Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

A deep LSTM network for the Spanish electricity consumption forecasting

Nowadays, electricity is a basic commodity necessary for the well-being of any modern society. Due to the growth in electricity consumption in recent years, mainly in large cities, electricity forecasting is key to the management of an efficient, sustainable and safe smart grid for the consumer. In this work, a deep neural network is proposed to address the electricity consumption forecasting in the short-term, namely, a long short-term memory (LSTM) network due to its ability to deal with sequential data such as time-series data. First, the optimal values for certain hyper-parameters have been obtained by a random search and a metaheuristic, called coronavirus optimization algorithm (CVOA), based on the propagation of the SARS-Cov-2 virus. Then, the optimal LSTM has been applied to predict the electricity demand with 4-h forecast horizon. Results using Spanish electricity data during nine years and half measured with 10-min frequency are presented and discussed. Finally, the performance of the proposed LSTM using random search and the LSTM using CVOA is compared, on the one hand, with that of recently published deep neural networks (such as a deep feed-forward neural network optimized with a grid search) and temporal fusion transformers optimized with a sampling algorithm, and, on the other hand, with traditional machine learning techniques, such as a linear regression, decision trees and tree-based ensemble techniques (gradient-boosted trees and random forest), achieving the smallest prediction error below 1.5%.

Coronavirus Optimization Algorithm: A Bioinspired Metaheuristic Based on the COVID-19 Propagation Model

This study proposes a novel bioinspired metaheuristic simulating how the coronavirus spreads and infects healthy people. From a primary infected individual (patient zero), the coronavirus rapidly infects new victims, creating large populations of infected people who will either die or spread infection. Relevant terms such as reinfection probability, super-spreading rate, social distancing measures, or traveling rate are introduced into the model to simulate the coronavirus activity as accurately as possible. The infected population initially grows exponentially over time, but taking into consideration social isolation measures, the mortality rate, and number of recoveries, the infected population gradually decreases. The coronavirus optimization algorithm has two major advantages when compared with other similar strategies. First, the input parameters are already set according to the disease statistics, preventing researchers from initializing them with arbitrary values. Second, the approach has the ability to end after several iterations, without setting this value either. Furthermore, a parallel multivirus version is proposed, where several coronavirus strains evolve over time and explore wider search space areas in less iterations. Finally, the metaheuristic has been combined with deep learning models, to find optimal hyperparameters during the training phase. As application case, the problem of electricity load time series forecasting has been addressed, showing quite remarkable performance.

[Liver transplantation: development, learning curve and results after the first 300 cases]

BACKGROUND

Liver transplantation (LT) is an option for people with liver failure who cannot be cured with other therapies and for some people with liver cancer.

AIM

To describe, and analyze the first 300 LT clinical results, and to establish our learning curve.

MATERIAL AND METHODS

Retrospective cohort study with data obtained from a prospectively collected LT Program database. We included all LT performed at a single center from March 1994 to September 2017. The database gathered demographics, diagnosis, indications for LT, surgical aspects and postoperative courses. We constructed a cumulative summation test for learning curve (LC-CUSUM) using 30-day post-LT mortality. Mortality at 30 days, and actuarial 1-, and 5-year survival rate were analyzed.

RESULTS

A total of 281 patients aged 54 (0-71) years (129 women) underwent 300 LT. Ten percent of patients were younger than 18 years old. The first, second and third indications for LT were non-alcoholic steatohepatitis, chronic autoimmune hepatitis and alcoholic liver cirrhosis, respectively. Acute liver failure was the LT indication in 51 cases (17%). The overall complication rate was 71%. Infectious and biliary complications were the most common of them (47 and 31% respectively). The LC-CUSUM curve shows that the first 30 patients corresponded to the learning curve. The peri-operative mortality was 8%. Actuarial 1 and 5-year survival rates were 82 and 71.4%, respectively.

CONCLUSIONS

Outcome improvement of a LT program depends on the accumulation of experience after the first 30 transplants and the peri-operative mortality directly impacted long-term survival.

Incidental versus non-incidental gallbladder cancer: index cholecystectomy before oncologic re-resection negatively impacts survival in T2b tumors

BACKGROUND

Conflicting data exists whether non-oncologic index cholecystectomy (IC) leading to discovery of incidental gallbladder cancer (IGBC) negatively impacts survival. This study aimed to determine whether a subgroup of patients derives a disadvantage from IC.

METHODS

Patients with IGBC and non-IGBC treated at an academic USA and Chilean center during 1999-2016 were compared. Patients with T1, T4 tumor or preoperative jaundice were excluded. T2 disease was classified into T2a (peritoneal-side tumor) and T2b (hepatic-side tumor). Disease-specific survival (DSS) and its predictors were analyzed.

RESULTS

Of the 196 patients included, 151 (77%) had IGBC. One hundred thirty-six (90%) patients of whom 118 (87%) had IGBC had T2 disease. Three-year DSS rates were similar between IGBC and non-IGBC for all patients. However, for T2b patients, 3-year survival rate was worse for IGBC (31% vs 85%; p = 0.019). In multivariate analysis of T2 patients, predictors of poor DSS were hepatic-side tumor hazard ratio [HR], 2.9; 95% CI, 1.6-5.4; p = 0.001) and N1 status (HR, 2.4; 95% CI, 1.6-3.6; p < 0.001).

CONCLUSIONS

Patients with T2b gallbladder cancer specifically benefit from a single operation. These patients should be identified preoperatively and referred to hepatobiliary center.

Optimal surgical treatment in patients with T1b gallbladder cancer: An international multicenter study

BACKGROUND

There is no consensus on the optimal treatment of T1b gallbladder cancer (GBC) due to the lack of evidence and the difficulty of anatomy and pathological standardization.

METHODS

A total of 272 patients with T1b GBC who underwent surgical resection at 14 centers with specialized hepatobiliary-pancreatic surgeons and pathologists in Korea, Japan, Chile, and the United States were studied. Clinical outcomes including disease-specific survival (DSS) rates according to the types of surgery were analyzed.

RESULTS

After excluding patients, the 237 qualifying patients consisted of 90 men and 147 women. Simple cholecystectomy (SC) was performed in 116 patients (48.9%) and extended cholecystectomy (EC) in 121 patients (51.1%). The overall 5-year DSS was 94.6%, and it was similar between SC and EC patients (93.7% vs. 95.5%, P = 0.496). The 5-year DSS was similar between SC and EC patients in America (82.3% vs. 100.0%, P = 0.249) as well as in Asia (98.6% vs. 95.2%, P = 0.690). The 5-year DSS also did not differ according to lymph node metastasis (P = 0.688) or tumor location (P = 0.474).

CONCLUSIONS

SC showed similar clinical outcomes (including recurrence) and survival outcomes as EC; therefore, EC is not needed for the treatment of T1b GBC.

A case report of pulmonary coinfection of Strongyloides stercoralis and Pneumocystis jiroveci

A case of pulmonary coinfection by Strongyloides stercoralis and Pneumocystis jiroveci has been detected in an AIDS patient treated in the Respiratory Intensive Care Unit of the Muñiz Hospital. At diagnosis, the patient presented cough with mucopurulent expectoration, dyspnea, fever, bilateral pulmonary infiltrates on the chest X-ray, negative bacilloscopy for acid fast bacteria and a CD4(+) T lymphocytes count of 52 cells/µL. The microbiological diagnosis was achieved by microscopic observation of the respiratory secretions obtained by bronchoalveolar lavage, while the wet mount examination revealed rhabditiform and filariform larvae of the nematode and foamy exudates, pathognomonic of the pulmonary pneumocystosis. It was the unique case of this association among about 3 000 samples performed in our laboratory in the last 10 years and diagnosed by microscopy. Other complementary stains (a rapid modification of Grocott, Kinyoun and Giemsa) were applied to the smears after the diagnosis of mycotic and parasitary infections achieved by fresh microscopy. Both physicians and microbiologists should take into account the possible coexistence of respiratory pathogens in immunocompromised patients, such as those with AIDS.

[Eccrine angiomatous hamartoma: a report of 2 cases]

Eccrine angiomatous hamartoma is a rare, benign tumor characterized by a proliferation of eccrine and vascular structures. We present 2 cases and review the characteristics of this disorder. The first patient was a 33-year-old woman who consulted for a brownish lesion on her back associated with local hyperhidrosis. The second patient was a 25-year-old man with an asymptomatic erythematous lesion on his left palm. In both patients a diagnosis of eccrine angiomatous hamartoma was made based on the histological findings. Eccrine angiomatous hamartoma is usually present at birth or develops during childhood. It is typically a solitary lesion and signs and symptoms can vary; diagnosis is therefore based on histological study. The most common site is on the distal parts of limbs. The lesions tend to be asymptomatic, but there may be associated pain and hyperhidrosis. Treatment is not usually necessary except in cases with persistent symptoms, excessive sweating, or cosmetic concerns.

Case report 798: Recurrent chondromyxoid fibroma in connective tissue of leg

In summary, this is a case of recurrent CMF in soft tissue, 17 years after the diagnosis of the initial lesion. The literature concerning this entity is reviewed and the histological and radiological patterns are considered. The causative factors are evaluated and the prognosis is discussed.

Renal cell carcinoma with acrometastasis: report of two cases and review of the literature

Metastases to the small bones of the hands and feet are rare. Although acrometastasis is usually a late manifestation of disseminated disease, it may be the primary manifestation of an occult carcinoma. Clinically it may be confused with benign disease and be treated improperly. We report two cases of renal cell carcinoma metastatic to the distal phalanx of a finger in Case 1 and the proximal phalanx of a toe in Case 2. The lesion was discovered following trauma in Case 1. In Case 2 there was no history of trauma. These acrometastases were the first evidence of metastatic disease in these two patients who had undergone a nephrectomy for Stage II renal cell carcinoma 2 yr and 1 yr prior to the development of acrometastases, respectively. Additional visceral metastases developed over the following months in Case 1, and the patient expired 7 mo after the discovery of the acrometastasis. In Case 2, the acrometastasis was the only site of metastases, and the patient is alive and well without evidence of disease as of the latest follow-up in January 1990. Review of the literature, including our cases, revealed 22 cases of renal cell carcinoma metastatic to the bones of the hand, nine cases to the bones of the foot, and three cases to the bones of both hand and foot. The clinical characteristics, pathogenetic mechanisms, and treatment are reviewed.