Gallbladder cancer: surgical treatment, immunotherapy, and targeted therapy

Gallbladder cancer is a common type of biliary tract tumor. Optimal management for early stage cases typically involves radical excision as the primary treatment modality. Various surgical techniques, including laparoscopic, robotic, and navigational surgery, have demonstrated favorable clinical outcomes in radical gallbladder excision. Unfortunately, most patients are ineligible for surgical intervention because of the advanced stage of the disease upon diagnosis. Consequently, non-surgical interventions, such as chemotherapy, radiotherapy, immunotherapy, and targeted therapy, have become the mainstay of treatment for patients in advanced stages. This review focuses on elucidating various surgical techniques as well as advancements in immunotherapy and targeted therapy in the context of recent advancements in gallbladder cancer research.

No differences in long-term clinical outcomes and survival rate of navigation-assisted versus conventional primary mobile-bearing total knee arthroplasty: A minimum 10-year follow-up

PURPOSE

This study aimed to compare long-term clinical and radiographic outcomes and survival rates between navigation-assisted (NAV) total knee arthroplasty (TKA) and conventional (CON) TKA using a mobile-bearing insert.

METHODS

From May 2008 to December 2009, 45 and 63 mobile-bearing TKA patients were enroled in the CON- and NAV-TKA groups with 146.8 months follow-up, respectively. Clinical outcomes (Western Ontario and McMaster University Osteoarthritis Index and Knee Society Scores), radiographic outcomes (hip-knee-ankle [HKA], lateral distal femoral, medial proximal tibial, γ, and δ angles), and survivorship were compared between both groups.

RESULTS

The number of HKA angle outliers (more than 3 degrees or less than -3 degree) was significantly lower in the NAV-TKA group (24.4% vs. 9.5%, p = 0.036) than in the CON-TKA group. However, long-term clinical outcomes were similar between both groups. The cumulative survival rate (best-case scenario) was 98.3% in the CON-TKA group and 97.5% in the NAV-TKA group, with no significant difference between the groups (p = 0.883).

CONCLUSION

Long-term clinical outcomes and survival rates were similar between the two groups despite fewer outliers of postoperative lower-limb alignment in the NAV-TKA group. Excellent survival rates were observed in both groups using mobile-bearing inserts.

LEVEL OF EVIDENCE

Level IV, case series.

Lymphatic flow mapping during colon cancer surgery using indocyanine green fluorescence imaging

With the development of surgical technology, indocyanine green (ICG) fluorescence navigation systems may be useful in various areas of colorectal surgery, including tumor location confirmation, bowel perfusion, ureter identification, and lymph node mapping. This review provides an overview of the current status of ICG-based navigation surgery in colorectal surgery, emphasizing its role in lymphatic flow mapping. This state-of-the-art approach will allow for appropriate oncological surgeries in the field of colorectal cancer and improve the patient's prognosis.

Current Approaches to Salvage Surgery for Head and Neck Cancer: A Comprehensive Review

Salvage surgeries of head and neck cancer are often complicated and do not always show decent results. This type of procedure is tough on the patient, as many crucial organs can be affected. A long period of reeducation usually follows the surgery because of the need to rehabilitate functions such as speech or swallowing. In order to lighten the journey of the patients, it is important to develop new technologies and techniques to ease the surgery and limit its damages. This seems even more crucial since progress has been made in the past years, allowing more salvage therapy to take place. This article aims at showing the available tools and procedures for salvage surgeries, such as transoral robotic surgery, free-flap surgery, sentinel node mapping, and many others, that help the work of the medical team to operate or obtain a better understanding of the status of the cancer when taken in charge. Yet, the surgical procedure is not the only thing determining the outcome of the operation. The patient themself and their cancer history also play an important part in the care and must be acknowledged.

Comparison of Survival Rate and Outcomes Between Conventional and Navigation-Assisted Primary Total Knee Arthroplasty in Severe Varus Knees: A Minimum 10-Year Follow-Up

BACKGROUND

This study aimed to compare the long-term clinical and radiographic outcomes and survival rates between navigation-assisted (NAV) total knee arthroplasty (TKA) and conventional (CON) TKA in patients with preoperative severe varus deformity.

METHODS

From January 2005 to December 2011, 152 TKAs and 62 TKAs with preoperative hip-knee-ankle (HKA) angles more than 15° were enrolled in the CON-TKA and NAV-TKA group with 135.7 months follow-up. Clinical outcomes (Western Ontario and McMaster University Osteoarthritis Index and Knee Society Scores), radiographic outcomes (HKA, α, β, γ, and δ angles), and survivorship were compared between the groups.

RESULTS

The mean value of radiographic outcomes was not statistically different; however, outliers of the HKA angle were significantly higher in the CON-TKA group (18.4% versus 8.1%, P = .04). However, long-term clinical outcomes were similar between both groups. The cumulative survival rate was 96.1% in the CON-TKA group and 96.8% in the NAV-TKA group, with no difference between the groups (P = .962).

CONCLUSION

NAV-TKA showed fewer outliers in the HKA angle for severe preoperative varus deformity compared with CON-TKA. The long-term clinical outcomes and survival rates were similar between the 2 techniques. A survival rate of more than 96% was observed in both groups.

STUDY DESIGN

Level III, retrospective comparative study.

Novel Pedicle Navigator Based on Micro Inertial Navigation System (MINS) and Bioelectric Impedance Analysis (BIA) to Facilitate Pedicle Screw Placement in Spine Surgery: Study in a Porcine Model

STUDY DESIGN

A porcine model.

OBJECTIVE

The study aims to design a novel pedicle navigator based on micro-inertial navigation system (MINS) and bioelectrical impedance analysis (BIA) to assist place pedicle screw placement and validate the utility of the system in enhancing pedicle screw placement.

SUMMARY OF BACKGROUND DATA

The incidence of pedicle screw malpositioning in complicated spinal surgery is still high.Procedures such as computed tomography image-guided navigation, and robot-assisted surgery have been used to improve the precision of pedicle screw placement, but it remains an unmet clinical need.

METHODS

The miniaturized integrated framework containing MINS was mounted inside the hollow handle of the pedicle finder. The inner core was complemented by a high-intensity electrode for measuring bioelectric impedance. Twelve healthy male Wuzhishan minipigs of similar age and weight were used in this experiment and randomized to the MINS-BIA or freehand (FH) group. Pedicle screw placement was determined according to the modified Gertzbein-Robbins grading system on computed tomography images. An impedance detected by probe equal to the baseline value for soft tissue was defined as cortical bone perforation.

RESULTS

A total of 216 screws were placed in 12 minipigs. There were 15 pedicle breaches in the navigator group and 31 in the FH group; the detection rates of these breaches were 14 of 15 (93.3%) and 25 of 31 (80.6%), respectively, with a statistically significant difference between groups. The mean offsets between the planned and postoperatively measured tilt angles of the screw trajectory were 4.5° ± 5.5° in the axial plane and 4.8° ± 3.3° in the sagittal plane with the navigator system and 7.0° ± 5.1° and 7.7° ± 4.7°, respectively, with the FH technique; the differences were statistically significant.

CONCLUSION

A novel and portable navigator based on MINS and BIA could be beneficial for improving or maintaining accuracy while reducing overall radiation exposure.

Hepatectomy guided by indocyanine green fluorescent imaging for visualizing bile leakage (with video)

Using indocyanine green (ICG), a standard reagent used in liver function tests, bile leaks from exfoliated liver sections can be detected with higher sensitivity than naked‐eye observation. This presentation will introduce the technique of using ICG to detect bile leaks that cannot be detected by the naked eye.

C-Arm-Free Minimally Invasive Cervical Pedicle Screw Fixation (MICEPS): A Technical Note

A minimally invasive posterolateral approach designed to avoid the lateral misplacement of midcervical pedicle screws was reported, but there is no technical report that describes this technique without C-arm fluoroscopy. We report the results of a 2.5 years follow-up of a 62-year-old female patient with C4 metastatic breast cancer. The patient suffered from severe neck pain and impending quadriplegia for 2 months after radiation therapy. We performed C-arm-free minimally invasive cervical pedicle screw fixation (MICEPS). The patient was suc-cessfully treated with surgery, and her neck pain was well controlled. She had neither neurological deficits nor neck pain at the final (2.5-year) follow-up. C-arm-free MICEPS is a useful technique; in addition, the sur-geons and staff have no risk of radiation exposure, there is a reduced need for postoperative imaging, and a decreased revision rate can be expected with C-arm-free MICEPS.

Development of recognised position-guided navigation system

BACKGROUND

Previously, we developed an image-guided navigation system (IG-NS) incorporating augmented reality technology. Nevertheless, the system could still only aid the operator by presenting imagery and was short of achieving the goal of developing a real navigation system. Therefore, we developed a recognised position-guided navigation system (RP-NS) and herein reported the functionality and usefulness of this system in a phantom model for clinical applications.

METHODS

We developed RP-NS which was reconstructed by adding the positional recognition and instruction functions with the cautions by displaying the images on the monitor with a voice to the IG-NS. We evaluated accuracy of positional recognition and instruction functions using phantom model. By utilising the chronological recording of the tip position of the surgical apparatus, the surgical precision of the operators was assessed. Finally, the feasibility of improvements in surgical precision using this system was evaluated.

RESULTS

The RP-NS indicated an accuracy of the position recognition functions with an error of 2.7 mm. The surgeons could perform partial hepatectomies within mean value of 7.5% error as compared with calculated volume according to the instruction. Improvements in surgical precision using this system were obtained on the surgeons with different levels.

CONCLUSIONS

The RP-NS was highly effective as a navigation system owing to precise positional recognition and adequate instruction functions. Therefore, these results indicate that the use of this system may complement differences in proficiency, and numerically evaluate surgical skills and analyse tendencies of surgeons.

The Efficacy of Intraoperative Fluorescent Imaging Using Indocyanine Green for Cholangiography During Cholecystectomy and Hepatectomy

Purpose

Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy. Intraoperative indocyanine green (ICG) cholangiography is a safe and useful navigation modality for confirming the biliary anatomy. ICG cholangiography is expected to be a routine method for helping avoid bile duct injuries.

Patients and Methods

We examined 25 patients who underwent intraoperative cholangiography using ICG fluorescence. Two methods of ICG injection are used: intrabiliary injection (percutaneous transhepatic gallbladder drainage [PTGBD], gallbladder [GB] puncture and endoscopic nasobiliary drainage [ENBD]) at a dosage of 0.025 mg during the operation or intravenous injection with 2.5 mg ICG preoperatively.

Results

There were 24 patients who underwent laparoscopic cholecystectomy and 1 patient who underwent hepatectomy. For laparoscopic cholecystectomy, the average operation time was 127 (50–197) minutes, and estimated blood loss was 43.2 (0–400) g. The ICG administration route was intravenous injections in 12 cases and intrabiliary injection in 12 cases (GB injection: 3 cases, PTGBD: 8 cases, ENBD:1 case). The course of the biliary tree was able to be confirmed in all cases that received direct injection into the biliary tract, whereas bile structures were recognizable in only 10 cases (83.3%) with intravenous injection. The postoperative hospital stay was 4.6 (3–9) days, and no postoperative complications (Clavien–Dindo ≧IIIa) were observed. For hepatectomy, a tumor located near the left Glissonian pedicle was resected using a fluorescence image guide. Biliary structures were fluorescent without injury after resecting the tumor. No adverse events due to ICG administration were observed, and the procedure was able to be performed safely.

Conclusion

ICG fluorescence imaging allows surgeons to visualize the course of the biliary tree in real time during cholecystectomy and hepatectomy. This is considered essential for hepatobiliary surgery to prevent biliary tree injury and ensure safe surgery.

Indocyanine green administration a day before surgery may increase bile duct detectability on fluorescence cholangiography during laparoscopic cholecystectomy

BACKGROUND

The optimal indocyanine green (ICG) administration protocol for fluorescence cholangiography during laparoscopic cholecystectomy (LC) has yet to be determined.

METHODS

A prospective study including 20 cases of ICG fluorescence-navigated LC was conducted. Accordingly, the first 10 patients were administered 2.5 mg of ICG on the day of surgery after intubation (surgery-day group), while the remaining 10 consecutive patients were administered 0.25 mg/kg of ICG on the evening before surgery (one-day-before group). Fluorescence intensity (FI) of each tissue and FI ratios were then compared between both groups.

RESULTS

The median interval between observation and ICG administration was 27 minutes and 16 hours 24 minutes in the surgery-day and one-day-before group, respectively. Although FI values for the common bile duct (CBD), liver, and hepatoduodenal ligament (HDL) were significantly lower in the one-day-before group than in the surgery-day group, CBD- , 0.6-1.2 vs 2.5, 0.9 = -4.8; P < .001), and CBD-HDL contrast (1.7, 1.4-2.4 vs 2.3, 1.5-13.3; P = .038) were significantly higher in the one-day-before group than in the surgery-day group.

CONCLUSION

ICG administration a day before LC may offer better CBD background contrast compared to administration just prior to surgery.

Computer-assisted navigation in orbitofacial surgery

The purpose of this systematic review is to investigate the most common indications, treatment, and outcomes of computer-assisted surgery (CAS) in ophthalmological practice. CAS has evolved over the years from a neurosurgical tool to maxillofacial as well as an instrument to orbitofacial surgeries. A detailed and organized scrutiny in relevant electronic databases, journals, and bibliographies of the cited articles was carried out. Clinical studies with a minimum of two study cases were included. Navigation surgery, posttraumatic orbital reconstruction, computer-assisted orbital surgery, image-guided orbital decompression, and optic canal decompression (OCD) were the areas of interest. The search generated 42 articles describing the use of navigation in facial surgery: 22 on orbital reconstructions, 5 related to lacrimal sac surgery, 4 on orbital decompression, 2 articles each on intraorbital foreign body and intraorbital tumors, 2 on faciomaxillary surgeries, 3 on cranial surgery, and 2 articles on navigation-guided OCD in traumatic optic neuropathy. In general, CAS is reported to be a useful tool for surgical planning, execution, evaluation, and research. The largest numbers of studies and patients were related to trauma. Treatment of complex orbital fractures was greatly improved by the use of CAS compared with empirically treated control groups. CAS seems to add a favourable potential to the surgical armamentarium. Planning details of the surgical approach in a three-dimensional virtual environment and execution with real-time guidance can help in considerable enhancement of precision. Financial investments and steep learning curve are the main hindrances to its popularity.

Assessing the Intraoperative Risk of Esophageal Perforation during Anterior Cervical Spine Surgery: A Study Using Intraoperative Computed Tomography

Introduction

Using intraoperative computed tomography (iCT), we aimed to clarify the course of the esophagus and pharynx during anterior cervical spine surgery to estimate the risk of intraoperative injury.

Methods

Sixteen patients who underwent anterior cervical spine surgery with intraoperative CT for registration of a navigation system without release of blade retraction were included. To investigate the status of the retracted esophagus and pharynx, the distance between the nasogastric tube and center of the vertebra (NVD) was measured at each disc and vertebral level (C4-7) using axial CT. The location of the cricoid cartilage, which may affect the shift of the esophagus and pharynx, was noted. Presence or absence of contact between the esophagus and the edge of the surgical blade was investigated.

Results

The NVDs were 28.0, 28.3, 28.9, 27.2, 24.7, 19.9, and 13.8 mm at C4, C4/5, C5, C5/6, C6, C6/7, and C7, respectively; NVDs at C6/7 or more caudal levels were significantly shorter than those at C6 or more cranial levels (P < 0.001). The cricoid cartilage was observed at the C4-C5/6 level. Esophageal contact with the edge of the blade was observed in nine cases at C6 or more caudal levels.

Conclusions

The esophagus, which was placed at C6 or more caudal levels, was directly retracted by the blade. Nevertheless, the pharynx, which was placed at C6 or more cranial levels, was mostly retracted with the cricoid cartilage. Thus, the risk of direct esophageal injury was higher at C6 or more caudal levels than at cranial levels.

Novel navigation system by augmented reality technology using a tablet PC for hepatobiliary and pancreatic surgery

BACKGROUND

We previously developed an image-guided navigation system (IG-NS) using augmented reality technology for hepatobiliary and pancreatic (HBP) surgery. This system superimposed a 3D model onto a stereoscope-captured surgical field (i.e., the scope method). Unfortunately, this method requires an expensive stereoscope, surgeons have to shift their eyesight away from the surgical field, and the method has poor controllability. Therefore, an IG-NS using a tablet PC (i.e., the tablet method) was developed. The aim of the current study is to evaluate the efficiency of this novel method.

METHODS

We studied 9 patients, for whom a 3D model was created from computed tomography images. After registration was performed, the 3D model was superimposed onto the surgical field, which was captured by the tablet PC's camera.

RESULTS

The IG-NS could be applied with very little time lag. The visibility and controllability of the tablet method were superior to those of the scope method. It was especially useful in surgery for multiple metastatic liver carcinoma due to easy localization of the position of the carcinomas and vessels.

CONCLUSIONS

We successfully developed the tablet method and tested it in a clinical setting. This system may contribute to surgical efficacy and improve the educational effects.

Three-dimensional Navigation for Thoracoscopic Sublobar Resection Using a Novel Wireless Marking System

We developed a novel localization technique for small intrapulmonary lesions using radiofrequency identification (RFID) technology. Micro-RFID markers with nickel-titanium coils were designed to be placed from subsegmental bronchi to the peripheral parenchyma. In this preclinical study, thoracoscopic subsegmentectomy of a canine pseudotumor model was performed to demonstrate the feasibility and three-dimensional positional accuracy of the system. To recover subcentimeter pseudotumors, markers were bronchoscopically placed to determine the resection line: (1) next to the pseudotumor; (2) in the responsible subsegmental bronchi as the central margin; and (3) on the intersubsegmental plane as the lateral margin. Specific marker positions were located by wireless communication using a wand-shaped probe with a 30-mm communication range, with the distance to the marker indicated by gradual changes in sound pitch. Thirty-four markers were placed for 10 pseudotumors (14.6 mm from the pleura) in 10 canines. Three markers were placed at a mean distance of 5.5 mm from the pseudotumors, and 11 central and 20 lateral markers were placed at mean distances of 17.2 and 20.7 mm from the pseudotumors, respectively. Central markers (20.5 mm from the pleura) were detected within 16.0 seconds in 2.9-mm-diameter bronchi. All resection stumps were within 5.4 mm (range 2-8 mm) from each marker, and pseudotumors were removed with adequate surgical margins toward the central (11.5 mm; range 7-16 mm) and lateral (12.4 mm; range 9-17 mm) directions. RFID wireless markers provided precise three-dimensional positional information and are a potential viable alternative to conventional markers.

Total knee arthroplasty in vascular malformation

In Klippel-Trenaunay syndrome, vascular malformations are not only in skin and superficial soft tissues but also in deep tissues like muscles bones and joints. It is well documemted that these recurrent intraarticular bleeds can cause early arthritis and joint pain. Performing arthroplasty in such patients is difficult and fraught with complications. We describe such a case where navigated total knee arthroplasty was performed with success to avoid the problems of intra medullary alignment used in the presence of intra medullary vascular malformations. We also suggest certain measures when knee arthroplasty is considered in such patients.

A feasibility study of NIR fluorescent image-guided surgery in head and neck cancer based on the assessment of optimum surgical time as revealed through dynamic imaging

BACKGROUND

In order to minimize surgical stress and preserve organs, endoscopic or robotic surgery is often performed when conducting head and neck surgery. However, it is impossible to physically touch tumors or to observe diffusely invaded deep organs through the procedure of endoscopic or robotic surgery. In order to visualize and safely resect tumors even in these cases, we propose using an indocyanine green (ICG) fluorescence method for navigation surgery in head and neck cancer.

OBJECTIVE

To determine the optimum surgical time for tumor resection after the administration of ICG based on the investigation of dynamic ICG fluorescence imaging.

METHODS

Nine patients underwent dynamic ICG fluorescence imaging for 360 minutes, assessing tumor visibility at 10, 30, 60, 120, 180, and 360 minutes. All cases were scored according to near-infrared (NIR) fluorescence imaging visibility scored from 0 to 5.

RESULTS

Dynamic NIR fluorescence imaging under the HyperEye Medical System indicated that the greatest contrast in fluorescent images between tumor and normal tissue could be observed from 30 minutes to 1 hour after the administration of ICG. The optimum surgical time was determined to be between 30 minutes to 2 hours after ICG injection. These findings are particularly useful for detection and safe resection of tumors invading the parapharyngeal space.

CONCLUSION

ICG fluorescence imaging is effective for the detection of head and neck cancer. Preliminary findings suggest that the optimum timing for surgery is from 30 minutes to 2 hours after the ICG injection.