laparoscopia/métodos , Recidiva Local de Neoplasia/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Recently, stratification of high-risk stage II colon cancer (CC) and the need for adjuvant chemotherapy have been the focus of attention. The aim of this retrospective study was to define high-risk factors for recurrent stage II CC using Prediction One auto-artificial intelligence (AI) software and develop a new predictive model for high-risk stage II CC. METHODS: The study included 259 consecutive pathological stage II CC patients undergoing curative resection at our institution between January 2000 and December 2016. Prediction One software with five-fold cross-validation was used to create a predictive model and receiver operating characteristic (ROC) curve. Predictive accuracy of AI was evaluated using the area under the ROC curve (AUC). We also evaluated the importance of variables (IOV) using a method based on permutation feature importance (IOV > 0.01 defined high-risk factors) to evaluate disease-free survival (DFS). RESULTS: The median observation period was 6.1 (range = 0.3-15.8) years. Thirty-seven patients had recurrence (14.3%); the AUC of the AI model was 0.775. Preoperative carcinoembryonic antigen > 5.0 ng/mL (IOV = 0.047), venous invasion (IOV = 0.014), and obstruction (IOV = 0.012) were high-risk factors contributing to cancer recurrence. Patients with 2-3 high-risk factors had lower 5-year DFS than those with 0-1 factor (87.4% vs 62.7%, p < 0.001). CONCLUSIONS: We developed a new predictive model that could predict recurrent high-risk stage II CC with high probability using auto-AI Prediction One software. Patients with ≥ 2 of the aforementioned factors are considered to have high risks for recurrent stage II CC and may benefit from adjuvant chemotherapy.
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Inteligência Artificial , Neoplasias do Colo , Humanos , Estudos Retrospectivos , Estadiamento de Neoplasias , Recidiva Local de Neoplasia/patologia , Neoplasias do Colo/patologia , Quimioterapia Adjuvante , PrognósticoRESUMO
BACKGROUND: There are various preoperative treatments that are useful for controlling local or distant metastases in lower rectal cancer. For planning perioperative management, preoperative stratification of optimal treatment strategies for each case is required. However, a stratification method has not yet been established. Therefore, we attempted to predict the prognosis of lower rectal cancer using preoperative magnetic resonance imaging (MRI) with artificial intelligence (AI). METHODS: This study included 54 patients [male:female ratio was 37:17, median age 70 years (range 49-107 years)] with lower rectal cancer who could be curatively resected without preoperative treatment at Tokyo Medical University Hospital from January 2010 to February 2017. In total, 878 preoperative T2 MRIs were analyzed. The primary endpoint was the presence or absence of recurrence, which was evaluated using the area under the receiver operating characteristic curve. The secondary endpoint was recurrence-free survival (RFS), which was evaluated using the Kaplan-Meier curve of the predicted recurrence (AI stage 1) and predicted recurrence-free (AI stage 0) groups. RESULTS: For recurrence prediction, the area under the curve (AUC) values for learning and test cases were 0.748 and 0.757, respectively. For prediction of recurrence in each case, the AUC values were 0.740 and 0.875, respectively. The 5-year RFS rates, according to the postoperative pathologic stage for all patients, were 100%, 64%, and 50% for stages 1, 2, and 3, respectively (p = 0.107). The 5-year RFS rates for AI stages 0 and 1 were 97% and 10%, respectively (p < 0.001 significant difference). CONCLUSIONS: We developed a prognostic model using AI and preoperative MRI images of patients with lower rectal cancer who had not undergone preoperative treatment, and the model could be useful in comparison with pathological classification.
Assuntos
Inteligência Artificial , Neoplasias Retais , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Prognóstico , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Imageamento por Ressonância MagnéticaRESUMO
PURPOSE: To evaluate common hepatic duct just distal to the HE anastomosis (d-CHD) prospectively for mucosal damage, inflammation, fibrosis, dysplasia, carcinoma in situ, malignant transformation, effects of serum amylase, and symptoms at presentation in CC cases ranging from children to adults. METHODS: Cross-sections of d-CHD obtained at cyst excision 2018-2023 from 65 CC patients; 40 children (< 15 years old), 25 adults (≥ 15) were examined with hematoxylin and eosin, Ki-67, S100P, IMP3, p53, and Masson's trichrome to determine an inflammation score (IS), fibrosis score (FS), and damaged mucosa rate (DMR; damaged mucosa expressed as a percentage of the internal circumference). RESULTS: Mean age at cyst excision ("age") was 18.2 years (range: 3 months-74 years). Significant inverse correlations were found for age and DMR (p = 0.002), age and IS (p = 0.011), and age and Ki-67 (p = 0.01). FS did not correlate with age (p = 0.32) despite significantly increased IS in children. Dysplasia was identified in a 4-month-old girl with cystic CC. Serum amylase was elevated in high DMR subjects. CONCLUSIONS: High DMR, high IS, and evidence of dysplasia in pediatric CC suggest children are at risk for serious sequelae best managed by precise histopathology, protocolized follow-up, and awareness that premalignant histopathology can arise in infancy.