The use of the da Vinci Xi robot system in colorectal cancer resections - why is it worth it?

<b>Introduction:</b> Surgery using robotic systems is taking over an increasingly wider field of open surgery and laparoscopy. Recently, this is particularly visible in colorectal surgery, where the advantages include better insight into the hard-to-reach area of the surgical field. Limited access to this method and relatively high costs remain a problem. </br></br> <b>Aim:</b> The aim of the work is to present the results of the introduction of robotic surgery at the regional Oncology Center in Wielkopolska in the field of safety and feasibility and the early oncological results for robotic colorectal surgery. </br></br> <b> Materials and methods:</b> From March 6, 2019 to the end of 2019, we performed 66 robotic colorectal procedures: 54 anterior resections of the sigmoid colon/rectum, 6 right hemicolectomies, 3 left hemicolectomies, 2 abdominoperineal resections, and one Hartmann's procedure. </br></br> <b> Results:</b> The final histopathological examination of all operated patients confirmed the complete resection (R0 procedure). The average age was 64 years and the average duration of surgery was 199 ± 52 min. None of the robotic procedures required conversion to open surgery or laparoscopy once they had started. The average hospitalization time was 6 ± 1 days, including patients with complications. Complications occurred in 8 patients, with the most common being anastomotic leak - 4 (6%). </br></br> <b>Conclusions:</b> The use of the latest da Vinci Xi robot system is a safe and effective alternative to open and laparoscopic surgery. Colorectal surgery confirms its special advantage in the case of low anterior resections of the rectum. Increasing the availability of equipment and training will allow expanding the scope of operations, including upper gastrointestinal tract.

Intramural gastric hematoma imitating a gastrointestinal stromal tumor - case report and literature review

The article presents a case report of a patient with an intramural gastric hematoma. Diagnostic examinations were suggestive of a suspected gastrointestinal stromal tumor Normal image was observed in gastroscopic examination while abdominal CT scan revealed a nodular lesion along the greater curvature of the stomach extending from the posterior wall and adjoining the pancreas and the spleen. The patient was qualified for surgical treatment. Laparotomy was performed followed by total gastric resection and Roux-en-Y reconstruction of the gastrointestinal tract. Post-operative histopathological examination revealed the presence of an extensive hematoma penetrating the perigastric fat tissue along with numerous hemosiderinophages and segmental indicators of formation of inflammatory granulation tissue suggestive of a chronic nature of the lesion. Immunohistochemical GIST assays (CD117, DOG-1, CD34, CD31, SMA, S-100, CKAE1/AE3, Ki-67) were negative. No complications were observed in the post-operative course. Patient is subject to continued follow-up and observation. Follow-up gastroscopy and abdominal CT scan performed 6 months after the surgery revealed an unremarkable image.

mRNA expression of steroidogenic enzymes, steroid hormone receptors and their coregulators in gastric cancer

Epidemiological and experimental findings suggest that the development of gastric cancer (GC) is regulated by steroid hormones. In postmenopausal women and older men, the majority of steroid hormones are produced locally in peripheral tissue through the enzymatic conversion of steroid precursors. Therefore, using reverse transcription-quantitative polymerase chain reaction analysis, the mRNA expression of genes encoding steroidogenic enzymes, including steroid sulfatase (STS), hydroxy-delta-5-steroid dehydrogenase 3 beta- and steroid delta-isomerase 1 (HSD3B1), 17β-hydroxysteroid dehydrogenase type 7 and aromatase (CYP19A1), was investigated in primary tumoral and adjacent healthy gastric mucosa from 60 patients with GC. Furthermore, the mRNA levels for estrogen receptor α, estrogen receptor β (ESR2) and androgen receptor (AR), along with their coregulators, including proline, glutamate and leucine rich protein 1, CREB binding protein, nuclear receptor coactivator 1 (NCOA1), nuclear receptor corepressor 1 (NCOR1) and nuclear receptor subfamily 2 group F member 1 (NR2F1), were investigated. Additionally, the association between the mRNA expression of these genes and the clinicopathological features of patients with GC was examined. Significantly decreased levels of STS, HSD3B1, ESR2, AR, NCOA1 and NCOR1 mRNA, in addition to significantly increased levels of CYP19A1 mRNA were demonstrated in tumoral tissue samples compared with adjacent healthy gastric tissue samples. Deregulated expression of these genes in the analyzed tissue samples was associated with certain clinicopathological features of GC, such as age and localization of the tumor. The results of the current study suggest that all of the genes analyzed are expressed in tumoral and adjacent healthy gastric mucosa. In addition, the results indicate that abnormal expression of STS, ESR2, AR, NCOA1 and NCOR1 may serve a role in the development and progression of GC, and may be associated with specific clinicopathological features in patients with GC.

Analysis Of Risk Factors Of Positive Peritoneal Cytology In Patients Treated For Gastric Cancer--Preliminary Report

Presence of free gastric cancer cells in the peritoneal cavity of patients who underwent surgical treatment for gastric cancer is a negative prognostic factor and caused rapid disease recurrence, manifested as peritoneal metastases. Positive peritoneal cytology despite lack of visible peritoneal metastases was regarded as M1 class in the TNM classification (7th edition) in 2010. The aim of the study was to analyze factors associated with positive peritoneal cytology and identify groups of patients in whom diagnostic laparoscopy plus peritoneal lavage in the diagnostic process could affect therapeutic decisions.

MATERIAL AND METHODS

The study enrolled patients with gastric cancer who underwent surgical treatment at the Department of Surgery, Wielkopolskie Oncology Center in Poznań. During the laparotomy, after opening of the peritoneal cavity, 200 ml of physiological saline at 37 °C was administered in the tumor region. After this fluid was mixed, 100 ml of lavage fluid was collected. This fluid was subsequently spun many times to obtain sediment for cytology and immunohistochemistry investigation using anti-BerEp-4, CK 7/20, and B72.3. Results of peritoneal cytology were analyzed jointly with clinical factors--patient's age, sex and pathology factors--tumor invasion, involvement of lymph nodes, histological grade, histological type according to Lauren and localization of the cancer in the stomach.

RESULTS

Analysis of the peritoneal fluid for presence of free cancer cells was done in 51 patients. Positive peritoneal cytology was found in 12 (23.5%) patients. In the group of patients with positive cytology, all patients had T3/T4 tumors and all were found to have lymph node metastases, while G3 cancer was found in 83.3% of patients. In patients with positive cytology, diffuse gastric cancer according to Lauren predominated (9 of 12 patients, 75%), while in patients with negative cytology--intestinal type (20 of 39 patients, 51.2%). In the group of patients with positive histology, the whole stomach was involved by the cancer process in 7 of 12 patients (58.3%), while in the group with negative histology, in 29 of 39 patients the tumor was located in the gastric body and prepyloric part (74.4%).

CONCLUSIONS

Based on this study we can conclude that determinants of positive peritoneal cytology include: tumor stage T3/T4, N+, G3, cancer located in the whole stomach, diffuse histological type according to Lauren.

The pharmacokinetics of oral ketoprofen in patients after gastric resection

BACKGROUND

Total and partial gastric resection may affect the pharmacokinetics of drugs, especially orally administered a few days after surgery. Ketoprofen is a non-steroidal anti-inflammatory drug (NSAID) broadly used to treat postoperative pain, including patients after gastric resection. The aim of the research was to analyse the pharmacokinetics (PK) of orally administered ketoprofen in patients after gastrectomy.

METHODS

The research was carried out on two groups of patients after total (TG; Roux-Y procedure) and partial (PG; Billroth II procedure) gastrectomy. The patients in group TG (n=15; mean [SD] age 61.86 [14.15] years; and BMI 24.20 [3.73] kg/m²) and group PG (n=5; mean [SD] age 62.40 [16.80] years; and BMI 23.98 [3.45] kg/m²) received ketoprofen in a single oral dose of 100mg. The measurement of ketoprofen plasma concentrations was made by means of the HPLC (high performance liquid chromatography) method.

RESULTS

The PK parameters in group TG and PG were as follows: maximum plasma concentration (C_max), 3.42 [0.99] and 4.66 [0.81] mg/l (p=0.0220); area under the plasma concentration-time curve from zero to infinity (AUC_0-∞), 9.12 [2.78] and 9.17 [2.87] mg×h/ml (p=0.9734); area under the first moment curve from zero to the time of infinity (AUMC_0-∞), 25.95 [8.52] and 26.53 [11.43] mg×h²/l (p=0.9056); time to reach maximum concentration (t_max), 0.47 [0.25] and 0.55 [0.27] h (p=0.5327), respectively.

CONCLUSIONS

Lower concentrations of ketoprofen in patients after gastrectomy suggest that it might be necessary to apply higher dose of the analgesic.

Comparison of Lymphatic System Staging Classifications in Patients with Gastric Cancer

Despite an observed decrease in the incidence of gastric cancer, it still remains an important clinical problem. It is the fourth most common cancer in the world and the second cause of death in cancer patients. The quality of lymphadenectomy procedure and the number of analysed lymph nodes are both important factors influencing the treatment of the patient. The aim of the study was to compare the lymph node ratio staging system with the 6th and 7th edition of the TNM classification.

MATERIAL AND METHODS

A group consisting of 493 patients who underwent surgery in 1998-2010 due to gastric cancer was used to compare the staging systems. Following statistical analysis, the following cut-off points were adopted for the lymph node ratio for the purpose of comparison: 0, from 0.05 to 0.3, from 0.3 to 0.5 and over 0.5. Subsequently the homogeneity (using chi-square test for linear trend) and the predictive value of the different classifications (using Akaike information criterion) were assessed in order to compare the lymph node ratio staging system with the 6th and 7th edition of the TNM classification.

RESULTS

The lymph node ratio classification has a higher discriminatory value than the TNM classifications (higher linear trend result). What is more, the lymph node ratio classification (LNR) had a lower Akaike information criterion value, which means that it has a higher prognostic value than the other classifications. ROC curves and the area under the curve (AUC) were utilised for the analysis of predictive value of the different classifications in patients with gastric cancer.

CONCLUSION

One may conclude, therefore, that the lymph node ratio staging system is the best classification of the lymphatic system in the presented group of patients.

Transcript level of AKR1C3 is down-regulated in gastric cancer

Steroid hormones have been shown to play a role in gastric carcinogenesis. Large amounts of steroid hormones are locally produced in the peripheral tissues of both genders. Type 5 of 17β-hydroxysteroid dehydrogenase, encoded by the AKR1C3 gene, plays a pivotal role in both androgen and estrogen metabolism, and its expression was found to be deregulated in different cancers. In this study we measured AKR1C3 transcript and protein levels in nontumoral and primary tumoral gastric tissues, and evaluated their association with some clinicopathological features of gastric cancer (GC). We found decreased levels of AKR1C3 transcript (p < 0.0001) and protein (p = 0.0021) in GC tissues compared with the adjacent, apparently histopathologically normal, mucosa. Lower levels of AKR1C3 transcript were observed in diffuse and intestinal types of GC, whereas AKR1C3 protein levels were decreased in tumors with multisite localization, in diffuse histological type, T3, T4, and G3 grades. We also determined the effect of the histone deacetylase inhibitor sodium butyrate (NaBu) on AKR1C3 expression in EPG 85-257 and HGC-27 GC cell lines. We found that NaBu elevates the levels of both AKR1C3 transcript and protein in the cell lines we investigated. Together, our results suggest that decreased expression of AKR1C3 may be involved in development of GC and can be restored by NaBu.

Analysis of sentinel lymph node biopsy results in colon cancer in regard of the anthropometric features of the population and body composition assessment formulas

Purpose

The aim of the study was to assess sentinel lymph node biopsy (SLNB) results in colon cancer (CC) regarding basic anthropometric features of the studied population and their derivatives calculated using mathematical formulas.

Methods

One hundred three SLNBs in CC have been analysed. Various indicators were calculated for every patient using mathematical formulas: BMI, Roher’s index, lean body weight, body fat percentage and body weight/ideal body weight for a given height ratios using the following formulas: Broca’s, Broca’s ideal weight, Broca–Brugsch, Lorenz’s, Potton’s, Devine’s, Robinson’s, Miller’s and Hamwi. The results were compared with accuracy, sensitivity and false negative results percentage by means of ROC curves and the test for structure indicators (for determined cut-off points).

Results

No statistically significant relationship between the results and patients' sex or age were found. ROC curve analysis did not reveal statistically significant relationships between the obtained results and indicators calculated on the basis of growth and weigh (all p > 0.05). The analyses of sensitivity and accuracy with determined cut-off point, in spite of differences amounting to 19 % (analysis of lean body weight/weight ratio), showed no statistical significance for any of the relationships (all p > 0.05).

Conclusions

No indicator with high diagnostic and prognostic value has been found. The problem of qualifying patients for SLNB in CC in regard of the anthropometric features of the population and body composition assessment formulas remains open and requires further analysis on larger populations.

The clinical importance of micrometastases within the lymphatic system in patients after total gastrectomy

BACKGROUND

In spite of radical gastrectomy with resection of the lymphatic system, where no metastases are found during histopathological examination, about 30% of patients have relapse of the neoplastic process. This situation may be caused by micrometastases or isolated neoplastic cells in the lymphatic system which were not identified during a standard histopathological examination.

AIM

The aim of the study was to evaluate the clinical importance of micrometastases within the lymphatic system in patients with gastric cancer.

MATERIALS AND METHODS

A group of 20 patients treated for gastric cancer were subjected to retrospective analysis. Of all the patients who underwent surgery, a group with tumours classified as T1 or T2 was selected. No metastases within the lymphatic system were found in the standard evaluation - N0 mark. Paraffin-embedded blocks of lymph nodes were cut and new specimens were made, which were then stained again by means of immunohistochemistry. Antibodies against cytokeratin AE1/AE3 were used.

RESULTS

A total of 319 lymph nodes were assessed in 20 patients in an H + E examination. After the immunohistochemical examination, micrometastases within the lymphatic system were found in 4 (20%) patients and isolated neoplastic cells in other 4 (20%) patients.

CONCLUSION

On the basis of numerous publications and our own material, we think that the presence of micrometastases may be related to a worse prognosis. The clinical importance of micrometastases within the lymphatic system in patients after total gastrectomy.

Intramuscular myxoma of the left leg-Case report of the lesion observed for several years

AIM

The aim of this study was to present the process of diagnosis and treatment of a patient with diagnosed intramuscular myxoma in the left lower limb.

BACKGROUND

Myxomas are benign neoplasms which can be found within large muscle groups. Histologically, these neoplasms are composed of a few elongated or star-shaped cells lying in abundant mucoid stroma. These tumours are characterized by expanding growth without forming distant metastases.

CASE DESCRIPTION

A man, 58, came to the Surgical Oncology Outpatient Clinic due to pain ailments and a growing tumour located in the rear group of the left shank muscles. The patient had been observing the lesion for several years, but related the occurrence of pain to the change in the nature of his job - from sedentary to standing. The patient underwent diagnostic imaging, a magnetic resonance imaging test, in which a tumour was described. A surgery was carried out where the tumour was resected together with the lateral head of the gastrocnemius muscle. No significant walking disorders, neurological deficits, either sensory or motor were observed. The follow-up imaging examinations, which were carried out a year after the surgery, did not reveal a relapse. The patient remains under the care of the Surgical Oncology Outpatient Clinic.

CONCLUSION

Myxomas are a group of benign neoplasms whose first symptom is the appearance of a palpable tumour whose stretching growth causes painful ailments. After magnetic resonance imaging and a diagnosis, it is necessary to plan the surgery. Radical resection of the lesion is a method of choice which guarantees long-lasting recovery.

Evaluation of the sentinel node biopsy in colorectal carcinoma including the results of immunohistochemical examinations

AIM

To evaluate the method and results of sentinel node biopsy including immunohistochemical examinations in resectable colorectal cancer.

MATERIAL AND METHODS

From April 2004 to April 2005, sentinel node biopsy was carried out with the dye method in 27 patients operated on for colorectal cancer. The standard examination of sentinel nodes consisted in the evaluation of individual H&E-dyed specimens from bisection of the node. The negative sentinel nodes were examined with the use of immunohistochemistry against cytokeratins AE1/AE3.

FINDINGS

The sentinel node was identified in 25 patients (92.6%). In a routine histopathological examination it included metastases in 3 cases. The sentinel node was clean in one patient whereas other regional nodes resected "en bloc" with the tumour included metastases. The sensitivity of the method was 75%, and the number of falsely negative results was 25%. Metastases (micrometastases) in the sentinel node were found in 2 other patients (8%) in the immunohistochemical examination. This examination did not change the results of the analysis in the patient with positive non-sentinel nodes and with the negative sentinel node in H&E dyeing. Nevertheless, the sensitivity of the method rose to 83.3% and the number of falsely negative results dropped to 16.7%.

CONCLUSIONS

1. The sentinel node biopsy using the dye method is a safe and relatively easy technique showing a high success rate (92.6%). 2. Low sensitivity of the method, as reflected in the literature, may result from lack of extended histopathological examinations performed on the sentinel node (e.g. immunohistochemistry). 3. Further research is necessary to determine the role and importance of the sentinel node biopsy in colorectal cancer.