Eduardo A. Vega

Effective Laparoscopic Management Lymph Node Dissection for Gallbladder Cancer

BackgroundPart of optimal prognostication of gallbladder cancer is optimal lymph node staging.1,2 Accurate laparoscopic lymph node staging is dependent on a systematic approach to sampling N1 and N2 lymph node stations.3 Stations with the highest risk of involvement are 12a, b, p and c, 13 and 16, as well as 8 and 9.4PatientA 59-year-old man underwent stem cell transplantation for acute myeloid leukemia. Thirty-nine days later he developed acute cholecystitis, which was managed with a cholecystostomy tube. Two months later, a laparoscopic cholecystectomy was performed where a T2 well- to moderately-differentiated gallbladder cancer was detected, along with an uninvolved lymph node in station 12c, and cystic duct stump negative for cancer.TechniqueWith the patient in the French position, wide kocherization allowed for sampling of lymph node stations 13 (retropancreatic) and 16 (aortocaval). Thereafter, a portal lymphadenectomy of stations 12a, b, c and p was performed. A partial resection of segments 4b and 5, as well as sampling of the cystic duct stump, completed the procedure.ConclusionAccurate prognostication is one of the major goals of oncologic re-resection of incidentally discovered gallbladder cancer. This can be achieved via a systematic and complete dissection of portal, aortocaval and retropancreatic lymph node stations. Targeting of stations 16 and 13 requires wide kocherization, and complete portal lymphadenectomy of stations 12a, c, p, and b necessitates safe, minimally invasive dissection of the hepatoduodenal ligament.

Incidental Gallbladder Cancer: Residual Cancer Discovered at Oncologic Extended Resection Determines Outcome: A Report from High- and Low-Incidence Countries

BackgroundGallbladder cancer detected incidentally after cholecystectomy (IGBC) currently is the most common diagnosis of gallbladder cancer, and oncologic extended resection (OER) is recommended for tumors classified higher than T1b. However, the precise prognostic significance of residual cancer (RC) found at the time of OER has not been well established. This analysis aimed to determine the prognostic impact of RC found in patients with IGBC undergoing OER.MethodsOutcomes for IGBC at a center for a low-incidence country (USA) and a high-incidence country (Chile) between January 1999 and June 2015 were analyzed. Residual cancer was defined as histologically proven cancer at OER. Predictors of disease-specific survival (DSS) were analyzed.ResultsOf 187 patients, 171 (91.4%) achieved complete resection (R0) at OER. The rates of surgical mortality and severe morbidity were respectively 1.1 and 9.6%. Of the 187 patients, 73 (39%) had RC. Perineural invasion and/or lymphovascular invasion and T3 stage were associated with the presence of RC. In both countries, RC was associated with a significantly shorter median survival (23% vs not reached; p < 0.001) and lower 5-year DSS rate (19% vs. 74%; p < 0.001) despite R0 resection. In the multivariable analysis, RC was an independent poor predictor of DSS (hazard ratio [HR], 4.00; 95% confidence interval [CI], 2.13–7.47; p < 0.001), as were lymphovascular and/or perineural invasion (HR, 1.95; 95% CI, 1.19–3.21; p = 0.008).ConclusionsThe presence of RC in patients undergoing OER for IGBC is associated with poor DSS in both high- and low-incidence countries, even when R0 resection is achieved. Residual cancer defines a high-risk cohort for whom adjuvant therapy may be beneficial.

Loss of muscle mass during preoperative chemotherapy as a prognosticator for poor survival in patients with colorectal liver metastases

Background: The survival impact of specific body composition changes during preoperative chemotherapy in patients with colorectal liver metastases undergoing curative‐intent surgery remains unclear. This study aimed to determine the impact of changes in body weight and muscle mass during preoperative chemotherapy on survival after hepatectomy in patients with colorectal liver metastases. Methods: Consecutive patients with colorectal liver metastases undergoing preoperative chemotherapy and curative hepatectomy during 2009–2013 were retrospectively analyzed. Recurrence‐free and overall survival were examined according to body compositions, including muscle mass, as measured by skeletal muscle index (area of muscle [cm2]/square of height [m2]), and body weight before and after preoperative chemotherapy. Results: The median follow‐up duration in overall 169 patients was 47 months. Skeletal muscle index and body weight changed significantly during chemotherapy (skeletal muscle index: –0.52 cm2/m2, P = .03; body weight: +1.1 kg, P = .002). Patients with major muscle mass loss (≥7%) had significantly shorter median RFS than patients with no or minor muscle mass loss (<7%) (9.6 months vs 15.9 months; P = .02). Although major muscle mass loss was associated with poor outcome, skeletal muscle index before or after preoperative chemotherapy was not associated with recurrence‐free or overall survival. On multivariate analysis, major muscle mass loss was independently associated with poorer recurrence‐free survival (hazard ratio, 1.76; P = .045). Conclusion: Major loss of muscle mass but not body weight loss during preoperative chemotherapy is significantly associated with poor recurrence‐free survival after hepatectomy in patients with colorectal liver metastases. The mechanisms mediating this association may inform future trials on maintaining muscle mass with dedicated nutrition and exercise programs to improve outcomes.

Minimally invasive management of the entire treatment sequence in patients with stage IV colorectal cancer: a propensity-score weighting analysis

BACKGROUND In patients with stage IV colorectal cancer (CRC), minimally invasive surgery (MIS) may offer optimal oncologic outcome with low morbidity. However, the relative benefit of MIS compared to open surgery in patients requiring multistage resections has not been evaluated. METHODS Patients who underwent totally minimally invasive (TMI) or totally open (TO) resections of CRC primary and liver metastases (CLM) in 2009-2016 were analyzed. Inverse probability of weighted adjustment by propensity score was performed before analyzing risk factors for complications and survival. RESULTS The study included 43 TMI and 121 TO patients. Before and after adjustment, TMI patients had significantly less cumulated postoperative complications (41% vs. 59%, p = 0.001), blood loss (median 100 vs. 200 ml, p = 0.001) and shorter length of hospital stay (median 4.5 vs. 6.0 days, p < 0.001). Multivariate analysis identified TO approach vs. MIS (OR = 2.4, p < 0.001), major liver resection (OR = 4.4, p < 0.001), and multiple CLM (OR = 2.3, p = 0.001) as independent risk factors for complications. 5-year overall survival was comparable (81% vs 68%, p = 0.59). CONCLUSION In patients with CRC undergoing multistage surgical treatment, MIS resection contributes to optimal perioperative outcomes without compromise in oncologic outcomes.