Reversal Surgery for Split Stoma with Peristomal Incision is Associated with Improved Postoperative Outcome in Patients with Crohn's Disease

BACKGROUND

Temporary stoma formation is common in Crohn's disease (CD), while stoma reversal is associated with postoperative morbidity. This study aimed to evaluate the postoperative outcomes of split stoma reversal, SSR (i.e., exteriorization of proximal and distal ends of the stoma through a small common opening) and end stoma closure, ESC (i.e., the proximal stump externalized, and distal end localized abdominally.

METHODS

Patients with CD who underwent stoma reversal surgeries between January 2017 and December 2021 were included. Demographic, clinical, and postoperative data were collected and analyzed to evaluate outcomes of reversal surgery.

RESULTS

A total of 255 patients who underwent stoma reversal surgeries met the inclusion criteria. SSR was superior to ESC in terms of operative time (80.0 vs. 120.0, p = 0.0004), intraoperative blood loss volume (20.0 vs. 100.0, p = 0.0002), incision length (3.0 vs. 15.0, p < 0.0001), surgical wound classification (0 vs. 8.3%, p = 0.04), postoperative hospital stay (7.0 vs. 9.0, p = 0.0007), hospital expense (45.6 vs. 54.2, p = 0.0003), and postoperative complications (23.8% vs. 44.3%, p = 0.0040). Although patients in the ESC group experienced more surgical recurrence than those in the SSR group (8.3% vs. 3.2%) during the follow-up, the Kaplan-Meier curve analysis revealed no statistical difference (p = 0.29).

CONCLUSIONS

The split stoma can be recommended when stoma construction is indicated in patients with Crohn's disease.

Hepatic encephalopathy post-TIPS: Current status and prospects in predictive assessment

Transjugular intrahepatic portosystemic shunt (TIPS) is an essential procedure for the treatment of portal hypertension but can result in hepatic encephalopathy (HE), a serious complication that worsens patient outcomes. Investigating predictors of HE after TIPS is essential to improve prognosis. This review analyzes risk factors and compares predictive models, weighing traditional scores such as Child-Pugh, Model for End-Stage Liver Disease (MELD), and albumin-bilirubin (ALBI) against emerging artificial intelligence (AI) techniques. While traditional scores provide initial insights into HE risk, they have limitations in dealing with clinical complexity. Advances in machine learning (ML), particularly when integrated with imaging and clinical data, offer refined assessments. These innovations suggest the potential for AI to significantly improve the prediction of post-TIPS HE. The study provides clinicians with a comprehensive overview of current prediction methods, while advocating for the integration of AI to increase the accuracy of post-TIPS HE assessments. By harnessing the power of AI, clinicians can better manage the risks associated with TIPS and tailor interventions to individual patient needs. Future research should therefore prioritize the development of advanced AI frameworks that can assimilate diverse data streams to support clinical decision-making. The goal is not only to more accurately predict HE, but also to improve overall patient care and quality of life.

Small nucleolar RNA expression profiles: A potential prognostic biomarker for non-viral Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a challenging cancer with high mortality rates, limited predictability, and a lack of effective prognostic indicators. The relationship between small nucleolar RNAs (snoRNAs) and HCC is poorly understood. Based on the literature data, snoRNA studies were primarily focused on viral-related causes of HCC, such as Hepatitis B or C viruses (HBV or HCV). According to these studies, we selected four snoRNAs (snoRA12, snoRA47, snoRA80E, and snoRD126) for exploration in the context of non-viral-related causes, including non-alcoholic steatohepatitis (NASH), non-alcoholic fatty liver diseases (NAFLD), and alcohol steatohepatitis. The primary goal of this study was to gain a deeper understanding of how snoRNA expression affects patient outcomes and whether it can serve as a prognostic tool for non-viral HCC. We conducted a study on tissue samples from 35 HCC patients who had undergone resection at Pilsen University Hospital. SnoRA12, snoRA47, snoRA80E, and snoRD126 were studied by quantitative real-time PCR (qRT-PCR) in tumor and non-tumor adjacent tissue (NTAT) samples. Kaplan-Meier analysis was performed to assess the association of snoRNAs expression levels with patient outcomes: time to recurrence (TTR), disease-free survival (DFS) and overall survival (OS). In tumor tissues, snoRA12, snoRA47 and snoRA80E were upregulated, while snoRD-126 was downregulated compared to NTAT. Low expression of snoRA47 and snoRD126 in patients was associated with longer TTR and DFS. The individual expression of snoRA12 and snoRA80E did not show associations with TTR and DFS. However, a combination of medium expression of snoRD126 and snoRA80E was associated with longer TTR and DFS, while high and low expressions of the combined snoRA126 and snoRA80E showed no significant association with TTR, DFS, and OS. Conversely, a combination of high expression of snoRA12 and snoRD126 was associated with shorter TTR. In conclusion, the results indicate that snoRA47 and snoRD126 exhibit good prognostic power specifically for non-viral related HCC. Both snoRA47 and snoRD126 showed favorable prognostication in single and combined analysis when assessing patient outcomes. Also, in combination analysis, snoRA80E and snoRA12 showed favorable prognosis, but not alone.

Involvement of selected circulating ncRNAs in the regulation of cognitive dysfunction induced by anesthesia

Post-operative cognitive dysfunction (POCD) refers to the functional impairment of the nervous system caused by prolonged exposure to anesthetics. It is known that prolonged exposure to anesthetics may increase the risk for the development of several cognitive impairments. The drugs used to induce general anesthesia are generally safe, owing to the CNS's direct and/or indirect self-protective activity against drug-induced damages. Non-coding RNAs have recently started to gain attention to better understand the mechanism of gene regulation correlated to cellular physiology and pathology. In order to provide new insights for the neuroprotective function of highly expressed ncRNAs in the central nervous system, we investigated their expression profile in the circulating exosomes of patients exposed to anesthesia vs healthy controls. The experimental design envisaged the recruitment of 30 adult patients undergoing general anesthesia and healthy controls. The effects of anesthetics have been evaluated on miR-34a and miR-124, on the lncRNAs MALAT-1, HOTAIR, GAS5, BLACAT1, HULC, PANDA, and on YRNAs. NcRNAs miR-34a, miR-124, MALAT-1, HOTAIR, GAS5, BLACAT1, and YRNA1 are significantly overexpressed following anesthesia, while YRNA5 is significantly down regulated. Some of them have neuroprotective function, while other correlate with neurological dysfunctions. Our data suggests that, during anesthesia, the toxic action of some non-coding RNAs could be compensated by other non-coding RNAs, both synthesized by the CNS or also transported into neurons from other tissues. It is reasonable to suppose a mutual action of these molecules likely to secure the CNS from anesthetics, that drive a convoluted cascade of ncRNA-dependent biological counter-responses. Our findings are novel in the field of brain dysfunction, indicating that some of the analyzed ncRNAs, although several of their functions still need to be addressed, could be suggested as potential biomarkers and therapeutic targets in post-operative cognitive dysfunction-related processes.

Solid pancreatic masses: What’s hidden beneath? Insights into rare pancreatic lesions

The diagnostic approach to solid pancreatic masses has significantly evolved from the era when a focal pancreatic mass was almost synonymous to pancreatic ductal adenocarcinoma, to a wide spectrum of pancreatic lesions, some of which have good prognosis. With the advent of advanced diagnostic tools, particularly refined imaging and tissue acquisition techniques, a broader spectrum of differential diagnoses has been recognized, encompassing conditions ranging from neuroendocrine tumors or inflammatory masses, to rare entities like metastatic clear cell sarcoma or solitary fibrous tumors. We herein discuss case reports of some rare pancreatic lesions, which were diagnosed by combining clinical and imaging features and endoscopic ultrasound-guided tissue sampling and confirmed on surgical specimens. Further reports on these rare pancreatic tumors will contribute to a better understanding of their pathogenesis and effective management.

Exploring dose and downregulation dynamics in lipid nanoparticles based siRNA therapy: Systematic review and meta-analysis

Small interfering RNA (siRNA) holds promise as a therapeutic approach for various diseases, yet challenges persist in achieving efficient delivery, biodistribution, and minimizing off-target effects. Lipidic nanoformulations are being developed to address these hurdles, but the optimal dose for preclinical investigations remains unclear. This systematic review and meta-analysis aims to determine the optimal dose of nanoformulated siRNA and explore factors influencing dose and biodistribution, informing future research in this field. A comprehensive search across four electronic databases identified 25 potential studies, with 15 selected for meta-analysis after screening. Quality assessment was conducted using SYRCLE's risk of bias tool modified for animal studies based on research question. Study found an average siRNA dose of 1.513 ± 0.377 mg/kg with mean downregulation of 65.79 % achieved, with siRNA-LNPs mainly accumulating in the liver. While individual factors showed no significant correlation, a positive association between dose and downregulation was observed, alongside other influencing factors. Extrapolating intravenous doses to potential oral doses, we suggest an initial oral dose range of 1.5 to 8 mg/kg, considering siRNA-LNPs bioavailability. These findings contribute to advancing RNA interference research and encourage further exploration of siRNA-based treatments in personalized medicine.

Laparoscopic right gastroepiploic artery-sparing distal gastric tube resection with lymph node dissection for gastric tube cancer after esophagectomy: A novel surgical approach (with video)

INTRODUCTION

Total resection of the gastric tube with lymphadenectomy for advanced gastric tube cancer is highly invasive and associated with severe complications. Other surgical option, partial gastrectomy or wedge resection, is insufficient if lymph node metastasis is suspected. Therefore, a technique balancing invasiveness and curability is required.

MATERIALS AND SURGICAL TECHNIQUE

First, we laparoscopically peeled off adhesions of the gastric tube, gastric mesentery (including the right gastroepiploic artery/vein), pericardial membrane, and aorta, up to the planned resection line. Subsequently, we cut the infrapyloric and right gastric arteries at their roots and dissected No. 5 and No. 6 lymph nodes. We taped and spared the right gastroepiploic artery and vein and dissected the tissues including No. 4d lymph nodes. Finally, the gastric tube was cut using a linear stapler, and the remaining gastric tube was anastomosed to the jejunum with a circular stapler. The mean operative time for the three cases treated using this intervention was 729 min. The patients were discharged on postoperative day 8 or 9 without any complications. They all remained alive and recurrence-free.

DISCUSSION

This novel approach balances invasiveness and curability by leveraging the advantages of laparoscopy. The procedure was performed safely and reproducibly in three consecutive cases, providing another viable option for the treatment of gastric tube cancer.

Colorectal cancer: Recent advances in management and treatment

Colorectal cancer (CRC) is the third most common cancer worldwide, and the second most common cause of cancer-related death. In 2020, the estimated number of deaths due to CRC was approximately 930000, accounting for 10% of all cancer deaths worldwide. Accordingly, there is a vast amount of ongoing research aiming to find new and improved treatment modalities for CRC that can potentially increase survival and decrease overall morbidity and mortality. Current management strategies for CRC include surgical procedures for resectable cases, and radiotherapy, chemotherapy, and immunotherapy, in addition to their combination, for non-resectable tumors. Despite these options, CRC remains incurable in 50% of cases. Nonetheless, significant improvements in research techniques have allowed for treatment approaches for CRC to be frequently updated, leading to the availability of new drugs and therapeutic strategies. This review summarizes the most recent therapeutic approaches for CRC, with special emphasis on new strategies that are currently being studied and have great potential to improve the prognosis and lifespan of patients with CRC.

Early versus delayed necrosectomy in pancreatic necrosis: A population-based cohort study on readmission, healthcare utilization, and in-hospital mortality

BACKGROUND

Acute necrotizing pancreatitis is a severe and life-threatening condition. It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications. Several minimally invasive and open necrosectomy procedures have been developed. Despite advancements in treatment modalities, the optimal timing to perform necrosectomy lacks consensus.

AIM

To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States.

METHODS

A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database. Patients with non-elective admissions for pancreatic necrosis were identified. The participants were divided into two groups based on the necrosectomy timing: The early group received intervention within 48 hours, whereas the delayed group underwent the procedure after 48 hours. The various intervention techniques included endoscopic, percutaneous, or surgical necrosectomy. The major outcomes of interest were 30-day readmission rates, healthcare utilization, and inpatient mortality.

RESULTS

A total of 1309 patients with pancreatic necrosis were included. After propensity score matching, 349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention. The early cohort had a 30-day readmission rate of 8.6% compared to 4.8% in the delayed cohort (P = 0.040). Early necrosectomy had lower rates of mechanical ventilation (2.9% vs 10.9%, P < 0.001), septic shock (8% vs 19.5%, P < 0.001), and in-hospital mortality (1.1% vs 4.3%, P = 0.01). Patients in the early intervention group incurred lower healthcare costs, with median total charges of $52202 compared to $147418 in the delayed group. Participants in the early cohort also had a relatively shorter median length of stay (6 vs 16 days, P < 0.001). The timing of necrosectomy did not significantly influence the risk of 30-day readmission, with a hazard ratio of 0.56 (95% confidence interval: 0.31-1.02, P = 0.06).

CONCLUSION

Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs. Delayed intervention does not significantly alter the risk of 30-day readmission.

Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced lumen-apposing metal stent for malignant biliary obstruction: A promising procedure

In this editorial, we comment on the article by Peng et al. Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage. The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound, endoscopic ultrasound (EUS), or both. Endoscopic retrograde cholangiopancreatography (ERCP) has been primarily recommended for the management of biliary obstruction, while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage (PTBD) are alternative choices for cases where ERCP has failed or is impossible. PTBD is limited by shortcomings of a higher rate of adverse events, more reinterventions, and severe complications. EUS-guided biliary drainage has a lower rate of adverse events than PTBD. EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) enables EUS-guided biliary-enteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire. The present meta-analysis showed that ECE-LAMS has a high efficacy and safety in relieving biliary obstruction in general, although the results of LAMS depending on the site of biliary obstruction. This study has highlighted the latest advances with a larger sample-based comprehensive analysis.

Multimodal modulation of hepatic ischemia/reperfusion-induced injury by phytochemical agents: A mechanistic evaluation of hepatoprotective potential and safety profiles

BACKGROUND

Hepatic ischemia-reperfusion (I/R) injury is a clinically fundamental phenomenon that occurs through liver resection surgery, trauma, shock, and transplantation.

AIMS OF THE REVIEW

This review article affords an expanded and comprehensive overview of various natural herbal ingredients that have demonstrated hepatoprotective effects against I/R injury through preclinical studies in animal models.

MATERIALS AND METHODS

For the objective of this investigation, an extensive examination was carried out utilizing diverse scientific databases involving PubMed, Google Scholar, Science Direct, Egyptian Knowledge Bank (EKB), and Research Gate. The investigation was conducted based on specific identifiable terms, such as hepatic ischemia/reperfusion injury, liver resection and transplantation, cytokines, inflammation, NF-kB, interleukins, herbs, plants, natural ingredients, phenolic extract, and aqueous extract.

RESULTS

Bioactive ingredients derived from ginseng, curcumin, resveratrol, epigallocatechin gallate, quercetin, lycopene, punicalagin, crocin, celastrol, andrographolide, silymarin, and others and their effects on hepatic IRI were discussed. The specific mechanisms of action, signaling pathways, and clinical relevance for attenuation of liver enzymes, cytokine production, immune cell infiltration, oxidative damage, and cell death signaling in rodent studies are analyzed in depth. Their complex molecular actions involve modulation of pathways like TLR4, NF-κB, Nrf2, Bcl-2 family proteins, and others.

CONCLUSION

The natural ingredients have promising values in the protection and treatment of various chronic aggressive clinical conditions, and that need to be evaluated on humans by clinical studies.

Severe acute pancreatitis complicated with intra-abdominal infection secondary to trauma: A case report

BACKGROUND

Pancreatic trauma (PT) is rare among traumatic injuries and has a low incidence, but it can still lead to severe infectious complications, resulting in a high mortality rate. Acute pancreatitis (AP) is a common complication after PT, and when combined with organ dysfunction and sepsis, it will result in a poorer prognosis.

CASE SUMMARY

We report a 25-year-old patient with multiple organ injuries, including the pancreas, due to abdominal trauma, who developed necrotising pancreatitis secondary to emergency caesarean section, combined with intra-abdominal infection (IAI). The patient underwent performed percutaneous drainage, pancreatic necrotic tissue debridement, and abdominal infection foci debridement on the patient.

CONCLUSION

We report a case of severe AP and IAI secondary to trauma. This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery, and a better outcome was obtained.

Enhanced recovery after surgery: Progress in adapted pathways for implementation in standard and emerging surgical settings

The concept of enhanced recovery after surgery (ERAS) has been practiced for decades and has been implemented in numerous surgical specialties. ERAS is a global surgical quality improvement initiative, and it is an element in the field of perioperative care. ERAS had shown significant clinical outcomes, patient-reported satisfaction, and improvements in medical service cost. ERAS has been developed for specific surgical procedures, but with the fast progress of newly introduced surgical procedures, the original ERAS have been developed and modified. Recently appearing Topics and future research trends encompass ERAS protocols for other types of surgery and the enhancement of perioperative status, including but not limited to pediatric surgery, laparoscopic and robotic assisted surgery, bariatric surgery, thoracic surgery, and renal transplantation. The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative, operative, and post-operative pathways. ERAS costs are higher than traditional care, but the patient’s clinical outcome and satisfaction are higher. ERAS is in progress in the fields of anesthetic tasks, pediatric surgery, and organ transplantation. Although ERAS has shown significant clinical outcomes, there are needs to modify the protocol for specific cases, hospital facilities, resources, and nurses training on elements of ERAS. Several challenges and limitations exist in the implementation of ERAS that deserve consideration, it includes: Frailty, maximizing nutrition, prehabilitation, treating preoperative anemia, and enhancing ERAS adoption globally are all included.

Stronger control of eating 3 months after sleeve gastrectomy predicts successful weight loss outcomes at one year

Background

Weight loss response to sleeve gastrectomy (SG) is variable and predicting the effectiveness of surgery is challenging and elusive. The aim of our study was to assess and quantify the association between eating control and weight loss outcomes and identify the control of eating (CoE) attributes during the early postoperative period that might predict good vs. poor response to SG at one year.

Methods

A prospective longitudinal cohort study using the Control of Eating Questionnaire (CoEQ) was designed as a series before and at 3-, 6-, and 12-months post-SG. Primary outcomes were changes in CoE attributes and percent of total weight loss (%TWL) 12-months post-surgery. Subjects were categorized based on %TWL as good (GR, ≥25 %) or poor responders (PR, <25 %). A receiver operating characteristic and logistic regression analyses were performed.

Results

We included 41 participants (80.5% females, 51.2% Hispanic, mean age 41.7±10.6, median baseline body mass index (BMI) 43.6 kg/m2 [range 35.2-66.3]) who completed the CoEQ at all four timepoints. The "Difficulty to control eating" score at 3 months revealed the highest area under the curve (AUC) (AUC 0.711; 95%CI 0.524-0.898; p=0.032). In a trade-off between a high Youden index and high sensitivity, the "Difficulty to control eating" score of 7 at 3 months was identified as the optimal cut-off for distinguishing between GRs and PRs. Score ≤7 at 3 months was strongly independently associated with a successful weight loss target of 25%TWL at one-year post-SG (Relative Risk 4.43; 95%CI 1.06-18.54; p=0.042).

Conclusion

"Difficulty to control eating" score at 3 months post-SG is an independent early predictor of optimal response (achieving a successful TWL target of ≥25 % at one-year post-SG). Our results support the utility of this easy-to-administer validated tool for predicting the effectiveness of SG and may assist in identifying individuals with suboptimal response early and helping them with interventions to attain optimal weight loss targets.

Reno-protective effect of nicorandil and pentoxifylline against potassium dichromate-induced acute renal injury via modulation p38MAPK/Nrf2/HO-1 and Notch1/TLR4/NF-κB signaling pathways

BACKGROUND

Occupational and environmental exposure to chromium compounds such as potassium dichromate (PDC) (K2Cr2O7) has emerged as a potential aetiologic cause for renal disease through apoptotic, and inflammatory reactions. The known potent antioxidants such as nicorandil (NIC) and/or pentoxifylline (PTX) were studied for their possible nephroprotective effect in PDC-treated rats.

METHODS

Forty male Wistar rats were divided into five groups; control, PDC group, NIC+PDC, PTX+PDC group, and combination+PDC group. Nephrotoxicity was evaluated histopathologically and biochemically. Invasive blood pressure, renal function parameters urea, creatinine, uric acid and albumin, glomerular filtration rate markers Cys-C, Kim-1 and NGAL, inflammatory markers IL-1β, IL-6, TNF-α, TGF-β, COX-II, p38MAPK, NF-κB and TLR4, oxidative stress SOD, GSH, MDA, MPO, HO-1 and Nrf2 and apoptotic mediators Notch1 and PCNA were evaluated. Besides, renal cortical histopathology was assayed as well.

RESULTS

PDC led to a considerable increase in indicators for kidney injury, renal function parameters, invasive blood pressure, oxidative stress, and inflammatory markers. They were markedly reduced by coadministration of PDC with either/or NIC and PTX. The NIC and PTX combination regimen showed a more significant improvement than either medication used alone. Our results demonstrated the nephroprotective effect of NIC, PTX, and their combined regimen on PDC-induced kidney injury through suppression of oxidative stress, apoptosis, and inflammatory response.

CONCLUSION

Renal recovery from PDC injury was achieved through enhanced MAPK/Nrf2/HO-1 and suppressed Notch1/TLR4/NF-κB signaling pathways. This study highlights the role of NIC and PTX as effective interventions to ameliorate nephrotoxicity in patients undergoing PDC toxicity.

Research progress of DNA methylation in colorectal cancer (Review)

DNA methylation is one of the earliest and most significant epigenetic mechanisms discovered. DNA methylation refers, in general, to the addition of a methyl group to a specific base in the DNA sequence under the catalysis of DNA methyltransferase, with S‑adenosine methionine as the methyl donor, via covalent bonding and chemical modifications. DNA methylation is an important factor in inducing cancer. There are different types of DNA methylation, and methylation at different sites plays different roles. It is well known that the progression of colorectal cancer (CRC) is affected by the methylation of key genes. The present review did not only discuss the potential relationship between DNA methylation and CRC but also discussed how DNA methylation affects the development of CRC by affecting key genes. Furthermore, the clinical significance of DNA methylation in CRC was highlighted, including that of the therapeutic targets and biomarkers of methylation; and the importance of DNA methylation inhibitors was discussed as a novel strategy for treatment of CRC. The present review did not only focus upon the latest research findings, but earlier reviews were also cited as references to older literature.

Isolated tubercular cholecystitis: A rare diagnostic challenge

Abdominal tuberculosis, particularly affecting the hepatobiliary system, presents a diagnostic challenge due to its rarity and its tendency to mimic neoplastic conditions. Tuberculosis of the gallbladder, especially in the absence of pulmonary infection, is exceedingly rare. We present a case of isolated tubercular cholecystitis in a 41-year-old female initially suspected to have neoplastic etiology. Radiological imaging revealed thickened gallbladder wall with heterogenous enhancement extending into the subcutaneous plane. Histopathological examination post-cholecystectomy confirmed tubercular etiology with epithelioid cell granulomas and focal necrosis, alongside the presence of acid-fast bacilli. Such cases pose diagnostic dilemmas due to overlapping clinical and radiological features with gallbladder carcinoma. This report emphasizes the importance of considering tuberculosis in differentials, particularly in endemic regions like India, even without pulmonary symptoms. Treatment involves postoperative administration of anti-tubercular drugs, with the preoperative diagnosis being challenging and rarely achieved due to the avoidance of invasive procedures like fine needle aspiration in suspected carcinoma cases. The rarity of isolated gallbladder tuberculosis underscores the necessity for comprehensive diagnostic evaluations and awareness among clinicians in endemic regions.

Anesthesia for Combined Heart-Liver Transplantation: A Narrative Review

In 1984, 21 years after the first liver transplantation, Thomas Starzl achieved a milestone by performing the world's first combined heart-liver transplantation. While still uncommon, the practice of combined heart-liver transplants is on the rise globally. In this review, the authors delve into the current literature on this procedure, highlighting the evolving landscape and key considerations for anesthesiologists. Over the years, there has been a remarkable increase in the number of combined heart-liver transplantations conducted worldwide. This surge is largely attributed to the growing population of adult survivors with single-ventricle physiology, palliated with a Fontan procedure, who later present with late Fontan failure and Fontan-associated liver disease. Research indicates that combined heart-liver transplantation is an effective treatment option, with reported outcomes comparable with isolated heart or liver transplants. Managing anesthesia during a combined heart-liver transplant procedure is challenging, especially in the context of underlying Fontan physiology. International experience in this field remains somewhat limited, with most techniques derived from expert opinions or experiences with single-organ heart and liver transplants. These procedures are highly complex and performed infrequently. As the number of combined heart-liver transplants continues to rise globally, there is a growing need for clear guidance on periprocedural surgical and anesthetic management. Anesthesiologists overseeing these patients must consider multiple factors, balancing various comorbidities with significant hemodynamic and metabolic shifts. An increase in (multicenter) studies focusing on specific interventions to enhance patient and organ outcomes is anticipated in the coming years.

Early drain site tumor recurrence post adjuvant chemotherapy for locally advanced colon carcinoma: Case report and literature review

INTRODUCTION

Colon carcinoma is the most common type of gastro-intestinal cancer. Despite radical surgery, locoregional recurrence has been observed in 4-11.5 % of patients. Abdominal wall metastasis at the drainage site is an extremely rare finding and only a few cases are described in the literature. The mechanism of this metastasis is unknown, and its management remains unclear due to the rarity of the condition.

CASE PRESENTATION

A 66-year-old patient underwent left colectomy for locally advanced colonic adenocarcinoma. Eight months after the end of adjuvant chemotherapy, the patient complained of a progressive mass of the left lumbar centered on the previous drain site scar. Abdominal wall recurrence was suspected. The patient had R0 mass excision. Histopathologic examination showed a parietal infiltration by a colloid adenocarcinoma. The patient underwent adjuvant chemotherapy. No recurrence was observed.

DISCUSSION

Since 1999 only six cases of colon cancer drainage site metastasis have been reported. Metachronous solitary abdominal wall metastasis after radical colectomy may occur via cancer cell implantation, lymphatic or hematogenous route, or direct invasion. In case of drain site metastasis, the most likely hypothesis is the implantation of tumor cells into the abdominal wall through the drainage route performed during surgery.

CONCLUSION

The appearance of abdominal wall mass after colon cancer resection must always be considered suspicious. To reduce the risk of abdominal wall metastasis we recommend minimizing tumor manipulation, resection the route of previous percutaneous drainage and performing a radical surgery. Metastasis resection combined with chemotherapy is the appropriate approach to treat these metastases.

Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer

BACKGROUND

Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus.

MATERIALS AND METHODS

This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up.

RESULTS

In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001).

CONCLUSION

Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.

Chimerism-Mediated Tolerance in Intestinal Transplantation

In this review, the authors outlined concepts and strategies to achieve immune tolerance through inducing hematopoietic chimerism after solid organ transplantation and introduced challenges and opportunities in harnessing two-way alloresponses to improve outcomes after intestinal transplantation (ITx). Next, the authors discussed the dynamics and phenotypes of peripheral blood and intestinal graft T-cell subset chimerism and their association with outcomes. The authors also summarized studies on other types of immune cells after ITx and their potential participation in chimerism-mediated tolerance. The authors further discussed strategies and future directions to promote chimerism-associated tolerance after ITx to overcome rejection and minimize immunosuppression.

Surgical Management of the Horrible Gallbladder

Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.

Diagnosing and managing small bowel neuroendocrine tumors presenting as acute obstruction in an elderly patient: A case report and comprehensive management overview

INTRODUCTION AND IMPORTANCE

Neuroendocrine tumors (NETs) of the small bowel are rare but clinically significant due to their challenging diagnostic pathways and potential for insidious progression. Early identification is critical for effective management and improved prognosis in these cases.

CLINICAL PRESENTATION

Here, we present a case of a 75-year-old patient with no significant medical history who presented acutely with diffuse abdominal pain, vomiting, and signs of bowel obstruction. Diagnostic workup, including CT imaging, revealed a distal ileal neuroendocrine mass with mesenteric lymphadenopathy, necessitating urgent surgical intervention.

DISCUSSION

This case underscores the diagnostic complexities and therapeutic challenges associated with small bowel NETs. Surgical resection with meticulous lymph node dissection remains the cornerstone of treatment, aimed at achieving complete tumor excision and optimal disease control. The role of imaging modalities and biochemical markers in guiding clinical decisions and postoperative management strategies is discussed considering the patient's clinical course.

CONCLUSION

Timely recognition and intervention are crucial in the management of small bowel NETs, given their potential for late presentation and nonspecific symptoms. Despite diagnostic and procedural challenges highlighted in this case, early surgical intervention and comprehensive follow-up are essential for achieving favorable outcomes and minimizing recurrence risks in patients with small bowel NETs.

Radiologic Occult Metastases in Pancreatic Cancer: Analysis of Risk Factors and Survival Outcomes in the Age of Contemporary Neoadjuvant Multi-agent Chemotherapy

BACKGROUND

Radiologic occult metastatic disease (ROMD) in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo contemporary neoadjuvant chemotherapy (NAC) has not been well studied. This study sought to analyze the incidence, risk factors, and oncologic outcomes for patients who underwent the NAC approach for PDAC.

METHODS

A retrospective review analyzed a prospectively maintained database of patients who had potentially resectable PDAC treated with NAC and were offered pancreatectomy at our institution from 2011 to 2022. Multivariable regression analysis was performed to assess risk factors associated with ROMD. Kaplan-Meier curves with log-rank analyses were generated to estimate time-to-event end points.

RESULTS

The study enrolled 366 patients. Upfront and borderline resectable anatomic staging comprised 80% of the cohort, whereas 20% had locally advanced disease. The most common NAC regimen was FOLFIRINOX (n = 274, 75%). For 55 patients (15%) who harbored ROMD, the most common site was liver-only metastases (n = 33, 60%). The independent risk factors for ROMD were increasing CA19-9 levels during NAC (odds ratio [OR], 7.01; confidence interval [CI], 1.97-24.96; p = 0.008), indeterminate liver lesions (OR, 2.19; CI, 1.09-4.39; p = 0.028), and enlarged para-aortic lymph nodes (OR, 6.87; CI, 2.07-22.74; p = 0.002) on preoperative cross-sectional imaging. Receipt of palliative chemotherapy (p < 0.001) and eventual formal pancreatectomy (p = 0.04) were associated with survival benefit in the log-rank analysis. The median overall survival (OS) of the patients with ROMD was nearly 15 months from the initial diagnosis, with radiologic evidence of metastases occurring after a median of 2 months.

CONCLUSIONS

Radiologic occult metastatic disease remains a clinical challenge associated with poor outcomes for patients who have PDAC treated with multi-agent NAC.

Impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy: a NSQIP retrospective cohort analysis of 25,848 patients

BACKGROUND

Efforts to preoperatively risk stratify and optimize patients before pancreaticoduodenectomy continue to improve outcomes. This study aims to determine the impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy and outline optimal hypoalbuminemia cut-off values in this population.

METHODS

The ACS-NSQIP (2016-2021) database was used to extract patients who underwent pancreaticoduodenectomy, comparing those with hypoalbuminemia (< 3.0 g/L) to those with normal albumin. Demographics and 30-day outcomes were compared. Multivariable modeling evaluated factors including hypoalbuminemia to characterize their independent effect on serious complications, and mortality. Optimal albumin cut-offs for serious complications and mortality were evaluated using receiver-operating characteristic curves.

RESULTS

We evaluated 25,848 pancreaticoduodenectomy patients with 2712 (10.5%) having preoperative hypoalbuminemia. Patients with hypoalbuminemia were older (68.2 vs. 65.1; p < 0.0001), and were significantly more likely to be ASA class 4 or higher (13.9% vs. 6.7%; p < 0.0001). Patients with hypoalbuminemia had significantly more 30-day complications and after controlling for comorbidities hypoalbuminemia remained a significant independent factor associated with 30-day serious complications (OR 1.80, p < 0.0001) but not mortality (OR 1.37, p = 0.152).

CONCLUSIONS

Hypoalbuminemia plays a significant role in 30-day morbidity following pancreaticoduodenectomy. Preoperative albumin may serve as a useful marker for risk stratification and optimization.

Patterns and Outcomes in Pediatric Abdominal Tuberculosis: A Single Centre Cohort Study

INTRODUCTION

Abdominal tuberculosis presents in a variety of ways. Different testing modalities must be applied in addition to having a high clinical suspicion to diagnose and initiate therapy. Medications have a good response; however, morbidity has been seen following surgical management of complicated presentations like intestinal obstruction and perforation. There is a paucity of studies in the pediatric age group which evaluate response to the different treatment regimen and identify factors associated with poorer outcomes in children with abdominal tuberculosis.

METHODS

Patient records of 75 children with abdominal tuberculosis at a single center were evaluated using a questionnaire, covering a 14-year period from 2007 to 2021. Demographic features, presenting signs and symptoms, investigations and treatment details were studied. In- person or telephonic follow-up was conducted to identify treatment outcomes.

RESULTS

Incidence of abdominal TB was 7%, of all TB children with a mean age of 10.1 years. Mesenteric lymph nodes were involved in 67% and small intestine in 33% cases. Surgery was required in 22 children. 85% children completed treatment. Small intestine involvement had higher probability of undergoing surgery. Of the 70 children with complete follow up, 64 were well and 6 children succumbed to the disease. Older age, small intestine involvement and surgery were independently associated with higher mortality.

CONCLUSION

Intestinal involvement is associated with greater need for surgical intervention and greater mortality. Adolescents have poorer outcomes. Further studies are required focusing on these individual subgroups to understand the patterns of presentation, causes for mortality and prevention.

LEVEL OF EVIDENCE

Level 5.

B-Cell Induction Therapies in Intestinal Transplantation

Despite advancements in short-term outcomes since the inception of intestinal transplant, significant long-term graft failure persists. Early successes are attributed to the utilization of tacrolimus for maintenance therapy, coupled with T-cell modulating induction regimens, which effectively reduce the incidence of acute cellular rejection. However, the challenge of chronic allograft injury remains unresolved. There is increasing evidence indicating a correlation between donor-specific antibodies and the survival of visceral allografts. Strategies aimed at reducing the presence or load of these antibodies may potentially enhance long-term outcomes. Consequently, our focus is now turning toward B-cell induction therapies as a possible solution.

Safety and Efficacy of Barbed Sutures Compared to Non-barbed Sutures in Bariatric Surgery: An Updated Systematic Review and Meta-analysis

PURPOSE

Mastering intracorporeal suturing is challenging in the evolution from conventional to laparoscopic bariatric surgery. Among various techniques competing for superiority in overcoming this hurdle, we focus on exploring the potential of barbed sutures through a meta-analysis that compares outcomes to those of conventional non-barbed sutures in bariatric surgery.

MATERIALS AND METHODS

We conducted a comprehensive search on PubMed, Scopus, and Embase to identify studies comparing barbed sutures with non-barbed sutures in bariatric surgeries, focusing on outcomes such as operative time, suturing time, postoperative complications, and hospital stay. The statistical analysis was carried out using RStudio version 4.3.2. Heterogeneity was assessed using the Cochrane Q test and I2 statistics.

RESULTS

Incorporating data from 11 studies involving a total of 27,442 patients, including 3,516 in the barbed suture group across various bariatric surgeries, our analysis demonstrates a significant reduction in suturing time (mean difference -4.87; 95% CI -8.43 to -1.30; p < 0.01; I2 = 99%) associated with the use of barbed sutures. Specifically, in Roux-en-Y gastric bypass, we observed a significant decrease in operative time (mean difference -12.11; 95% CI -19.27 to -4.95; p < 0.01; I2 = 93%). Subgroup analyses and leave-one-out analyses consistently supported these findings. Furthermore, we found that the mean body mass index did not significantly predict the mean difference in operative time outcome. No significant differences emerged in hospital stay or postoperative complications, including leak, bleeding, stenosis, and bowel obstruction (p > 0.05).

CONCLUSION

Our study findings address barbed sutures as a potential alternative for laparoscopic intracorporeal suturing in bariatric surgery.

Real-time quantification of laser speckle contrast imaging during intestinal laparoscopic surgery: successful demonstration in a porcine intestinal ischemia model

BACKGROUND

Anastomotic leakage (AL) is a dreaded complication following colorectal cancer surgery, impacting patient outcome and leads to increasing healthcare consumption as well as economic burden. Bowel perfusion is a significant modifiable factor for anastomotic healing and thus crucial for reducing AL.

AIMS

The study aimed to calculate a cut-off value for quantified laser speckle perfusion units (LSPUs) in order to differentiate between ischemic and well-perfused tissue and to assess inter-observer reliability.

METHODS

LSCI was performed using a porcine ischemic small bowel loop model with the PerfusiX-Imaging® system. An ischemic area, a well-perfused area, and watershed areas, were selected based on the LSCI colormap. Subsequently, local capillary lactate (LCL) levels were measured. A logarithmic curve estimation tested the correlation between LSPU and LCL levels. A cut-off value for LSPU and lactate was calculated, based on anatomically ischemic and well-perfused tissue. Inter-observer variability analysis was performed with 10 observers.

RESULTS

Directly after ligation of the mesenteric arteries, differences in LSPU values between ischemic and well-perfused tissue were significant (p < 0.001) and increased significantly throughout all following measurements. LCL levels were significantly different (p < 0.001) at both 60 and 120 min. Logarithmic curve estimation showed an R2 value of 0.56 between LSPU and LCL values. A LSPU cut-off value was determined at 69, with a sensitivity of 0.94 and specificity of 0.87. A LCL cut-off value of 3.8 mmol/L was found, with a sensitivity and specificity of 0.97 and 1.0, respectively. There was no difference in assessment between experienced and unexperienced observers. Cohen's Kappa values were moderate to good (0.52-0.66).

CONCLUSION

Real-time quantification of LSPUs may be a feasible intraoperative method to assess tissue perfusion and a cut-off value could be determined with high sensitivity and specificity. Inter-observer variability was moderate to good, irrespective of prior experience with the technique.

Intra-ampullary Papillary Tubular Neoplasm (IAPN): Clinicopathologic Analysis of 72 Cases Highlights the Distinctive Characteristics of a Poorly Recognized Entity

The guidelines recently recognized the intra-ampullary papillary tubular neoplasm (IAPN) as a distinct tumor entity. However, the data on IAPN and its distinction from other ampullary tumors remain limited. A detailed clinicopathologic analysis of 72 previously unpublished IAPNs was performed. The patients were: male/female=1.8; mean age=67 years (range: 42 to 86 y); mean size=2.3 cm. Gross-microscopic correlation was crucial. From the duodenal perspective, the ampulla was typically raised symmetrically, with a patulous orifice, and was otherwise covered by stretched normal duodenal mucosa. However, in 6 cases, the protrusion of the intra-ampullary tumor to the duodenal surface gave the impression of an "ampullary-duodenal tumor," with the accurate diagnosis of IAPN established only by microscopic correlation illustrating the abrupt ending of the lesion at the edge of the ampulla. Microscopically, the preinvasive component often revealed mixed phenotypes (44.4% predominantly nonintestinal). The invasion was common (94%), typically small (mean=1.2 cm), primarily pancreatobiliary-type (75%), and showed aggressive features (lymphovascular invasion in 66%, perineural invasion in 41%, high budding in 30%). In 6 cases, the preinvasive component was pure intestinal, but the invasive component was pancreatobiliary. LN metastasis was identified in 42% (32% in those with ≤1 cm invasion). The prognosis was significantly better than ampullary-ductal carcinomas (median: 69 vs. 41 months; 3-year: 68% vs. 55%; and 5-year: 51% vs. 35%, P =0.047). In conclusion, unlike ampullary-duodenal carcinomas, IAPNs are often (44.4%) predominantly nonintestinal and commonly (94%) invasive, displaying aggressive features and LN metastasis even when minimally invasive, all of which render them less amenable to ampullectomy. However, their prognosis is still better than that of the "ampullary-ductal" carcinomas, with which IAPNs are currently grouped in CAP protocols (while IAPNs are kindreds of intraductal tumors of the pancreatobiliary tract, the latter represents the ampullary counterpart of pancreatic adenocarcinoma/cholangiocarcinoma).

Establishment and characterization of the PDAC-X3 cell line: a novel Chinese-origin pancreatic ductal adenocarcinoma cell line

In this study, a novel pancreatic cancer cell line, termed pancreatic ductal adenocarcinoma (PDAC)-X3 cell line, was successfully derived from the primary tumor. Comprehensive analyses of its malignant phenotype, molecular properties, specific biomarkers, and histological features confirmed that PDAC-X3 cells serve as a valuable model for investigating the underlying mechanisms driving pancreatic carcinogenesis and advancing potential therapeutic strategies. The newly established cell line was continuously cultured for over 12 months and was stably passaged through more than 50 generations. Morphologically, PDAC-X3 cells displayed characteristics typical of epithelial tumors. The population doubling time for PDAC-X3 cells was determined to be 50 h. Karyotype analysis revealed that 75% of PDAC-X3 cells presented as hypotriploid, while 25% were sub-tetraploid, with representative karyotypes being 53 and XY der (1) inv (9) der (22). In suspension culture, PDAC-X3 cells efficiently formed organoids. Upon inoculation into BALB/C nude mice, these cells initiated the development of xenograft tumors, achieving a tumor formation rate of 33%. Morphologically, these xenografted tumors closely resembled the primary tumor. Drug sensitivity assays indicated that PDAC-X3 cells exhibited resistance to oxaliplatin but demonstrated sensitivity to 5-Fluorouracil (5-FU), gemcitabine, and paclitaxel. Immunohistochemical analysis revealed that CK7, CK19, E-cadherin, Vimentin, CA19-9 were positively expressed in PDAC-X3 cells. Meanwhile, the expression rate for Ki-67 was 30%, and that for CEA was not detected. Our findings underscore that PDAC-X3 represents a novel pancreatic cancer cell line, positioning it as a valuable model for basic research and the advancement of therapeutic strategies against pancreatic cancer.

A Prognostic Model Based on the Log Odds Ratio of Positive Lymph Nodes Predicts Prognosis of Patients with Rectal Cancer

OBJECTIVE

This study aimed to compare the prognostic value of rectal cancer by comparing different lymph node staging systems, and a nomogram was constructed based on superior lymph node staging.

METHODS

Overall, 8700 patients with rectal cancer was obtained from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The area under the curve (AUC), the C index, and the Akaike informativeness criteria (AIC) were used to examine the predict ability of various lymph node staging methods. Prognostic indicators were assessed using univariate and multivariate COX regression, and further correlation nomograms were created after the data were randomly split into training and validation cohorts. To evaluate the effectiveness of the model, the C index, calibration curves, decision curves (DCA), and receiver operating characteristic curve (ROC) were used. We ran Kaplan-Meier survival analyses to look for variations in risk classification.

RESULTS

While compared to the N-stage positive lymph node ratio (LNR), the log odds ratio of positive lymph nodes (LODDS) had the highest predictive effectiveness. Multifactorial COX regression analyses were used to create nomograms for overall survival (OS) and cancer-specific survival (CSS). The C indices of OS and CSS for this model were considerably higher than those for TNM staging in the training cohort. The created nomograms demonstrated good efficacy based on ROC, rectification, and decision curves. Kaplan-Meier survival analysis revealed notable variations in patient survival across various patient strata.

CONCLUSIONS

Compared to AJCC staging, the LODDS-based nomograms have a more accurate predictive effectiveness in predicting OS and CSS in patients with rectal cancer.

Current Status of Laparoscopic Liver Resection

The evolution of laparoscopic liver surgery, originating in the 1990s, has been marked by significant advancements and milestones, overcoming initial technical hurdles and gaining widespread acceptance within the surgical community as a precise and safe alternative to open procedures. Along this journey, numerous challenges emerged, leading to the accumulation of evidence and the development of guidelines aimed at assisting surgeons in determining the safety, suitability, and complexity of laparoscopic liver resection. This chapter provides a thorough examination of key aspects of laparoscopic liver resection, including difficulty scoring systems, criteria for patient selection, technical considerations, outcomes across different types of liver lesions, and the innovative solutions developed to address challenges, thus offering a comprehensive overview of laparoscopic liver resection, and highlighting its evolving significance in modern hepatobiliary surgery.

Elective Surgery Trends and Outcomes of Nonagenarians and Centenarians in Otolaryngology-Head and Neck Surgery: A NSQIP Study

OBJECTIVE

To describe types and outcomes of elective otolaryngological surgeries undergone by patients ≥90 years of age and to assess whether very old age is an independent risk factor for postsurgical complications and death.

METHODS

The National Surgical Quality Improvement Program, a validated national prospective surgical outcomes database, was used to identify all patients aged 65 years and older who underwent elective otolaryngological procedures from 2011 to 2020. Study outcomes included minor complications, major life-threatening complications, and 30-day mortality. Predictors of outcomes, including frailty, were identified using univariable analyses and age was added into the final logistic regression models with stepwise selection.

RESULTS

A total of 40,723 patients met inclusion criteria; 629 (1.5%) patients were ≥90 years of age. Of the 63,389 procedures, head and neck (67.6%) and facial plastics and reconstructive (15.0%) procedures were most common. The overall incidence of major life-threatening complications, minor complications, and death was 2.0%, 3.5%, and 0.4%, respectively. Age ≥90 was significantly associated with an increased risk for 30-day mortality, but not with major or minor postoperative complications. A high modified frailty index was significantly associated with an increased risk for major postoperative complications and death amongst patients ≥90 years.

CONCLUSIONS

Elective otolaryngological surgery can be safe in relatively healthy nonagenarians and centenarians, though there is a small increased risk of 30-day mortality. Although older age can predispose patients to other comorbidities, age alone should not deter surgeons and patients from considering elective otolaryngological procedures. Frailty may be a better predictor for surgical outcomes.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:3989-3996, 2024.

Diagnostic value of dual-source, dual-energy computed tomography combined with the neutrophil-lymphocyte ratio for discriminating gastric signet ring cell from mixed signet ring cell and non-signet ring cell carcinomas

PURPOSE

To explore the diagnostic value of dual-source computed tomography (DSCT) and neutrophil to lymphocyte ratio (NLR) for differentiating gastric signet ring cell carcinoma (SRC) from mixed SRC (mSRC) and non-SRC (nSRC).

METHODS

This retrospective study included patients with gastric adenocarcinoma who underwent DSCT between August 2019 and June 2021 at our Hospital. The iodine concentration in the venous phase (ICvp), standardized iodine concentration (NICVP), and the slope of the energy spectrum curve (kVP) were extracted from DSCT data. NLR was determined from laboratory results. DSCT (including ICVP, NICVP, and kVP) and combination (including DSCT model and NLR) models were established based on the multinomial logistic regression analysis. The receiver operator characteristic (ROC) curve and area under the curve (AUC) were used to evaluate the diagnostic value.

RESULTS

A total of 155 patients (SRC [n = 45, aged 61.22 ± 11.4 years], mSRC [n = 60, aged 61.09 ± 12.7 years], and nSRC [n = 50, aged 67.66 ± 8.76 years]) were included. There were significant differences in NLR, ICVP, NICVP, and kVP among the SRC, mSRC, and nSRC groups (all P < 0.001). The AUC of the combination model for SRC vs. mSRC + nSRC was 0.964 (95% CI: 0.923-1.000), with a sensitivity of 98.3% and a specificity of 86.7%, higher than with DSCT (AUC: 0.959, 95% CI: 0.919-0.998, sensitivity: 90.0%, specificity: 89.9%) or NLR (AUC: 0.670, 95% CI: 0.577-0.768, sensitivity: 62.2%, specificity: 61.8%).

CONCLUSION

DSCT combined with NLR showed high diagnostic efficacy in differentiating SRC from mSRC and nSRC.

Association of body mass index with anal human papillomavirus infection and histologically confirmed high-grade squamous intraepithelial lesions in people who receive services at the Anal Neoplasia Clinic in Puerto Rico

Objective

This study aimed to assess the association of body mass index (BMI) with anal high-risk human papillomavirus (HR-HPV) and biopsy-confirmed histologic anal high-grade squamous intraepithelial lesions (HSIL) among a clinic-based sample of Hispanics in Puerto Rico.

Methods

This cross-sectional study evaluated medical records of adults who received services at the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center between October 2014 and December 2022. The study included 543 records with complete clinical information regarding anal HR-HPV and anal HSIL status. Chi-square and logistic regression analyses were performed.

Results

Mean age of participants was 44.10 ± 13.24 years, 65.2% were men, 71.7% were HIV-infected, 74.4% had anal HR-HPV infection, and 37.9% had biopsy-confirmed HSIL. Regarding BMI, 2.4% were underweight, 31.9% normal weight, and 39.0 % overweight; while 17.3 % had class I, 5.2% class II, and 4.2% class III obesity. No significant association was observed between BMI and anal HR-HPV infection in adjusted analyses. Lower odds of anal HSIL were observed among overweight individuals (OR: 0.63, 95% CI: 0.41 - 0.99) and those with class II/III obesity (OR: 0.48, 95% CI: 0.22 - 1.01) compared to adults with underweight/normal BMI, after adjusting for potential confounders. No significant association was observed for class I obesity.

Conclusion

BMI was not associated with anal HR-HPV infection. Overweight and obese individuals had lower odds of having anal HSIL than adults with underweight/normal BMI. This finding could suggest underdiagnosis of HSIL among overweight/obese individuals, or reduced risk in this group.

The role of NCAPH in cancer treatment

Many solid tumors frequently overexpress Non-SMC Condensin I Complex Subunit H (NCAPH), and new studies suggest that NCAPH may be a target gene for clinical cancer therapy. Numerous investigations have shown that a variety of transcription factors, including as MYBL2, FOXP3, GATA3, and OTC1, can stimulate the transcription of NCAPH. Additionally, NCAPH stimulates many oncogenic signaling pathways, such as β-Catenin/PD-L1, PI3K/AKT/SGK3, MEK/ERK, AURKB/AKT/mTOR, PI3K/PDK1/AKT, and Chk1/Chk2. Tumor immune microenvironment modification and tumor growth, apoptosis, metastasis, stemness, and treatment resistance all depend on these signals. NCAPH has the ability to form complexes with other proteins that are involved in glycolysis, DNA damage repair, and chromatin remodeling. This review indicates that NCAPH expression in most malignant tumors is associated with poor prognosis and low recurrence-free survival.

The integration of artificial intelligence in robotic surgery: A narrative review

BACKGROUND

The rise of high-definition imaging and robotic surgery has independently been associated with improved postoperative outcomes. However, steep learning curves and finite human cognitive ability limit the facility in imaging interpretation and interaction with the robotic surgery console interfaces. This review presents innovative ways in which artificial intelligence integrates preoperative imaging and surgery to help overcome these limitations and to further advance robotic operations.

METHODS

PubMed was queried for "artificial intelligence," "machine learning," and "robotic surgery." From the 182 publications in English, a further in-depth review of the cited literature was performed.

RESULTS

Artificial intelligence boasts efficiency and proclivity for large amounts of unwieldy and unstructured data. Its wide adoption has significant practice-changing implications throughout the perioperative period. Assessment of preoperative imaging can augment preoperative surgeon knowledge by accessing pathology data that have been traditionally only available postoperatively through analysis of preoperative imaging. Intraoperatively, the interaction of artificial intelligence with augmented reality through the dynamic overlay of preoperative anatomical knowledge atop the robotic operative field can outline safe dissection planes, helping surgeons make critical real-time intraoperative decisions. Finally, semi-independent artificial intelligence-assisted robotic operations may one day be performed by artificial intelligence with limited human intervention.

CONCLUSION

As artificial intelligence has allowed machines to think and problem-solve like humans, it promises further advancement of existing technologies and a revolution of individualized patient care. Further research and ethical precautions are necessary before the full implementation of artificial intelligence in robotic surgery.

Colorectal Adenosquamous Carcinoma: Demographics, Tumor Characteristics, and Survival Benefits of Surgery with Chemoradiation

BACKGROUND

Colorectal adenosquamous carcinoma (ASC) is a rare subtype of colorectal carcinoma. This study presents findings from a large database query to highlight the demographic, clinical, and pathological factors, prognosis, and survival of colorectal ASC.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients with colorectal ASC diagnosed between 2000 and 2020 and assess factors associated with overall survival (OS) and cause-specific survival (CSS).

RESULTS

Among 284 identified cases, the median age of diagnosis was 64 years. The majority of patients were White (69.0%), with income ≤ $70,000 ( 62.3%), and lived in metropolitan areas (85.6%). Regarding tumor characteristics, the majority of tumors were poorly differentiated (49.6%), regional stage (39.8%), size of > 4.0 cm ( 41.5%), and had a negative lymph node status (47.2%). Primary sites were the rectum (35.2%) and colon ( 64.8%). In patients with primary site to the rectum, the majority of treatment modality was multimodal therapy (40.0%). The main treatment modality for the primary site to the colon was surgery only (46.2%), followed by surgery + chemotherapy (34.2%). The overall 5-year survival was 31.3 (95% C.I. 28.4-34.2) and the 5-year cause-specific survival (CSS) was 40.1% (95% C.I. 36.9-43.3). Multivariate analysis showed age ≥ 60 years, regional stage, and distant stage were negative prognostic factors. An income of > $70,000, multimodal therapy, and surgery with chemotherapy were positive prognostic factors.

CONCLUSION

Colorectal adenosquamous carcinomas are more common in the non-Hispanic White populations and appear more frequently later in life (based on the median age of diagnosis at 64). Factors that contributed to a worse prognosis were an age of diagnosis ≥ 60 years, regional stage, and distant stage.

Minimally invasive umbilical hernia repair is safe for patients with liver dysfunction: A propensity-score-matched analysis of approach and outcomes using ACS-NSQIP

BACKGROUND

Umbilical hernias are highly prevalent in patients with liver dysfunction, ascites, and cirrhosis. This patient population carries significant perioperative risk and poses significant challenges because of their comorbidities. Literature suggests that elective repair of umbilical hernias can lead to better outcomes by reducing the risk of ascitic leak and compromised bowel. Medical optimization followed by open repair has been the standard approach; however, little is known about whether a laparoscopic approach may be equivalent or superior.

METHODS

We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2021 for umbilical hernia repairs in patients with liver dysfunction, as defined per the aspartate aminotransferase to platelet ratio index ≥1. We compare operative outcomes for open and laparoscopic repair, adjusting for confounders using propensity score matching and stratifying by case acuity.

RESULTS

We identified 1,983 patients with liver dysfunction who underwent umbilical hernia repair. Most patients (86%) were operated via an open approach rather than laparoscopy. Operative outcomes between the laparoscopy and open group were comparable regarding mortality and serious complications. Notably, length of stay and need for blood transfusion intraoperatively or postoperatively were reduced in the laparoscopy group (P < .001). These findings remained significant after subgroup analysis with propensity matching stratified by elective and emergency case types.

CONCLUSION

Minimally invasive umbilical hernia repair in liver dysfunction is as safe and, in some metrics, superior to open technique. We found no difference in mortality although hospital stays and the need for blood transfusions were lower in the laparoscopy groups. Prospective randomized trials are needed to validate these findings further.

Sustained improved emergency laparotomy outcomes over 3 years after a transdisciplinary perioperative care pathway-A 1:1 propensity score matched study

BACKGROUND

Emergency laparotomy is associated with high morbidity and significant global health burden. This study aims to compare postoperative outcomes of patients who underwent emergency laparotomy before and after implementation of a emergency laparotomy pathway.

METHODS

This is a single-center study of all patients who presented with an acute abdomen and/or conditions requiring emergency laparotomy during pre-emergency laparotomy pathway (retrospective cohort from January 2016 to December 2018) and after the emergency laparotomy pathway (prospective cohort from January 2019 to December 2021). Patients who underwent emergency laparotomy for trauma or vascular surgery were excluded. A 1:1 propensity score matching was performed to address for confounding factors.

RESULTS

There were 888 patients (emergency laparotomy pathway, n = 428, and pre-emergency laparotomy pathway, n = 460) in the unmatched cohort. The mean age was 63.0 ± 15.4 years, and 43.8% had predicted mortality >10% using Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity. The most common indication for emergency laparotomy was intestinal obstruction (30.5%). Overall incidence rates of major morbidity and 30-day mortality were 16.2% and 3.5%, respectively. There were 736 patients (n = 368 patients per arm) after propensity score matching. Demographic characteristics were comparable after propensity score matching. The emergency laparotomy pathway was associated with more patients assessed by geriatric medicine (odds ratio = 15.22; P < .001), reduced major morbidity (odds ratio = 0.63; P = .024), reduced intra-abdominal collection (odds ratio = 0.39; P = .006), and need for unplanned radiological and/or surgical intervention after index emergency laparotomy (odds ratio = 0.63; P = .024). Length of stay and 30-day mortality were comparable between the emergency laparotomy pathway and pre-emergency laparotomy pathway in both the unmatched and propensity score matched cohort.

CONCLUSION

Sustained improved postoperative outcomes were achieved 3 years postimplementation of the emergency laparotomy pathway .

Intraperitoneal administration of doxorubicin-encapsulated Brucea javanica oil nanoemulsion against malignant ascites

Malignant ascites is a common complication of advanced cancers, which reduces survival rates and diminishes patients' quality of life. Intraperitoneal chemotherapy is a conventional method for treating cancer-related ascites, but the poor drug retention of conventional drugs requires frequent administration to maintain sustained anti-tumor effects. In this study, we encapsulated doxorubicin (DOX) into Brucea javanica oil (BJO) to develop a water-in-oil (W/O) nanoemulsion called BJO@DOX for the treatment of malignant ascites through in-situ intraperitoneal administration. BJO significantly induced apoptosis of S180 cells by upregulating the expression of p53 and caspase-3 (cleaved). Additionally, BJO notably downregulated the expression of Bcl-2, further promoting apoptosis of S180 cells. Cell apoptosis significantly inhibited ascites formation and tumor cell proliferation in a mouse model. The combination of DOX and BJO exhibited satisfactory synergistic effects, consequently prolonging the survival period of mice. Histological examination of major organs indicated that the nanoemulsion had excellent biosafety in vivo. The BJO@DOX nanoemulsion represents a promising platform for in-situ chemotherapy of malignant ascites.

Subtotal laparoscopic cholecystectomy versus conversion to open as a bailout procedure: a cohort study

BACKGROUND

The aim of this study is to evaluate morbidity and mortality in patients taken to conversion to open procedure (CO) and subtotal laparoscopic cholecystectomy (SLC) as bailout procedures when performing difficult laparoscopic cholecystectomy.

METHOD

This observational cohort study retrospectively analyzed patients taken to SLC or CO as bailout surgery during difficult laparoscopic cholecystectomy between 2014 and 2022. Univariable and multivariable logistic regression models were used to identify prognostic factors for morbimortality.

RESULTS

A total of 675 patients were included. Of the 675 patients (mean [SD] age 63.85 ± 16.00 years; 390 [57.7%] male) included in the analysis, 452 (67%) underwent CO and 223 (33%) underwent SLC. Overall, neither procedure had an increased risk of major complications (89 [19.69%] vs 35 [15.69%] P.207). However, CO had an increased risk of bile duct injury (18 [3.98] vs 1 [0.44] P.009), bleeding (mean [SD] 165.43 ± 368.57 vs 43.25 ± 123.42 P < .001), intestinal injury (20 [4.42%] vs 0 [0.00] P.001), and wound infection (18 [3.98%] vs 2 [0.89%] P.026), while SLC had a higher risk of bile leak (15 [3.31] vs 16 [7.17] P.024). On the multivariable analysis, Charlson comorbidity index (odds ratio [OR], 1.20; CI95%, 1.01-1.42), use of anticoagulant agents (OR, 2.56; CI95%, 1.21-5.44), classification of severity of cholecystitis grade III (OR, 2.96; CI95%, 1.48-5.94), and emergency admission (OR, 6.07; CI95%, 1.33-27.74) were associated with presenting major complications.

CONCLUSIONS

SLC was less associated with complications; however, there is scant evidence on its long-term outcomes. Further research is needed on SLC to establish if it is the safest in the long-term as a bailout procedure.

Endoscopic ultrasound-guided radiofrequency ablation of pancreatic tumors

PURPOSE OF REVIEW

Surgery is a cornerstone in the management of pancreatic cancer and precancerous pancreatic lesions. However, many patients are not suitable candidates for surgery at the time of diagnosis for various reasons. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) appears to be a promising treatment option for patients who are ineligible for surgery for management of pancreatic adenocarcinoma (PDAC), and pancreatic neuroendocrine tumors (PNETs), and pancreatic cystic lesions (PCLs).

RECENT FINDINGS

EUS-RFA may serve as an adjunct to chemotherapy or palliative measures for inoperable cases of PDAC. Given its feasibility and efficacy, EUS-RFA has an evolving niche as a minimally invasive and potentially definitive treatment for PNETs and high-risk PCLs such as intraductal papillary mucinous neoplasms (IPMNs). EUS-RFA is a generally well tolerated procedure, with abdominal pain and acute pancreatitis being the most common adverse effects, though the risk can be mitigated through prophylactic measures.

SUMMARY

There is an increasing body of evidence to support the use of EUS-RFA in managing pancreatic lesions, either as definitive, adjunctive, or palliative treatment, depending on lesion type.

Endoscopic Glue Injection Versus Endoscopic Human Thrombin Injection for Bleeding Gastric Varices-A Randomized Controlled Trial

BACKGROUND

Acute gastric variceal bleeding (AGVB) is a potentially fatal consequence of portal hypertension, accounting for 10% to 30% of all variceal bleeding. Although endoscopic cyanoacrylate glue injection is a common treatment for acute hemostasis, it has been linked to significant side effects. In the treatment of AGVB, there is limited evidence of the efficacy and relative safety of endoscopic human thrombin injection over glue injection.

MATERIALS AND METHODS

A total of 52 AGVB patients were randomized to receive either thrombin injection (25 patients) or glue injection (27 patients). The primary outcome was the incidence of any glue or thrombin injection-related post-therapy complications. Initial hemostasis, rebleeding, and mortality were all secondary end goals.

RESULTS

Both groups had comparable baseline data. Hemostasis of active bleeding at endoscopy was 100.0% (10/10) in the thrombin group and 87.5% (7/8) in the glue group ( P =0.44). Treatment failure after 5 days occurred in 2 patients (6.1%) in the glue group compared with none in the thrombin group ( P =0.165). Between 6 and 42 days after index bleeding, rebleeding occurred in 4 patients in the thrombin group compared with 6 patients in the glue group ( P =0.728). In the thrombin group, none of the patients had post-treatment ulcers on gastric varices compared with 14.81% (4/27) that occurred in the glue group ( P =0.045), a statistically significant observation. Overall, complications occurred in 4 (20%) and 11 (40.7%) patients in the thrombin and glue groups, respectively ( P =0.105). Two patients in the glue group died.

CONCLUSION

To achieve successful AGVB hemostasis, endoscopic thrombin injection has been proven efficacious. However, glue injection may be linked to a higher rate of rebleeding and post-therapy gastric variceal ulceration compared with thrombin.

"GLI1 Subcellular Localization and Overexpression as Prognostic Factors for Disease-Free Survival in Colorectal Carcinoma"

PURPOSE

Glioma-associated oncogene homolog-1 (GLI1) is amplified in human glioblastoma, and there is growing evidence suggesting its significant role in tumor development and metastasis. Our aim was to investigate the role of the GLI-1 gene in the progression of colorectal cancer (CRC) and its correlation with various clinicopathological features. Additionally, we examined the impact of the GLI-1 gene and other factors on the prognosis of CRC.

METHODS

We analyzed a total of 98 confirmed CRC cases and adjacent normal tissue controls. Patients suspected of having colon cancer underwent a colonoscopy and targeted biopsy, while those with rectal cancer underwent CT scans and MRI. GLI1 expression was detected using real-time PCR assay, Western blotting, and immunohistochemistry.

RESULTS

The GLI1 gene was observed to be overexpressed in tumor tissues at both the protein and mRNA levels (p < 0.05). In addition, GLI1 overexpression was significantly associated with various factors such as tumor invasion (T3/T4), presence of lymph nodes, lymph node metastasis (LNM), stage (III/IV), tumor site (colon), tumor size (≥ 3 cm), localization (nucleocytoplasmic), strong staining intensity and recurrence (p < 0.05). The results of survival analysis showed that the patients with overexpression of GLI1 had a significantly lower DFS rate which was 21 months compared to those with normal expression who had 31 months (p < 0.05). Moreover, individuals with early onset disease (15 months) were more likely to have cytoplasmic localization of the GLI1 gene as opposed to nucleo-cytoplasmic localization of GLI1 which presented late-onset disease( 23 months) (p < 0.05). Finally, Stage and PNI (p < 0.05) were found to independently affect outcomes of CRC according to Cox regression analysis.

CONCLUSION

High expression of GLI-1 in CRC is associated with adverse pathology and poor prognosis for patients. The correlation between cytoplasmic localization of GLI-1 and reduced disease-free survival holds potential for guiding prognosis and treatment. Further research is needed to develop strategies targeting GLI-1 for improved outcomes.

Efficacy of the omental roll-up technique in pancreaticojejunostomy to prevent postoperative pancreatic fistula after pancreaticoduodenectomy

Backgrounds/Aims

Pancreaticoduodenectomy (PD) is being performed more frequently. A pancreaticojejunostomy (PJ) leak is the major determinant of patient outcomes. An omental flap around PJ might improve postoperative outcomes.

Methods

A prospective randomized controlled trial was planned at PGIMER, Chandigarh. Fifty-eight patients meeting the criteria were included in the study. Group A underwent PD with omental roll-up and group B underwent standard PD.

Results

The mean age of patients in group A was 57.1 ± 14.3 years and 51.2 ± 10.7 in group B. Jaundice (p = 0.667), abdominal pain (p = 0.69), and co-morbidities were equal among the groups. The body mass index of patients in group B was higher at 24.3 ± 5.4 kg/m2 (p = 0.03). The common bile duct diameter (12.6 ± 5.3 mm vs. 17.2 ± 10.3 mm, p = 0.13) and the pancreatic duct diameter (4.06 ± 2.01 mm vs. 4.60 ± 2.43 mm, p = 0.91) were comparable. The intraoperative blood loss (mL) was significantly higher in group B (233.33 ± 9.57 vs. 343.33 ± 177.14, p = 0.04). Drain fluid amylase levels on postoperative day (POD) 1 (p = 0.97) and POD3 (p = 0.92) were comparable. The rate of postoperative pancreatic fistula (POPF) grade A (p ≥ 0.99) and grade B (p = 0.54) were comparable. The mean postoperative length of stay among was similar (p = 0.89).

Conclusions

An omental wrap can be performed without increase in complexity of the procedure. However, its utility in preventing POPFs and morbidity remains unclear.

Meta-analysis and trial sequential analysis of pancreatic stump closure using a hand-sewn or stapler technique in distal pancreatectomy

This study aimed to compare outcomes of hand-sewn and stapler closure techniques of pancreatic stump in patients undergoing distal pancreatectomy (DP). Impact of stapler closure reinforcement using mesh on outcomes was also evaluated. Literature search was carried out using multiple data sources to identify studies that compared hand-sewn and stapler closure techniques in management of pancreatic stump following DP. Odds ratio (OR) was determined for clinically relevant postoperative pancreatic fistula (POPF) via random-effects modelling. Subsequently, trial sequential analysis was performed. Thirty-two studies with a total of 4,022 patients undergoing DP with hand-sewn (n = 1,184) or stapler (n = 2,838) closure technique of pancreatic stump were analyzed. Hand-sewn closure significantly increased the risk of clinically relevant POPF compared to stapler closure (OR: 1.56, p = 0.02). When stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.54, p = 0.002). When only randomized controlled trials were considered, there was no significant difference in clinically relevant POPF between hand-sewn and stapler closure techniques (OR: 1.20, p = 0.64) or between reinforced and standard stapler closure techniques (OR: 0.50, p = 0.08). When observational studies were considered, hand-sewn closure was associated with a significantly higher rate of clinically relevant POPF compared to stapler closure (OR: 1.59, p = 0.03). Moreover, when stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.55, p = 0.02). Trial sequential analysis detected risk of type 2 error. In conclusion, reinforced stapler closure in DP may reduce risk of clinically relevant POPF compared to hand-sewn closure or stapler closure without reinforcement. Future randomized research is needed to provide stronger evidence.