Accurate Nodal Staging in Pancreatic Cancer in the Era of Neoadjuvant Therapy
Author list: Ammar A. Javed, Ding Ding, Erum Baig, Michael J. Wright, Jonathan A. Teinor, Daniyal Mansoor, Elizabeth Thompson, Ralph H. Hruban, Amol Narang, William R. Burns III, Richard A. Burkhart, Kelly Lafaro, Matthew J. Weiss, John L. Cameron, Christopher L. Wolfgang & Jin He
Nodal disease is prognostic in pancreatic ductal adenocarcinoma (PDAC); however, optimal number of examined lymph nodes (ELNs) required to accurately stage nodal disease in the current era of neoadjuvant therapy remains unknown. The aim of the study was to evaluate the optimal number of ELNs in patients with neoadjuvantly treated PDAC.
A retrospective study was performed on patients with PDAC undergoing resection following neoadjuvant treatment between 2011 and 2018. Clinicopathological data were extracted and analyzed.
Of 546 patients included, 232 (42.5%) had lymph node metastases. The median recurrence free survival (RFS) was 10.6 months (95% confidence interval: 9.7–11.7) and nodal disease was independently associated with shorter RFS (9.1 vs 11.9 months; p < 0.001). A cutoff of 22 ELNs was identified that stratified patients by RFS. Patients with N1 and N2 disease had similar median RFS (9.1 vs 8.9 months; p = 0.410). On multivariable analysis, ELN of ≥ 22 was found to be significantly associated with longer RFS among patients with N0 disease (14.2 vs. 10.9 months, p = 0.046). However, ELN has no impact on RFS for patients with N1/N2 disease (9.5 vs. 8.4 months, p = 0.190). Adjuvant therapy was associated with RFS only in patients with residual nodal disease.
Lymph node metastases remain prognostic in PDAC patients after neoadjuvant treatment. Among N0 patients, a cutoff of 22 ELN was associated with improved RFS and resulted in optimal nodal staging.
National Trends in Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography During Index Hospitalization for Mild Gallstone Pancreatitis
Author list: Hassan Aziz, Nicole Segalini, Zubair Ahmed, Shahzaib Ahmad, Martin D. Goodman & Martin Hertl
Guidelines call for cholecystectomy during the index hospitalization for patients with gallstone pancreatitis. Therefore, the study sought to determine the trends for cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (ERCP) for mild gallstone pancreatitis.
A retrospective analysis of the 2010–2018 Nationwide Readmission Database (NRD) was performed to identify patients with mild gallstone pancreatitis. The primary aim was to identify the trends in the use of cholecystectomy in these patients, and the secondary aim was to assess if ERCP alone was protective against readmission.
A total of 510,470 patients with mild gallstone pancreatitis were identified. There has been an increasing trend in ERCP use (25% in 2018 vs. 22% in 2010; p-0.001) and a decline in cholecystectomy (37% in 2018 vs. 46% in 2010; p-0.001) prior to discharge. Multivariate analysis revealed higher 30-day readmission for patients who underwent ERCP without cholecystectomy (odds ratio1.3; 95% confidence interval, 1.1–3.5) during the index admission.
There has been a decline in the use of cholecystectomy during index hospitalization for mild gallstone pancreatitis. In addition, ERCP was not protective against 30-day readmission from mild gallstone pancreatitis.
Influence of Probiotics Administration Before Liver Resection in Patients with Liver Disease: A Controlled Trial
Author list: Edouard Roussel, Carole Brasse-Lagnel, Jean-Jacques Tuech, Helène Montialoux, Eloise Papet, Pauline Tortajada, Soumeya Bekri & Lilian Schwarz
By inhibiting the growth of pathogenic bacteria and modulating the local intestinal immune system, probiotics may reduce bacterial translocation and systemic endotoxaemia, factors partially responsible for post-operative complications following liver resection for hepatocellular carcinoma in patients with cirrhosis.
Patients with resectable hepatocellular carcinoma developed in the setting of chronic liver disease were prospectively divided into two equal-sized groups: one receiving probiotic treatment 14 days prior to surgery and the other receiving placebo. The primary endpoint was the level of circulating endotoxins after hepatectomy. Secondary endpoints were systemic inflammation (inflammatory cytokine levels), post-operative liver function and overall post-operative complication rate.
From May 2013 to December 2018, 64 patients were randomized, and 54 patients were included in the analysis, 27 in each arm. No significant change in endotoxin levels was observed over time in either group (P = 0.299). No difference between the groups in terms of post-operative liver function and overall complication rates was observed. The only differences observed were significant increases in the levels of TNFalpha (P = 0.019) and interleukin 1-b (P = 0.028) in the probiotic group in the post-operative period.
Contrary to the modest data reported in the literature, the administration of probiotics before minor liver resection for hepatocellular carcinoma developed in the setting of compensated chronic liver disease does not seem to have an impact on circulating endotoxin levels or post-operative complication rates.
Trial registration: NCT02021253.
Clinical, Biochemical, Tumoural and Mutation Profile of VHL- and MEN2A-Associated Pheochromocytoma: A Comparative Study
Author list: Mallika Dhanda, Amit Agarwal, Kausik Mandal, Sushil Gupta, M. Sabaretnam, Gyan Chand, Anjali Mishra, Gaurav Agarwal & Saroj Kanta Mishra
To compare clinical, biochemical, tumoural and mutational characteristics of Von Hippel Lindau Syndrome (VHL)-associated pheochromocytoma (PCC) to multiple endocrine neoplasia 2A (MEN2A)-associated pheochromocytoma.
Retrospective study design in a tertiary health care centre in Northern India.
A total of 47 patients with biochemical and histologically proven pheochromocytoma/paraganglioma (PCC/PGL): 29 associated with VHL and 18 with MEN2A, were divided in two cohorts, respectively. Analysis of their medical records along with a prospective follow-up was done.
There were more children <19 years in VHL group (13 vs 1). Despite majority of VHL-PCC showing elevation of normetanephrine (NMN) (93%) as compared to MEN2A-PCC (22.2%), 75.8% presented with hypertension as compared to MEN2A (33.3%). The average size of VHL-PCC tumours was 5.66 cm. VHL-PCC as compared to MEN2A-PCC were multifocal (75% vs 61.1%), bilateral synchronous (72.4 vs 61.1%) and extra-adrenal (17.2% vs 0%). Both VHL (24%) and MEN2A-PCC (27.7%) showed multiple nodules, but more MEN2A PCC showed extra-tumoural hyperplasia (44.4% vs. 6.8%). In VHL, the commonest mutation (n = 17) was missense mutation with a hot spot on exon 3, while in MEN2A-PCC majority (66.6%) had 634 mutation in exon 11 and only 2 patients had the rare 611 mutation in exon 10.
In contrast to world literature, our study suggests Indian VHL-PCC can be symptomatic in spite of noradrenergic phenotype, large in size and multifocal. Multiple nodules in VHL-PCC could increase risk of recurrence following subtotal adrenalectomy.
Multimodal Assessments of Altered Sensation after Transoral Endoscopic Thyroidectomy
Author list: Jina Kim & Insoo Suh
Link: https: //rdcu.be/cFMjA
Inspirational Women in Surgery: Professor Angelita Habr-Gama MD, PhD, Colorectal Surgeon, Brazil
Author list: Orlando Jorge Torres & Savio George Barreto
Dr. Philippa Mercer: A Leader and Advocate for Equity in Surgery in New Zealand
Author list: Ross Roberts & Jessica Vlok
We Asked The Experts: The Tropical Surgeon: Everywhere in Chains But Not Imprisoned
Author list: Akaninyene Eseme Ubom, Oluwaseun Oludotun Sowemimo & Nyawira Wahome Ng’ayu
Systematic Reviews and Meta-Analyses: My First Paper: Mortality Following Appendicectomy in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis
Author list: Adil Rashid, Alisha Gupta, Alfred Adiamah, Joe West, Matthew Grainge & David J. Humes
With the global prevalence of liver cirrhosis rising, this systematic review aimed to define the perioperative risk of mortality in these patients following appendicectomy.
Systematic searches of Medline, EMBASE, Cochrane Library databases, ICTRP, and Clinical trials.gov were undertaken to identify studies including patients with cirrhosis undergoing appendicectomy, published since database inception to March 2021. Studies had to report mortality. Two review authors independently identified eligible studies and extracted data. Pooled analysis of in-patient and 30-day mortality was performed.
Of the 948 studies identified, four were included and this comprised three nationwide database studies (USA and Denmark) and one multi-centre observational study (Japan). A total of 923 patients had cirrhosis and 167,211 patients did not. In-patient mortality ranged from 0 to 1.7% in patients with cirrhosis and 0.17 to 0.3% in patients without. 30-day mortality was 9% in patients with cirrhosis compared to 0.3% in those without. One study stratified cirrhotic patients into compensated and decompensated groups. In patients with compensated cirrhosis, mortality following laparoscopic appendicectomy (0.5%) was significantly lower than open appendicectomy (3.2%). The meta-analysis highlighted a tenfold increase in perioperative mortality in cirrhotic patients (OR 9.92 (95% CI 4.67 to 21.06, I2 = 28%). All studies reported an increased length of stay in patients with cirrhosis.
This review suggests that appendicectomy in the cirrhotic population is associated with increased mortality. LA may be safer in this population. Lack of information on cirrhosis severity and failure to control for age and co-morbidities make the results difficult to interpret. Further large population-based studies are required.
One-Year Outcomes Following Emergency Laparotomy: A Systematic Review
Author list: Zi Qin Ng & Dieter Weber
Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL.
A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed.
Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%.
The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients.