Correlation of Ki-67 indices from biopsy and resection specimens of neuroendocrine tumours

INTRODUCTION Neuroendocrine tumours (NETs) are a heterogeneous group of tumours with a highly variable presentation and prognosis. Management decisions are complex. Ki-67 levels in tissue samples are a key indicator used to grade tumours and guide treatment. This study assessed whether the Ki-67 index and tumour grade generated from tissue samples correlated with that assessed in resection specimens. METHODS This was a retrospective cohort analysis of all patients who had both a tissue sample and a resection specimen analysed in our trust, a tertiary referral centre, during 2012 and 2013. RESULTS Data from 36 patients were reviewed. Ki-67 indices from tissue samples and resection specimens showed strong correlation (r=0.95, p<0.001). Tumour grading was the same in the tissue sample and resection specimens for 22 patients (61.1%). In four patients (11.1%), the tissue sample overestimated the grade while in ten (27.8%), the sample underestimated the grade. CONCLUSIONS In most cases, the Ki-67 index and tumour grade from the tissue sample matched that of the resection specimen. However, in nearly 40% of cases, the tissue sample grading did not match the resection tumour grading. In the majority of these, the tissue sample underestimated disease activity. A low Ki-67 index in a tissue sample should therefore be taken as provisional and should not, in isolation, persuade clinicians to choose a more conservative treatment approach if there is clinical, biochemical or radiological evidence suggestive of a more aggressive disease pathology.

Neck Dissection Shoulder Syndrome: Quantification and Three-Dimensional Evaluation with an Optoelectronic Tracking System

Objective 3-dimensional biomechanical changes of the shoulder at rest or during arm elevation were measured by means of a new specific method using an optoelectronic detection system that was developed for computer-aided surgery. Additionally, the shoulder syndrome following neck dissection was evaluated by the recognized orthopedic shoulder Constant score. The statistical evaluation encompassed 12 patients with unilateral radical neck dissection (RND), 12 patients with unilateral modified radical neck dissection (MRND) with preservation of the accessory nerve, and 10 healthy subjects. The healthy shoulders showed normal kinematic behavior, the so-called "scapulohumeral rhythm" (SHR). After MRND, the static scapular position and SHR showed no significant 3-dimensional variations. In contrast, RND produced a highly significant scapular displacement at rest (p < .01) and a near-total abolition of SHR. The Constant scores were significantly lower after RND than after MRND (p < .01). Three-dimensional evaluation of the shoulder syndrome supports the Constant score, quantifying what can be measured objectively.

Learning Curve for Laparoscopic Pancreaticoduodenectomy: a CUSUM Analysis

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD), an advanced minimally invasive technique, has demonstrated advantages to open pancreaticoduodenectomy (OPD). However, this complex procedure requires a relatively long training period to ensure technical proficiency. This study was therefore designed to analyze the learning curve for LPD.

METHODS

From October 2010 to September 2015, 63 standard pancreaticoduodenectomy procedures were to be performed laparoscopically by a single surgeon at the Department of Pancreatic Surgery, West China Hospital, Sichuan University, China. After applying the inclusion and exclusion criteria, a total of 57 patients were included in the study. Data for all the patients, including preoperative, intraoperative, and postoperative variables, were prospectively collected and analyzed. The learning curve for LPD was evaluated using both cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. All of the variables among the learning curve phases were compared.

RESULTS

Based on the CUSUM and the RA-CUSUM analyses, the learning curve for LPD was grouped into three phases: phase I was the initial learning period (cases 1-11), phase II represented the technical competence period (cases 12-38), and phase III was regarded as the challenging period (cases 39-57). The operative time, intraoperative blood loss, and postoperative ICU demand significantly decreased with the learning curve. More lymph nodes were collected after the initial learning period. There were no significant differences in terms of postoperative complications or the 30-day mortality among the three phases. More challenging cases were encountered in phase III.

CONCLUSIONS

According to this study, the learning curve for LPD consisted of three phases. Conservatively, to attain technical competence for performing LPD, a minimum of 40 cases are required for laparoscopic surgeons with a degree of laparoscopic experience.

Use of Molecular Profiling to Guide Treatment Decisions in Patients with Neuroendocrine Tumors: Preliminary Results

This case series demonstrates the potential of molecular profiling to improve selection of antitumor therapies in the treatment of patients with neuroendocrine and carcinoid tumors. Carcinoid tumors resected at one institution over a 3-year period were sent for molecular profiling to guide choice of treatment. Potentially beneficial therapies were identified based on the measured expression of 20 proteins and oncogenes and a comprehensive review of the chemotherapy response literature. The clinical charts of 41 patients were reviewed retrospectively, and 12 were selected as representatives of the range of effects molecular profiling has on carcinoid treatment. Their presentation, molecular profile results, treatment, and disease progression is reviewed in the following case series. A total of nine patients were treated with drugs identified as potentially beneficial by molecular profile reports. These include capecitabine, 5-fluorouracil, temozolomide, oxaliplatin, and gemcitabine. Based on clinical symptoms, serum markers of disease, and radiographic evidence five of nine patients responded to treatment, two had mixed responses, and two did not respond to treatment. At this early juncture, our critique of molecular profiling for neuroendocrine tumors is favorable, as a significant number of our patients responded to drugs identified by molecular profiling as potentially beneficial.

Restrictive blood transfusion protocol in malignant upper gastrointestinal and pancreatic resections patients reduces blood transfusions with no increase in patient morbidity

BACKGROUND

The purpose of this study was to determine the impact of a restrictive blood transfusion protocol on the number of transfusions performed and the related effect on patient morbidity.

METHODS

A cohort study was performed using our prospective database with information from January 1, 2000, to June 1, 2013. The restrictive blood transfusion protocol was implemented in September 2011, so this date served as the separation point for the date of operation criteria.

RESULTS

For the study, 415 patients undergoing operation for an abdominal malignancy were reviewed. After the restrictive blood transfusion protocol, the percentage of patients who received blood dropped from 35.6% to 28.3%. The percentage of patients who experienced perioperative complication was significantly higher in transfused patients compared with those who did not receive blood (P = .0001). There was no statistical significance observed between the 5 groups for the length of stay at the hospital after their procedure.

CONCLUSIONS

The restrictive blood transfusion protocol resulted in a reduction of the percentage of patients transfused, and there was no evidence to suggest that it negatively affected the outcomes of patients in this group.

Enteral metallic stenting by balloon enteroscopy for obstruction of surgically reconstructed intestine

We present three cases of self-expandable metallic stent (SEMS) placement using a balloon enteroscope (BE) and its overtube (OT) for malignant obstruction of surgically reconstructed intestine. A BE is effective for the insertion of an endoscope into the deep bowel. However, SEMS placement is impossible through the working channel, because the working channel of BE is too small and too long for the stent device. Therefore, we used a technique in which the BE is inserted as far as the stenotic area; thereafter, the BE is removed, leaving only the OT, and then the stent is placed by inserting the stent device through the OT. In the present three cases, a modification of this technique resulted in the successful placement of the SEMS for obstruction of surgically reconstructed intestine, and the procedures were performed without serious complications. We consider that the present procedure is extremely effective as a palliative treatment for distal bowel stenosis, such as in the surgically reconstructed intestine.

Mutation-targeted therapy with sunitinib or everolimus in patients with advanced low-grade or intermediate-grade neuroendocrine tumours of the gastrointestinal tract and pancreas with or without cytoreductive surgery: protocol for a phase II clinical trial

INTRODUCTION

Finding the optimal management strategy for patients with advanced, metastatic neuroendocrine tumours (NETs) of the gastrointestinal tract and pancreas is a work in progress. Sunitinib and everolimus are currently approved for the treatment of progressive, unresectable, locally advanced or metastatic low-grade or intermediate-grade pancreatic NETs. However, mutation-targeted therapy with sunitinib or everolimus has not been studied in this patient population.

METHODS AND ANALYSIS

This prospective, open-label phase II clinical trial was designed to determine if mutation-targeting therapy with sunitinib or everolimus for patients with advanced low-grade or intermediate-grade NETs is more effective than historically expected results with progression-free survival (PFS) as the primary end point. Patients ≥18 years of age with progressive, low-grade or intermediate-grade locally advanced or metastatic NETs are eligible for this study. Patients will undergo tumour biopsy (if they are not a surgical candidate) for tumour genotyping. Patients will be assigned to sunitininb or everolimus based on somatic/germline mutations profile. Patients who have disease progression on either sunitinib or everolimus will crossover to the other drug. Treatment will continue until disease progression, unacceptable toxicity, or consent to withdrawal. Using the proposed criteria, 44 patients will be accrued within each treatment group during a 48-month period (a total of 88 patients for the 2 treatments), and followed for up to an additional 12 months (a total of 60 months from entry of the first patient) to achieve 80% power in order to test whether there is an improvement in PFS compared to historically expected results, with a 0.10 α level one-sided significance test.

ETHICS AND DISSEMINATION

The study protocol was approved by the institutional review board of the National Cancer Institute (NCI-IRB Number 15C0040; iRIS Reference Number 339636). The results will be published in a peer-reviewed journal and shared with the worldwide medical community.

TRIAL REGISTRATION NUMBER

NCT02315625.

Current perioperative outcomes for patients with disseminated cancer

BACKGROUND

Surgical morbidity and mortality (M&M) for patients with disseminated malignancy (DMa) is high, and some have questioned the role of surgery. Therefore, we sought to characterize temporal trends in M&M among DMa patients, hypothesizing that surgical intervention would remain prevalent.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program from 2006-2010. Excluding patients undergoing a primary hepatic operation, we identified 21,755 patients with DMa. Parametric and/or nonparametric statistics and logistic regression were used to evaluate temporal trends and predictors of M&M.

RESULTS

The prevalence of surgical intervention for DMa declined slightly over the time period, from 1.9%-1.6% of all procedures (P < 0.01). Among DMa patients, the most frequent operations performed were bowel resection, other gastrointestinal procedures, and multivisceral resections, these all showed small statistically significant decreases over time (P < 0.01). The rate of emergency operations also decreased (P < 0.01). In contrast, the rate of preoperative independent functional status rose, whereas the rate of preoperative weight loss and sepsis decreased (P < 0.01). Rates of 30-d morbidity (33.7 versus 26.6%), serious morbidity (19.8 versus 14.2%), and mortality (10.4 versus 9.3%) all decreased over the study period (P < 0.05). Multivariate analysis identified standard predictors (e.g., impaired functional status, preoperative weight loss, preoperative sepsis, and hypoalbuminemia) of worse 30-d M&M.

CONCLUSIONS

Thirty-day morbidity, serious morbidity, and mortality have decreased incrementally for patients with DMa undergoing surgical intervention, but surgical intervention remains prevalent. These data further highlight the importance of careful patient selection and goal-directed therapy in patients with incurable malignancy.

Outcome after pancreaticoduodenectomy for malignancy in elderly patients

BACKGROUND/AIMS

To evaluate short-term outcomes and long-term survival after pancreaticoduodenectomy for malignancy in elderly Chinese patients (aged 70 years or older) compared with younger patients.

METHODOLOGY

Between January 2005 and December 2013, 216 consecutive patients who underwent a PD with pancreatic cancer or periampullary cancers in our institution were recruited in this study. Sixty-eight patients aged 70 years or older when they underwent PD, while 148 patients younger than 70.

RESULTS

There were no significant differences in postoperative mortality (p = 0.104), overall morbidity (p = 0.057) and surgical complications (p = 0.200) between the elderly patients and the younger patients. Elderly patients had a significantly higher incidence of cardiac events (p = 0.008) and pneumonia (p = 0.041) postoperatively. The postoperative hospital stay in the older age group was significantly longer (p = 0.013). The overall survival did not differ between the two age groups both when patients with pancreatic cancer were analyzed (p = 0.836) and when patients with periampullary cancers were analyzed (p = 0.817).

CONCLUSIONS

Our results showed that pancreaticoduodenectomy for malignancy in Chinese patients over 70 years old could be performed safely. Age should not be considered as a contraindication to pancreaticoduodenectomy.

Perioperative administration of Daikenchuto (TJ-100) reduces the postoperative paralytic ileus in patients with pancreaticoduodenectomy

BACKGROUND/AIMS

No study has reported whether perioperative administration of Daikenchuto (TJ-100) reduced paralytic ileus after pancreaticoduodenectomy (PD).

METHODOLOGY

Forty-five consecutive patients that were scheduled to undergo PD at Wakayama Medical University Hospital between August 2010 and August 2011 were enrolled in this study including the first cohort (n = 15) as the control group and the subsequent cohort (n = 30) as the TJ-100 group. This trial was registered at UMIN-CTR ID# 000005056.

RESULTS

Postoperative paralytic ileus occurred more frequently in the control group (73.3% of the control group and 20.0% of the TJ-100 group; p = 0.001). The first passages of flatus significantly improved earlier in the TJ-100 group than in the control group (p = 0.014). A multiple cytokine assay of the drainage and serum showed that IL-9 and IL-10 in the drainage was significantly higher on postoperative day 1 in the TJ-100 group. There were no complications associated with the preoperative administration of TJ-100 before surgery, and no significant differences were observed between the two groups in the incidence of postoperative Gradel-2 diarrhea (CTCAE4.0).

CONCLUSIONS

Perioperative administration of TJ-100 was feasible and reduced the incidence of paralytic ileus in PD, and further randomized controlled trials should be conducted.

A simple, secure and universal two-layer continuous running suture pancreaticojejunostomy following pancreaticoduodenectomy

Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy. We introduce here a simple, secure and universal technique for pancreaticojejunostomy with a two-layer continuous running suture. We also report on the preliminary results for grades of pancreatic fistulas among patients who underwent this new technique. 51 consecutive cases were successfully performed using this new technique during pancreaticoduodenectomy. The overall morbidity was 29.4%. Only 3 (5.9%) grade B pancreatic fistulas were observed postoperatively, and were successfully treated with conservative management. The time taken to create the pancreatic anastomosis was less than 15 minutes in all cases. In conclusion, this novel pancreatic anastomosis technique is easy and quick to perform, universally applicable, and appears to be a secure technique that reduces pancreatic fistula rates after pancreaticoduodenectomy.

[EPIDURAL ANESTHESIA AND ANALGESIA IN ONCOLOGIC SURGERY ON ABDOMINAL ORGANS]

The use of epidural anesthesia (EA) in 75 patients during abdominal surgery has revealed a number of advantages of EA over endotracheal anesthesia. EA reduces the consumption of analgesics and myorelaxants and the time of postoperative artificial ventilation of lungs as well as offers more qualitative analgesia.

[STENTING VERSUS PALLIATIVE SURGERY IN PATIENTS WITH MALIGNANT GASTROINTESTINAL STENOSIS]

AIM

Retrospective analysis of the results of stenting versus surgical palliation in patients with malignant gastrointestinal stenosis.

MATERIAL AND METHODS

85 patients underwent endoscopic stenting (41) or surgical intervention (44). Level of stenosis: gastric outlet (23/38), multi-level gastric obstruction (2/3), duodenum or jejunum (12/3), gastrojejunoanastomosis (3/0) and gastroduodenoanastomosis (1/0). 49 self-expanding metal stents were implanted in 41 patients. 41 gastroenteroanastomoses and 3 jejunostomas were performed in surgical group.

RESULTS

Stents were successfully inserted in all patients. Early complications were observed in 3 (7.3%) patients after stenting and in 9 (20.5%) after surgical palliation, p = 0.0755. Postoperative lethality was 2,4% (1 patient) after stenting and 31.8% (14 patients) after surgery, p = 0.0003. Mean hospital stay was 15 days in stenting group and 23 days in surgical group, p < 0.001. There was no statistically significant difference in long-term results, neither in late complications (p = 0.3691), nor in survival (p =0.3697).

CONCLUSION

Endoscopic placement of self-expanding stents is an effective method of restoration of oral intake in patients with malignant gastrointestinal obstruction. Stenting is associated with equal rates of early and late complications, lower mortality and decreased in-hospital stay as compared with surgery, and therefore may be recommended as a final palliation in inoperable patients.

Extrauterine fibroids: a diagnostic challenge and a long-term battle

Extrauterine fibroids often present a diagnostic challenge due to the unusual locations they arise from. We present a series of rare extrauterine fibroids. In recent years, these fibroids have been associated with previous morcellated hysterectomies or myomectomies. Our series of six patients were found to have extrauterine fibroids (confirmed through histology) and underwent open hysterectomy and open or laparoscopic myomectomy. Four had undergone previous laparoscopic myomectomies while the other two had no previous intra-abdominal surgeries. Postsurgical occurrence may be caused by incomplete removal of morcellated fibroid tissue. Spontaneous occurrence can be associated with congenital Müllerian system defects. Extrapolating from this hypothesis, we recommend physicians to make sure that counselling for extrauterine seeding and dissemination of unexpected malignancy is undertaken in cases of minimally invasive surgeries where morcellation is expected. Long-term tumour surveillance is thus essential in such instances.

Inflammation-based prognostic score predicts biliary stent patency in patients with unresectable malignant biliary obstruction

BACKGROUND

An inflammation-based prognostic score, the modified Glasgow prognostic score (mGPS), has been reported to be useful for predicting postoperative survival in patients with various types of cancer. However, no studies have investigated whether the mGPS can predict biliary stent (BS) patency in patients undergoing BS placement for unresectable malignant biliary obstruction (UMBO).

AIM

To evaluate the usefulness of the mGPS for predicting BS patency in patients undergoing intraoperative placement of uncovered expandable metallic stents (EMSs) for UMBO.

PATIENTS AND METHODS

The mGPS was calculated as follows: patients with both an elevated C-reactive protein (CRP) level (>1.0 mg/dl) and hypoalbuminemia (<3.5 g/dl) were allocated a score of 2. Patients with only an elevated CRP level were allocated a score of 1, and patients without an elevated CRP level were allocated a score of 0. EMS patency was compared by Kaplan-Meier analysis and log-rank test between the two groups (mGPS 0 vs. mGPS 1 or 2). The significant risk factors for EMS occlusion were investigated by Cox proportional hazards model analysis.

RESULTS

Kaplan-Meier analysis revealed that patients with mGPS 1 (n=7) and 2 (n=19) had a lower EMS patency rate (p=0.014) than patients with mGPS 0 (n=37). Although univariate analyses revealed that a high serum total bilirubin level, stent-in-stent placement, and mGPS 1 or 2 were significant risk factors predictive of EMS occlusion, multivariate analysis demonstrated that no independent risk factors were significant.

CONCLUSION

mGPS is a significant predictor of EMS patency in patients undergoing intraoperative placement of BS.

Role of Ki-67 proliferation index in the assessment of patients with neuroendocrine neoplasias regarding the stage of disease

BACKGROUND

Neuroendocrine neoplasias (NEN) of the gastroenteropancreatic (GEP) system frequently present with metastatic deposits. The proliferation marker Ki-67 is used for diagnosis and to assess the prognosis of disease. The aim of our study was to evaluate the usefulness of Ki-67 % in the assessment of NEN patients with regard to their disease stage in clinical practice. Additionally, a comparative analysis of Ki-67 levels among different sites of disease was performed.

METHODS

This retrospective study included patients with GEP NEN referred to our center from 2010 to 2012. The NEN diagnosis was confirmed by standard histopathology. Ki-67 immunohistochemistry was done on paraffin-embedded sections using an automated Leica immunohistochemistry machine. NEN grading was carried out according to European Neuroendocrine Tumor Society recommendations (low grade [G1] to intermediate grade [G2], well to moderately differentiated neuroendocrine neoplasms; high-grade [G3], moderately to poorly differentiated neuroendocrine neoplasms). Results of tumor staging and grading were correlated. In a subgroup of cases, comparative analysis of Ki-67 levels in different sites of disease was carried out.

RESULTS

One hundred sixty-one GEP NEN patients were included in the study. Metastatic disease was seen in 46.1 % (53/115) of G1 tumors, 77.8 % (28/36) of G2 tumors, and 100 % of (10/10) G3 tumors (p = 0.0002). When stratified according to primary tumor site, metastatic disease was documented in 42.9 % (36/84) of patients with pancreatic NEN and in 91.9 % (34/37) of those with small intestinal primary. Stage IV metastatic disease was present in 27.8 % (32/115) and 72.2 % (26/36) of the G1 and G2 tumors, respectively, and in 90 % (9/10) of the G3 tumors. Assessment of the Ki-67 index for a subset of cases at metastatic sites as well as the primary tumor site showed discrepancies in 35.3 % cases. In 7/9 (77.8 %) patients with liver metastases, Ki-67 % was higher in the liver lesions than in the primary tumor.

CONCLUSIONS

Patients with GEP NEN exhibiting a high Ki-67 proliferation index present with metastatic disease in the vast majority of cases. Depending upon the primary tumor site, metastases are to be expected also in tumors with low Ki-67 %, although they are considered less aggressive. Different disease sites may express heterogeneous Ki-67 levels.

Laparoscopic surgery for benign and malign diseases of the digestive system: Indications, limitations, and evidence

The laparoscopic technique was introduced in gastrointestinal surgery in the mid 1980s. Since then, the development of this technique has been extraordinary. Triggered by technical innovations (stapling devices or coagulation/dissecting devices), nowadays any type of gastrointestinal resection has been successfully performed laparoscopically and can be performed laparoscopically dependent on the patient’s condition. This summary gives an overview over 30 years of laparoscopic surgery with focus on today’s indications and evidence. Main indications remain the more common procedures, e.g., appendectomy, cholecystectomy, bariatric procedures or colorectal resections. For all these indications, the laparoscopic approach has become the gold standard with less perioperative morbidity. Regarding oncological outcome there have been several high-quality randomized controlled trials which demonstrated equivalency between laparoscopic and open colorectal resections. Less common procedures like esophagectomy, oncological gastrectomy, liver and pancreatic resections can be performed successfully as well by an experienced surgeon. However, the evidence for these special indications is poor and a general recommendation cannot be given. In conclusion, laparoscopic surgery has revolutionized the field of gastrointestinal surgery by reducing perioperative morbidity without disregarding surgical principles especially in oncological surgery.

Is additional enrichment of diet in branched-chain amino acids or glutamine beneficial for patients receiving total parenteral nutrition after gastrointestinal cancer surgery?

OBJECTIVES

Total Parenteral Nutrition (TPN) is necessary in patients unable to receive oral or enteral feeding for a period of at least 7 days. Branched-chain amino acids (BCAA): valine (Val), leucine (Leu), and isoleucine (Ile) are essential amino acids, which are important regulators in protein metabolism. They are also the main nitrogen source for glutamine synthesis in muscles. In this process they undergo irreversible degradation and cannot be reutilised for protein synthesis. In catabolic states, like cancers, glutamine demand increases and therefore also its utilisation, which can decrease the level of BCAA required for Gln synthesis. The purpose of this study was to evaluate the necessity of BCAA or glutamine-enriched TPN in patients after gastrointestinal cancers surgery.

MATERIAL AND METHODS

Our aim was to investigate changes of plasma BCAA and glutamine concentrations in patients operated for colorectal, small intestine or pancreatic cancer and who are either receiving TPN or not in the postoperative period. Free amino acids plasma concentrations were determined by the ion-exchange chromatography.

RESULTS

Surgery in the control group caused a decrease in Val, Ile and Leu concentrations in the postoperative period. In TPN patients this depression was inhibited beginning from the third day after surgery, except for Val and Leu in colorectal cancer group. In control and TPN patient groups, Gln concentration decreased after the surgery and subsequently increased beginning from the third day after the operation.

CONCLUSIONS

Gastrointestinal cancer patients' surgery results in decrease in BCAA concentrations. Standard TPN exerts a beneficial effect on the BCAA level in patients with pancreatic and small intestine cancer. In colorectal cancer such TPN should be enriched with Leu and Val.

The current status of preoperative biliary drainage for patients who receive pancreaticoduodenectomy for periampullary carcinoma: a comprehensive review

BACKGROUND

Surgery on patients with malignant obstructive jaundice carries increased risks of postoperative morbidity and mortality. Preoperative biliary drainage has been developed to reduce this procedure-related risks, but its role in patients who are going to receive pancreaticoduodenectomy for periampullary carcinoma is still controversial.

METHODS

This article aimed at reviewing the current status of preoperative biliary drainage for patients with peri-ampullary tumors who were candidates for pancreaticoduodenectomy. A MEDLINE and PubMed database search from 1980 to 2013 was performed to identify relevant articles using the keywords "pancreaticoduodenectomy", "preoperative biliary drainage", "jaundice", "peri-ampullary neoplasm" and "carcinoma of pancreas". Additional papers were identified by a manual search of the references from the key articles.

RESULTS

There were six randomized controlled trials (RCTs) and 5 meta-analyses on preoperative biliary drainage for patients with malignant obstructive jaundice. Most of the results of these studies could not be used to define the role of preoperative biliary drainage for patients who received pancreaticoduodenectomy for periampullary carcinoma because: first, the majority of these studies were on bypass or palliative resections; second, various pathologies with both proximal and distal biliary obstruction were included; third, there were different forms of percutaneous or endoscopic drainage procedures; fourth, there were different durations of preoperative drainage; and finally, there were variations in the definition of events and outcomes. There was only one RCT which included a homogeneous group of patients with carcinoma of pancreas who underwent pancreaticoduodenectomy. For patients with periampullary tumor, the RCTS and meta-analyses showed no benefit of preoperative biliary drainage. Instead, there were some concerns about the drainage-related complications and the increase in positive intraoperative bile culture rate and the associated infective complication rate postoperatively.

CONCLUSION

Routine preoperative biliary drainage showed no beneficial effect on the surgical outcome for patients with periampullary tumor. A selective approach of preoperative biliary drainage should be adopted for these patients. The optimal duration and modality of preoperative biliary drainage remain unclear.

[Evaluation of the application of endoscopic submucosal dissction in gastrointestinal cysts]

OBJECTIVE

To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for the treatment of gastrointestinal cysts.

METHODS

Clinicopathological data of 40 patients with gastrointestinal cyst undergoing ESD in our center during January 2008 and February 2012 were analyzed retrospectively. Complications, en bloc resection rate, and local recurrence were assessed.

RESULTS

Eight lesions located in the esophagus, 11 in the stomach, 5 in the duodenum, and 16 in the colorectum. Thirty-seven lesions were successfully resected with ESD in an en bloc fashion (92.5%). During the operation, one perforation was encountered in the ascending colon and was clipped; one massive hemorrhage occurred in the esophagus and was treated with balloon compression. Postoperative pathological examination revealed cyst samples were intact without lesions in lateral and basal resection margins. Local recurrence was not found in 36 patients during a median postoperative follow-up of 9.7 months (range, 6-12 months).

CONCLUSION

ESD is a safe and effective procedure for the treatment of gastrointestinal cysts.

Digestive cancer surgery in the era of sentinel node and epithelial-mesenchymal transition

Lymph node involvement is one of the most important prognostic indicators of carcinoma of the digestive tract. Although the therapeutic impact of lymphadenectomy has not been proven and the number of retrieved nodes cannot be considered a measure of successful cancer surgery, an adequate lymph node count should be guaranteed to accurately assess the N-stage through the number of involved nodes, lymph node ratio, number of negative nodes, ratio of negative to positive nodes, and log odds, i.e., the log of the ratio between the number of positive lymph nodes and the number of negative lymph nodes in digestive carcinomas. As lymphadenectomy is not without complications, sentinel node mapping has been used as the rational procedure to select patients with early digestive carcinoma in whom nodal dissection may be omitted or a more limited nodal dissection may be preferred. However, due to anatomical and technical issues, sentinel node mapping and nodal basin dissection are not yet the standard of care in early digestive cancer. Moreover, in light of the biological, prognostic and therapeutic impact of tumor budding and tumor deposits, two epithelial-mesenchymal transition-related phenomena that are involved in tumor progression, the role of staging and surgical procedures in digestive carcinomas could be redefined.

[Effect of anaesthesia on incidence of postoperative delirium after major abdominal surgery in elderly patients]

Delirium can be caused by haemodynamics abnormalities during anaesthesia. The main role in delirium appearance is given to decreasing of cerebral perfusion pressure. Especially it can happen in patients with underlying intracranial hypertension. Anaesthetics effects on intracranial pressure are different therefore cerebral hypoperfusion can happens in these patients even without systemic hypotension. Purpose of the study was to define an effect of cerebral perfusion pressure decreasing during different technics of anaesthesia on frequency of delirium in elderly patients after major abdominal surgery. The article deals with results of study of 182 patients (medium age 69 y.o.) underwent elective major abdominal surgery. Delirium frequency was 11%, continuing of delirium was 3 days. The frequency of delirium was higher in patients who had got anaesthesia based on sevoflurane. Additionally these patients had higher frequency of cerebral perfusion pressure decreasing. Conclusions; Anaesthesia based on sevoflurane is characterized by higher frequency of postoperative delirium in elderly patients after major abdominal surgery.

An invasive extragastrointestinal stromal tumor curably resected following imatinib treatment

Extragastrointestinal stromal tumors (EGISTs) are rare tumors located outside the gastrointestinal tract. While curable resection is accepted as a noninvasive EGIST treatment, the therapeutic strategy for invasive EGISTs has not yet been established. The present report is the first to show a case of invasive EGIST completely resected after downsizing the tumor with imatinib treatment. A 69-year-old female had multiple masses adjacent to the stomach and ileocecum. The primary lesion measured 18 cm in size and had invaded the stomach, pancreas and liver. The histological findings of fine-needle aspiration samples revealed a proliferation of dysplastic spindle cells that exhibited immunoreactivity for anti-c-kit antibodies. The masses were therefore diagnosed as multiple GISTs with invasion to other organs, with origin difficult to determine at the time. Nineteen months after the imatinib treatment, the tumors were downsized and distinct from the stomach, pancreas and liver. Accordingly, the tumors were regarded to be EGISTs derived from the mesentery. Because they slightly regressed 26 months after treatment, surgery was applied to remove the EGISTs. The intraoperative findings showed no invasive signs, and the tumors were completely removed. The histological findings revealed the presence of dysplastic and c-kit-positive spindle cells in the tumor with an MIB-I index of more than 5%, resulting in a final diagnosis of high-risk EGIST derived from the mesentery. No recurrence was detected for 16 months after resection. In conclusion, preoperative treatment with imatinib followed by curable resection is a feasible option to cure invasive EGISTs.