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Converted-hepatopancreatoduodenectomy for an intraoperative positive ductal margin after pancreatoduodenectomy in distal cholangiocarcinoma. Langenbecks Arch Surg 2022; 407:2843-2852. [PMID: 35931877 DOI: 10.1007/s00423-022-02598-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/20/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE Pancreatoduodenectomy (PD) is the standard treatment for distal cholangiocarcinoma, and a negative ductal margin (DM0) is indispensable for the long-term survival. When intraoperative frozen sections of ductal margin after PD are positive, converted-hepatopancreatoduodenectomy (C-HPD) is the final option available to gain an additional ductal margin. However, the efficacy of C-HPD remains unclear. METHODS Patients who underwent PD or C-HPD for distal cholangiocarcinoma between 2002 and 2019 were analyzed. The type of hepatectomy in C-HPD was restricted to left hepatectomy to prevent posthepatectomy liver failure. RESULTS Of 203 patients who underwent PD for distal cholangiocarcinoma, 49 patients exhibited intraoperative positive ductal margin (DM1) after PD. Eleven patients underwent C-HPD for intraoperative DM1 after PD, in which intraoperative DM1 with invasive carcinoma (DM1inv) was observed in 3 patients, and intraoperative DM1 with carcinoma in situ (DM1cis) was observed in 8 patients. The median additional ductal margin yielded by C-HPD was 9 mm (interquartile range 7-13 mm). C-HPD eradicated intraoperative DM1inv in 3 patients, with 2 patients showing DM0 and 1 patient showing DM1cis. Regarding 8 patients who underwent C-HPD for intraoperative DM1cis, 4 patients had DM0, but the others had DM1cis. C-HPD was associated with a high complication rate, but no mortality was observed. The median survival time of patients who underwent C-HPD was 48.8 months. CONCLUSION C-HPD was able to safely eradicate intraoperative DM1inv after PD. However, the length of the resected bile duct according to C-HPD may not be sufficient to remove intraoperative DM1cis after PD.
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Well-Differentiated Grade 3 Neuroendocrine Tumors: Characteristics, Treatments, and Outcomes From a Population-Based Study. Pancreas 2022; 51:756-762. [PMID: 36395400 PMCID: PMC9722384 DOI: 10.1097/mpa.0000000000002100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We evaluated a population-based cohort of metastatic well-differentiated grade 3 gastroenteropancreatic neuroendocrine tumors (G3 NETs) to describe their characteristics, prognosis, and treatment outcomes. METHODS The British Columbia provincial database was queried for G3 NETs diagnosed 2004 to 2021, and charts were reviewed to describe clinical features and outcomes. RESULTS Forty-one patients were identified, most were diagnosed with pancreatic (58.5%) or midgut (26.8%) primary tumor and Ki-67 was less than 55% in 68.3%. The primary was resected in 19 (46.3%) with median disease-free survival of 25.2 months. Once metastatic, patients received a median of one line of systemic therapy. Median overall survival with metastatic disease was 33.8 months. Median progression-free survival was longest in patients treated with capecitabine-temozolomide (20.6 months) or somatostatin analogs (7.9 months), while etoposide-platinum provided little benefit (2.4 months). Limited data of efficacy for targeted therapies and radionuclide therapy was available. Seven patients (17.1%) were also treated with local therapies, which were associated with improved overall survival (median not reached, hazard ratio, 0.23; P = 0.012). CONCLUSIONS Capecitabine-temozolomide and somatostatin analogs were associated with clinically meaningful benefit, and use of local therapies provided benefits in selected patients. Multidisciplinary discussion is essential to optimize individual outcomes in this heterogeneous population.
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203
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Cadili L, Vasilyeva E, Li J, Kim P, Chung S, Segedi M. Pancreas tail adenocarcinoma tumor size is highly predictive of positive margins after a nonradical resection. Am J Surg 2022; 224:728-732. [PMID: 35643634 DOI: 10.1016/j.amjsurg.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 04/16/2022] [Accepted: 05/20/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radical resection (RAMPS) of left sided pancreatic ductal adenocarcinoma (PDAC) is effective in achieving R0 margins; however, not universally accepted due to lack of improved survival. We hypothesized that only larger tumors lead to R1 in non-RAMPS procedures. METHODS A retrospective review of charts between 2008 and 2020 was performed. The primary outcome was evaluating R0 resection based on left-sided tumors' size and location, and secondary outcomes were OS and DFS. RESULTS Sixty-eight percent had R0 resection. R1 groups' tumors were larger (5.5 cm vs. 3.8 cm, p = 0.004) and had higher LVI involvement (p = 0.003). OS and DFS did not differ on multivariate analysis. Tumor size above 4 cm in the tail was associated with R1 (p = 0.01). CONCLUSIONS Larger tumors in the tail, but not body were associated with R1, but not worse survival. Perhaps larger tumors in the tail are a surrogate marker of poor disease biology.
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Affiliation(s)
- Lina Cadili
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elizaveta Vasilyeva
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Li
- Division of Liver and Pancreas Transplantation, University of California Los Angeles, Los Angeles, CA, USA
| | - Peter Kim
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Stephen Chung
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Maja Segedi
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Seppey R, Benjamin A, Lambrakis P. A novel approach to managing ruptured umbilical hernias in cirrhosis. ANZ J Surg 2022; 92:2524-2528. [DOI: 10.1111/ans.17936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/15/2022] [Accepted: 07/14/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Romain Seppey
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
| | - Aditya Benjamin
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
| | - Paul Lambrakis
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
- School of Medicine University of New South Wales Sydney New South Wales Australia
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205
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Chuang SH, Chuang SC. Single-incision laparoscopic surgery to treat hepatopancreatobiliary cancer: A technical review. World J Gastroenterol 2022; 28:3359-3369. [PMID: 36158268 PMCID: PMC9346466 DOI: 10.3748/wjg.v28.i27.3359] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/20/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, was launched to minimize incisional traumatic effects in the 1990s. Minor SILS, such as cholecystectomies, have been gaining in popularity over the past few decades. Its application in complicated hepatopancreatobiliary (HPB) surgeries, however, has made slow progress due to instrumental and technical limitations, costs, and safety concerns. While minimally invasive abdominal surgery is pushing the boundaries, advanced laparoscopic HPB surgeries have been shown to be comparable to open operations in terms of patient and oncologic safety, including hepatectomies, distal pancreatectomies (DP), and pancreaticoduodenectomies (PD). In contrast, advanced SILS for HPB malignancy has only been reported in a few small case series. Most of the procedures involved minor liver resections and DP; major hepatectomies were rarely described. Single-incision laparoscopic PD has not yet been reported. We herein review the published SILS for HPB cancer in the literature and our three-year experience focusing on the technical aspects.
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Affiliation(s)
- Shu-Hung Chuang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Shih-Chang Chuang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
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206
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Al-Tarakji M, Zarour A, Singh R, Ghali MS. The Role of Alvarado Score in Predicting Acute Appendicitis and Its Severity in Correlation to Histopathology: A Retrospective Study in a Qatar Population. Cureus 2022; 14:e26902. [PMID: 35983388 PMCID: PMC9376215 DOI: 10.7759/cureus.26902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2022] [Indexed: 12/07/2022] Open
Abstract
Background/objective Acute appendicitis (AA) is one of the most common surgical emergencies that require a proper diagnosis to avoid a negative outcome in the case of missed or delayed diagnosis. Our study aims to assess the diagnostic power of the Alvarado score and the prediction of the severity of acute appendicitis in correlation to intraoperative findings and the final histopathology (HP) result. Methods This retrospective study was applied to 1,303 patients with clinically proven acute appendicitis (AA) and available HP results. We correlated Alvarado score to the gold standard HP and intraoperative findings. We selected the cutoff point of Alvarado at 5 and 7 as they were the most frequent cutoff value mentioned in the literature and based on the ROC curve in this study to assess sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results The mean age of the study cohort is 33.3 ± 9.5 years, with a male predominance (75.8%). The negative appendectomy (NA) rate was 4%. The operative complication rate was 1.2%, and we recorded one mortality case (0.1%). The diagnostic evidence of AA was in 95.9% of cases. Alvarado score ≥ 7 presented sensitivity and specificity of 66.4% and 69.8%, respectively, with PPV of 98.1% and NPV of 8.1%, with an accuracy of 66.5%. For Alvarado score ≥ 5, the sensitivity was 91.2%, specificity was 22.6%, PPV was 96.5%, NPV was 9.8%, and accuracy was 88.4%. In addition, we demonstrated statistical significance between Alvarado risk stratification with HP and intraoperative grades (p = 0.001 each). Conclusion The Alvarado scoring system alone is not enough to diagnose AA with unsatisfactory sensitivity and specificity. However, it is a good indicator of the severity of AA that we can depend on to prioritize those patients waiting for surgery.
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207
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Sheen J, Bowen J, Whitmore H, Bowling K. Hyponatremia as a Marker of Complicated Appendicitis: A Retrospective Analysis. Cureus 2022; 14:e26672. [PMID: 35949749 PMCID: PMC9357972 DOI: 10.7759/cureus.26672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 11/05/2022] Open
Abstract
Background The aim of this study is to investigate the potential role of hyponatremia as a biochemical predictor of complicated appendicitis.
The effective employment of biochemical markers to identify early and predict progression to complicated appendicitis would be beneficial in triaging those most requiring urgent appendicectomy. A marker of interest and subject of recent study in the literature is sodium. Methods and Materials This study was designed as a single-center, retrospective analysis of all appendicectomies performed between January 1, 2018 and March 10, 2021. Patients were categorized into pediatric and adult groups and subdivided into uncomplicated or complicated appendicitis. We utilized the Chi-square test and crude odds ratio (OR) rates to assess significance of serum sodium level values. Results In total, 890 patients underwent appendicectomy (181 pediatric, 709 adult cases). Within the pediatric group, 10 uncomplicated cases and 16 complicated cases were found to be hyponatremic. The result for hyponatremia as a diagnostic marker for complicated cases in this group was not significant at p<0.05, with a Chi-square test result of 1.6067 and p-value 0.204963 (OR 1.7538, 95% confidence interval (CI) 0.7312-4.2070). Adults displaying hyponatremia comprised four uncomplicated and 34 complicated cases, with calculated OR 7.915 (95% CI 2.7656-22.6521). Chi-square test result was 20.1687 with a p-value of <0.00001 and, thus, statistically significant. Conclusion Our findings suggest that hyponatremia can be employed as an indicator of complicated appendicitis in an adult population. This correlates with the findings of a recent systematic review of this topic and implicates this as a subject worthy of further study.
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208
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Treatment Response and Conditional Survival in Advanced Pancreatic Cancer Patients Treated with FOLFIRINOX: A Multicenter Cohort Study. JOURNAL OF ONCOLOGY 2022; 2022:8549487. [PMID: 35847365 PMCID: PMC9283068 DOI: 10.1155/2022/8549487] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022]
Abstract
Background FOLFIRINOX chemotherapy is the current Dutch standard of care for locally advanced (LAPC) and metastatic pancreatic cancer (PDAC) patients with good performance status. The objective of this study was to evaluate real-world response rates and survival in advanced PDAC and to assess conditional survival after FOLFIRINOX. Methods A multicenter, retrospective cohort study was conducted in four hospitals in the Netherlands. Consecutive patients with LAPC or metastatic PDAC, treated with FOLFIRINOX, were included. Results Between 2012 and 2018, 284 patients were included: n = 136 with LAPC and n = 148 with metastatic PDAC. Objective response rates were similar in both the groups: 14.0% in LAPC and 18.2% in metastatic patients. The disease control rate was higher in LAPC patients (77.2%) compared to metastatic PDAC (51.4%, P < 0.001). Median overall survival (OS) in LAPC patients was 12.7 months (95% CI 11.4–14.1 months). Their 2-year survival probability increased from 14% to 26% one year after the completion of FOLFIRINOX. Median OS in metastatic PDAC patients was 8.1 months (95% CI 6.5–9.6 months); 2-year survival probability increased from 10% to 29% after one year. Discussion. Our study provides real-world estimates of response rates, survival, and conditional survival in patients with advanced PDAC treated with FOLFIRINOX. These results are useful for patient counseling and clinical decision making.
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de Almeida Leite RM, de Souza AV, Bay CP, Cauley C, Bordeianou L, Goldstone R, Francone T, Kunitake H, Ricciardi R. Delayed Operative Management in Complicated Acute Appendicitis-Is Avoiding Extended Resection Worth the Wait ? Results from a Global Cohort Study. J Gastrointest Surg 2022; 26:1482-1489. [PMID: 35449429 DOI: 10.1007/s11605-022-05311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal management of complicated acute appendicitis remains undefined. According to current guidelines, a trial of non-operative management with delayed appendectomy may be associated with better outcomes for patients, including a reduced rate of extended resection appendectomy. METHODS We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement program to analyze the outcomes of hemodynamically stable patients presenting with complicated (abscess, perforation, or both) appendicitis submitted to early (less than 24 h) or delayed (24 h or more) operative management. RESULTS Delayed operative management was associated with a significant reduction of the rate of extended resection appendectomy (RR: 2.15, 95% CI: 1.59 - 2.81, p < 0.001). Delayed operative management was associated with a non-significant trend towards reduced mortality (RR: 2.17; 95% CI: 0.98-2.85, p = 0.05). Delayed operative management was also associated with a significant decrease in total operative time and a significant reduction in the rate of postoperative abscess. There was no association between delayed intervention and medical related morbidity (RR: 1.01; 95% CI 0.91-1.11, p 0.811). However, delayed operative management was associated with a significant increase in total length of stay (coefficient 1.10; 95% CI: 1.02 to 1.18, p < 0.001). CONCLUSION Delayed operative management may be associated with a reduction in the need of extended resection appendectomy, shorter operative time, and a trend towards reduced mortality. On the other hand, it may also be associated with an increased length of in-hospital stay and short-term morbidity.
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Affiliation(s)
- Rodrigo Moisés de Almeida Leite
- Harvard Medical School, Boston, MA, USA.,Section of Colon & Rectal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
| | | | | | - Christy Cauley
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Rob Goldstone
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Todd Francone
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiroko Kunitake
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rocco Ricciardi
- Section of Colon & Rectal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA.
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Iizuka Y, Hikone M, Shimizu Y, Tanabe M, Sugiyama K, Hamabe Y. Intestinal evisceration and Staphylococcus aureus bacteremia due to ruptured umbilical hernia in a patient with liver cirrhosis: a case report and literature review. Oxf Med Case Reports 2022; 2022:omac078. [PMID: 35903616 PMCID: PMC9318879 DOI: 10.1093/omcr/omac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Rupture of umbilical hernias is a potentially life-threatening condition that can occur in cirrhotic patients due to ascites. To the best of our knowledge, there are no previous reports on bacteremia following intestinal evisceration due to a ruptured umbilical hernia. Herein, we report a case of a 42-year-old female with a history of complicated alcoholic liver cirrhosis and schizophrenia who presented with intestinal evisceration and Staphylococcus aureus bacteremia secondary to a ruptured umbilical hernia. Due to a 2-day delay from presentation to hospitalization, the patient had a high risk for infection with skin flora. Initiation of appropriate antibiotic therapy, prompt surgical repair and adequate postoperative control of ascites markedly improved the patient’s condition. In cases of prolonged intestinal evisceration in adults with a ruptured umbilical hernia, bacteremia treatment with antibiotics coverage for skin flora should be considered.
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Affiliation(s)
- Yuki Iizuka
- Department of Emergency and Critical Care Medicine , Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
- Tertiary Emergency Medical Center (Trauma and Critical Center), Tokyo Metropolitan Bokutoh Hospital , Tokyo, Japan
| | - Mayu Hikone
- Tertiary Emergency Medical Center (Trauma and Critical Center), Tokyo Metropolitan Bokutoh Hospital , Tokyo, Japan
| | - Yusuke Shimizu
- Tertiary Emergency Medical Center (Trauma and Critical Center), Tokyo Metropolitan Bokutoh Hospital , Tokyo, Japan
| | - Maki Tanabe
- Tertiary Emergency Medical Center (Trauma and Critical Center), Tokyo Metropolitan Bokutoh Hospital , Tokyo, Japan
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center (Trauma and Critical Center), Tokyo Metropolitan Bokutoh Hospital , Tokyo, Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center (Trauma and Critical Center), Tokyo Metropolitan Bokutoh Hospital , Tokyo, Japan
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211
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The role of hepatic and pancreatic metastatectomy in the management of metastatic renal cell carcinoma: A systematic review. Surg Oncol 2022; 44:101819. [DOI: 10.1016/j.suronc.2022.101819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 07/04/2022] [Accepted: 07/11/2022] [Indexed: 12/09/2022]
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212
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Zhang X, Wang J, Wu B, Li T, Jin L, Wu Y, Gao P, Zhang Z, Qin X, Zhu C. A nomogram-based model and ultrasonic radiomic features for gallbladder polyp classification. J Gastroenterol Hepatol 2022; 37:1380-1388. [PMID: 35357026 DOI: 10.1111/jgh.15841] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 01/25/2022] [Accepted: 03/20/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Gallbladder polyps (GBPs) are relatively common. Many studies have attempted to distinguish between benign and neoplastic GBPs to identify early-stage gallbladder carcinoma. We have established an accurate neoplastic predictive model and evaluated the effectiveness of radiomics in predicting malignancy in patients with GBPs. METHODS A total of 503 patients confirmed through postoperative pathology were included in this retrospective study. Clinical information and ultrasonographic findings were retrospectively analyzed. The model was constructed from independent risk factors using Spearman correlation and logistic regression analysis of a training cohort of 250 GBP patients, and its efficacy was verified using an internal validation group of 253 consecutive patients through the receiver operating characteristic curve (ROC). The area of GBPs was delimited manually, and the texture features of ultrasound images were analyzed using correlation and ROC analysis. RESULTS Independent predictors, including age, gallstones, carcinoembryonic antigen, polyp size, and sessile shape, were incorporated into the nomogram model for the neoplastic potential of GBPs. Compared with other proposed prediction methods, the established nomogram model showed good discrimination ability in the training group (area under the curve [AUC]: 0.865) and validation group (AUC: 0.845). Regarding ultrasonic radiomics, the minimum caliper diameter was identified as the only independent predictor (AUC: 0.841). CONCLUSIONS Our preoperative nomogram model can successfully evaluate the neoplastic potential of GBPs using simple clinical data, and our study verified the use of radiomics in GBP identification, which may be valuable for avoiding unnecessary surgery in patients.
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Affiliation(s)
- Xudong Zhang
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Jincheng Wang
- Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Baoqiang Wu
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Tao Li
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Lei Jin
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Yong Wu
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Peng Gao
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China.,Clinic College, Dalian Medical University, Dalian, China
| | - Zhen Zhang
- Clinic College, Dalian Medical University, Dalian, China
| | - Xihu Qin
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Chunfu Zhu
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
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Zhang L, Zhang J, Xu Y. Letter to the editor regarding “Liver Resection and role of Extended Histology (LiREcH study) in patients with multifocal colorectal cancer liver metastases”. HPB (Oxford) 2022; 25:484. [PMID: 37028829 DOI: 10.1016/j.hpb.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 06/21/2022] [Accepted: 06/28/2022] [Indexed: 04/09/2023]
Affiliation(s)
- Lei Zhang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Junwei Zhang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yiyao Xu
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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Zouari M, Ben Ameur H, Krichen E, Kraiem N, Ben Dhaou M, Mhiri R. Time to Surgery Does Not Impact Outcome in Pediatric Appendicitis. Surg Infect (Larchmt) 2022; 23:558-563. [PMID: 35704046 DOI: 10.1089/sur.2022.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Despite the high prevalence of acute appendicitis in children and substantial resource utilization associated with this condition, no consensus has been reached on optimal timing for performing appendectomies. The aim of this study was to examine the association between time to appendectomy and outcomes and assess the feasibility of delayed appendectomy in children. Patients and Methods: We performed a retrospective analysis of all patients younger than 14 years of age undergoing an appendectomy for suspected appendicitis. We divided our patients into two groups based on whether their time to appendectomy was shorter or longer than eight hours: group A, early appendectomy and group B, delayed appendectomy. Then we compared the two study groups regarding demographic, clinical, and radiographic characteristics, peri-operative data, and outcomes. Results: During the eight-year study period, a total of 1,141 patients underwent appendectomies. After applying exclusion criteria, 852 children were included: 544 (63.8%) in group A and 308 (36.2%) in group B. There were no differences in the rate of complicated appendicitis at exploration, post-operative complications, length of post-operative hospital stay, and 30-day re-admission rate between the two study groups. Conclusions: Our study demonstrated that delaying appendectomy within 24 hours of presentation is safe and feasible for pediatric acute appendicitis. Therefore, patients presenting during nighttime hours could be initially treated conservatively with antibiotic agents. This allows the surgeon to delay surgery to the following day.
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Affiliation(s)
- Mohamed Zouari
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia.,Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Hana Ben Ameur
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia.,Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Emna Krichen
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia.,Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Najoua Kraiem
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia.,Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Mahdi Ben Dhaou
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia.,Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Riadh Mhiri
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia.,Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
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Laparoscopic hepatopancreaticoduodenectomy for synchronous gallbladder cancer and extrahepatic cholangiocarcinoma: a case report. World J Surg Oncol 2022; 20:190. [PMID: 35681223 PMCID: PMC9178805 DOI: 10.1186/s12957-022-02628-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
Background Hepatopancreaticoduodenectomy (HPD) is one of the most complex procedures, and it is very rarely reported. Laparoscopic HPD (LHPD) is even rarer. To date, there are only 3 reports of LHPD for locally advanced gallbladder cancer (GBC) or extrahepatic cholangiocarcinoma (ECC). This is the first report of LHPD for synchronous GBC and ECC. Case presentation A 75-year-old female patient complained of jaundice for 2 weeks without fever or abdominal pain. She was diagnosed with synchronous GBC and ECC. After a comprehensive preparation, she underwent a laparoscopic pancreaticoduodenectomy and resection of hepatic segments of IVb and V, and her digestive tract reconstruction followed Child’s methods. She was discharged on the 12th day postoperatively without pancreatic leakage, biliary leakage, or liver failure. Conclusions LHPD is safe and feasible for selected cases of GBCs or ECCs.
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Spallarossa A, Tasso B, Russo E, Villa C, Brullo C. The Development of FAK Inhibitors: A Five-Year Update. Int J Mol Sci 2022; 23:ijms23126381. [PMID: 35742823 PMCID: PMC9223874 DOI: 10.3390/ijms23126381] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 02/06/2023] Open
Abstract
Focal adhesion kinase (FAK) is a non-receptor tyrosine kinase over-expressed in different solid cancers. In recent years, FAK has been recognized as a new target for the development of antitumor agents, useful to contrast tumor development and metastasis formation. To date, studies on the role of FAK and FAK inhibitors are of great interest for both pharmaceutical companies and academia. This review is focused on compounds able to block FAK with different potencies and with different mechanisms of action, that have appeared in the literature since 2017. Furthermore, new emerging PROTAC molecules have appeared in the literature. This summary could improve knowledge of new FAK inhibitors and provide information for future investigations, in particular, from a medicinal chemistry point of view.
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Bertsimas D, Margonis GA, Sujichantararat S, Boerner T, Ma Y, Wang J, Kamphues C, Sasaki K, Tang S, Gagniere J, Dupré A, Løes IM, Wagner D, Stasinos G, Macher-Beer A, Burkhart R, Morioka D, Imai K, Ardiles V, O'Connor JM, Pawlik TM, Poultsides G, Seeliger H, Beyer K, Kaczirek K, Kornprat P, Aucejo FN, de Santibañes E, Baba H, Endo I, Lønning PE, Kreis ME, Weiss MJ, Wolfgang CL, D'Angelica M. Using Artificial Intelligence to Find the Optimal Margin Width in Hepatectomy for Colorectal Cancer Liver Metastases. JAMA Surg 2022; 157:e221819. [PMID: 35648428 DOI: 10.1001/jamasurg.2022.1819] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance In patients with resectable colorectal cancer liver metastases (CRLM), the choice of surgical technique and resection margin are the only variables that are under the surgeon's direct control and may influence oncologic outcomes. There is currently no consensus on the optimal margin width. Objective To determine the optimal margin width in CRLM by using artificial intelligence-based techniques developed by the Massachusetts Institute of Technology and to assess whether optimal margin width should be individualized based on patient characteristics. Design, Setting, and Participants The internal cohort of the study included patients who underwent curative-intent surgery for KRAS-variant CRLM between January 1, 2000, and December 31, 2017, at Johns Hopkins Hospital, Baltimore, Maryland, Memorial Sloan Kettering Cancer Center, New York, New York, and Charité-University of Berlin, Berlin, Germany. Patients from institutions in France, Norway, the US, Austria, Argentina, and Japan were retrospectively identified from institutional databases and formed the external cohort of the study. Data were analyzed from April 15, 2019, to November 11, 2021. Exposures Hepatectomy. Main Outcomes and Measures Patients with KRAS-variant CRLM who underwent surgery between 2000 and 2017 at 3 tertiary centers formed the internal cohort (training and testing). In the training cohort, an artificial intelligence-based technique called optimal policy trees (OPTs) was used by building on random forest (RF) predictive models to infer the margin width associated with the maximal decrease in death probability for a given patient (ie, optimal margin width). The RF component was validated by calculating its area under the curve (AUC) in the testing cohort, whereas the OPT component was validated by a game theory-based approach called Shapley additive explanations (SHAP). Patients from international institutions formed an external validation cohort, and a new RF model was trained to externally validate the OPT-based optimal margin values. Results This cohort study included a total of 1843 patients (internal cohort, 965; external cohort, 878). The internal cohort included 386 patients (median [IQR] age, 58.3 [49.0-68.7] years; 200 men [51.8%]) with KRAS-variant tumors. The AUC of the RF counterfactual model was 0.76 in both the internal training and testing cohorts, which is the highest ever reported. The recommended optimal margin widths for patient subgroups A, B, C, and D were 6, 7, 12, and 7 mm, respectively. The SHAP analysis largely confirmed this by suggesting 6 to 7 mm for subgroup A, 7 mm for subgroup B, 7 to 8 mm for subgroup C, and 7 mm for subgroup D. The external cohort included 375 patients (median [IQR] age, 61.0 [53.0-70.0] years; 218 men [58.1%]) with KRAS-variant tumors. The new RF model had an AUC of 0.78, which allowed for a reliable external validation of the OPT-based optimal margin. The external validation was successful as it confirmed the association of the optimal margin width of 7 mm with a considerable prolongation of survival in the external cohort. Conclusions and Relevance This cohort study used artificial intelligence-based methodologies to provide a possible resolution to the long-standing debate on optimal margin width in CRLM.
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Affiliation(s)
- Dimitris Bertsimas
- Operations Research Center, Massachusetts Institute of Technology, Cambridge
| | - Georgios Antonios Margonis
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of General and Visceral Surgery, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Suleeporn Sujichantararat
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge
| | - Thomas Boerner
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yu Ma
- Operations Research Center, Massachusetts Institute of Technology, Cambridge
| | - Jane Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carsten Kamphues
- Department of General and Visceral Surgery, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Seehanah Tang
- Operations Research Center, Massachusetts Institute of Technology, Cambridge
| | - Johan Gagniere
- Service de Chirurgie Digestive, CHU Clermont-Ferrand, Inserm, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Aurelien Dupré
- Service de Chirurgie Digestive, CHU Clermont-Ferrand, Inserm, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Inger Marie Løes
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Doris Wagner
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | | | | | - Richard Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daisuke Morioka
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Victoria Ardiles
- Hepatopancreatobiliary Surgery and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - George Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Hendrik Seeliger
- Department of General and Visceral Surgery, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Katharina Beyer
- Department of General and Visceral Surgery, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Klaus Kaczirek
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Kornprat
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | - Federico N Aucejo
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eduardo de Santibañes
- Hepatopancreatobiliary Surgery and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Per Eystein Lønning
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Martin E Kreis
- Department of General and Visceral Surgery, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Surgery, Zucker School of Medicine at Hofstra, Northwell Health Cancer Institute, Lake Success, New York
| | - Christopher L Wolfgang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Surgery, New York University School of Medicine, New York
| | - Michael D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Lee S, Connelly TM, Ryan JM, Power-Foley M, Neary PM. Outcomes of the Macroscopically Normal Appendix Left in Situ in Patients with Suspected Appendicitis. World J Surg 2022; 46:1353-1358. [PMID: 35274182 DOI: 10.1007/s00268-022-06497-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Right iliac fossa (RIF) pain is a common indication for laparoscopy to diagnose and treat appendicitis. When a macroscopically normal appendix is found, there is no standard consensus regarding excision. Some surgeons remove the appendix due to the risk of microscopic inflammation and to avoid a future, repeat laparoscopy for possible appendicitis. Alternatively, others leave the appendix in situ to avoid morbidity from a potentially unnecessary procedure. We aimed to evaluate the outcomes of patients with macroscopically normal appendices left in situ. METHODS All emergency laparoscopies without appendicectomy between January 1st 2010- December 31st 2020 were identified from theatre records. All operative notes were individually evaluated and comments on the macroscopic appearance of the appendix and any intra-operative pathology were recorded. Only patients undergoing laparoscopy for suspected appendicitis with macroscopically normal appendices were included. RESULTS A total of 120 patients [median age 21.68 (range 9-90.8) years] were included. The cohort was predominantly female (n=105, 87.5%). Forty-eight patients (40.0%) had a positive finding during index laparoscopy. During a median duration of 94.5 (range 8-131) months' follow-up, 16 patients (13.33%) underwent a repeat laparoscopy for recurrent RIF pain. Thirteen (10.8% of total cohort) subsequently underwent an appendicectomy. Histology confirmed acute appendicitis in six cases (4.17% of entire cohort). On subanalysis of smaller cohort, index laparoscopies with no positive findings (n=72), nine patients (12.5%) underwent appendicectomy with two (2.7%) appendices demonstrating appendicitis on histological examination. CONCLUSION 87% of the total cohort with a normal appendix at laparoscopy for RIF pain did not undergo further laparoscopy. Less than 5% of the total cohort and 2.7% of subanalysis cohort had an appendicectomy for histologically-proven appendicitis within the follow-up period. From the evidence in this study, we conclude that leaving the appendix in situ unless macroscopically inflamed is a viable alternative to excision.
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Affiliation(s)
- Sara Lee
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland.
| | - Tara M Connelly
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland
| | - Jessica M Ryan
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland
| | - Megan Power-Foley
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland
| | - Peter M Neary
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland
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Holmberg M, Linder S, Kordes M, Liljefors M, Ghorbani P, Löhr JM, Sparrelid E. Impact of spatio-temporal recurrence pattern on overall survival for invasive intraductal papillary mucinous neoplasia - A comparison with pancreatic ductal adenocarcinoma. Pancreatology 2022; 22:598-607. [PMID: 35501218 DOI: 10.1016/j.pan.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/07/2022] [Accepted: 04/12/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Resections for intraductal papillary mucinous neoplasia (IPMN) have increased dramatically during the last decade. Recurrence pattern and impact of adjuvant chemotherapy for solid pancreatic ductal adenocarcinoma (PDAC) is well known, but not for invasive IPMN (inv-IPMN). OBJECTIVES To elucidate the impact of spatio-temporal recurrence pattern and adjuvant chemotherapy on overall survival for inv-IPMN compared with PDAC. METHODS We conducted a retrospective single-center observational study of consecutive patients ≥18 years of age who underwent resection for inv-IPMN or PDAC at Karolinska University Hospital, between 2009 and 2018. Different initial recurrence sites and time frames as well as predictors for death were assessed with multivariable Cox and logistic regressions. Survival analyses were performed using the Kaplan-Meier model and log rank test. RESULTS Of 396 resected patients, 92 were inv-IPMN and 304 PDAC. Both recurrence rate and death rate within three-years were lower for inv-IPMN compared to PDAC (p = 0.006 and p = 0.007 respectively). Across the whole cohort, the most common recurrence patterns were multi-site (25%), single-site liver (21%) and single-site locoregional (10%) recurrence. The most prominent predictors for death in multivariable Cox regression, especially if occurred within the first year, were multi-site (HR 17.0), single-site peritoneal (HR 13.6) and single-site liver (HR 13.1) recurrence. These predictors were less common in inv-IPMN compared to PDAC (p = 0.007). The effect of adjuvant chemotherapy was similar in the two groups. CONCLUSION Resected inv-IPMN exhibits a less aggressive recurrence pattern than PDAC that translates into a more favorable overall survival.
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Affiliation(s)
- Marcus Holmberg
- Division of Upper Gastrointestinal Diseases, Karolinska University Hospital, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
| | - Stefan Linder
- Division of Upper Gastrointestinal Diseases, Karolinska University Hospital, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Maximilian Kordes
- Division of Upper Gastrointestinal Diseases, Karolinska University Hospital, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Maria Liljefors
- Division of Upper Gastrointestinal Diseases, Karolinska University Hospital, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Poya Ghorbani
- Division of Upper Gastrointestinal Diseases, Karolinska University Hospital, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - J-Matthias Löhr
- Division of Upper Gastrointestinal Diseases, Karolinska University Hospital, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Upper Gastrointestinal Diseases, Karolinska University Hospital, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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de Liguori Carino N, Baltatzis M, Maroso F, Spiers HVM, Deshpande R, Jamdar S, Satyadas T, Sheen AJ, Siriwardena AK, O'Reilly DA. A fast-track surgery programme leads to timelier treatment and higher resection rates in pancreatic cancer. HPB (Oxford) 2022; 24:893-900. [PMID: 34802941 DOI: 10.1016/j.hpb.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/09/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim was to perform a propensity-matched comparison of patients with pancreatic cancer undergoing surgery, with and without biliary stenting and an intention to treat analysis of long-term survival between the two groups. METHODS This was an observational study of a cohort of consecutive patients presenting with obstructive jaundice and undergoing pancreatoduodenectomy for pancreatic and periampullary malignancies between November 2015 and May 2019. RESULTS In this study of 216 consecutive operable patients, 70 followed the fast-track pathway and 146 had pre-operative biliary drainage. All 70 patients in the FT group and 122 out of 146 in the PBD group proceeded to surgery (100% and 83.6% respectively, p = 0.001). Interval time from diagnostic CT scan to surgery and from MDT decision to treat to surgery was shorter in the FT group, (median 8 vs 43 days p < 0.001 and 3 vs 36 days p < 0.001 respectively) as was the overall time from diagnostic CT to adjuvant treatment (88 vs 121 days p < 0.001). Postoperative outcomes including complications, readmission and mortality rates were comparable in the two groups. There was no difference in survival. CONCLUSION For a person with pancreatic cancer who is proceeding to surgery, the best approach is to avoid pre-operative biliary drainage.
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Affiliation(s)
- Nicola de Liguori Carino
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fabio Maroso
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Harry V M Spiers
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Rahul Deshpande
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Thomas Satyadas
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Aali J Sheen
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Centre for Biomedicine, Manchester Metropolitan University, Manchester, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Derek A O'Reilly
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.
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Lam S, Kumar B, Loke YK, Orme SE, Dhatariya K. Glycated haemoglobin and the risk of postoperative complications in people without diabetes: a prospective population-based study in UK Biobank. Anaesthesia 2022; 77:659-667. [PMID: 35238399 PMCID: PMC9314702 DOI: 10.1111/anae.15684] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/13/2022]
Abstract
The aim of our study was to clarify the association between glycated haemoglobin (HbA1c ) and postoperative outcomes in people without an existing diagnosis of diabetes. Half a million adults were recruited into the UK Biobank prospective cohort study between March 2006 and October 2010. We divided participants into three groups: no diagnosis of diabetes and HbA1c < 42 mmol.mol-1 ; no diagnosis of diabetes and elevated HbA1c (≥ 42 mmol.mol-1 with no upper limit); and prevalent diabetes (regardless of HbA1c concentration) at recruitment. We followed up participants by linkage with routinely collected hospital data to determine any surgical procedures undertaken after recruitment and the associated postoperative outcomes. Our main outcome measure was a composite primary outcome of 30-day major postoperative complications and 90-day all-cause mortality. We used logistic regression to estimate the odds of the primary outcome by group. We limited analyses to those who underwent surgery within one year of recruitment (n = 26,653). In a combined effects logistic regression model, participants not known to have diabetes with HbA1c ≥ 42 mmol.mol-1 had increased odds of the primary outcome (OR [95% CI] 1.43 [1.02-2.02]; p = 0.04), when compared with those without diabetes and HbA1c < 42 mmol.mol-1 . This effect was attenuated and no longer statistically significant in a direct effects model with adjustment for hyperglycaemia-related comorbidity (OR [95% CI] 1.37 [0.97-1.93]; p = 0.07). Elevated pre-operative HbA1c in people without diabetes may be associated with an increased risk of complications, but the association is likely confounded by end-organ comorbidity. In contrast to previous evidence, our findings suggest that to prevent adverse postoperative outcomes, optimisation of pre-existing morbidity should take precedence over reducing HbA1c in people without diabetes.
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Affiliation(s)
- S. Lam
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
- Department of General SurgeryNorfolk and Norwich University Hospital NHS TrustUK
| | - B. Kumar
- Department of Upper Gastrointestinal SurgeryNorfolk and Norwich University Hospital NHS TrustUK
- Norwich Medical SchoolUniversity of East AngliaUK
| | - Y. K. Loke
- Norwich Medical SchoolUniversity of East AngliaUK
| | - S. E. Orme
- Norwich Medical SchoolUniversity of East AngliaUK
| | - K. Dhatariya
- Elsie Bertram Diabetes CentreNorfolk and Norwich University Hospital NHS TrustUK
- Norwich Medical SchoolUniversity of East AngliaUK
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Que QY, Zhang LC, Bao JQ, Ling SB, Xu X. Role of surgical treatments in high-grade or advanced gastroenteropancreatic neuroendocrine neoplasms. World J Gastrointest Surg 2022; 14:397-408. [PMID: 35734618 PMCID: PMC9160682 DOI: 10.4240/wjgs.v14.i5.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/19/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
Over the last 40 years, the incidence and prevalence of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) have continued to increase. Compared to other epithelial neoplasms in the same organ, GEP-NENs exhibit indolent biological behavior, resulting in more chances to undergo surgery. However, the role of surgery in high-grade or advanced GEP-NENs is still controversial. Surgery is associated with survival improvement of well-differentiated high-grade GEP-NENs, whereas poorly differentiated GEP-NENs that may benefit from resection require careful selection based on Ki67 and other tissue biomarkers. Additionally, surgery also plays an important role in locally advanced and metastatic disease. For locally advanced GEP-NENs, isolated major vascular involvement is no longer an absolute contraindication. In the setting of metastatic GEP-NENs, radical intended surgery is recommended for patients with low-grade and resectable metastases. For unresectable metastatic disease, a variety of surgical approaches, including cytoreduction of liver metastasis, liver transplantation, and surgery after neoadjuvant treatment, show survival benefits. Primary tumor resection in GEP-NENs with unresectable metastatic disease is associated with symptom control, prolonged survival, and improved sensitivity toward systemic therapies. Although there is no established neoadjuvant or adjuvant strategy, increasing attention has been given to this emerging research area. Some studies have reported that neoadjuvant therapy effectively reduces tumor burden, improves the effectiveness of subsequent surgery, and decreases surgical complications.
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Affiliation(s)
- Qing-Yang Que
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou 310006, Zhejiang Province, China
- Zhejiang University Cancer Center, Hangzhou 310006, Zhejiang Province, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310006, Zhejiang Province, China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Lin-Cheng Zhang
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou 310006, Zhejiang Province, China
- Zhejiang University Cancer Center, Hangzhou 310006, Zhejiang Province, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310006, Zhejiang Province, China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Jia-Qi Bao
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou 310006, Zhejiang Province, China
- Zhejiang University Cancer Center, Hangzhou 310006, Zhejiang Province, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310006, Zhejiang Province, China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Sun-Bin Ling
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou 310006, Zhejiang Province, China
- Zhejiang University Cancer Center, Hangzhou 310006, Zhejiang Province, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310006, Zhejiang Province, China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Xiao Xu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou 310006, Zhejiang Province, China
- Zhejiang University Cancer Center, Hangzhou 310006, Zhejiang Province, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310006, Zhejiang Province, China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
- Institute of Organ Transplantation, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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Nutu A, Wilson M, Ross E, Joshi K, Sutcliffe R, Roberts K, Marudanayagam R, Muiesan P, Chatzizacharias N, Mirza D, Isaac J, Dasari BVM. Influence of middle hepatic vein resection during right or left hepatectomy on post hepatectomy outcomes. Ann Hepatobiliary Pancreat Surg 2022; 26:257-262. [PMID: 35599354 PMCID: PMC9428431 DOI: 10.14701/ahbps.21-159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/24/2022] [Accepted: 02/04/2022] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Middle hepatic vein (MHV) is usually preserved as a part of the right or left hepatectomy in order preserve the venous outflow of remnant liver. The aim of this study was to evaluate if resection of MHV could influence post-resection outcomes of standard right or left hepatectomy. Methods Patients who underwent standard right or left hepatectomy between January 2015 and December 2019 were included. Anatomical remnant liver volumes were measured retrospectively using the Hermes workstation (Hermes Medical Solutions AB, Stockholm, Sweden). Uni- and multi-variate analyses were performed to assess the difference in outcomes of those with preservation of MHV and those without preservation. Results A total of 144 patients were included. Right hepatectomy was performed for 114 (79.2%) and left hepatectomy was performed for 30 (20.8%) patients. MHV was resected for 13 (9.0%) in addition to the standard right or left hepatectomy. Median remnant liver volume was significantly higher in the MHV resected group (p < 0.01). There was no significant difference in serum level of bilirubin, international normalized ratio, alanine aminotransferase, creatinine on postoperative day 1, 3, 5, or 10, ≥ grade IIIa complications (p = 0.44), or 90-day mortality (p = 0.41). On multivariable analysis, resection of the MHV did not influence the incidence of post hepatectomy liver failure (p = 0.52). Conclusions Resection of the MHV at standard right or left hepatectomy did not have a negative impact on postoperative outcomes of patients with adequate remnant liver volume.
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Affiliation(s)
- Anisa Nutu
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Michael Wilson
- Department of Nuclear Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Erin Ross
- Department of Nuclear Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Kunal Joshi
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert Sutcliffe
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Keith Roberts
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Ravi Marudanayagam
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Paolo Muiesan
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Nikolaos Chatzizacharias
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius Mirza
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Bobby V. M. Dasari
- Department of Hepato-Biliary and Pancreatic and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
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Alarabiyat M, Raza SS, Isaac J, Mirza D, Marudanayagam R, Roberts K, Abradelo M, Bartlett DC, Dasari BV, Sutcliffe RP, Chatzizacharias NA. Incidental gallbladder cancer diagnosis confers survival advantage irrespective of tumour stage and characteristics. World J Gastroenterol 2022; 28:1996-2007. [PMID: 35664962 PMCID: PMC9150056 DOI: 10.3748/wjg.v28.i18.1996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/22/2022] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Incidental gallbladder cancer (IGBC) represents 50%-60% of gallbladder cancer cases. Data are conflicting on the role of IGBC diagnosis in oncological outcomes. Some studies suggest that IGBC diagnosis does not affect outcomes, while others that overall survival (OS) is longer in these cases compared to non-incidental diagnosis (NIGBC). Furthermore, some studies reported early tumour stages and histopathologic characteristics as possible confounders, while others not.
AIM To investigate the role of IGBC diagnosis on patients’ overall survival, especially after surgical treatment with curative intent.
METHODS Retrospective analysis of all patient referrals with gallbladder cancer between 2008 and 2020 in a tertiary hepatobiliary centre. Statistical comparison of patient and tumour characteristics between IGBC and NIGBC subgroups was performed. Survival analysis for the whole cohort, surgical and non-surgical subgroups was done with the Kaplan-Meier method and the use of log rank test. Risk analysis was performed with univariable and multivariable Cox regression analysis.
RESULTS The cohort included 261 patients with gallbladder cancer. 65% of cases had NIGBC and 35% had IGBC. A total of 90 patients received surgical treatment (66% of IGBC cases and 19% of NIGBC cases). NIGBC patients had more advanced T stage and required more extensive resections than IGBC ones. OS was longer in patients with IGBC in the whole cohort (29 vs 4 mo, P < 0.001), as well as in the non-surgical (14 vs 2 mo, P < 0.001) and surgical subgroups (29 vs 16.5 mo, P = 0.001). Disease free survival (DFS) after surgery was longer in patients with IGBC (21.5 mo vs 8.5 mo, P = 0.007). N stage and resection margin status were identified as independent predictors of OS and DFS. NIGBC diagnosis was identified as an independent predictor of OS.
CONCLUSION IGBC diagnosis may confer a survival advantage independently of the pathological stage and tumour characteristics. Prospective studies are required to further investigate this, including detailed pathological analysis and molecular gene expression.
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Affiliation(s)
- Moath Alarabiyat
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - Syed Soulat Raza
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - John Isaac
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - Darius Mirza
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - Ravi Marudanayagam
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - Keith Roberts
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - Manuel Abradelo
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - David C Bartlett
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - Bobby V Dasari
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - Robert P Sutcliffe
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham B15 2GW, United Kingdom
| | - Nikolaos A Chatzizacharias
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
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Exploration of the System-Level Mechanisms of the Herbal Drug FDY003 for Pancreatic Cancer Treatment: A Network Pharmacological Investigation. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:7160209. [PMID: 35591866 PMCID: PMC9113891 DOI: 10.1155/2022/7160209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/12/2022] [Indexed: 11/18/2022]
Abstract
Pancreatic cancer (PC) is the most lethal cancer with the lowest survival rate globally. Although the prescription of herbal drugs against PC is gaining increasing attention, their polypharmacological therapeutic mechanisms are yet to be fully understood. Based on network pharmacology, we explored the anti-PC properties and system-level mechanisms of the herbal drug FDY003. FDY003 decreased the viability of human PC cells and strengthened their chemosensitivity. Network pharmacological analysis of FDY003 indicated the presence of 16 active phytochemical components and 123 PC-related pharmacological targets. Functional enrichment analysis revealed that the PC-related targets of FDY003 participate in the regulation of cell growth and proliferation, cell cycle process, cell survival, and cell death. In addition, FDY003 was shown to target diverse key pathways associated with PC pathophysiology, namely, the PIK3-Akt, MAPK, FoxO, focal adhesion, TNF, p53, HIF-1, and Ras pathways. Our network pharmacological findings advance the mechanistic understanding of the anti-PC properties of FDY003 from a system perspective.
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226
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Bronswijk M, Jaekers J, Vanella G, Struyve M, Miserez M, van der Merwe S. Umbilical hernia repair in patients with cirrhosis: who, when and how to treat. Hernia 2022; 26:1447-1457. [PMID: 35507128 DOI: 10.1007/s10029-022-02617-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/09/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past. METHODS The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia. RESULTS Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances. CONCLUSION Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and cirrhosis.
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Affiliation(s)
- M Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium.,Imelda GI Clinical Research Center, Bonheiden, Belgium
| | - J Jaekers
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - G Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Struyve
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - S van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Laboratory of Hepatology, CHROMETA Department, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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227
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Bergquist JR, Shariq OA, Li AY, Worth PJ, Chatzizacharias N, Soonawalla Z, Athanasopoulos P, Toumpanakis C, Hansen P, Parks RW, Connor S, Parker K, Koea J, Srinivasa S, Ielpo B, Lopez EV, Norton JA, Lawrence B, Visser BC. Clinical features and postoperative survival in patients with sporadic versus multiple endocrine neoplasia type 1-related pancreatic neuroendocrine tumors: An international cohort study. Surgery 2022; 172:723-728. [PMID: 35577612 DOI: 10.1016/j.surg.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/19/2022] [Accepted: 04/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal surgical management of pancreatic neuroendocrine tumors in patients with multiple endocrine neoplasia type 1 is controversial. This study sought to compare clinicopathologic characteristics and outcomes of multiple endocrine neoplasia type 1-associated and sporadic pancreatic neuroendocrine tumors from a large multi-national database. METHODS A multi-institutional, international database of patients with surgically resected pancreatic neuroendocrine tumors was analyzed. The cohort was divided into 2 groups: those with multiple endocrine neoplasia type 1 versus those with sporadic disease. Clinicopathologic comparisons were made. Overall and disease-free survival were analyzed. Propensity score matching was used to reduce bias. RESULTS Of 651 patients included, 45 (6.9%) had multiple endocrine neoplasia type 1 and 606 sporadic pancreatic neuroendocrine tumors. Multiple endocrine neoplasia type 1-associated pancreatic neuroendocrine tumors were more common in younger patients and associated with multifocal disease at the time of surgery and higher T-stage. Lymph node involvement and the presence of metastasis were similar. Total pancreatectomy rate was 5-fold higher in the multiple endocrine neoplasia type 1 cohort. Median survival did not differ (disease-free survival 126 months multiple endocrine neoplasia type 1 vs 198 months sporadic, P > .5). After matching, survival remained similar (overall survival not reached in either cohort, disease-free survival 126 months multiple endocrine neoplasia type 1 vs 198 months sporadic, P > .5). Equivalence in overall survival and disease-free survival persisted even when patients who underwent subtotal and total pancreatectomy were excluded. CONCLUSION Multiple endocrine neoplasia type 1-associated pancreatic neuroendocrine tumors are more common in younger patients and are associated with multifocality and higher T-stage. Survival for patients with multiple endocrine neoplasia type 1-associated pancreatic neuroendocrine tumors is comparable to those with sporadic pancreatic neuroendocrine tumors, even in the absence of radical pancreatectomy. Consideration should be given to parenchymal-sparing surgery to preserve pancreatic function.
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228
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Sugumar K, Hurtado A, Naik I, Hue JJ, Rothermel LD, Ammori JB, Hardacre JM, Winter JM, Ocuin LM. Multimodal therapy with or without irreversible electroporation for unresectable locally advanced pancreatic adenocarcinoma: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:586-595. [PMID: 35000842 DOI: 10.1016/j.hpb.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/29/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) is used as a locoregional treatment modality for patients with locally advanced pancreatic cancer (LAPC), but is non-curative and is associated with postoperative morbidity and mortality. We performed a systematic review and meta-analysis comparing survival outcomes of multimodal therapy with or without IRE. METHODS Separate searches were performed for multimodal therapy + IRE and multimodal therapy alone given the lack of comparative literature using PubMed, SCOPUS, and Cochrane Library in 3/2021. We determined overall survival (OS) and progression-free survival (PFS) from diagnosis and time of IRE. Treatment-related morbidity and mortality was determined. RESULTS Of 585 published articles, 48 met inclusion criteria for IRE (n = 27) and without IRE (n = 21) with data for 1420 (IRE) and 1348 (without IRE) patients. The 6/12/24 months OS with IRE was 99%/84%/28%. The 6/12/24 months OS without IRE was 99%/80%/12%. At 12 months from IRE, OS was 55% and PFS was 12%. The mean major complication and 90-day mortality rates for IRE were 17.95% and 2.65%. CONCLUSION Multimodal therapy alone is associated with similar OS to multimodal therapy + IRE in patients with LAPC. Most patients progress and nearly half die within 1 year of the IRE procedure. Given the lack of quality prospective data, IRE should remain experimental and be used with caution in LAPC.
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Affiliation(s)
- Kavin Sugumar
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Alex Hurtado
- Case Western Reserve University School of Medicine and the Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Ilora Naik
- Case Western Reserve University School of Medicine and the Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Jonathan J Hue
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Luke D Rothermel
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - John B Ammori
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Jordan M Winter
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Lee M Ocuin
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA.
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Tazeoglu D, Esmer AC, Arslan B, Dag A. Did the COVID-19 Pandemic Affect the Management of Patients With Acute Appendicitis? Cureus 2022; 14:e24631. [PMID: 35664393 PMCID: PMC9152159 DOI: 10.7759/cureus.24631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 12/02/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has changed the lives and habits of people all over the world. In this study, it was planned to investigate the effect of the COVID-19 pandemic on the diagnosis and treatment duration of acute appendicitis (AA), morbidity and mortality. Methods The data of patients who were operated on with the diagnosis of AA in our clinic between March 2019 and March 2021, divided into pre-COVID and post-COVID periods, were analyzed. Patients diagnosed with AA, who had the only appendectomy perioperatively, and who had complete preoperative blood analysis and radiological imaging data were included in the study. Results The time from the onset of symptoms to the time of admission to the hospital was statistically significantly longer than in the post-COVID group (p=0.04). During the COVID-19 pandemic period, the use of ultrasonography was statistically significantly reduced (p<0.01); computed tomography use increased (p<0.001). Laparoscopic appendectomy as a surgical technique decreased statistically significantly during the pandemic period (p=0.02). Postoperative complications and the postoperative complication severity degrees were not statistically significant between periods (p=0.24, p=0.68). The risk for the occurrence of postoperative complications in COVID-19 positive patients was statistically higher (p=0.01) (OR: 9.38 95% CI: 1.96 - 44.88). Conclusion The COVID-19 pandemic had caused delays in the admission and diagnosis of patients who might need surgery due to AA. Postoperative complication frequency and complication severity classification were not affected. COVID-19 positivity was a risk factor for complex AA presenting with periappendicular abscess, gangrenous and perforated appendix.
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230
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Zhang X, Wang J, Wu B, Li T, Jin L, Wu Y, Gao P, Zhang Z, Qin X, Zhu C. A Nomogram-based Model to Predict Neoplastic Risk for Patients with Gallbladder Polyps. J Clin Transl Hepatol 2022; 10:263-272. [PMID: 35528981 PMCID: PMC9039700 DOI: 10.14218/jcth.2021.00078] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/14/2021] [Accepted: 06/02/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS Gallbladder polyp (GBP) assessment aims to identify the early stages of gallbladder carcinoma. Many studies have analyzed the risk factors for malignant GBPs. In this retrospective study, we aimed to establish a more accurate predictive model for potential neoplastic polyps in patients with GBPs. METHODS We developed a nomogram-based model in a training cohort of 233 GBP patients. Clinical information, ultrasonographic findings, and blood test findings were analyzed. Mann-Whitney U test and multivariate logistic regression analyses were used to identify independent predictors and establish the nomogram model. An internal validation was conducted in 225 consecutive patients. Performance and clinical benefit of the model were evaluated using receiver operating characteristic curves and decision curve analysis (DCA), respectively. RESULTS Age, cholelithiasis, carcinoembryonic antigen, polyp size, and sessile shape were confirmed as independent predictors of GBP neoplastic potential in the training group. Compared with five other proposed prediction methods, the established nomogram model presented better discrimination of neoplastic GBPs in the training cohort (area under the curve [AUC]: 0.846) and the validation cohort (AUC: 0.835). DCA demonstrated that the greatest clinical benefit was provided by the nomogram compared with the other five methods. CONCLUSIONS Our developed preoperative nomogram model can successfully be used to evaluate the neoplastic potential of GBPs based on simple clinical variables that maybe useful for clinical decision-making.
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Affiliation(s)
- Xudong Zhang
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
- Nanjing Medical University, Nanjing, Jiangsu, China
| | | | - Baoqiang Wu
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Tao Li
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Lei Jin
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Yong Wu
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Peng Gao
- Dalian Medical University, Dalian, Liaoning, China
| | - Zhen Zhang
- Dalian Medical University, Dalian, Liaoning, China
| | - Xihu Qin
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
- Nanjing Medical University, Nanjing, Jiangsu, China
- Correspondence to: Xihu Qin and Chunfu Zhu, Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, XingLong Road 29#, Changzhou, Jiangsu 213000, China. ORCID: https://orcid.org/0000-0002-4350-1679 (XQ), https://orcid.org/0000-0002-4363-5781 (CZ). Tel: +86-17301538687 (XQ) and 86-13961190702 (CZ), Fax: +86-0519-8811-5560, E-mail: (XQ) and (CZ)
| | - Chunfu Zhu
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
- Correspondence to: Xihu Qin and Chunfu Zhu, Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, XingLong Road 29#, Changzhou, Jiangsu 213000, China. ORCID: https://orcid.org/0000-0002-4350-1679 (XQ), https://orcid.org/0000-0002-4363-5781 (CZ). Tel: +86-17301538687 (XQ) and 86-13961190702 (CZ), Fax: +86-0519-8811-5560, E-mail: (XQ) and (CZ)
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231
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Wu D, Jin W, Zhang Y, An Y, Chen X, Chen W. Insights From the Analysis of Clinicopathological and Prognostic Factors in Patients With Gallbladder Cancer. Front Oncol 2022; 12:889334. [PMID: 35494009 PMCID: PMC9046570 DOI: 10.3389/fonc.2022.889334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/23/2022] [Indexed: 12/01/2022] Open
Abstract
Aims To investigate the clinical efficacy and prognostic factors of primary gallbladder cancer (GBC) treated by radical surgery. Methods The clinical and pathological data of 168 patients with primary gallbladder cancer admitted and treated in the Third Affiliated Hospital of Soochow University from January 1st, 2010 to December 31st, 2018 were analyzed retrospectively. Kaplan Meier method was used to draw the survival curve and evaluate the survival rate. Chi-square test was used for univariate analysis and binary logistic regression was used for multivariate analysis. Results 94 cases showed symptoms of abdominal pain and abdominal distension. 7 cases showed symptoms of fatigue and weight loss. Jaundice occurred in 10 patients. Fever occurred in 6 patients. 51 patients had no symptoms at all. The median survival time of 168 patients was 35.0 (1.0 ~ 142.0) months. The overall 1-, 2- and 3-year cumulative survival rates were 69.6%, 55.4% and 48.8% respectively. The univariate analysis indicated that preoperative bilirubin, tumor size, tumor location, pathological type, degree of differentiation, liver invasion, nerve invasion, vascular invasion, surgical margin, filtration depth and N staging were significant factors influencing prognosis of patients with primary GBC (P<0.05). The results of multivariate analysis demonstrated that degree of differentiation, nerve invasion, filtration depth and N staging were independent risk factors for prognosis of patients with primary GBC (P<0.05). Conclusion Patients with risk factors of gallbladder cancer should be more active in early cholecystectomy to avoid the malignant transformation of benign diseases. Degree of differentiation, nerve invasion, filtration depth and N staging were important factors for poor prognosis of patients with primary GBC. For T4 staging patients, preoperative evaluation should be more comprehensive, and patients and surgeons should be more prudent in adopting appropriate clinical treatment. The primary purpose should be prolonging the survival time and improving the quality of life.
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Affiliation(s)
| | | | | | | | | | - Weibo Chen
- *Correspondence: Weibo Chen, ; Xuemin Chen,
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232
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Snitkjær C, Jensen KK, Henriksen NA, Werge MP, Kimer N, Gluud LL, Christoffersen MW. Umbilical hernia repair in patients with cirrhosis: systematic review of mortality and complications. Hernia 2022; 26:1435-1445. [PMID: 35412192 DOI: 10.1007/s10029-022-02598-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Umbilical hernia is a common and potential serious condition in patients with cirrhosis. This systematic review evaluated the risks associated with emergency and elective hernia repair in patients with cirrhosis. METHODS Systematic review of clinical trials identified through manual and electronic searches in several databases (last update November 2021). The primary random-effects meta-analyses evaluated mortality in patients with or without cirrhosis or following emergency versus elective repair. The quality of the evidence was assessed using GRADE and Newcastle Ottawa Scale. RESULTS Thirteen prospective and 10 retrospective studies including a total of 3229 patients were included. The evidence was graded as very low quality for all outcomes (mortality and postoperative complications within 90 days). In total 191 patients (6%) died after undergoing umbilical hernia repair. Patients with cirrhosis were more than eight times as likely to die after surgery compared with patients without cirrhosis [OR = 8.50, 95% CI (1.91-37.86)] corresponding to 69 more deaths/1000 patients. Among patients with cirrhosis, mortality was higher after emergency versus elective repair [OR = 2.67, 95% CI (1.87-3.97)] corresponding to 52 more deaths/1000 patients. Postoperative complications were more common in patients with cirrhosis compared with patients without cirrhosis. CONCLUSION Patients with cirrhosis undergoing emergency umbilical hernia repair have a considerably increased risk of death and severe complications. Accordingly, additional evidence is needed to evaluate methods that would allow elective umbilical hernia repair in patients with cirrhosis.
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Affiliation(s)
- C Snitkjær
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.
| | - K K Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - N A Henriksen
- Abdominal Center, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M P Werge
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - N Kimer
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - L L Gluud
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - M W Christoffersen
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
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Risk factors for periappendiceal adhesions in acute appendicitis: a retrospective comparative study. BMC Surg 2022; 22:134. [PMID: 35392891 PMCID: PMC8991578 DOI: 10.1186/s12893-022-01579-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/23/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Acute appendicitis usually requires immediate surgical treatment, but appendectomies were difficult for some patients with severe periappendiceal adhesions. We investigated risk factors of intraoperative adhesions to help surgeons make better treatment plans for appendicitis. Methods We retrospectively analyzed 186 cases diagnosed with acute appendicitis and underwent surgery in Shandong Provincial Hospital affiliated to Shandong First Medical University between January 2018 and December 2019. According to the degree of intraoperative adhesions, they were divided into mild, moderate and severe groups. Then, we analyzed a number of preoperative factors contributed to adhesions, suppuration and perforation during appendectomy in 186 patients. Results Contrast to the moderate group (MoG) and the mild group (MiG), the severe degree of adhesions group (SG) had a higher intraoperative perforation and suppuration rate, a greater likelihood of conversion to open and more postoperative complications. Multivariable logistic regression analysis showed that recurrent appendicitis and high neutrophil percentage were independently associated with periappendiceal adhesions. The preoperative ultrasonography (US) revealed periappendiceal fluid and high neutrophil percentage were independently associated with appendix suppuration. A high preoperative neutrophil percentage was independently associated with appendix perforation. Conclusions Recurrent appendicitis and preoperative high neutrophil percentage were risk factors of periappendiceal adhesions; preoperative US revealed periappendiceal fluid and high neutrophil percentage were risk factors of appendix suppuration; and a high preoperative neutrophil percentage was a risk factor of appendix perforation.
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Sageshima J, Chandar J, Chen LJ, Shah R, Al Nuss A, Vincenzi P, Morsi M, Figueiro J, Vianna R, Ciancio G, Burke GW. How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond. Transplantation 2022; 106:709-721. [PMID: 34310100 DOI: 10.1097/tp.0000000000003888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.
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Affiliation(s)
- Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rushi Shah
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ammar Al Nuss
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Paolo Vincenzi
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rodrigo Vianna
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
- Division of Liver and GI Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - George W Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
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Xia J, Wang Z, Yang D, Li R, Liang G, Chen H, Heidari AA, Turabieh H, Mafarja M, Pan Z. Performance optimization of support vector machine with oppositional grasshopper optimization for acute appendicitis diagnosis. Comput Biol Med 2022; 143:105206. [PMID: 35101730 DOI: 10.1016/j.compbiomed.2021.105206] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/27/2021] [Accepted: 12/30/2021] [Indexed: 12/13/2022]
Abstract
Preoperative differentiation of complicated and uncomplicated appendicitis is challenging. The research goal was to construct a new intelligent diagnostic rule that is accurate, fast, noninvasive, and cost-effective, distinguishing between complicated and uncomplicated appendicitis. Overall, 298 patients with acute appendicitis from the Wenzhou Central Hospital were recruited, and information on their demographic characteristics, clinical findings, and laboratory data was retrospectively reviewed and applied in this study. First, the most significant variables, including C-reactive protein (CRP), heart rate, body temperature, and neutrophils discriminating complicated from uncomplicated appendicitis, were identified using random forest analysis. Second, an improved grasshopper optimization algorithm-based support vector machine was used to construct the diagnostic model to discriminate complicated appendicitis (CAP) from uncomplicated appendicitis (UAP). The resultant optimal model can produce an average of 83.56% accuracy, 81.71% sensitivity, 85.33% specificity, and 0.6732 Matthews correlation coefficients. Based on existing routinely available markers, the proposed intelligent diagnosis model is highly reliable. Thus, the model can potentially be used to assist doctors in making correct clinical decisions.
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Affiliation(s)
- Jianfu Xia
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Zhifei Wang
- Department of Hepatobiliary, Pancreatic and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Hangzhou, 310014, China.
| | - Daqing Yang
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Rizeng Li
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Guoxi Liang
- Department of Information Technology, Wenzhou Polytechnic, Wenzhou, 325035, China.
| | - Huiling Chen
- Department of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, 325035, China.
| | - Ali Asghar Heidari
- Department of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, 325035, China.
| | - Hamza Turabieh
- Department of Information Technology, College of Computers and Information Technology, Taif University, P.O. Box 11099, Taif, 21944, Taif, Saudi Arabia.
| | - Majdi Mafarja
- Department of Computer Science, Birzeit University, Birzeit, 72439, Palestine.
| | - Zhifang Pan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, PR China.
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Daamen LA, Dorland G, Brada LJH, Groot VP, van Oosten AF, Besselink MG, Bosscha K, Bonsing BA, Busch OR, Cirkel GA, van Dam RM, Festen S, Groot Koerkamp B, Haj Mohammad N, van der Harst E, de Hingh IHJT, Intven MPW, Kazemier G, Los M, de Meijer VE, Nieuwenhuijs VB, Roos D, Schreinemakers JMJ, Stommel MWJ, Verdonk RC, Verkooijen HM, Molenaar IQ, van Santvoort HC. Preoperative predictors for early and very early disease recurrence in patients undergoing resection of pancreatic ductal adenocarcinoma. HPB (Oxford) 2022; 24:535-546. [PMID: 34642090 DOI: 10.1016/j.hpb.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 07/02/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to identify predictors for early and very early disease recurrence in patients undergoing resection of pancreatic ductal adenocarcinoma (PDAC) resection with and without neoadjuvant therapy. METHODS Included were patients who underwent PDAC resection (2014-2016). Multivariable multinomial regression was performed to identify preoperative predictors for manifestation of recurrence within 3, 6 and 12 months after PDAC resection. RESULTS 836 patients with a median follow-up of 37 (interquartile range [IQR] 30-48) months and overall survival of 18 (IQR 10-32) months were analyzed. 670 patients (80%) developed recurrence: 82 patients (10%) <3 months, 96 patients (11%) within 3-6 months and 226 patients (27%) within 6-12 months. LogCA 19-9 (OR 1.25 [95% CI 1.10-1.41]; P < 0.001) and neoadjuvant treatment (OR 0.09 [95% CI 0.01-0.68]; P = 0.02) were associated with recurrence <3 months. LogCA 19-9 (OR 1.23 [95% CI 1.10-1.38]; P < 0.001) and 0-90° venous involvement on CT imaging (OR 2.93 [95% CI 1.60-5.37]; P < 0.001) were associated with recurrence within 3-6 months. A Charlson Age Comorbidity Index ≥4 (OR 1.53 [95% CI 1.09-2.16]; P = 0.02) and logCA 19-9 (OR 1.24 [95% CI 1.14-1.35]; P < 0.001) were related to recurrence within 6-12 months. CONCLUSION This study demonstrates preoperative predictors that are associated with the manifestation of early and very early recurrence after PDAC resection. Knowledge of these predictors can be used to guide individualized surveillance and treatment strategies.
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Affiliation(s)
- Lois A Daamen
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands; Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands.
| | - Galina Dorland
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands; Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Lilly J H Brada
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands; Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Vincent P Groot
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - A Floortje van Oosten
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands; Dept. of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marc G Besselink
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Koop Bosscha
- Dept. of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Bert A Bonsing
- Dept. of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Olivier R Busch
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Geert A Cirkel
- Dept. of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands; Dept. of Medical Oncology, Meander Medical Center, Amersfoort, the Netherlands
| | | | | | | | - Nadia Haj Mohammad
- Dept. of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | | | | | - Martijn P W Intven
- Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Geert Kazemier
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Maartje Los
- Dept. of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Vincent E de Meijer
- Dept. of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Daphne Roos
- Dept. of Surgery, Reinier de Graaf Group, Delft, the Netherlands
| | | | - Martijn W J Stommel
- Dept. of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C Verdonk
- Dept. of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Centre Utrecht, the Netherlands; Utrecht University, Utrecht, the Netherlands
| | - I Quintus Molenaar
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Hjalmar C van Santvoort
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands.
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Isolated Pancreatic Metastases of Renal Cell Cancer: Genetics and Epigenetics of an Unusual Tumour Entity. Cancers (Basel) 2022; 14:cancers14061539. [PMID: 35326690 PMCID: PMC8945920 DOI: 10.3390/cancers14061539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 03/14/2022] [Indexed: 12/16/2022] Open
Abstract
Isolated pancreatic metastases of renal cell carcinoma (isPMRCC) are a rare manifestation of metastatic renal cell carcinoma (mRCC) characterized by two peculiarities: (1). The definite or at least long-term exclusive occurrence of metastases in the pancreas and (2). an unusual low tumour aggressiveness with slow tumour progression and consecutive, good treatment results. According to current knowledge, the exclusive occurrence of pancreatic metastases is due to a highly specific and highly selective seed and soil mechanism, which does not allow metastases settlement outside the pancreas, and whose detailed genetic/epigenetic causes are not yet elucidated. Recent studies have shed light on some of the pathways involved for the protracted course of the disease and highlighted a special genetic profile (lack of loss of 9p, lower weight genome instability index, low frequency of BAP1 alterations, and a high frequency of PBRM1 loss), which deviates from the conventional mRCC profile. Finally, the question of the reasons for the long-term relative genetic stability of the involved cell clones, which is an essential prerequisite for a favourable prognosis, remains unanswered.
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238
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Bastiaenen VP, van Vliet JLP, de Savornin Lohman EAJ, Corten BJGA, de Jonge J, Kraima AC, Swank HA, van Acker GJD, van Geloven AAW, In 't Hof KH, Koens L, de Reuver PR, van Rossem CC, Slooter GD, Tanis PJ, Terpstra V, Dijkgraaf MGW, Bemelman WA. Safety and economic analysis of selective histopathology following cholecystectomy: multicentre, prospective, cross-sectional FANCY study. Br J Surg 2022; 109:355-362. [PMID: 35245363 PMCID: PMC10364776 DOI: 10.1093/bjs/znab469] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/12/2021] [Accepted: 12/22/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is ongoing debate concerning the necessity of routine histopathological examination following cholecystectomy. In order to reduce the pathology workload and save costs, a selective approach has been suggested, but evidence regarding its oncological safety is lacking. METHODS In this multicentre, prospective, cross-sectional study, all gallbladders removed for gallstone disease or cholecystitis were systematically examined by the surgeon for macroscopic abnormalities indicative of malignancy. Before sending all specimens to the pathologist, the surgeon judged whether histopathological examination was indicated. The main outcomes were the number of patients with hypothetically missed malignancy with clinical consequences (upper limit two-sided 95 per cent c.i. below 3:1000 considered oncologically safe) and potential cost savings of selective histopathological examination. RESULTS Twenty-two (2.19:1000) of 10 041 specimens exhibited malignancy with clinical consequences. In case of a selective policy, surgeons would have held back 7846 of 10041 (78.1 per cent) gallbladders from histopathological examination. Malignancy with clinical consequences would have been missed in seven of 7846 patients (0.89:1000, upper limit 95% c.i. 1.40:1000). No patient benefitted from the clinical consequences, while two were harmed (futile additional surgery). Of 15 patients in whom malignancy with clinical consequences would have been diagnosed, one benefitted (residual disease radically removed), two potentially benefitted (palliative systemic therapy), and four experienced harm (futile additional surgery). Estimated cost savings established by replacing routine for selective histopathological examination were €703 500 per 10 000 patients. CONCLUSION Selective histopathological examination following cholecystectomy is oncologically safe and could reduce pathology workload, costs, and futile re-resections.
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Affiliation(s)
- Vivian P Bastiaenen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jaap L P van Vliet
- Department of Surgery, Haaglanden Medical Centre, 2512 VA The Hague, The Netherlands
| | | | | | - Joske de Jonge
- Department of Surgery, Tergooi Hospital, 1213 XZ Hilversum, The Netherlands
| | - Anne C Kraima
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.,Department of Surgery, Albert Schweitzer Hospital, 3318 AT Dordrecht, The Netherlands
| | - Hilko A Swank
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.,Department of Surgery, Albert Schweitzer Hospital, 3318 AT Dordrecht, The Netherlands
| | - Gijs J D van Acker
- Department of Surgery, Haaglanden Medical Centre, 2512 VA The Hague, The Netherlands
| | | | - Klaas H In 't Hof
- Department of Surgery, Flevo Hospital, 1315 RA Almere, The Netherlands
| | - Lianne Koens
- Department of Pathology, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | | | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Centre, 5504 DB Veldhoven, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Valeska Terpstra
- Department of Pathology, Haaglanden Medical Centre, 2512 VA The Hague, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Alyhari Q, Ahmed F, Nasreldin M, Nikbakht HA, Alamin A, Al-Wageeh S, Ghabisha S, Al-Shami E, Mohammed F. Prehospital Delay and Its Associated Factors in Sudanese Patients Presenting With Acute Appendicitis at a Teaching Hospital. Cureus 2022; 14:e23036. [PMID: 35425682 PMCID: PMC9005156 DOI: 10.7759/cureus.23036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background Delayed prehospital presentation of acute appendicitis may increase the risk of perforation and other complications. This study investigated the prevalence of prehospital delay in the presentation of acute appendicitis, clinical features, and outcomes in Sudanese patients. Method A retrospective study conducted from January 2017 to December 2020 in a teaching hospital affiliated with Gezira University enrolled 191 patients with prehospital delay presentation of acute appendicitis (at least 48 hours from symptom onset). Patient characteristics, causative factors, primary treatment, and complication rate were gathered and analyzed. Result The mean age of the patients was 36.55 ± 16.3 years (range: 15-78 years), with 122 (64%) males and 69 (36%) females. Most cases of prehospital delay were misdiagnosed firstly as other diseases (n = 124, 65%). The physicians made misdiagnosis of acute appendicitis in 65 (53%) patients. Age less than 30 years, male gender, living in rural areas, and lower educational level are associated with a high incidence of prehospital delay presentation of acute appendicitis (p < 0.05). Most cases have appendicular mass (46%, p < 0.001). Wound infection was the most common postoperative complication (7.85%, p < 0.001). Conclusion The high incidence rate of prehospital delay presentation of acute appendicitis is associated with patients' age ofless than 30 years, male gender, living in a rural area, and lower educational level. With the high rate of misdiagnosed acute appendicitis, it is essential to increase the knowledge about the signs and symptoms of appendicitis among our physicians and health practitioners.
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240
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Claydon O, Down B, Kumar S. Patient Outcomes Related to In-Hospital Delays in Appendicectomy for Appendicitis: A Retrospective Study. Cureus 2022; 14:e23034. [PMID: 35419245 PMCID: PMC8994569 DOI: 10.7759/cureus.23034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background and objective In many hospitals, the availability of operating theatres and access to senior surgical and anaesthetic support diminish during night hours. Therefore, urgent surgery is sometimes postponed until the following morning rather than performed overnight, if it is judged to be safe. In this study, we aimed to determine if a delay in laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, correlated with worse patient outcomes. Our primary outcome was delayed discharge from the hospital. Our secondary outcomes were appendicitis severity, conversions, and postoperative complications. Methods We undertook a retrospective review of the medical records of patients who underwent laparoscopic appendicectomy for appendicitis at a UK district general hospital between 01/01/2018 and 30/08/2019. For each patient, clinical and demographic information, and time of hospital admission, surgery, and discharge were collected. Delayed discharge was defined as "time to discharge" >24 hours after surgery. Results A total of 446 patients were included in the study. In 137 patients (30.7%), "time to surgery" was under 12 hours; in 309 patients (69.3%) "time to surgery" was over 12 hours. Of note, 319 patients (71.5%) had a delayed discharge; 303 patients (67.9%) had complicated appendicitis, and 143 patients had severe appendicitis (32.1%). No statistically significant association between "time to surgery" and delayed discharge, appendicitis severity, conversion, or 30-day re-presentations was observed. Conclusion Time from admission to the start of appendicectomy did not affect patient outcomes. Short in-hospital delays in appendicectomy, such as an overnight delay, may be safe in certain patients and should be determined based on clinical judgement.
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241
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Sutton TL, Pommier RF, Mayo SC, Gilbert EW, Papavasiliou P, Babicky M, Gerry J, Sheppard BC, Worth PJ. Similar Outcomes in Minimally Invasive versus Open Management of Primary Pancreatic Neuroendocrine Tumors: A Regional, Multi-Institutional Collaborative Analysis. Cancers (Basel) 2022; 14:cancers14061387. [PMID: 35326539 PMCID: PMC8946133 DOI: 10.3390/cancers14061387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 11/16/2022] Open
Abstract
In pancreatic neuroendocrine tumors (PNETs), the impact of minimally invasive (MI) versus open resection on outcomes remains poorly studied. We queried a multi-institutional pancreatic cancer registry for patients with resected non-metastatic PNET from 1996−2020. Recurrence-free (RFS), disease-specific survival (DSS), and operative complications were evaluated. Two hundred and eighty-two patients were identified. Operations were open in 139 (49%) and MI in 143 (51%). Pancreaticoduodenectomy was performed in 77 (27%, n = 23 MI), distal pancreatectomy in 184 (65%, n = 109 MI), enucleation in 13 (5%), and total pancreatectomy in eight (3%). Median follow-up was 50 months. Thirty-six recurrences and 13 deaths from recurrent disease yielded 5-year RFS and DSS of 85% and 95%, respectively. On multivariable analysis, grade 1 (HR 0.07, p < 0.001) and grade 2 (HR 0.20, p = 0.002) tumors were associated with improved RFS, while T3/T4 tumors were associated with worse RFS (OR 2.78, p = 0.04). MI resection was not associated with RFS (HR 0.53, p = 0.14). There was insufficient mortality to evaluate DSS with multivariable analysis. Of 159 patients with available NSQIP data, incisional surgical site infections (SSIs), organ space SSIs, Grade B/C pancreatic fistulas, reoperations, and need for percutaneous drainage did not differ by operative approach (all p > 0.2). Nodal harvest was similar for MI versus open distal pancreatectomies (p = 0.16) and pancreaticoduodenectomies (p = 0.28). Minimally invasive surgical management of PNETs is equivalent for oncologic and postoperative outcomes.
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Affiliation(s)
- Thomas L. Sutton
- Department of Surgery, Division of General Surgery, Oregon Heath & Science University (OHSU), Portland, OR 97239, USA; (T.L.S.); (E.W.G.); (B.C.S.)
| | - Rodney F. Pommier
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Oregon Heath & Science University (OHSU), Portland, OR 97239, USA; (R.F.P.); (S.C.M.)
| | - Skye C. Mayo
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Oregon Heath & Science University (OHSU), Portland, OR 97239, USA; (R.F.P.); (S.C.M.)
| | - Erin W. Gilbert
- Department of Surgery, Division of General Surgery, Oregon Heath & Science University (OHSU), Portland, OR 97239, USA; (T.L.S.); (E.W.G.); (B.C.S.)
| | | | - Michele Babicky
- The Oregon Clinic, Center for Advanced Surgery, Portland, OR 97213, USA; (M.B.); (J.G.)
| | - Jon Gerry
- The Oregon Clinic, Center for Advanced Surgery, Portland, OR 97213, USA; (M.B.); (J.G.)
| | - Brett C. Sheppard
- Department of Surgery, Division of General Surgery, Oregon Heath & Science University (OHSU), Portland, OR 97239, USA; (T.L.S.); (E.W.G.); (B.C.S.)
| | - Patrick J. Worth
- Department of Surgery, Division of General Surgery, Oregon Heath & Science University (OHSU), Portland, OR 97239, USA; (T.L.S.); (E.W.G.); (B.C.S.)
- Correspondence: ; Tel.: +1-503-346-0243; Fax: +1-503-494-8884
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Morató O, Villamonte M, Sánchez-Velázquez P, Pueyo-Périz E, Grande L, Ielpo B, Rosso E, Anselmo A, Burdío F. KRAS Assessment Following ESMO Recommendations for Colorectal Liver Metastases. Is It Always Worth It? Healthcare (Basel) 2022; 10:healthcare10030472. [PMID: 35326950 PMCID: PMC8951263 DOI: 10.3390/healthcare10030472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Genetic evaluation is essential in assessing colorectal cancer (CRC) and colorectal liver metastasis (CRLM). The aim of this study was to determine the pragmatic value of KRAS on oncological outcomes after CRLM according to the ESMO recommendations and to query whether it is necessary to request KRAS testing in each situation. Methods: A retrospective cohort of 126 patients who underwent surgery for hepatic resection for CRLM between 2009 and 2020 were reviewed. The patients were divided into three categories: wild-type KRAS, mutated KRAS and impractical KRAS according to their oncological variables. The impractical (not tested) KRAS group included patients with metachronous tumours and negative lymph nodes harvested. Disease-free survival (DFS), overall survival (OS) and hepatic recurrence-free survival (HRFS) were calculated by the Kaplan–Meier method, and a multivariable analysis was conducted using the Cox proportional hazards regression model. Results: Of the 108 patients identified, 35 cases had KRAS wild-type, 50 cases had a KRAS mutation and the remaining 23 were classified as impractical KRAS. Significantly longer medians for OS, HRFS and DFS were found in the impractical KRAS group. In the multivariable analyses, the KRAS mutational gene was the only variable that was maintained through OS, HRFS and DFS. For HRFS (HR: 13.63; 95% confidence interval (CI): 1.35–100.62; p = 0.010 for KRAS), for DFS (HR: 10.06; 95% CI: 2.40–42.17; p = 0.002 for KRAS) and for OS (HR: 4.55%; 95% CI: 1.37–15.10; p = 0.013). Conclusion: Our study considers the possibility of unnecessary KRAS testing in patients with metachronous tumours and negative lymph nodes harvested. Combining the genetic mutational profile (i.e., KRAS in specific cases) with tumour characteristics helps patient selection and achieves the best prognosis after CRLM resection.
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Affiliation(s)
- Olga Morató
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Hospital del Mar, Medical Research Institute (IMIM), University Pompeu Fabra, 08003 Barcelona, Spain; (M.V.); (P.S.-V.); (E.P.-P.); (L.G.); (B.I.); (F.B.)
- Correspondence: ; Tel.: +34-93-2483000
| | - Maria Villamonte
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Hospital del Mar, Medical Research Institute (IMIM), University Pompeu Fabra, 08003 Barcelona, Spain; (M.V.); (P.S.-V.); (E.P.-P.); (L.G.); (B.I.); (F.B.)
| | - Patricia Sánchez-Velázquez
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Hospital del Mar, Medical Research Institute (IMIM), University Pompeu Fabra, 08003 Barcelona, Spain; (M.V.); (P.S.-V.); (E.P.-P.); (L.G.); (B.I.); (F.B.)
| | - Eva Pueyo-Périz
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Hospital del Mar, Medical Research Institute (IMIM), University Pompeu Fabra, 08003 Barcelona, Spain; (M.V.); (P.S.-V.); (E.P.-P.); (L.G.); (B.I.); (F.B.)
| | - Luís Grande
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Hospital del Mar, Medical Research Institute (IMIM), University Pompeu Fabra, 08003 Barcelona, Spain; (M.V.); (P.S.-V.); (E.P.-P.); (L.G.); (B.I.); (F.B.)
| | - Benedetto Ielpo
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Hospital del Mar, Medical Research Institute (IMIM), University Pompeu Fabra, 08003 Barcelona, Spain; (M.V.); (P.S.-V.); (E.P.-P.); (L.G.); (B.I.); (F.B.)
| | - Edoardo Rosso
- Unité des Maladies de l’Appareil Digestif et Endocrine, Department of Surgery and Robotics, Centre Hospitalier de Luxembourg, L-1210 Luxembourg, Luxembourg;
| | - Alessandro Anselmo
- HPB and Transplant Unit, Department of Surgery, Policlinico Tor Vergata, 00173 Rome, Italy;
| | - Fernando Burdío
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Hospital del Mar, Medical Research Institute (IMIM), University Pompeu Fabra, 08003 Barcelona, Spain; (M.V.); (P.S.-V.); (E.P.-P.); (L.G.); (B.I.); (F.B.)
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Papadakos SP, Petrogiannopoulos L, Pergaris A, Theocharis S. The EPH/Ephrin System in Colorectal Cancer. Int J Mol Sci 2022; 23:ijms23052761. [PMID: 35269901 PMCID: PMC8910949 DOI: 10.3390/ijms23052761] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/26/2022] [Accepted: 02/27/2022] [Indexed: 01/27/2023] Open
Abstract
The EPH/ephrin system constitutes a bidirectional signaling pathway comprised of a family of tyrosine kinase receptors in tandem with their plasma membrane-bound ligand (ephrins). Its significance in a wide variety of physiologic and pathologic processes has been recognized during the past decades. In carcinogenesis, EPH/ephrins coordinate a wide spectrum of pathologic processes, such as angiogenesis, vessel infiltration, and metastasis. Despite the recent advances in colorectal cancer (CRC) diagnosis and treatment, it remains a leading cause of death globally, accounting for 9.2% of all cancer deaths. A growing body of literature has been published lately revitalizing our scientific interest towards the role of EPH/ephrins in pathogenesis and the treatment of CRC. The aim of the present review is to present the recent CRC data which might lead to clinical practice changes in the future.
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Affiliation(s)
- Stavros P Papadakos
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Leonidas Petrogiannopoulos
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Alexandros Pergaris
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Stamatios Theocharis
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 157 72 Athens, Greece
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Yin B, Gao R, Xu Q, Wang X, Wu W. Surgical management for pancreatic neuroendocrine neoplasms with synchronous hepatic metastases: A literature review. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2021.100055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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McIntyre CA, Cohen NA, Goldman DA, Gonen M, Sadot E, O’Reilly EM, Varghese AM, Yu KH, Balachandran VP, Soares KC, D’Angelica MI, Drebin JA, Kingham TP, Allen PJ, Wei AC, Jarnagin WR. Induction FOLFIRINOX for patients with locally unresectable pancreatic ductal adenocarcinoma. J Surg Oncol 2022; 125:425-436. [PMID: 34719035 PMCID: PMC8933849 DOI: 10.1002/jso.26735] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Patients with locally advanced pancreatic adenocarcinoma (PDAC) receive induction chemotherapy with or without radiation, with the goal of R0 resection and improving survival. Herein, we evaluate the outcomes of patients who presented with Stage III PDAC and received induction FOLFIRINOX. METHODS An institutional database was queried for consecutive patients who received induction FOLFIRINOX for locally unresectable PDAC between 2010 and 2016. Clinical and radiographic parameters were assessed pre- and posttreatment, and clinical outcomes were evaluated. RESULTS There were 200 patients who met the inclusion criteria. The median number of cycles of FOLFIRINOX was 8, 70% (n = 140) received radiation, and 18% (n = 36) underwent resection. Median overall survival (OS) in resected patients was 36 months (95% confidence interval [CI]: 24-56), and this group had improved OS compared to patients that did not undergo resection (hazard ratio (95% CI): 0.41 (0.26-0.64), p < 0.001). Patients (n = 112) who did not progress on induction therapy but remained unresectable had a median OS of 23.9 months (95% CI: 21.1-25.4). CONCLUSION Nearly 20% of patients with locally advanced PDAC responded sufficiently to induction FOLFIRINOX to undergo resection, which was associated with improved OS compared to patients that did not undergo resection. Patients with stable disease who remain unresectable represent a group of patients with locally advanced PDAC who may benefit from optimization of additional nonoperative treatment.
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Affiliation(s)
- Caitlin A. McIntyre
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Noah A. Cohen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debra A. Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eran Sadot
- Department of Surgery, Rabin Medical Center, Tel Aviv, Israel
| | - Eileen M. O’Reilly
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anna M. Varghese
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth H. Yu
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vinod P. Balachandran
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kevin C. Soares
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael I. D’Angelica
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey A. Drebin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - T. Peter Kingham
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter J. Allen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alice C. Wei
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William R. Jarnagin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY,Corresponding Author, Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
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In-hospital delay of surgery increases the rate of complicated appendicitis in patients presenting with short duration of symptoms: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:3879-3886. [PMID: 35211772 DOI: 10.1007/s00068-022-01912-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Current practice allows for surgery for acute appendicitis to be delayed up to 24 h in the belief that there will be no increase in complicated appendicitis rates. We evaluated the combined effect of Patient Time (between symptom onset and hospital admission) and Hospital Time (between hospital admission and surgery) on the surgical outcome. We hypothesized that in patients with a short Patient Time, increased Hospital Times will be associated with a higher rate of complicated appendicitis, even in patients operated within 24 h. METHODS Retrospective evaluation of medical files of patients operated for acute appendicitis between 12/2006 and 12/2016. RESULTS Of 2749 patients with acute appendicitis included in this analysis, 818 (29.8%) were admitted with symptom onset the same day as admission, 577 (21.0%) reported symptom onset had started the previous day but less than 24 h before admission, and 1354 (49.3%) had over 24 h of symptoms. In patients with symptom onset the same day, a gradual increase in the rate of complicated appendicitis was noted with increasing Hospital Times (≤ 6 h-6.3%; 6-12 h-9.9%; 12-18 h-14.7%; and 18-24 h-12.7%; p = 0.017). In all other patients no differences in the rate of complicated appendicitis were noted as long as the patients were operated within 24 h of admission. CONCLUSION In patients with a short Patient Time, delaying operation is associated with an increased rate of complicated appendicitis and this group of patients should be prioritized for early surgery. CLINICAL TRIALS Study registered as ClinicalTrials.gov Identifier: NCT04689906 ( https://clinicaltrials.gov/ct2/show/NCT04689906?term=ashkenazi+itamar&draw=2&rank=2 ).
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Shen Z, Sun P, Jiang M, Zhen Z, Liu J, Ye M, Huang W. Endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy versus open appendectomy for acute appendicitis: a pilot study. BMC Gastroenterol 2022; 22:63. [PMID: 35152882 PMCID: PMC8842886 DOI: 10.1186/s12876-022-02139-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 02/03/2022] [Indexed: 12/28/2022] Open
Abstract
Background An increasing number of studies have shown the merits of endoscopic retrograde appendicitis therapy (ERAT) in diagnosing and treating acute uncomplicated appendicitis. However, no related prospective controlled studies have been reported yet. Our aim is to assess the feasibility and safety of ERAT in the treatment of acute uncomplicated appendicitis. Methods In this open-label, randomized trial, participants were randomly allocated to the ERAT group, laparoscopic appendectomy (LA) group and open appendectomy (OA) group. The primary outcome was the clinical success rate of the treatment. Intention-to-treat analysis was used in the study. Results The study comprised of 99 patients, with 33 participants in each group. The clinical success rate was 87.88% (29/33), 96.97% (32/33) and 100% (33/33) in the ERAT, LA and OA group, respectively. In the ERAT group, 4 patients failed ERAT due to difficult cannulation. In LA group, 1 patient failed because of abdominal adhesion. There were no significant differences among the three treatment groups regarding the clinical success rate (P = 0.123). The median duration of follow-up was 22 months. There were no significant differences (P = 0.693) among the three groups in terms of adverse events and the final crossover rate of ERAT to surgery was 21.21% (7/33). Conclusion ERAT can serve as an alternative and efficient method to treat acute uncomplicated appendicitis. Trial registration The study is registered with the WHO Primary Registry-Chinese Clinical Trial Registry (ChiCTR1900025812).
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Chang YJ, Chen LJ, Chang YJ. Did the severity of appendicitis increase during the COVID-19 pandemic? PLoS One 2022; 17:e0263814. [PMID: 35143582 PMCID: PMC8830628 DOI: 10.1371/journal.pone.0263814] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 01/23/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This study aimed to assess the severity of appendicitis during the coronavirus disease 2019 (COVID-19) pandemic, as patients with appendicitis may procrastinate seeking medical attention during the pandemic. METHODS Information on patients with appendicitis who were treated at the Taipei City Hospital during the COVID-19 pandemic (January 1, 2020 to June 30, 2020) was retrieved. Patients who were diagnosed with appendicitis and treated at the same hospital from January 1, 2019 to July 1, 2019 were designated as the control group. Multivariate logistic regression analysis was conducted to assess changes in the severity of appendicitis (at a 2-week interval) between the two groups. RESULTS We identified 307 (study group: 149; control group: 158) consecutive patients with appendicitis. The mean age was 46.2 +- 19.8 years. Between the two groups, there were no significant differences in age, sex, comorbidity, surgery type (laparoscopic or open appendectomy) or surgery time. The number of patients in the study group decreased between January 29, 2020 and April 21, 2020, which paralleled the period of spikes in the confirmed COVID-19 cases and restricted daily activities. The percentage of uncomplicated and complicated appendicitis (excluding mild appendicitis or normal appendix) in the study group increased between February 26 and March 10, as well as between April 8 and April 21. In the multivariate regression analysis, the odds of uncomplicated and complicated appendicitis increased in three bi-weeks for the study group but not in the control group. CONCLUSION The severity of acute appendicitis might increase during the COVID-19 pandemic, because patients with mild appendicitis (or abdominal pain) may hesitate to seek help.
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Affiliation(s)
- Yao-Jen Chang
- Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
| | - Li-Ju Chen
- University of Taipei, Taipei, Taiwan
- Department of Ophthalmology, HepingFuyou Branch, Taipei City Hospital, Taipei, Taiwan
| | - Yun-Jau Chang
- Department of General Surgery, National Taiwan University Hospital, Taipei, Taiwan
- Department of General Surgery, Zhong-Xing Branch, Taipei City Hospital, Taipei, Taiwan
- * E-mail:
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Implications of RAS Mutations on Oncological Outcomes of Surgical Resection and Thermal Ablation Techniques in the Treatment of Colorectal Liver Metastases. Cancers (Basel) 2022; 14:cancers14030816. [PMID: 35159083 PMCID: PMC8834154 DOI: 10.3390/cancers14030816] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Modern management of colorectal liver metastases (CRLM) requires a thorough knowledge of tumor biology and oncogenes mutations. RAS mutations are of paramount interest for the indication of targeted therapies and is increasingly considered as a negative prognostic factor for patients undergoing surgical resection or ablation for CRLM. Several studies discussed the results of specific technical considerations according to RAS mutational status on the oncological outcomes after surgical resection/ablation for CRLM. We reviewed the available data on the real impact of RAS mutations on the prognosis with special regard to the need of a tailored surgical (ablation) approach according to tumoral biology. Abstract Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related death. More than 50% of patients with CRC will develop liver metastases (CRLM) during their disease. In the era of precision surgery for CRLM, several advances have been made in the multimodal management of this disease. Surgical treatment, combined with a modern chemotherapy regimen and targeted therapies, is the only potential curative treatment. Unfortunately, 70% of patients treated for CRLM experience recurrence. RAS mutations are associated with worse overall and recurrence-free survival. Other mutations such as BRAF, associated RAS /TP53 and APC/PIK3CA mutations are important genetic markers to evaluate tumor biology. Somatic mutations are of paramount interest for tailoring preoperative treatment, defining a surgical resection strategy and the indication for ablation techniques. Herein, the most relevant studies dealing with RAS mutations and the management of CRLM were reviewed. Controversies about the implication of this mutation in surgical and ablative treatments were also discussed.
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Aryan M, McPhail J, Ravi S, Harris P, Allamneni C, Shoreibah M. Perioperative Transjugular Intrahepatic Portosystemic Shunt Is Associated With Decreased Postoperative Complications in Decompensated Cirrhotics Undergoing Abdominal Surgery. Am Surg 2022; 88:1613-1620. [PMID: 35113676 DOI: 10.1177/00031348211069784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Operative risk in patients with cirrhosis is related to the severity of liver disease and nature of procedure. Pre and postoperative portal decompression via transjugular intrahepatic portosystemic shunt (TIPS) are logical approaches to facilitate surgery and improve postoperative outcomes. We compared postoperative outcomes of decompensated cirrhotics undergoing abdominal surgery either with or without perioperative TIPS placement. METHODS We performed a retrospective review of 41 decompensated cirrhotic patients who had abdominal surgery from 2010-2019 at the University of Alabama at Birmingham. Patients were stratified based on having received either perioperative TIPS or no TIPS. Demographics, laboratory data, perioperative TIPS status and postoperative complications were compared between the 2 groups using Fisher exact test and Student 2 sample t-test. RESULTS Group 1 consisted of 28 patients who had TIPS procedure, with 21 being preoperative and 7 being postoperative. Group 2 had 13 patients who had abdominal surgery without TIPS. When compared to those with perioperative TIPS, patients without TIPS had a significantly increased incidence of postoperative ascites (33% vs 77%, P = .0026), infection (18% vs 54%, P = .028), and acute kidney injury (AKI) (14% vs 46%, P = .0485). Additionally, postoperative Model of End Stage Liver Disease Sodium score was significantly higher in patients without TIPS (22 ± 4.74) when compared to those who had TIPS (17.14 ± 5.48) (P = .009). DISCUSSION Perioperative TIPS placement in decompensated cirrhotics was associated with decreased postoperative ascites, infection, and AKI when compared to those without TIPS. Further studies are needed to validate our findings.
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Affiliation(s)
- Mahmoud Aryan
- Tinsley Harrison Internal Medicine Residency, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - James McPhail
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sujan Ravi
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Patrick Harris
- Division of Gastroenterology and Hepatology, Department of Medicine, 3989Baylor University, Houston, TX, USA
| | - Chaitanya Allamneni
- Division of Digestive Diseases, Department of Medicine, 1371Emory University, Atlanta, GA, USA
| | - Mohamed Shoreibah
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
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