Laparoscopic gastrectomy for gastric cancer: A single cancer center experience

Objectives

Laparoscopic gastrectomy (LG) was challenging to most surgeons due to the two-dimensional view, difficult manipulations of the instruments, ergonomic discomfort, and the associated muscular spasm and effort. Technological advances with improved surgical experience, have made LG a more feasible and favorable approach for gastric cancer (GC) patients.

Material and Methods

LG was performed in 44 patients with GC between July 2015 to June 2022, in the Department of Surgical Oncology, Oncology Center, Mansoura University, Egypt, and we assessed the surgical outcomes of this approach as an initial experience of a single cancer center.

Results

Twenty-seven patients underwent laparoscopic distal gastrectomy, and seventeen underwent laparoscopic total gastrectomy. Two cases had combined resection. Operative time was 339.2 ± 76.73 min, while blood loss was 153.86 ± 57.51 mL. The patients were ambulant on postoperative day 0, oral intake was started within three days (range 1-5 days) and the hospital stay was six days (range 3-9 days).

Conclusion

LG for GC is a feasible approach for both early and advanced GC patients as it allows for adequate diagnosis of the peritoneal disease, meticulous dissection, and identification of the lymph nodes with minimal blood loss and decrease surgery-related problems and encourage the early patients' discharge from hospital and return to daily life activities.

Nipple Sparing Goldilocks Mastectomy, A New Modification of the Original Technique

Objective:

Although Goldilocks mastectomy offers good aesthetic outcomes. Removal of the nipple-areolar complex (NAC) often has a negative psychological impact. The objective of this study was to assess the feasibility and esthetic outcome of this technique with salvage of the NAC using a dermal pedicle.

Materials and Methods:

The study included female patients suffering from breast carcinoma with large and or ptotic breast. Patients were offered Goldilocks mastectomy. Those who were unfit for anesthesia, those with locally advanced or metastatic disease or those refusing the procedure were excluded.

Results:

Fifteen female patients (18 breasts) with a mean age of 51.6 years underwent Goldilocks breast reconstruction with a trial of NAC preservation. The mean body mass index was 39.1 kg/m2. More than half (56%) were cup C, while 44% were cup D. Seven cases (46.7%) showed grade II ptosis and 8 (53.3%) were grade III. The mean operative time was 168 minutes (range 130–240 minutes). NAC ischemic changes were noted in five cases; two (11%) were partial while three (17%) were total. Two cases (11%) suffered from flap loss and one of them was total. No locoregional recurrence or distant metastases were observed.

Conclusion:

The Goldilocks mastectomy with nipple preservation is an appealing and feasible option for a certain group of patients who have large-sized and/or ptotic breasts. Nevertheless, it is a time-consuming technique with relatively higher rates of flap and NAC complications. Further, studies are required with a larger number of cases and longer follow-up.

Surgical and Oncological Outcomes after Neoadjuvant Therapy for Non-Metastatic Gastric GISTs

Surgical resection with negative margins of non-metastatic gastric GISTs is considered the main therapeutic option in GISTs treatment. Neoadjuvant therapy with imatinib is associated with higher response rates in advanced GISTs. We reported 34 patients with non-metastatic gastric GISTs who underwent partial gastrectomy at the Oncology Center, Mansoura University, Egypt, after receiving a daily dose of 400 mg of imatinib as a neoadjuvant treatment in the period between October 2012 and January 2021. Twenty-two cases underwent open partial gastrectomy, and twelve cases had a laparoscopic partial gastrectomy. The median tumor size at diagnosis was 13.5 cm (range 9-26 cm) and the duration of neoadjuvant therapy was 10.91 months (range 4-12 months). Thirty-three patients had a partial response, while one patient showed progression of the disease on neoadjuvant treatment. Adjuvant therapy was conducted in 29 (85.3%) cases. Complications of neoadjuvant treatment were reported in seven cases in the form of gastritis, bleeding per rectum, fatigue, thrombocytopenia, neutropenia, and edema lower limbs. The disease-free survival (DFS) in this study was 34.53 months, and the overall survival (OS) was 37 months. Recurrence developed in two cases, gastric and peritoneal recurrence (25 and 48 months from the initial diagnosis, respectively). We have concluded that neoadjuvant treatment with imatinib for non-metastatic gastric GISTs is a safe and effective method for tumor downsizing and devitalization to allow minimally invasive and/or organ sparing surgery. Moreover, it decreases the risk of intraoperative tumor rupture and relapse, thus improving the oncological outcome of such tumors.

The Evaluation of a Cost-Effective Method for Tumour Marking Prior to Neo-Adjuvant Chemotherapy Using Silver Rods

Objective

The lack of objective documentation of pre-neoadjuvant chemotherapy (NAC) tumour margins is a major constraint in performing safe breast conserving surgery (BCS) in patients with breast cancer. Using a novel method of marking pre-NACT tumour margins with indigenous silver wire markers, this retrospective observational study attempted to assess the feasibility of safe BCS in breast cancer patients by performing excision wide of the marked pre-NACT margins.

Materials and Methods

This retrospective observational study was conducted on breast cancer patients who were attending our oncology centre between May, 2015 and April, 2022. All patients had received NAC followed by surgery as recommended by our multidisciplinary team. All the patients had a primary operable solitary breast cancer. We used radiopaque metallic rods made from silver to localize tumour margins prior to NAC.

Results

Sixty-four breast cancer patients were included; none had marker-related complications. Following NAC, BCS could be easily performed in 60 patients guided by the silver markers, which were used as temporary implants and removed during surgery. Only 2 patients were seen with positive margins and were converted to mastectomy.

Conclusion

Breast cancer localization using sterile silver markers before the initiation of NAC is safe, easy, inexpensive, and effective, causing no morbidity or significant pain to the patients.

Primary thyroid chondrosarcoma: a case report of an extremely rare malignancy

Introduction

There are different types of malignant tumors that can affect the thyroid gland where differentiated thyroid carcinomas (papillary and follicular) are the most common representing nearly 90% of cases. Non-epithelial malignancies were also reported to affect the thyroid gland particularly lymphomas and sarcomas that were reported in literature to range from 0.01 to 1.5% of thyroid carcinoma. Herein, we present a case with primary thyroid chondrosarcoma, an extremely rare malignancy of the thyroid gland.

Case presentation

We present a 79-year-old female patient complaining of hard thyroid swelling that was proved to be primary thyroid chondrosarcoma after histopathological assessment.

Conclusion

Chondrosarcoma of the thyroid gland is extremely rare either in the primary or metastatic setting. Although the prognosis is bad, surgery is the main line of treatment after early prompt diagnosis.

Laparoscopically Harvested Omental Flap for Immediate Total Breast Reconstruction; Lessons Learnt Through Ten-Year Experience in a Tertiary Oncology Center

Background. Most of the publications about Laparoscopically harvested omental flap after skin sparing mastectomy were case reports or case series. Most of them were designed for partial breast reconstruction and were lacking long-term follow-up for cosmetic results, oncologic safety, and detailed methodology. Our study aimed at highlighting the place of this method of reconstruction with long-term oncologic safety and cosmetic outcome. Methods. This study included 95 women who were candidates for skin-sparing mastectomy. Those with body mass index below 25 and above 40, those with omental resection or expected marked adhesions were excluded. All patients were consented to then undergo breast reconstruction using pedicled laparoscopically harvested omental flap. Results. The mean BMI was 34. The mean tumor size was 3.4 cm. The mean total operative time was 129 minutes. Inadequate volume occurred in 12 patients (13%). The mean total drainage output was 750 ml with 8.7% incidence of seroma. Partial breast envelop necrosis was encountered in 5 cases. Partial flap loss occurred in 2 patients. Fat necrosis occurred in 11 cases. Mastectomy and abdominal complications were accepted. Local recurrence was met in one patient and distant metastases occurred in 3 cases. 83.7% of patients expressed excellent and good aesthetic outcomes. Conclusion. When skin sparing mastectomy is chosen with suitable body mass index, laparoscopically harvested omental flap is a very safe and attractive option for total breast reconstruction with a minimal donor site morbidity, satisfactory cosmetic outcome with no compromise of the oncologic safety.

Laparoscopic Partial Gastrectomy for Large Gastric GISTs

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are considered the most common mesenchymal tumors in the gastrointestinal tract and the stomach is the most frequently site affected (50-60%). The safety and feasibility of laparoscopic surgery for gastric GISTs of sizes larger than 5 cm remains unclear. It depends on the surgical skills, tumor location, and the learning curve of the surgeons.

METHODS

Between December 2013 and January 2021, 30 patients diagnosed with gastric GISTs underwent laparoscopic partial gastrectomy. This is a retrospective study done in Surgical Oncology unit, Oncology Center, Mansoura University, Egypt.

RESULTS

The most common tumor location was in the greater curvature in (46.7%). The mean tumor size was 9.5 cm (range 5-17 cm). All of the patients underwent laparoscopic partial gastrectomy. Associated splenectomy was done for only one patient. The mean operative time was 152.67 min and the estimated blood loss (EBL) was 139.33 ml. The mean hospital stay was 3.53 days. The mean follow-up period was 32.4 months.

CONCLUSION

Laparoscopic resection for gastric GISTs has become a feasible method. Patients with large tumors have the same favorable outcomes as small tumors. Large-sized GISTs may receive neoadjuvant therapy to downstage the disease and make it amenable for laparoscopic resection.

Sentinel lymph node biopsy in breast cancer guided by CT lymphography; History, evolution and current applications

Sentinel lymph node biopsy (SLNB) has efficiently replaced axillary lymph node dissection (ALND) in axillary staging in node-negative breast cancer patients. Dual sentinel lymph node (SLN) localization using radioisotopes and blue dye is the standard technique for SLN mapping. Yet, nuclear medicine facilities are not widely available worldwide. In Japan, Computed tomography lymphography (CTLG) is presented as an SLN mapping technique which was first suggested in 2003 by Suga et al. Multiple subsequent studies confirmed the efficacy of CTLG in SLN mapping in breast cancer. Further applications of the technique followed; such as prediction of SLN metastasis using CTLG, the use of CTLG guided SLN biopsy after neoadjuvant therapy, video-assisted CTLG guided SLN biopsy, the use of real-time virtual sonography with 3-D CTLG, and preoperative localization of the CTLG mapped SLN using either real-time virtual sonography (RVS) guided Indocyanine green (ICG) injection or its marking using liquid charcoal and silver wire and the use of SPIO enhanced magnetic resonance imaging (MRI) for prediction of metastasis in SLNs detected by CTLG. This efficacy and variable applications open the door for conducting wide-scale randomized controlled trials to suggest using CTLG as an efficient alternative for the use of radioisotopes in SLN mapping in breast cancer patients, especially in low and middle-income countries.

Multicentric adrenocorticotropic hormone -producing steroid cell tumor of the fallopian tube & broad ligament in a 15 year old girl

Steroid cell tumors occur usually in the ovaries with very few reported cases of extra-ovarian origin. Our patient was a fifteen year old female, complaining from secondary amenorrhea and voice deepening. Values of serum cortisol, DHEA, FSH & LH were normal. Serum Testosterone was elevated while ACTH-pm was markedly elevated. MRI described bilateral solid para-ovarian masses. Exploration revealed two bilateral tubal extraluminal cysts & a right broad ligament cyst which were all excised. Pathological examination led to the diagnosis of steroid cell tumor. Serum testosterone & ACTH returned to normal levels after surgery with subsequent regression of the virilizing symptoms. We can conclude that extra-ovarian steroid cell tumors are extremely rare. They are usually presented with virilizing symptoms and hormonal abnormalities. Surgery is the main line of treatment.

Safety and Efficacy of Using Staplers and Vessel Sealing Devices for Laparoscopic Splenectomy: A Randomized Controlled Trial

Background. Laparoscopic splenectomy (LS) is considered the operation of choice on elective basis for managing patients with certain hematological disorders. Hemostatic control of the splenic pedicle is one of the crucial steps in LS. This study compares the safety and efficacy of using endoscopic staplers and vessel sealing devices to control the splenic pedicle in patients with nonsevere splenomegaly. Methods. Fifty-one consecutive patients with different blood disorders including idiopathic thrombocytopenic purpura (ITP), hypersplenism, and lymphoma were randomized for elective LS. Traditional steps of LS, via lateral approach, were followed, and pedicle control was done with either endovascular gastrointestinal anastomosis stapler (n = 26) or vessel sealing device (Ligasure) (n = 25). Results. No difference was noted with different splenic spans when using either methods of pedicle control (P = .145). The volume of blood loss was higher in the Ligasure group compared to the staplers group (182 mL vs 131 mL, respectively), but was not statistically significant (P = .249). Conversion to open was notably higher in the Ligasure group (P = .034), but the intraoperative complications were comparable in both groups (P = .357). Conclusion. The use of vessel sealing devices for splenic pedicle control has comparable surgical outcomes compared with the use of endoscopic staplers for LS, but with higher rate of conversion to open surgery.

Preoperative localization of sentinel lymph node in breast cancer patients by silver wire insertion or liquid charcoal injection guided by CT lymphography

Dual localization of SLN in breast cancer patients using isotope & dye is the best-approved modality with limitations such as high cost of radioactive materials, complex logistic preparations & scheduling issues, especially in developing countries. We investigated the feasibility & accuracy of a novel technique for SLN localization using silver wire insertion or liquid charcoal injection guided by CT lymphography. 120 patients with clinically node-negative breast cancer were enrolled. In the test group, SLN was localized using preoperative CTLG guided injection of liquid charcoal or by placing a 3 cm silver wire. In addition, intraoperative SLN mapping was performed using methylene blue dye followed by searching for the SLN localized by both methods. In the control group, SLN was localized by the blue dye only. Feasibility, accuracy, detection rates, and number of SLNs retrieved were reported as well as matching between the LN detected with the CTLG and that detected with the dye technique. SLN could be detected in 59 out of 60 patients (98.3%) in the test group and in 54 out of 60 patients (90%) in the control group (P = .057). In self-controlled analysis of the test group comparing CTLG only to dye only was significant (P = .050). Comparing charcoal to silver wire in detection was statistically insignificant (P = .5). This novel method can offer advantages which are as follows: being more accurate than the dye alone, saving operative time, abandoning complex logistic preparations for the radioisotope, and solving the problem of timing.

Complete Mesocolic Excision With Central Vascular Ligation in Comparison With Conventional Surgery for Patients With Colon Cancer - The Experiences at Two Centers

Purpose

Revolutions have occurred over the last 3 decades in the management of patients with colorectal cancer. Most advances were in rectal cancer surgery, especially after the introduction of the total mesorectal excision (TME) by Heald. However, no parallel advances regarding colon cancer surgeries have occurred. In 2009, Hohenberger introduced a new concept trying to translate the survival advantages of TME to patients with colon cancer. This relatively new concept of a complete mesocolic excision (CME) with central vascular ligation (CVL) in the management of patients with colon cancer represents an evolution in operative technique. We performed a comparative study between CME with CVL and conventional surgery for patients with colon cancer at Italian and Egyptian cancer centers, considering surgical quality and clinical outcome.

Methods

Seventy-nine Egyptian patients underwent conventional surgery (non-CME group) while 52 Italian patients underwent CME with sharp dissection between the embryological planes and CVL of the supplying vessels (CME group).

Results

Significantly better results were observed in terms of lymph node yield (CME group: 22.5 vs. non-CME group: 12; P < 0.0001) and lymph node ratio (CME group: 0.03 vs. non-CME group: 0.22; P < 0.0001). Regarding surgical morbidity, no significant difference was noted (CME group: 2 vs. non-CME group: 5; P < 0.702).

Conclusion

CME appears to be a safe procedure when performed by experienced hands through proper embryological planes. It also provides a superior specimen, with a higher lymph node yield, which consequently affects the lymph node ratio. Eventually, CME with CVL should be increasingly adopted and studied more deeply.

Propensity score-matched comparison between complete mesocolic excision and classic right hemicolectomy for colon cancer

BACKGROUND

The prognosis of right colon cancer remains disappointing. Complete mesocolic excision (CME) with central vascular ligation (CVL), based on the same oncological principles of total mesorectal excision, has been speculated to result in a better outcome. To evaluate the oncological adequacy of CME with CVL, we carried out a comparative study with propensity score-matched analysis between two different surgical procedures performed at Italian and Egyptian University cancer centers.

METHODS

Forty-six Egyptian patients underwent conventional right hemicolectomy, while eighty-eight Italian patients underwent CME with sharp dissection between the embryological planes, exposure of the superior mesenteric vessels with extended lymphadenectomy, and CVL.

RESULTS

All operations were successful with no increase in postoperative complications (10% in the patients undergoing CME vs. 19.5% in Egyptian patients). Number of harvested nodes (21 vs. 13) and lymph node ratio (0.08 vs. 0.22) were significantly different in patients undergoing CME (P=0.0001 and P=0.005, respectively). In these patients, the risk of cancer relapse was reduced to as much as one third (8% vs. 22%), even in node-positive tumors, and locoregional recurrences were never experienced. The classic operation was significantly associated with poor outcome (5-year disease-free survival rates were 89.2% in the group undergoing CME and 49.1% in the classic group, P=0.02). Propensity score-matched analysis warranted optimal balance and confirmed overall results.

CONCLUSIONS

Right colon cancer patients undergoing CME benefitted from more oncological adequacy, with no increased postoperative complication rate, a decreased locoregional recurrence rate, and a better long-term outcome than patients operated on with the conventional procedure.

Standardizing the Protocols for Enhanced Recovery From Colorectal Cancer Surgery: Are We a Step Closer to Ideal Recovery?

PURPOSE

Enhanced recovery protocols are being implemented into the standard of care in surgical practice. This study aimed to insert a steadfast set of elements into the perioperative care pathway to establish an improved recovery program for colorectal cancer patients.

METHODS

Seventy patients planned for elective laparoscopic colorectal resection were randomized into 2 groups: conventional recovery group (n = 35) and enhanced recovery group (n = 35). The primary outcome was the length of hospital stay. Secondary outcomes included the times of removal of nasogastric tubes (NGTs), successful enteral feeding, and removal of drains, postoperative complications, intra-hospital mortality, and rate of readmission.

RESULTS

The mean postoperative hospital stay was 4.49 ± 0.85 days vs. 13.31 ± 6.9 days (P < 0.001), the mean time of removal of NGTs was 0.77 ± 1.031 days vs. 3.26 ± 2.737 days (P < 0.001), the mean time of successful enteral feeding was 1.89 ± 1.13 days vs. 5.46 ± 1.67 days (P < 0.001), and the mean time for removal of intra-abdominal drains was 2.94 ± 1.056 days vs. 9.06 ± 3.757 days (P < 0.001) for the enhanced and the conventional groups, respectively. Complications were significantly lower among patients in the enhanced group (25.7% vs. 65.7%) (P = 0.001). The rates of readmission were similar in the 2 groups.

CONCLUSION

Applying definite evidence-based elements to the colorectal rehabilitation program significantly boosts the recovery pathway with favorable outcomes, including faster recovery of gastrointestinal tract functions, lower morbidities, and eventually earlier discharge from the hospital.

Outcome of pectoralis major myomammary flap for post-mastectomy breast reconstruction: extended experience

BACKGROUND

In the past decade there has been an enormously expanding interest among rural Egyptian patients, relatives, and treating oncologists in post-mastectomy reconstruction as an integral part of patient care. We introduced our technique of pectoralis major myomammary cutaneous flap for single-stage reconstruction of large breasts, nipple, and areola.

METHODS

The new technique is based on performing modified radical mastectomy in the classic manner, and then using a pectoralis major myocutaneous pedicled flap from the other side in breast reconstruction. The flap is based on the pectoral branch of the thoracoacromial artery, and a sector from the medial part of the healthy breast with its overlying skin and a part of the nipple-areola complex is included with the flap. This technique was used in our center in one 118 patients, with very promising results.

RESULTS

Major flap necrosis was not observed in patients treated with this technique, and there were no local recurrences observed during the follow-up period. Excellent cosmetic results were achieved in 49 of the 118 (41.5%) cases.

CONCLUSION

We recommend this new technique as a single-stage, simple solution for reconstruction of large breasts after mastectomy.