Endoscopic and Surgical Treatment of Gastrointestinal Neuroendocrine Neoplasms: A Population-based Comparative Study

BACKGROUND

Controversy surrounds the indications for endoscopic treatment (ET) versus surgery in addressing gastrointestinal neuroendocrine neoplasms (GI-NENs). This paper aims to compare the long-term survival prognosis between ET and surgery for patients with GI-NENs.

METHODS

A retrospective analysis of GI-NEN patients diagnosed between 2000 and 2020 was conducted using the SEER database. Overall survival (OS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Prognostic factors were assessed through univariate and multivariate Cox regression analyses. Propensity score matching (PSM) was employed to adjust for clinical variables.

RESULTS

This study encompassed 12,016 patients with GI-NENs, with 3732 patients (31.1%) undergoing ET and 8284 patients (68.9%) opting for surgery. The rectum was the most frequent location for ET, while the small bowel was the predominant site for surgery. Both the ET and surgical groups exhibited similar overall survival risk and cancer-specific survival risk before and after matching. No significant differences in the 1-year, 3-year, 5-year, and 10-year OS and CSS rates were observed between the ET and surgery groups after PSM. Nevertheless, subgroup analysis revealed a significantly better CSS in the ET group than the surgery group, particularly in stage I and tumors sized <10mm ( P <0.01). In the colon subgroup, the OS and CSS of the ET group were superior to those of the surgery group ( P <0.05).

CONCLUSION

Endoscopic treatment and surgery demonstrate comparable long-term survival prognoses for treating GI-NENs. ET emerges as a viable option for patients averse to surgical interventions.

A perforation of a duodenal diverticulum in a 97-year-old patient after total gastrectomy and Roux-en-Y reconstruction: a case report

Most duodenal diverticula (DD) are asymptomatic and rarely develop perforations. Perforation is the most serious complication of DD and often requires emergency surgery. A 97-year-old woman who had undergone total gastrectomy and Roux-en-Y reconstruction 30 years ago was referred to our department with chief complaints of abdominal pain and fever during her hospitalization after femoral neck fracture surgery in the orthopedic department. Contrast-enhanced computed tomography showed free air and residue in the abdominal cavity and right retroperitoneum, and an emergency laparotomy was performed. The abdominal cavity was mildly contaminated, and a 6-cm DD with a 1-cm perforation in the wall of the diverticulum on the contralateral side of the mesentery of the duodenum was found. Diverticulectomy and duodenal closure were performed and a drainage tube was placed. The patient experienced no complications and was transferred to the orthopedic department on postoperative day 10. Reports of perforation of DD after gastrectomy are very rare. Particular attention should be paid to perforation of DD after Billroth-II and Roux-en-Y reconstructions as they involve the formation of a duodenal stump that differs from the normal anatomy and may be highly invasive surgical procedures, depending on the degree of inflammation and fistula formation.

Acute cholangitis: a state-of-the-art review

Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts. It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15%, despite advances in broad-spectrum antimicrobial therapy and improved access to emergency biliary tract decompression procedures. Even though not much has changed in recent years in terms of diagnosis or treatment, new data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis. Moreover, different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures that can help when consecrated treatments such as endoscopic retrograde cholangiopancreatography (ERCP) fail, cannot be performed, or are unavailable have been proposed. This state-of-the-art review aims to offer a complete and updated assessment of the epidemiology, novel diagnostic and therapeutic methods, complications, and prognostic variables of acute cholangitis. The authors will review the prognostic implications of unusual complications, the relevance of regular bile samples and antibiograms, and their new role in guiding antibiotic therapy and limiting antibiotic resistance to present an organized and comprehensive approach to the care of acute cholangitis.

The effect of obesity on the outcomes of laparoscopic adrenal surgery in patients with Cushing syndrome

Purpose

The aim of this study is to investigate the effect of obesity on the results of laparoscopic adrenal surgery in patients with Cushing syndrome.

Methods

This retrospective study was performed in Department of General Surgery at Erciyes University School of Medicine between January 2010 and January 2023. Our analysis included Cushing syndrome patients who underwent unilateral laparoscopic adrenalectomy (LA) with the transabdominal lateral approach. All patients were evaluated in terms of age, sex, tumor diameter, body mass index (BMI), American Society of Anesthesiologists physical status classification, morbidities, surgery history, tumor side, operative time, conversion to open surgery, complications, and length of hospital stay.

Results

A total of 90 patients (75 females and 15 males) underwent a transperitoneal LA. Patients were divided into 2 groups according to their BMI: obese group (≥30 kg/m2; n = 53, 58.8%) and nonobese group (<30 kg/m2; n = 37, 41.2%). All patients were classified into 3 subgroups: obese patient group, BMI ≥30-39 kg/m2 (n = 23); morbidly obese patient group, BMI ≥40 kg/m2 (n = 14); and nonobese patient group, BMI <30 kg/m2 (n = 53). There was no significant difference in intraoperative complications, conversion to open surgery, operative time, or length of hospital stay between the groups. Only conversion to open surgery was a risk factor for postoperative complications in univariate and multivariate analyses (odds ratio, 15.4; 95% confidence interval, 1.277-185.599; P = 0.031).

Conclusion

Our results showed that LA is safe and effective in patients with Cushing syndrome with morbid obesity, allowing acceptable morbidity and length of hospital stay.

Omental torsion mimicking acute appendicitis: A case report

INTRODUCTION

Omental torsion is a rare cause of acute abdominal pain caused by twisting of the omentum along its long axis, thus compromising its vascularity. Its presentation is non-specific and can mimic other common pathologies, making its pre-operative diagnosis challenging.

PRESENTATION OF CASE

A 44-year-old female presented for periumbilical abdominal pain. Her laboratory results showed no leukocytosis and CRP was within normal range. CT scan of the abdomen and pelvis with oral and IV contrast showed a well demarcated pericecal mass at the right side, mostly suggestive of transmesenteric internal herniation with strangulation. The patient eventually required laparoscopic surgical intervention.

DISCUSSION

The acute abdominal manifestations in patients with omental torsion are due to the development of edema and necrotic tissue distal of the torsion after the arterial supply and venous drainage have been obstructed. Rotation around the right gastroepiploic artery is considered to be the most common cause of omental torsion. Primary torsion is considered to be idiopathic, while secondary torsion occurs due to an identifiable predisposing pathology such as omental cysts, hernias, adhesions, or intra-abdominal tumors. Since symptoms of omental torsion are non-specific, it is crucial to consider the differential diagnosis and rule out other causes of acute abdomen. Surgical intervention is the mainstay treatment when there is uncertainty in the diagnosis, or when the patient's clinical, radiological, and laboratory findings worsen with conservative treatment.

CONCLUSION

Early surgical intervention in cases of omental torsion reduces the incidence of formation of abscesses, adhesions, and omental necrosis. In cases of non-operative candidates, conservative treatment is the best option; therefore, the choice of treatment of omental torsion should be considered on a case-by-case basis.

Functional outcomes and quality of life following open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: a systematic review and meta-analysis

BACKGROUND

The standard surgical treatment for rectal cancer is total mesorectal excision (TME), which may negatively affect patients' functional outcomes and quality of life (QoL). However, it is unclear how different TME techniques may impact patients' functional outcomes and QoL. This systematic review and meta-analysis evaluated functional outcomes of urinary, sexual, and fecal functioning as well as QoL after open, laparoscopic (L-TME), robot-assisted (R-TME), and transanal total mesorectal excision (TaTME).

METHODS

A systematic review and meta-analysis, based on the preferred reporting items for systematic reviews and meta-analysis statement, were conducted (PROSPERO: CRD42021240851). A literature review was performed (sources: PubMed, Medline, Embase, Scopus, Web of Science, and Cochrane Library databases; end-of-search date: September 1, 2023), and a quality assessment was performed using the Methodological index for non-randomized studies. A random-effects model was used to pool the data for the meta-analyses.

RESULTS

Nineteen studies were included, reporting on 2495 patients (88 open, 1171 L-TME, 995 R-TME, and 241 TaTME). Quantitative analyses comparing L-TME vs. R-TME showed no significant differences regarding urinary and sexual functioning, except for urinary function at three months post-surgery, which favoured R-TME (SMD [CI] -0 .15 [- 0.24 to - 0.06], p = 0.02; n = 401). Qualitative analyses identified most studies did not find significant differences in urinary, sexual, and fecal functioning and QoL between different techniques.

CONCLUSIONS

This systematic review and meta-analysis highlight a significant gap in the literature concerning the evaluation of functional outcomes and QoL after TME for rectal cancer treatment. This study emphasizes the need for high-quality, randomized-controlled, and prospective cohort studies evaluating these outcomes. Based on the limited available evidence, this systematic review and meta-analysis suggests no significant differences in patients' urinary, sexual, and fecal functioning and their QoL across various TME techniques.

A head-to-head comparison of computed tomography- and magnetic resonance imaging-based radiomics in assessing pediatric peripheral neuroblastic tumor cell behavior

PURPOSE

To compare the performance of radiomics from contrast-enhanced computed tomography (CECT) and non-contrast magnetic resonance imaging (MRI) in assessing cellular behavior in pediatric peripheral neuroblastic tumors (PNTs).

MATERIALS AND METHODS

A retrospective analysis of 81 PNT patients who underwent venous phase CECT, T1-weighted imaging (T1WI), and T2-weighted imaging (T2WI) scans was conducted. The patients were classified into neuroblastoma and ganglioneuroblastoma/ganglioneuroma based on their pathological subtypes. Additionally, they were categorized into favorable histology and unfavorable histology according to the International Neuroblastoma Pathology Classification (INPC). Tumor regions of interest were segmented on CECT, axial T1WI, and axial T2WI images, and radiomics models were developed based on the selected radiomics features. Following five-fold cross-validation, the performance of the radiomics models derived from CECT and MRI was compared using the area under the receiver operating characteristic curve (AUC) and accuracy.

RESULTS

For discriminating pathological subtypes, the AUC for CECT radiomics models ranged from 0.765 to 0.870, with an accuracy range of 0.728 to 0.815. In contrast, the AUC for MRI radiomics models ranged from 0.549 to 0.748, with an accuracy range of 0.531 to 0.778. Regarding the discrimination of INPC subgroups, the AUC for CECT radiomics models ranged from 0.503 to 0.759, with an accuracy range of 0.432 to 0.741. Meanwhile, the AUC for MRI radiomics models ranged from 0.512 to 0.739, with an accuracy range of 0.605 to 0.815.

CONCLUSIONS

CECT radiomics outperforms non-contrast MRI radiomics in evaluating pathological subtypes. When assessing INPC subgroups, CECT radiomics demonstrates comparability with non-contrast MRI radiomics.

Risk factors and outcomes associated with external ventricular drain related hemorrhage

OBJECTIVE

The objective of this study was to determine risk factors predictive of external ventricular drain (EVD)-related hemorrhage and the association of such hemorrhages with mortality, discharge disposition, length of stay (LOS), and total cost.

METHODS

After Institutional Review Board approval, data was collected retrospectively for adult patients requiring EVD placement from 2015 to 2018 at the authors' institution. Collected data included demographic patient information, peri-procedural factors, and relevant post-procedural measures. Computerized tomography (CT) images and associated radiologic reports were independently reviewed, identifying hemorrhages accompanying EVD placement.

RESULTS

From this 487-patient sample, 85 (17.5 %) patients had hemorrhages, including asymptomatic hemorrhages identified on imaging alone. A univariable analysis of patient parameters in the overall cohort was performed to identify possible predictors of hemorrhage. Age (p = 0.002), Charlson Comorbidity Index (CCI) (p < 0.001), platelet count (p = 0.002), presence of uremia (p = 0.035), and the number of times the EVD was replaced (p < 0.001) were associated with hemorrhage in univariable models. The experience of the resident surgeon based on post-graduate year (PGY level) and the number of attempts/passes needed for EVD placement were not associated with hemorrhage risk. Significant predictor of hemorrhage confirmed in a multivariable analysis only included the number of times the EVD was replaced (OR = 2.78, adjusted p < 0.001). Outcomes between EVD-related hemorrhage versus no hemorrhage groups, including mortality, discharge disposition, LOS, and cost, were compared. EVD-related hemorrhage was found to be associated with increased mortality (OR = 3.58, adjusted p < 0.001) and decreased likelihood of discharge home (OR = 0.13, adjusted p = 0.030) in the associated multivariable regressions.

CONCLUSION

The number of times an EVD was replaced was associated with EVD-related hemorrhage outcome. EVD-related hemorrhage is associated with increased mortality and a decreased likelihood of being discharged home.

Evaluation of neuraxial analgesia on outcomes for patients undergoing robot assisted abdominal surgery

STUDY OBJECTIVE

Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery.

DESIGN

Systematic review.

SETTINGS

Robot assisted abdominal surgery.

PATIENTS

Adults.

INTERVENTIONS

Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials.

MAIN RESULTS

We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I2 = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent.

CONCLUSIONS

Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited.

The impact of delayed closure of ileostomy on postoperative complications in patients with Crohn's disease: a case-matched study

Ileostomy creation is a common procedure to mitigate postoperative complications in Crohn's disease (CD) patients. However, the optimal timing for ileostomy closure remains controversial. This study aims to investigate whether delayed ileostomy closure (> 6 months post formation) affects postoperative complications compared to early closure (≤ 6 months post formation). Consecutive CD patients who underwent ileostomy reversal at a tertiary care center between January 1, 2013, and December 1, 2021, were included. The study compared patients who underwent early ileostomy closure to matched patients undergoing delayed ileostomy closure. The 90-day postoperative complications were compared between the two groups. The study included 352 eligible patients for ileostomy reversion. Our data showed that patients undergoing delayed ileostomy closure had higher incidence of ileostomy-related infectious complications (12% vs. 4%, p = 0.008), a longer postoperative hospital stay (10 days with an IQR of 7-12 days versus 8 days with an IQR of 7-11 days, p = 0.024), and increased rate of ileus (28% versus 15%, p = 0.003). There were 256 patients included after 1:1 propensity score matching. The results revealed no significant differences in postoperative hospital stay, infectious or non-infectious complications except for a statistically significant increase in the incidence of ileus in the delayed closure group (p = 0.01). Patients undergoing delayed ileostomy closure has similar outcomes to early closure in terms of postoperative complications, except for a higher incidence of ileus.

A Fast, Affordable, and Minimally Invasive Diagnostic Test for Cancer of Unknown Primary Using DNA Methylation Profiling

Currently, we cannot provide a conclusive diagnosis for 3% to 5% of people who are confronted with cancer. These patients have cancer of unknown primary (CUP), ie, a metastasized cancer for which the tissue of origin cannot be determined. Studies have shown that the DNA methylation profile is a unique "fingerprint" that can be used to classify tumors. Here we used cell-free reduced representation bisulfite sequencing (cfRRBS), a technique that allows us to identify the methylation profile starting from minimal amounts of highly fragmented DNA, for CUP diagnosis on formalin-fixed paraffin-embedded (FFPE) tissue and liquid biopsies. We collected 80 primary tumor FFPE samples covering 16 tumor entities together with 15 healthy plasma samples to use as a custom cfRRBS reference data set. Entity-specific methylation regions are defined for each entity to build a classifier based on nonnegative least squares deconvolution. This classification framework was tested on 30 FFPE, 19 plasma, and 40 pleural and peritoneal effusion samples of both known metastatic tumors and clinical CUPs for which pathological investigation finally resulted in a cancer diagnosis. Using this framework, 27 of 30 FFPE (all CUPs) and 16 of 19 plasma samples (10/13 CUPs) obtained an accurate diagnosis, with a minimal DNA input of 400 pg. Diagnosis of the 40 pleural and peritoneal effusion samples is possible in 9 of 27 samples with negative/inconclusive cytology (6/13 CUPs), showing that cell-free DNA (cfDNA) methylation profiling could complement routine cytologic analysis. However, a low "cfDNA - high-molecular weight DNA ratio" has a considerable impact on the prediction accuracy. Moreover, the accuracy improves significantly if the predicted tumor percentage is >7%. This proof-of-concept study shows the feasibility of using DNA methylation profiling on FFPE and liquid biopsy samples such as blood, ascites, and pleural effusions in a fast and affordable way. Our novel RRBS-based technique requires minimal DNA input, can be performed in <1 week, and is highly adaptable to specific diagnostic problems as we only use 5 FFPE references per tumor entity. We believe that cfRRBS methylation profiling could be a valuable addition to the pathologist's toolbox in the diagnosis of CUPs.

[Severe cholecystitis during the COVID-19 pandemic : Influence of the COVID-19 pandemic on the frequency of surgery and outcome for elective and emergency cholecystectomy: a monocentric retrospective cohort analysis]

BACKGROUND

With the outbreak of the COVID-19 pandemic medical care focused on management of the infectious event. Elective interventions were cancelled and the general advice was to stay at home. How this impacted urgent and elective cholecystectomies is the subject of this work.

METHOD

Urgent and elective cholecystectomy patients during the first year of the pandemic were compared with those of the previous year. The primary endpoint was the frequency of surgery. Furthermore, the American Society of Anesthesiologists (ASA) score, symptom duration until presentation as well as until surgery, preoperative inflammatory parameters, imaging, positive Murphy's sign, type and duration of surgery, intraoperative drain placement, intraoperative and histological severity, need for and duration of postoperative antibiotic therapy, intensive care stay, length of stay and occurrence of postoperative complications were recorded.

RESULTS

During the pandemic patients were sicker (ASA 2.13 vs. 2.31; p = 0.039), the operating time was prolonged (64.4 min vs. 74.9 min; p = 0.001) and patients were more likely to have concomitant peritonitis (15.4% vs. 29.1%: p = 0.007). Furthermore, there was a trend in the presence of leukocytosis, a positive Murphy's sign, intraoperative drain placement, intraoperative severity of inflammation, duration of postoperative antibiotic therapy and complication rate.

CONCLUSION

During the COVID-19 pandemic cholecystitis presented with more pronounced inflammation, the surgical conditions were more difficult and postoperative recovery was prolonged.

Clinical significance of lncRNA XIST expression in cholangiocarcinoma and its effect on cell migration and invasion

BACKGROUND

Cholangiocarcinoma is a malignant tumor that occurs in the bile duct system, and the prognosis of patients is poor. Currently, research suggests that long non-coding RNAs (lncRNAs) in the treatment and prevention of cholangiocarcinoma. This study primarily focuses on the regulation and potential mechanism of the lncRNA XIST (XIST) in cholangiocarcinoma.

METHODS

The levels of XIST and miR-126-3p in cholangiocarcinoma tissues and cells were detected using real-time quantitative polymerase chain reaction (RT-qPCR). Cell transfection status, including migration and invasion, was examined via the Transwell method. The relationship between XIST and miR-126-3p was observed by dual-luciferase gene reporter assay and verified by rescue assays. Additionally, the prognostic significance of XIST in cholangiocarcinoma was determined using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

XIST expression was increased in cholangiocarcinoma, while miR-126-3p was decreased, in both tissues and cells. The successful construction of silencing XIST was found to inhibit the count of cell migration and invasion. XIST directly targeted miR-126-3p to regulate the progression of cholangiocarcinoma.

CONCLUSION

XIST sponging miR-126-3p inhibited the progression of cholangiocarcinoma and improved the prognosis for patients. This finding provides new insights and opportunities for future studies on cholangiocarcinoma prognostic biomarkers.

Perioperative Blood Transfusions and Cancer Progression: A Narrative Review

PURPOSE OF REVIEW

To examine the most recent evidence about known controversies on the effect of perioperative transfusion on cancer progression.

RECENT FINDINGS

Laboratory evidence suggests that transfusion-related immunomodulation can be modified by blood management and storage practices, but it is likely of less intensity than the effect of the surgical stress response. Clinical evidence has questioned the independent effect of blood transfusion on cancer progression for some cancers but supported it for others. Despite major changes in surgery and anesthesia, cancer surgery remains a major player in perioperative blood product utilization. Prospective data is still required to strengthen or refute existing associations. Transfusion-related immunomodulation in cancer surgery is well-documented, but the extent to which it affects cancer progression is unclear. Associations between transfusion and cancer progression are disease-specific. Increasing evidence shows autologous blood transfusion may be safe in cancer surgery.

Primary leiomyosarcoma of the colon: a report of two cases and review of literature

Introduction

Primary leiomyosarcoma (LMS) of the colon is a rare neoplasm and constitutes less than 0.1% of all colon malignancies. These tumors are more aggressive and have poorer prognoses than other gastrointestinal tumors, including gastrointestinal stromal tumors (GIST) or adenocarcinomas. The authors herein report two cases and review the literature to highlight the epidemiology, diagnosis, treatment and prognosis of this uncommon malignancy.

Case report

The authors reported two very rare cases of LMS of left colon, which referred to our institution with symptoms of abdominal pain. After the initial investigations, patients were diagnosed with primary colonic leiomyosarcoma that underwent laparotomy. In both cases pathological examination revealed a spindle cell tumor growing circumferentially and transmurally in the colon. Final immunohistochemistry were positive with SMA, CK and desmin without the expression of GIST markers (CD117, CD34 and DOG1) that confirmed leiomyosarcoma. One patient was diagnosed with diffused peritoneal metastasis at 6 months postoperatively and he died after 2 months of paliative care, another one is still on active surveillance.

Discussion

LMS of the colon is a really rare entity and is only presented in clinical case reports. LMS has non-specific symptoms and is commonly diagnosed when it reaches a large size. Surgery is a mainstay treatment option. Nowadays, there is no clear evidence for the effectiveness of chemotherapy and radiation therapy.

Conclusion

LMS is a rare neoplasm of colon. For the time being, there is no guidelines for treatment, but surgery still plays a fundamental role.

Efficacy and safety of transanal opening of intersphincteric space in the treatment of high complex anal fistula: A meta‑analysis

The best treatment of high complex anal fistula (HCAF) is to avoid anal incontinence while improving the cure rate. On this basis, several surgical procedures for preserving the anal sphincter have been proposed. The purpose of the present study was to evaluate the efficacy and safety of transanal opening of intersphincteric space for treating HCAF. PubMed, Cochrane Library, China National Knowledge Infrastructure and the Wanfang databases were searched to collate all the articles on transanal opening of intersphincteric space for treating HCAF. A total of two researchers independently completed the whole process, from screening and inclusion to data extraction and the data was included in the RevMan 5.3 software for analysis. The main outcomes included the patients' essential characteristics, primary healing rate, management after recurrence, final healing rate, anal incontinence score before and after surgery, postoperative complication rate and types of complications. A total of six articles were included in this meta-analysis. The results showed that the weighted final healing rate of patients following transanal opening of intersphincteric space was 89% [risk differences (RD)=0.89; 95% confidence interval (CI)=0.86-0.92; I2=0%; P<0.00001]. The results of the anal incontinence score showed that there was no significant difference between the results before and after transanal opening of intersphincteric space surgery mean differences [(MD)=-0.04, Cl=-0.10-0.02, I2=0%; P=0.21]. Only 11 patients were reported to have complications, including urinary retention and bleeding following transanal opening of intersphincteric space with a complication rate of 8% (11/138) and the weighted average complication rate was 6% (RD=0.06,95% CI=0.02-0.10; I2=9%; P=0.003). Transanal opening of intersphincteric space has a high cure rate, a favorable anal incontinence score, fewer types of postoperative complications and a low complication rate; it can be used as a minimally invasive and sphincter-preserving surgical method for treating HCAF and is worthy of further promotion and research in clinical practice.

Pulmonary and intestinal tuberculosis with COVID-19 complicated with fluidopneumothorax and colovesical fistula: The importance of diagnosis complexity in line with clinical setting

The complication of hydropneumothorax and colovesical fistula is rare, especially in patients with tuberculosis (TB) and COVID-19. This particular situation poses a management difficulty, and can significantly threaten the patient's life without a clear diagnosis and timely treatment. We report a 28-year-old woman with pulmonary and intestinal TB with COVID-19 complicated with hydropneumothorax and colovesical fistula (CVF) which worsened her condition. Treatment for this patient was given according to the diagnosis. Her condition improved and she was discharged after 30 days of hospitalization, while elective surgery for CVF was not performed because there were no clinical symptoms complained of by this patient after completing TB treatment (9 months after hospital discharge). This case report highlights the importance of considering pulmonary and intestinal TB with COVID-19 as the cause of hydropneumothorax and CVF. Early and complex diagnosis is essential for proper management, as well as the efficacy of medical therapy and treatment for controlling such advanced stages of the disease. A complex condition with many symptoms can overlap with other diseases. Clinicians should consider the clinical symptoms, radiological imaging, and standard or supporting examination for accurate diagnosis to find the etiology of the diseases. Complete treatment for TB should be considered as the treatment choice (nonsurgical therapy) for CVF caused by TB before deciding on surgical intervention.

Predicting lymph node metastasis in colorectal cancer patients: development and validation of a column chart model

Lymph node metastasis (LNM) is one of the crucial factors in determining the optimal treatment approach for colorectal cancer. The objective of this study was to establish and validate a column chart for predicting LNM in colon cancer patients. We extracted a total of 83,430 cases of colon cancer from the Surveillance, Epidemiology, and End Results (SEER) database, spanning the years 2010-2017. These cases were divided into a training group and a testing group in a 7:3 ratio. An additional 8545 patients from the years 2018-2019 were used for external validation. Univariate and multivariate logistic regression models were employed in the training set to identify predictive factors. Models were developed using logistic regression, LASSO regression, ridge regression, and elastic net regression algorithms. Model performance was quantified by calculating the area under the ROC curve (AUC) and its corresponding 95% confidence interval. The results demonstrated that tumor location, grade, age, tumor size, T stage, race, and CEA were independent predictors of LNM in CRC patients. The logistic regression model yielded an AUC of 0.708 (0.7038-0.7122), outperforming ridge regression and achieving similar AUC values as LASSO regression and elastic net regression. Based on the logistic regression algorithm, we constructed a column chart for predicting LNM in CRC patients. Further subgroup analysis based on gender, age, and grade indicated that the logistic prediction model exhibited good adaptability across all subgroups. Our column chart displayed excellent predictive capability and serves as a useful tool for clinicians in predicting LNM in colorectal cancer patients.

Benign hepatic schwannoma in a patient with chronic hepatitis B infection: A case report

A primary benign hepatic schwannoma is an extremely rare disease with a good prognosis. A 55-year-old man with chronic hepatitis B was referred to our hospital because of jaundice, weight loss, and a hepatic lesion found during an ultrasound examination. Magnetic resonance image revealed a 55 × 120 mm solid mass lesion in the segment V and VIII of the liver. The mass extended directly to the segmental biliary ducts and common hepatic duct, causing obstruction of the biliary duct and upstream dilatation, particularly in the left liver lobe. Following the insertion of a percutaneous transhepatic biliary drainage, a biopsy was performed under ultrasound guidance. Histological examination confirmed a benign schwannoma, identified by characteristic pathological findings and positive immunoreactions with S-100 protein, but negative for c-kit, CD117, or CD34. The patient's tumor was removed and upon examination, it was discovered to be a mass filled with pinkish-yellow fluid, measuring 12 × 5 × 5 cm. This is the first known case of a benign schwannoma in the liver parenchyma of a patient with chronic hepatitis B. Furthermore, most previous cases of benign liver schwannomas have reported a smaller size than this case, which is slightly larger.

Maximizing mesh mileage: evaluating the long-term performance of a novel hybrid mesh for ventral hernia repair

PURPOSE

The objective of this study is to evaluate the safety and long-term outcomes of GORE Synecor™ in ventral hernia repair (VHR).

METHODS

This retrospective, single-center case review analyzed outcomes in patients who underwent VHR with Synecor from May 2016 to December 2022. Primary outcomes were hernia recurrence and mesh infection rates. Secondary outcomes were 30-day morbidity, 30-day mortality, 30-day readmission, re-operation, surgical-site infection (SSI) and occurrence (SSO) rates, and occurrences requiring intervention (SSOI).

RESULTS

278 patients were identified. Mean follow-up was 24.1 (0.2-87.1) months. Mean hernia defect size was 63.4 (± 77.2) cm2. Overall hernia recurrence and mesh infection rates were 5.0% and 1.4% respectively. No mesh infections required full explantation. We report the following overall rates: 13.3% 30-day morbidity, 4.7% 30-day readmission, 2.9% re-operation, 7.2% SSI, 6.1% SSO, and 2.9% SSOI. 30-day morbidity was significantly higher in non-clean (42.1% vs 11.2%, p < 0.01), onlay (OL) mesh (37.0% vs preperitoneal (PP) 16.4%, p = 0.05 vs retrorectus (RR) 15.0%, p < 0.05 vs intraperitoneal (IP) 5.2%, p < 0.001), and open cases (23.5% vs 3.1% laparoscopic vs 4.4% robotic, p < 0.01). SSI rates were significantly higher in non-clean (31.6% vs 5.4%, p < 0.001), OL mesh (29.6% vs RR 11.3%, p < 0.05 vs PP 5.5%, p < 0.01 vs IP 0.0%, p < 0.001), and open cases (15.2% vs 0% laparoscopic vs 0% robotic, p < 0.05).

CONCLUSION

Long-term performance of a novel hybrid mesh in VHR demonstrates a low recurrence rate and favorable safety profile in various defect sizes and mesh placement locations.

The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update

Background: The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature. Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation. Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs. Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.

Management of Esophageal Inflammatory Myofibroblastic Tumor With Endoscopic Submucosal Dissection

Inflammatory myofibroblastic tumors are rare tumors that have been described in virtually all organs. Even though they are extremely rare in the esophagus, several cases have been described in the literature. Surgical resection has been the therapeutic modality used in most of those cases. In this report, we describe a case of inflammatory myofibroblastic tumor that was successfully managed endoscopically for the first time with the endoscopic submucosal dissection technique.

Preclinical validation of a customized circuit for ex situ uninterrupted cold-to-warm prolonged perfusion of the liver

CONTEXT

Clinical adoption of ex situ liver perfusion is growing. While hypothermic perfusion protects against ischemia-reperfusion injury in marginal grafts, normothermic perfusion enables organ viability assessment and therefore selection of borderline grafts. The combination of hypothermic and normothermic perfusion, known as "cold-to-warm," may be the optimal sequence for organ preservation, but is difficult to achieve with most commercial perfusion systems. We developed an adaptable customized circuit allowing uninterrupted "cold-to-warm" perfusion and conducted preclinical studies on healthy porcine livers and discarded human livers to demonstrate the circuit's efficacy.

METHODS

In collaboration with bioengineers, we developed a customized circuit that adapts to extracorporeal circulation consoles used in cardiovascular surgery and includes a proprietary reservoir enabling easy perfusate change without interrupting perfusion. This preclinical study was conducted on porcine and human livers. Perfusion parameters (pressures, flows, oxygenation) and organ viability were monitored.

RESULTS

The customized circuit was adapted to a LivaNova S5® console, and the perfusions were flow-driven with real-time pressure monitoring. Ten porcine liver and 12 discarded human liver perfusions were performed during 14 to 18 h and 7 to 25 h, respectively. No hyperpressure was observed (porcine and human portal pressure 2-6 and 2-8 mm Hg; arterial pressure 10-65 and 20-65 mm Hg, respectively). No severe histological tissue injury was observed (Suzuki score ≤ 3 at the end of perfusion). Seven (70%) porcine livers and five (42%) human livers met the UK viability criteria.

CONCLUSION

The customized circuit and system design enables smooth uninterrupted "cold-to-warm" perfusion not present in current commercial perfusion systems.

Predicting lymph node metastasis using preoperative parameters in patients with T1 ampulla of vater cancer

BACKGROUND

Lymph node (LN) metastasis is an established prognostic factor for patients with surgically resected ampulla of Vater (AoV) cancer. The standard procedure for radical resection, including removal of regional LNs, is pancreaticoduodenectomy (PD); however, local excision has been considered as an alternative option for patients in the early stage cancer with significant comorbidities. In the present study, we elucidated the preoperative factors associated with LN metastasis to determine the appropriate surgical extent for T1 AoV cancer.

METHODS

We included patients who underwent surgery for T1 AoV cancer at Samsung Medical Center and Severance Hospital between 2000 and 2019. Risk factors were analyzed to identify the preoperative parameters associated with LN metastasis or regional LN recurrence during follow-up. Finally, using the identified risk factors, a prediction model was constructed.

RESULTS

Among 342 patients, 311 patients underwent PD, whereas 31 patients underwent transduodenal ampullectomy. Fourty-eight patients had LN metastasis according to pathology report, and two patients presented with regional LN recurrence. Age, carbohydrate antigen 19 - 9 (CA 19 - 9), and tumor differentiation were identified as factors associated with the increased risk of LN metastasis or regional LN recurrence. The area under the curve of the prediction model with these three factors was 0.728.

CONCLUSION

Our newly developed prediction model using age, CA 19 - 9, and tumor differentiation can help select patients who require PD over local excision. Nevertheless, additional in-depth analysis is warranted to select appropriate surgical extent for patients with presumed T1 AoV cancer.

Prognostic significance of preoperative osteosarcopenia on patient' outcomes after emergency surgery for gastrointestinal perforation

PURPOSE

Sarcopenia is a prognostic predictor in emergency surgery. However, there are no reports on the relationship between osteopenia and in-hospital mortality. This study clarified the effect of preoperative osteosarcopenia on patients with gastrointestinal perforation after emergency surgery.

METHODS

We included 216 patients with gastrointestinal perforations who underwent emergency surgery between January 2013 and December 2022. Osteopenia was evaluated by measuring the pixel density in the mid-vertebral core of the 11th thoracic vertebra. Sarcopenia was evaluated by measuring the area of the psoas muscle at the level of the third lumbar vertebra. Osteosarcopenia is defined as the combination of osteopenia and sarcopenia.

RESULTS

Osteosarcomas were identified in 42 patients. Among patients with osteosarcopenia, older and female patients and those with an American Society of Anesthesiologists Physical Status of ≥ 3 were significantly more common, and the body mass index, hemoglobin value, and albumin level were significantly lower in these patients than in patients without osteosarcopenia. Furthermore, the osteosarcopenia group presented with more postoperative complications than patients without osteosarcopenia (P < 0.01). In the multivariate analysis, age ≥ 74 years old (P = 0.04) and osteosarcopenia (P = 0.04) were independent and significant predictors of in-hospital mortality.

CONCLUSION

Preoperative osteosarcopenia is a risk factor of in-hospital mortality in patients with gastrointestinal perforation after emergency surgery.

Effects of Indocyanine Green (ICG) Imaging-Assisted Cholecystectomy on Intraoperative and Postoperative Complications: A meta-Analysis

BACKGROUND

Accurate recognition of Calot's triangle during cholecystectomy is important in preventing intraoperative and postoperative complications. The use of indocyanine green (ICG) fluorescence imaging has become increasingly prevalent in cholecystectomy procedures. Our study aimed to evaluate the specific effects of ICG-assisted imaging in reducing complications.

MATERIALS AND METHODS

A comprehensive search of databases including PubMed, Web of Science, Europe PMC, and WANFANGH DATA was conducted to identify relevant articles up to July 5, 2023. Review Manager 5.3 software was applied to statistical analysis.

RESULTS

Our meta-analysis of 14 studies involving 3576 patients compared the ICG group (1351 patients) to the control group (2225 patients). The ICG group had a lower incidence of postoperative complications (4.78% vs 7.25%; RR .71; 95%CI: .54-.95; P = .02). Bile leakage was significantly reduced in the ICG group (.43% vs 2.02%; RR = .27; 95%CI: .12-.62; I2 = 0; P = .002), and they also had a lower bile duct drainage rate (24.8% vs 31.8% RR = .64, 95% CI: .44-.91, P = .01). Intraoperative complexes showed no statistically significant difference between the 2 groups (1.16% vs 9.24%; RR .17; 95%CI .03-1.02), but the incidence of intraoperative bleeding is lower in the ICG group.

CONCLUSION

ICG fluorescence imaging-assisted cholecystectomy was associated with a range of benefits, including a lower incidence of postoperative complications, decreased rates of bile leakage, reduced bile duct drainage, fewer intraoperative complications, and reduced intraoperative bleeding.

Transduodenal robotic ampullectomy: tips and tricks and strategies for postoperative duodenal fistula management (with video)

Transduodenal Ampullectomy (TA) is a procedure for resecting low-malignancy ampullary tumors, with postoperative fistula as a notable complication. This study aims to clarify the indications for TA, outline the surgical robotic technique, and emphasize the importance of comprehensive complication management alongside the surgical approach. This multimedia article provides a detailed exposition of the robotic TA surgical technique, including the most important steps involved in exposing and reimplanting biliary and pancreatic ducts. The procedure encompasses the mobilization of the hepatic flexure of the colon, an extensive Kocher maneuver for duodenal mobilization, and ampulla exposure through a duodenal incision. Employing retraction loop sutures enhances surgical field visibility. Reconstruction involves securing pancreatic and biliary ducts to the duodenal mucosa, each tutored with a silicon catheter, and suturing for ampullectomy completion. The total operative time was 380 min. Final histopathology disclosed high-grade dysplasia with an isolated focus of adenocarcinoma (pT1), accompanied by clear resection margins. A postoperative duodenal fistula occurred, managed successfully through conservative treatment, utilizing subcutaneous drainage. Despite accurate robotic TA execution, complications may arise. This study underscores the importance of a comprehensive approach, incorporating meticulous surgical technique and effective complication management, to optimize patient outcomes.

Pedicled falciform ligament flap use as an alternative surgical technique in peptic ulcer perforation repair: a case report and review of literature

Peptic ulcer disease (PUD) affects ~4 million people globally. Peptic ulcer perforation (PUP) is a serious complication of PUD associated with high mortality and morbidity. Hence, a high index of clinical suspicion is crucial in diagnosing such cases. Here, we present a case of a 19-year-old male who presented with 4 days of severe abdominal pain, fever, and vomiting. On examination, signs of acute abdomen were evident, and an erect chest X-ray confirmed free air under the diaphragm. The patient underwent an emergency midline laparotomy, during which 1000 ml of purulent fluid was evacuated. A perforation measuring 8 × 8 mm2 was repaired using the falciform ligament due to the unavailability of adequate healthy omentum. His postoperative recovery was uneventful. This case report underscores the importance of considering the falciform ligament as a viable and effective alternative for the closure of PUP when the omentum is unavailable.

Enhanced Recovery After Surgery versus Conventional Care in Cholecystectomy: A Systematic Review and Meta-Analysis

Objectives: The primary objective of this study was to evaluate the safety and efficacy of the enhanced recovery after surgery (ERAS) protocol in cholecystectomy, comparing it with standard care. Methods: A comprehensive literature search was conducted in December 2023, using globally recognized databases such as PubMed, Embase, and the Cochrane Library. Various parameters were compared using Review Manager software. This study was duly registered with PROSPERO (CRD420223). Results: The meta-analysis included nine studies, encompassing a total of 1920 patients. The findings revealed that the ERAS group, in comparison to traditional care, experienced shorter hospitalization periods (weighted mean difference [WMD]: -1.23, 95% confidence interval [CI]: -1.98 to -0.47; P = .001), lower visual analog scale at 24 hours (WMD: -1.10, 95% CI: -1.30 to -0.90; P < .00001), faster time to first flatus (WMD: -4.48, 95% CI: -4.50 to -4.46; P < .00001), and reduced operative times (WMD: -9.94, 95% CI: -17.88 to -0.96; P = .03). In addition, there was a notable decrease in instances of postoperative nausea and vomiting (odds ratio [OR]: 0.46, 95% CI: 0.28 to 0.74; P = .002). No significant differences were observed in readmission rates, blood loss, postoperative complications, or bile leakage between the two care methods. Conclusions: This study substantiates that the ERAS protocol is an advantageous perioperative care strategy for patients undergoing cholecystectomy. It significantly outperforms traditional care in reducing the length of stay, decreasing the likelihood of postoperative nausea/vomiting, alleviating postoperative pain, and accelerating the time to the first flatus. These findings highlight the effectiveness of ERAS in enhancing patient outcomes in cholecystectomy.

Nonoperative management of acute complicated diverticulitis with pericolic and/or distant extraluminal air: A systematic review

INTRODUCTION

Colonic Diverticular Disease (CDD) is a multifactorial inflammatory disease. Acute diverticulitis (AD), with extraluminal free air (both pericolic and distant), represents about 15% of radiological scenarios and remains a therapeutic challenge for surgeons. Currently, the WSES guidelines suggest trying a conservative strategy both in the presence of pericolic and distant free extraluminal air, even if both have respectively weak recommendation based on low/very low-quality evidence.

METHODS

We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. PubMed/MEDLINE, Scopus, Web of Science, and Embase databases were used to identify articles of interest.

RESULTS

A total of 2380 patients with AD and extraluminal free air (both pericolic and distant) who underwent nonoperative management (NOM) were analyzed. Of the 2380 patients, 2095(88%) were successfully treated with NOM, while 285 (12%) patients failed. A total of 1574 (93.1%) patients with pericolic extraluminal free air had a successful NOM with 6.9% (117) failure rates, while 135 (71.1%) patients with distant extraluminal free air had a successful NOM with 28.9% (55) failure rates. Regarding distant recurrence, we recorded a rate of 18.3% (261/1430), while a rate of 11.3% (167/1472) was recorded for patients undergoing elective surgery.

CONCLUSION

NOM for patients with AD and extraluminal free air (both pericolic and distant) seems to be feasible and safe despite a higher failure rate in the distant subgroup, which remains the most challenging clinical scenario to deal with through conservative treatment.

Enteral Nutrition Therapy: Historical Perspective, Utilization, and Complications

PURPOSE OF REVIEW

Enteral nutrition (EN) therapy can provide vital nutrition support for patients with various medical conditions as long as it is indicated and supported by ethical reasoning. This review seeks to offer a detailed account of the history of EN development, highlighting key milestones and recent advances in the field. Additionally, it covers common complications associated with EN and their management.

RECENT FINDINGS

After years of research and development, we have reached newer generations of enteral feeding formulations, more options for enteral tubes and connectors, and a better understanding of EN therapy challenges. Given the availability of many different formulas, selecting a feeding formula with the best evidence for specific indications for enteral feeding is recommended. Initiation of enteral feeding with standard polymeric formula remains the standard of care. Transition to small-bore connectors remains suboptimal. Evidence-based practices should be followed to recognize and reduce possible enteral feeding complications early.

Multidisciplinary approach to evaluation of rectovaginal fistulas

Thorough evaluation of a rectovaginal fistula is essential to optimize surgical repair. The underlying cause should be addressed and treated, which can affect the timing and the approach to repair. It is imperative to be well prepared because the highest chance of successful closure occurs during the initial repair attempt. Our objective was to demonstrate how multidisciplinary colorectal surgery and urogynecology teams use specific methods during the examination under anesthesia to evaluate a complex rectovaginal fistula and to optimize the surgical approach to repair. Anesthesia may be provided with monitored anesthesia care and a posterior perineal block. This pain control allows for a wide range of techniques to evaluate the fistula using anoscopy, fistula probe, hydrogen peroxide, and sigmoidoscopy. In addition, the teams show how curettage and subsequent seton placement can encourage closure by secondary intention and decrease the risk of abscess formation, respectively.

Surgical Considerations in Portal Hypertension

This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH is 50% to 60% in compensated cirrhosis and 100% in decompensated cirrhosis. The feasibility and safety of hepatic and nonhepatic surgical procedures in patients with PH has been shown. Adequate preoperative risk assessment and optimization of PH are integral parts of patient assessment. The occurrence of adverse outcomes after surgery has decreased over time in this specific population, due to the development of techniques and improved perioperative multidisciplinary care.

Probiotic Compounds Enhanced Recovery after Surgery for Patients with Distal Gastric Cancer: A Prospective, Controlled Clinical Trial

BACKGROUND

Enhanced recovery after surgery (ERAS) for radical distal gastrectomy needs to be improved urgently. We investigated the effects of probiotic compounds (including Lactobacillus plantarum, L. rhamnosus, L. acidophilus, and Bifidobacterium animalis subsp.lactis) on enhance recovery after gastrectomy.

METHODS

The patients in this prospective study were divided into probiotic group (PG group, n = 36) and placebo group (CG group, n = 38), taking corresponding capsule according to the protocol during the perioperative period. We compared the trends in perioperative hematologic findings and the postoperative outcomes. Patients' feces were collected for bacterial 16S rRNA sequencing. Patients were followed up at 1 month postoperatively.

RESULTS

After the application of probiotics, the patients' postoperative inflammatory response level was reduced, and the trend of postoperative NLR decrease was significantly faster in the patients of the PG group than in the CG group (P = 0.047, partial η2 = 0.054). The trend of postoperative increase in serum albumin concentration in the patients of the PG group was significantly better than that in the CG group (P = 0.016, partial η2 = 0.078). In addition, patients in the PG group met discharge criteria earlier postoperatively and had fewer medical expenses. The quality of life of PG group was improved postoperatively. Postoperative inflammation-related markers, including the ratio of Firmicutes/Bacteroidetes, were increasing in untreated patients. In addition, the postoperative microbial diversity and abundance in the PG group remained stable.

CONCLUSIONS

Probiotic compounds can reduce the inflammatory response after gastrectomy and enhance the recovery of the DGC patients by maintaining the stability of the gut microbiota.

Artificial Intelligence and Machine Learning in Cancer Pain: A Systematic Review

BACKGROUND/OBJECTIVES

Pain is a challenging multifaceted symptom reported by most cancer patients. This systematic review aims to explore applications of artificial intelligence/machine learning (AI/ML) in predicting pain-related outcomes and pain management in cancer.

METHODS

A comprehensive search of Ovid MEDLINE, EMBASE and Web of Science databases was conducted using terms: "Cancer", "Pain", "Pain Management", "Analgesics", "Artificial Intelligence", "Machine Learning", and "Neural Networks" published up to September 7, 2023. AI/ML models, their validation and performance were summarized. Quality assessment was conducted using PROBAST risk-of-bias andadherence to TRIPOD guidelines.

RESULTS

Forty four studies from 2006-2023 were included. Nineteen studies used AI/ML for classifying pain after cancer therapy [median AUC 0.80 (range 0.76-0.94)]. Eighteen studies focused on cancer pain research [median AUC 0.86 (range 0.50-0.99)], and 7 focused on applying AI/ML for cancer pain management, [median AUC 0.71 (range 0.47-0.89)]. Median AUC (0.77) of models across all studies. Random forest models demonstrated the highest performance (median AUC 0.81), lasso models had the highest median sensitivity (1), while Support Vector Machine had the highest median specificity (0.74). Overall adherence to TRIPOD guidelines was 70.7%. Overall, high risk-of-bias (77.3%), lack of external validation (14%) and clinical application (23%) was detected. Reporting of model calibration was also missing (5%).

CONCLUSION

Implementation of AI/ML tools promises significant advances in the classification, risk stratification, and management decisions for cancer pain. Further research focusing on quality improvement, model calibration, rigorous external clinical validation in real healthcare settings is imperative for ensuring its practical and reliable application in clinical practice.

Inhibition of DNMTs increases neoantigen-reactive T-cell toxicity against microsatellite-stable colorectal cancer in combination with radiotherapy

The therapeutic efficacy of immunotherapy is limited in the majority of colorectal cancer patients due to the low mutational and neoantigen burdens in this immunogenically "cold" microsatellite stability-colorectal cancer (MSS-CRC) cohort. Here, we showed that DNA methyltransferase (DNMT) inhibition upregulated neoantigen-bearing gene expression in MSS-CRC, resulting in increased neoantigen presentation by MHC class I in tumor cells and leading to increased neoantigen-specific T-cell activation in combination with radiotherapy. The cytotoxicity of neoantigen-reactive T cells (NRTs) to DNMTi-treated cancer cells was highly cytotoxic, and these cells secreted high IFNγ levels targeting MSS-CRC cells after ex vivo expansion of NRTs with DNMTi-treated tumor antigens. Moreover, the therapeutic efficacy of NRTs further increased when NRTs were combined with radiotherapy in vivo. Administration of DNMTi-augmented NRTs and radiotherapy achieved an ∼50 % complete response and extended survival time in an immunocompetent MSS-CRC animal model. Moreover, remarkably, splenocytes from these mice exhibited neoantigen-specific T-cell responses, indicating that radiotherapy in combination with DNMTi-augmented NRTs prolonged and increased neoantigen-specific T-cell toxicity in MSS-CRC patients. In addition, these DNMTi-augmented NRTs markedly increase the therapeutic efficacy of cancer vaccines and immune checkpoint inhibitors (ICIs). These data suggest that a combination of radiotherapy and epi-immunotherapeutic agents improves the function of ex vivo-expanded neoantigen-reactive T cells and increases the tumor-specific cytotoxic effector population to enhance therapeutic efficacy in MSS-CRC.

Portuguese Pancreatic Club Perspectives on Endoscopic Ultrasound-Guided and Surgical Treatment of Pancreatic Neuroendocrine Tumors

Pancreatic neuroendocrine tumors (panNETs) are a group of neoplasms with heterogenous biological and clinical phenotypes. Although historically regarded as rare, the incidence of these tumors has been increasing, mostly owing to improvements in the detection of small, asymptomatic tumors with imaging. The heterogeneity of these lesions creates significant challenges regarding diagnosis, staging, and treatment. Endoscopic ultrasound (EUS) has improved the characterization of pancreatic lesions. Furthermore, EUS nowadays has evolved from a purely diagnostic modality to allow the performance of minimally invasive locoregional therapy for pancreatic focal lesions. The choice of treatment as well as the treatment goals depend on several factors, including tumor secretory status, grading, staging, and patient performance status. Surgery has been the mainstay for the management of these patients, particularly for localized, low-grade, large panNETs >2 cm. Over the last decade, a significant body of evidence has been accumulated evaluating the role of EUS for the ablative therapy of panNETs, namely by the use of chemoablative agents and radiofrequency. Although endoscopic techniques are not routinely recommended by international guidelines, they may be considered for the treatment of smaller lesions in patients who are unwilling or unfit for pancreatic surgery. In this review, we summarize the existing evidence on the interventional techniques for the treatment of patients with panNETs, focusing on the EUS-guided and surgical approaches.

Pelvic Radiation Therapy Increases Risk of Pouch Failure in Patients with Inflammatory Bowel Disease and Ileal Pouch

BACKGROUND

The effect of radiation on the ileal pouch is less well studied in patients with inflammatory bowel disease (IBD) and ileal pouch-anal anastomosis.

AIMS

This retrospective study investigates the impact of external radiation therapy on the outcomes of ileal pouches.

METHODS

The study included 82 patients with IBD and ileal pouches, of whom 12 received pelvic radiation, 16 abdominal radiation, 14 radiation in other fields, and 40 served as controls with no radiation. Pouch-related outcomes, including pouch failure, worsening of symptoms, pouchitis, and development of strictures, along with changes in Pouch Disease Activity Index (PDAI) scores pre- and post-radiation were assessed.

RESULTS

The pelvic radiation group exhibited a significantly higher rate of pouch failure (25%, p < 0.004) and worsening pouch-related symptoms (75%, p = 0.012) compared to other groups. Although not statistically significant, a higher incidence of pouchitis was observed in the pelvic radiation group (45.5%, p = 0.071). Strictures were more common in the pelvic radiation group (25%, p = 0.043). Logistic regression analysis revealed that pelvic radiation significantly increased the odds of pouch-related adverse outcomes (OR 5.66; 95% confidence interval: 1.61-21.5).

CONCLUSION

Pelvic radiation significantly impacts the outcomes of ileal pouches in patients with IBD, increasing the risk of pouch failure, symptom exacerbation, and structural complications. These findings underscore the need for careful consideration of radiation therapy in this patient population and highlight the importance of closely monitoring and managing radiation-induced pouch dysfunction.

The Infected Polypropylene Mesh: When Does Biofilm Form and Which Antiseptic Solution Most Effectively Removes It?

BACKGROUND

Polypropylene (PPE) mesh is commonly utilized to reconstruct catastrophic extensor mechanism disruptions in revision total knee arthroplasty. Unfortunately, these procedures are associated with a high rate of periprosthetic joint infection. The purpose of the current study was to: 1) visualize and quantify the progression of bacterial biofilm growth on PPE-mesh; and 2) determine which antiseptic solutions effectively remove viable bacteria.

METHODS

Knitted PPE mesh samples were cultured with either methicillin-sensitive Staphylococcus aureus (MSSA) or Escherichia coli (E. coli) for 7 days, with regular quantification of colony forming units (CFUs) and visualization using scanning electron microscopy to identify maturity. Immature (24 hour) and mature (72 hour) biofilm was treated with one of 5 commercial antiseptics for 3 minutes. A 0.05% chlorhexidine gluconate, a surfactant-based formulation of ethanol, acetic acid, sodium acetate, benzalkonium chloride, diluted povidone-iodine (0.35%), undiluted (10%) povidone-iodine, and 1:1 combination of 10% povidone-iodine and 3% hydrogen peroxide. A 3-log reduction in CFUs compared to saline was considered clinically meaningful.

RESULTS

The CFU counts plateaued, indicating maturity, at 72 hours for both MSSA and E. coli. The scanning electron microscopy confirmed confluent biofilm formation after 72 hours. The 10% povidone-iodine was clinically effective against all MSSA biofilms and immature E. coli biofilms. The 10% povidone-iodine with hydrogen peroxide was effective in all conditions. Only 10% povidone iodine formulations produced significantly (P < .0083) reduced CFU counts against mature biofilms.

CONCLUSIONS

Bacteria rapidly form biofilm on PPE mesh. Mesh contamination can be catastrophic, and clinicians should consider utilizing an antiseptic solution at the conclusion of mesh implantation. Undiluted povidone-iodine with hydrogen peroxide should be considered when attempting to salvage infected PPE mesh.

Robotic versus laparoscopic right colectomy for nonmetastatic pT4 colon cancer: A European multicentre propensity score-matched analysis

AIM

Minimally invasive surgery has been increasingly adopted for locally advanced colon cancer. However, evidence comparing robotic (RRC) versus laparoscopic right colectomy (LRC) for nonmetastatic pT4 cancers is lacking.

METHODS

This was a multicentre propensity score-matched (PSM) study of a cohort of consecutive patients with pT4 right colon cancer treated with RRC or LRC. The two surgical approaches were compared in terms of R0, number of lymph nodes harvested, intra- and postoperative complication rates, overall (OS), and disease-free survival (DFS).

RESULTS

Among a total of 200 patients, 39 RRC were compared with 78 PS-matched LRC patients. The R0 rate was similar between RRC and LRC (92.3% vs. 96.2%, respectively; p = 0.399), as was the odds of retrieving 12 or more lymph nodes (97.4% vs. 96.2%; p = 1). No significant difference was noted for the mean operating time (192.9 min vs. 198.3 min; p = 0.750). However, RRC was associated with fewer conversions to laparotomy (5.1% vs. 20.5%; p = 0.032), less blood loss (36.9 vs. 95.2 mL; p < 0.0001), fewer postoperative complications (17.9% vs. 41%; p = 0.013), a shorter time to flatus (2 vs. 2.8 days; p = 0.009), and a shorter hospital stay (6.4 vs. 9.5 days; p < 0.0001) compared with LRC. These results were confirmed even when converted procedures were excluded from the analysis. The 1-, 3- and 5-year OS (p = 0.757) and DFS (p = 0.321) did not significantly differ between RRC and LRC.

CONCLUSION

Adequate oncological outcomes are observed for RRC and LRC performed for pT4 right colon cancer. However, RRC is associated with lower conversion rates and improved short-term postoperative outcomes.

Aspects and outcomes of surveillance for individuals at high-risk of pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related deaths and is associated with a poor prognosis. The majority of these cancers are detected at a late stage, contributing to the bad prognosis. This underscores the need for novel, enhanced early detection strategies to improve the outcomes. While population-based screening is not recommended due to the relatively low incidence of PDAC, surveillance is recommended for individuals at high risk for PDAC due to their increased incidence of the disease. However, the outcomes of pancreatic cancer surveillance in high-risk individuals are not sorted out yet. In this review, we will address the identification of individuals at high risk for PDAC, discuss the objectives and targets of surveillance, outline how surveillance programs are organized, summarize the outcomes of high-risk individuals undergoing pancreatic cancer surveillance, and conclude with a future perspective on pancreatic cancer surveillance and novel developments.

A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM

BACKGROUND

The number of trials investigating the effects of deep neuromuscular blockade (NMB) on surgical conditions and patient outcomes is steadily increasing. Consensus on which surgical procedures benefit from deep NMB (a posttetanic count [PTC] of 1 to 2) and how to implement it has not been reached. The European Society of Anaesthesiology and Intensive Care does not advise routine application but recommends use of deep NMB to improve surgical conditions on indication. This study investigates the optimal dosing strategy to reach and maintain adequate deep NMB during total intravenous anesthesia.

METHODS

Data from three trials investigating deep NMB during laparoscopic surgery with total intravenous anesthesia (n = 424) were pooled to analyze the required rocuronium dose, when to start continuous infusion, and how to adjust. The resulting algorithm was validated (n = 32) and compared to the success rate in ongoing studies in which the algorithm was not used (n = 180).

RESULTS

The mean rocuronium dose based on actual bodyweight for PTC 1 to 2 was (mean ± SD) 1.0 ± 0.27 mg · kg-1 ·h-1 in the trials, in which mean duration of surgery was 116 min. An induction dose of 0.6 mg ·kg-1 led to a PTC of 1 to 5 in a quarter of patients after a mean of 11 min. The remaining patients were equally divided over too shallow (additional bolus and direct start of continuous infusion) or too deep; a 15-min wait after PTC of 0 for return of PTC to 1 or higher. Using the proposed algorithm, a mean 76% of all 5-min measurements throughout surgery were on target PTC 1 to 2 in the validation cohort. The algorithm performed significantly better than anesthesiology residents without the algorithm, even after a learning curve from 0 to 20 patients (42% on target, P ≤ 0.001, Cohen's d = 1.4 [95% CI, 0.9 to 1.8]) to 81 to 100 patients (61% on target, P ≤ 0.05, Cohen's d = 0.7 [95% CI, 0.1 to 1.2]).

CONCLUSIONS

This study proposes a dosing algorithm for deep NMB with rocuronium in patients receiving total intravenous anesthesia.

EDITOR’S PERSPECTIVE

Endoscopic techniques for management of large colorectal polyps, strictures and leaks

The implementation of screening colonoscopy with polyp removal has significantly decreased mortality rates associated with colorectal cancer (CRC), although it remains a major cause of cancer-related deaths globally. CRC typically originates from adenomatous polyps, and increased removal of these growths has led to reduced CRC incidence and mortality. Endoscopic polypectomy techniques, including hot and cold snare polypectomy, play a pivotal role in this process. While both methods are effective for small polyps (<10 mm), recent evidence favors cold snare polypectomy due to its superior safety profile and comparable complete resection rates. Large polyps (>10 mm), particularly those with advanced features, pose increased cancer risks and often require meticulous assessment and advanced endoscopic techniques, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for resection. This chapter also provides a practical overview of endoscopic techniques for managing colonic obstructions and pericolonic fluid collections, detailing their indications, advantages, disadvantages, and complications. The goal is to improve understanding and application in clinical practice. Additionally, we provide a summary of endoscopic closure techniques that have revolutionized the management of perforations and fistulas, offering safe and effective alternatives to surgery.

Pembrolizumab in combination with trastuzumab for treatment of HER2-positive advanced gastric or gastro-esophageal junction cancer

Introduction

Gastric cancer remains a challenging malignancy with a high global mortality rate. Recent advances in targeted therapy and immunotherapy have shown promise in improving patient outcomes. This paper reviews the impact of incorporating targeted agents such as trastuzumab and immunotherapeutic agents like pembrolizumab into standard chemotherapy regimens for gastric cancer treatment.

Methods

A comprehensive analysis was conducted on pivotal clinical trials, including KEYNOTE-590, KEYNOTE-811, and ToGA, focusing on their methodologies, patient populations, treatment regimens, and outcome measures. The review also explored emerging research avenues in precision medicine, particularly genomic sequencing and biomarker identification.

Aim

To assess the efficacy and survival benefits of adding trastuzumab and pembrolizumab to standard chemotherapy in the treatment of gastric cancer and to outline future directions in gastric cancer research.

Results

Including trastuzumab and pembrolizumab in treatment regimens for human epidermal growth factor receptor 2 (HER2)-positive and PD-L1-expressing gastric cancers significantly improved progression-free and overall survival rates compared to chemotherapy alone. These findings highlight the potential of personalized therapy in enhancing treatment outcomes. Furthermore, ongoing research into the gastric cancer microenvironment and the role of the microbiome suggests novel targets for future therapeutic interventions.

Conclusion

The integration of targeted and immunotherapeutic agents with traditional chemotherapy represents a pivotal shift in gastric cancer treatment, moving towards more personalized and effective regimens.

Self-organising maps in the analysis of strains of human abdominal wall to identify areas of similar mechanical behaviour

The study refers to the application of a type of artificial neural network called the Self-Organising Map (SOM) for the identification of areas of the human abdominal wall that behave in a similar mechanical way. The research is based on data acquired during in vivo tests using the digital image correlation technique (DIC). The mechanical behaviour of the human abdominal wall is analysed during changing intra-abdominal pressure. SOM allow to study simultaneously three variables in four time/load steps. The variables refer to the principal strains and their directions. SOM classifies all the abdominal surface data points into clusters that behave similarly in accordance with the 12 variables. The analysis of the clusters provides a better insight into abdominal wall deformation and its evolution under pressure than when observing a single mechanical variable. The presented results may provide a better understanding of the mechanics of the living human abdominal wall. It might be particularly useful when selecting proper implants as well as for the design of surgical meshes for the treatment of abdominal hernias, which would be mechanically compatible with identified regions of the human anterior abdominal wall, and possibly open the way for patient-specific solutions.