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.

LARGE CELL METASTATIC PANCREATIC NEUROENDOCRINE CARCINOMA TREATED WITH SOMATOSTATIN ANALOGUES - CASE REPORT AND LITERATURE REVIEW

We report the case of a 55-year-old-male with a large cell metastatic pancreatic neuroendocrine carcinoma treated for 14 months with lanreotide autogel having a stable disease (SD) and not responding to chemotherapy. The somatostatin analogues (SSA) were introduced after an episode of diarrhea and controlled the disease. Progression-free survival (PFS) as determined by Computerized Tomography (CT) scans was obtained for 14 months. After more than a year, the patient's health state deteriorated along with progressive disease. The capecitabine-temozolomide regimen was challenged, but after three cycles, a rapid clinical decline was noted.

Conclusion

This unexpected event (diarrhea) in the course of the disease could represent the beginning of carcinoid syndrome. While the lanreotide autogel helped the episode of diarrhea pass, it also helped gain control over the disease itself.

PROGNOSTIC FACTORS IN PATIENTS WITH SURGICAL RESECTION OF PANCREATIC NEUROENDOCRINE TUMOURS

CONTEXT

Pancreatic neuroendocrine tumours (PanNETs) are rare pancreatic neoplasms. PanNETs can be treated by multimodal approach including surgery, locoregional and systemic therapy.

OBJECTIVE

The aim of the present study is to evaluate predictive factors of overall survival in patients with PanNETs surgically treated at a single center.

SUBJECTS AND METHODS

The study group consisted of 120 patients with PanNETs who had undergone surgery at the Center of Digestive Diseases and Liver Transplantation of Fundeni Clinical Institute, Bucharest, Romania. Surgical resection of the primary tumor was performed in 110 patients.

RESULTS

Tumor size > 2 cm (p=0.048) (90% CI) lymph node involvement (p=0.048), ENET grade (p<0.001), distant metastases (p<0.001), Ki 67 index (<2%, 2-5%, 5-10%, 10-20%, >20%) (p<0.001) were identified as significant prognostic factors for OS on univariate analysis. Using multivariate Cox proportional regression model we found that distant metastases and Ki 67 index were independent risk factors for the survival outcome.

CONCLUSIONS

Surgery with curative intent should be considered in all cases if clinically appropriate and technically feasible. High grade (Ki67 index ≥10%) tumours were associated with a 2- fold increase in risk of death as compared to those with a Ki67 <10%.

Metachronous Ampulla of Vater Carcinoma after Curative-Intent Surgery for Klatskin Tumor

Resection represents the single hope for long-term survival in a patient diagnosed with a hilar cholangiocarcinoma (Klatskin tumor). However, the largest part of these patients develops a recurrent disease. Second metachronous periampullary cancers after a curative-intent surgery for a Klatskin tumor represent an exceptional pathology, and the management of these patients was poorly documented. Hereby, it is presented a 32-year-old patient with bile duct resection, left hemi-hepatectomy and loco-regional lymph nodes dissection, for a type IIIB Bismuth-Corlette Klatskin tumor, which, furthermore, 6 years later, underwent a pancreaticoduodenectomy for a metachronous carcinoma of the ampulla of Vater. The management and outcomes were discussed in the reported case, along with a literature review of the previously published patients. In conclusion, a metachronous periampullary carcinoma after resection of a Klatskin tumor should be distinguished from a loco-regional recurrent disease. While most of the patients with recurrences are suitable to only chemotherapy and or radiotherapy, a second curative-intent surgery (i.e., pancreaticoduodenectomy) is feasible in the largest part of the patients with a metachronous cancer, with good long-term outcomes.

Emphysematous cystitis: an unreported complication after pancreaticoduodenectomy

Pancreaticoduodenectomy was associated with an increased morbidity, and septic complications are the primary cause of death in these patients. However, severe sepsis, caused by a postoperative urinary tract infection, is uncommon. It is presented the case of a 72 years old man, with a pylorus-preserving pancreaticoduodenectomy for an ampullary adenocarcinoma. Postoperatively, the patient developed a chyle leak, and a severe urinary tract infection (i.e., emphysematous cystitis), with septic shock. The diagnosis, management and outcome are discussed. In conclusion, emphysematous cystitis is a potentially life-threatening complication, which may occur due to the postoperative immunodepression after pancreaticoduodenectomy.

Impact of a portal/superior mesenteric vein resection during pancreatico-duodenectomy for pancreatic head adenocarcinoma

AIM

The impact of venous resection (VR) in pancreatico-dudenectomy (PD) for pancreatic adenocarcinoma (PDAC) is controversial. The aim of the study is to comparatively assess the postoperative outcomes after PD with and without VR for PDAC and to identify predictors of morbidity and survival in the subgroup of PD with VR.

METHODS

The data of 51 PD with VR were compared with those of 183 PD without VR. Binary logistic regression and Cox survival analyses were performed.

RESULTS

Both the operative time and estimated blood loss was significantly higher in the VR group (P<0.001). A trend towards an increased 90-day mortality (9.8% vs. 5.5%) and severe morbidity (20% vs. 13%) was observed when a VR was performed (P ≥0.264). The median overall survival time after the PD with and without VR was 13 months and 17 months, respectively (P=0.845). The absence of histological tumor invasion of the VR was found as the only independent predictor for a better survival (HR=0.359; 95% CI 0.161-0.803; P=0.013).

CONCLUSION

A PD with VR can be safely incorporated in a pancreatic surgeon armamentarium. However, the trend towards increased mortality and severe morbidity rates should be expected, along with higher operative time and blood loss, compared with PD without VR. Associated VR does not appear to significantly impair the prognosis after PD for PDAC; however, histological tumor invasion of the VR has a negative impact on the survival.

An unclassified congenital bile duct cyst

Congenital bile duct cysts are rare in adulthood. The most frequently used classification was proposed by Todani in 1977. However, in rare cases, not all the bile duct cysts are suitable to this classification. Hereby, we describe the case of an unclassified and very rare form of congenital bile duct cyst--isolated cystic duct cyst. En-block resection of the cyst, along with gallbladder, is the treatment of choice. Although exceptional, cystic duct cysts should be included in Todani classification so that the surgeons to be aware for this variation.

The Todani classification for bile duct cysts: an overview

Bile duct cysts are a rare medical condition and are more frequent in children. However, the disease is becoming increasingly common in adults. The modified Todani classification, which is based on anatomical characteristics, is the current standard classification method. However, this classification does not take the following factors into consideration: different epidemiology, pathogenesis, risk of malignant transformation, clinical and imaging aspects, and different therapeutical approaches for all the bile duct cysts. Thus, some clinicians denied its clinical significance and viability. Moreover, some rare variants (i.e., cystic duct cysts) of bile duct cysts were initially not included and were subsequently categorized as type VI. Although it clusters different diseases, the Todani classification of bile duct cysts should also be used in clinical practice because it is simple, reproducible and widely agreed upon, thereby allowing an appropriate comparative analysis between different series of patients who are classified based on this scheme. Exceptional, cystic duct cysts should be included in the Todani classification (as a subtype of type II BDC rather than as a "new" type VI) so that the gastroenterologists, radiologists and surgeons are aware of this variation.

Left-sided duplication of inferior vena cava: clinical implications in a patient with sigmoid adenocarcinoma

Double inferior vena cava is a rare congenital anomaly, usually detected by computed tomography or magnetic resonance imaging. Although asymptomatic, it may have a clinical significance, as it may mimic a para-aortic lymphadenopaty. A case of left-sided duplication of the inferior vena cava in a patient with sigmoid colon cancer is presented. The diagnostic pitfalls and clinical implications are discussed. Accurate preoperative assessment of such an anatomical variant is of utmost importance, this way potentially life-threatening surgical complications, particularly when a minimally invasive approach is planned, are prevented.

Digestive tumor bank protocol: from surgical specimens to genomic studies of digestive cancers

Cancer is a complex polygenic and multifactorial disease, resulting from successive dynamic changes in the genome of somatic cells and from the accumulation of molecular alterations in both tumour cells and host cells. For the majority of cancers, including many malignancies of the gastrointestinal tract, our current means of diagnosis and treatment of the tumors are grossly insufficient. In recent years the development of several gene expression profiling methods such as comparative genomic hybridization (CGH), differential display, serial analysis of gene expression (SAGE) and DNA arrays, together with the sequencing of the human genome, has provided an opportunity to monitor and investigate the complete cascade of molecular events leading to tumor development and progression. Given the central role played by surgeons in the current management of patients with solid cancers, it is of paramount importance for them to know the principles characterizing this laboratory tools to critically assess the results originating from this biotechnology. We describe in this article the scientific partnership between Fundeni Clinical Institute Bucharest, Romania and RNtech Company, Paris, France for the development of a center of biological resources (Biobank) as well as the standardized protocol of working with the biological samples, the ongoing projects and the future perspectives.