T. Peter Kingham

Ablation of Perivascular Hepatic Malignant Tumors with Irreversible Electroporation

BACKGROUND Ablation is increasingly used to treat primary and secondary liver cancer. Ablation near portal pedicles and hepatic veins is challenging. Irreversible electroporation (IRE) is a new ablation technique that does not rely on heat and, in animals, appears to be safe and effective when applied near hepatic veins and portal pedicles. This study evaluated the safety and short-term outcomes of IRE to ablate perivascular malignant liver tumors. STUDY DESIGN A retrospective review of patients treated with IRE between January 1, 2011 and November 2, 2011 was performed. Patients were selected for IRE when resection or thermal ablation was not indicated due to tumor location. Treatment outcomes were classified by local, regional, and systemic recurrence and complications. Local failure was defined as abnormal enhancement at the periphery of an ablation defect on post-procedure contrast imaging. RESULTS Twenty-eight patients had 65 tumors treated. Twenty-two patients (79%) were treated via an open approach and 6 (21%) were treated percutaneously. Median tumor size was 1 cm (range 0.5 to 5 cm). Twenty-five tumors were <1 cm from a major hepatic vein; 16 were <1 cm from a major portal pedicle. Complications included 1 intraoperative arrhythmia and 1 postoperative portal vein thrombosis. Overall morbidity was 3%. There were no treatment-associated mortalities. At median follow-up of 6 months, there was 1 tumor with persistent disease (1.9%) and 3 tumors recurred locally (5.7%). CONCLUSIONS This early analysis of IRE treatment of perivascular malignant hepatic tumors demonstrates safety for treating liver malignancies. Larger studies and longer follow-up are necessary to determine long-term efficacy.

Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care.

HYPOTHESIS Lack of access to surgical care is a public health crisis in developing countries. There are few data that describe a nations ability to provide surgical care. This study combines information quantifying the infrastructure, human resources, interventions (ie, procedures), emergency equipment and supplies for resuscitation, and surgical procedures offered at many government hospitals in Sierra Leone. SETTING Site visits were performed in 2008 at 10 of the 17 government civilian hospitals in Sierra Leone. MAIN OUTCOME MEASURES The World Health Organizations Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity. RESULTS There was a paucity of electricity, running water, oxygen, and fuel at the government hospitals in Sierra Leone. There were only 10 Sierra Leonean surgeons practicing in the surveyed government hospitals. Many procedures performed at most of the hospitals were cesarean sections, hernia repairs, and appendectomies. There were few supplies at any of the hospitals, forcing patients to provide their own. There was a disparity between conditions at the government hospitals and those at the private and mission hospitals. CONCLUSION There are severe shortages in all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone. While it will be difficult to improve the infrastructure of government hospitals, training additional personnel to deliver safe surgical care is possible. The situational analysis tool is a valuable mechanism to quantify a nations surgical capacity. It provides the background data that have been lacking in the discussion of surgery as a public health problem and will assist in gauging the effectiveness of interventions to improve surgical infrastructure and care.

Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey

BACKGROUND Surgical care is increasingly recognised as an important part of global health yet data for the burden of surgical disease are scarce. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) was developed to measure the prevalence of surgical conditions and surgically treatable deaths in low-income and middle-income countries. We administered this survey countrywide in Sierra Leone, which ranks 180 of the 187 nations on the UN Development Index. METHODS The study was done between Jan 9 and Feb 3, 2012. 75 of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters, with a probability proportional to the population size. In each cluster 25 households were randomly selected to take part in the survey. Data were collected via handheld tablets by trained local medical and nursing students. A household representative was interviewed to establish the number of household members (defined as those who ate from the same pot and slept in the same structure the night before the interview), identify deaths in the household during the previous year, and establish whether any of the deceased household members had a condition needing surgery in the week before death. Two randomly selected household members underwent a head-to-toe verbal examination and need for surgical care was recorded on the basis of the response to whether they had a condition that they believed needed surgical assessment or care. FINDINGS Of the 1875 targeted households, data were analysed for 1843 (98%). 896 of 3645 (25%; 95% CI 22·9-26·2) respondents reported a surgical condition needing attention and 179 of 709 (25%; 95% CI 22·5-27·9) deaths of household members in the previous year might have been averted by timely surgical care. INTERPRETATION Our results show a large unmet need for surgical consultations in Sierra Leone and provide a baseline against which future surgical programmes can be measured. Additional surveys in other low-income and middle-income countries are needed to document and confirm what seems to be a neglected component of global health. FUNDING Surgeons OverSeas, Thompson Family Foundation.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US

Minimally-Invasive vs Open Pancreaticoduodenectomy: Systematic Review and Meta-Analysis

6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Treatment of cancer in sub-Saharan Africa

Laparoscopic approaches are routinely used for a variety of procedures in general surgery and various surgical specialties including surgical oncology. Since publication of the first series of laparoscopic cholecystectomy in the late 1980s, the field of minimally invasive surgery (MIS) has expanded dramatically and is now regarded as an established specialty. Many oncologic procedures have proved not only feasible and safe, but oncologically equivalent to traditional open procedures regarding both immediate operative variables of interest (margins, lymph node retrieval, and morbidity) and long-term outcomes. Pancreaticoduodenectomy (PD) poses a particular challenge. During this procedure, there is extensive retroperitoneal dissection around anatomically complex and hazardous structures, and a prolonged reconstruction that includes 3 technically demanding anastomoses. Given this complex gastrointestinal reconstruction, it has been generally thought that the minimally invasive approach would not significantly decrease recovery time (hospital stay), yet it would significantly increase operative time. Even though minimally invasive PD was reported as early as 1994, laparoscopic surgeons have been reluctant to routinely perform it. Since this first description now almost 20 years ago, a large number of single-institution series of minimally invasive (including laparoscopic-assisted, totally laparoscopic, and more

Surgical Considerations in Older Adults With Cancer

Cancer is rapidly becoming a public health crisis in low-income and middle-income countries. In sub-Saharan Africa, patients often present with advanced disease. Little health-care infrastructure exists, and few personnel are available for the care of patients. Surgeons are often central to cancer care in the region, since they can be the only physician a patient sees for diagnosis, treatment (including chemotherapy), and palliative care. Poor access to surgical care is a major impediment to cancer care in sub-Saharan Africa. Additional obstacles include the cost of oncological care, poor infrastructure, and the scarcity of medical oncologists, pathologists, radiation oncologists, and other health-care workers who are needed for cancer care. We describe treatment options for patients with cancer in sub-Saharan Africa, with a focus on the role of surgery in relation to medical and radiation oncology, and argue that surgery must be included in public health efforts to improve cancer care in the region.

Combined Stimulation with Interleukin-18 and CpG Induces Murine Natural Killer Dendritic Cells to Produce IFN-γ and Inhibit Tumor Growth

PURPOSE The aging of the population is a real concern for surgical oncologists, who are increasingly being asked to treat patients who would not have been considered for surgery in the past. In many cases, decisions are made with relatively little evidence, most of which was derived from trials in which older age was a limiting factor for recruitment. METHODS This review focuses on risk assessment and perioperative management. It describes the relationship between age and outcomes for colon, lung, hepatobiliary, and head and neck cancer, which are predominantly diseases of the elderly and are a major cause of morbidity and mortality. RESULTS Effective surgery requires safe performance as well as reasonable postoperative life expectancy and maintenance of quality of life. Treatment decisions for potentially vulnerable elderly patients should take into account data obtained from the evaluation of geriatric syndromes, such as frailty, functional and cognitive limitations, malnutrition, comorbidities, and polypharmacy, as well as social support. Postoperative care should include prevention and treatment of complications seen more frequently in the elderly, including postoperative delirium, functional decline, and the need for institutionalization. CONCLUSION Surgery remains the best modality for treatment of solid tumors, and chronologic age alone should not be a determinant for treatment decisions. With adequate perioperative risk stratification, functional assessment, and oncologic prognostication, elderly patients with cancer can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.

A Retrospective Comparison of Microwave Ablation vs. Radiofrequency Ablation for Colorectal Cancer Hepatic Metastases

Natural killer dendritic cells (NKDC) are a novel subtype of dendritic cells with natural killer (NK) cell properties. IFN-gamma is a pleiotropic cytokine that plays an important role in the innate immune response to tumors. Based on our previous finding that the combination of Toll-like receptor 9 ligand CpG and interleukin (IL)-4 stimulates NKDC to produce IFN-gamma, we hypothesized that NKDC are the major IFN-gamma-producing dendritic cell subtype and may play a significant role in the host antitumor response. We found that under several conditions in vitro and in vivo NKDC accounted for the majority of IFN-gamma production by murine spleen CD11c(+) cells. IL-18 alone induced NKDC to secrete IFN-gamma, and the combination of IL-18 and CpG resulted in a synergistic increase in IFN-gamma production, both in vitro and in vivo. NK cells made 26-fold less IFN-gamma under the same conditions in vitro, whereas dendritic cells produced a negligible amount. The mechanism of IFN-gamma secretion by NKDC depended on IL-12. NKDC selectively proliferated in vitro and in vivo in response to the combination of IL-18 and CpG. Systemic treatment with IL-18 and CpG reduced the number of B16F10 melanoma lung metastases. The mechanism depended on NK1.1(+) cells, as their depletion abrogated the effect. IL-18 and CpG activated NKDC provided greater tumor protection than NK cells in IFN-gamma(-/-) mice. Thus, NKDC are the major dendritic cell subtype to produce IFN-gamma. The combined use of IL-18 and CpG is a viable strategy to potentiate the antitumor function of NKDC.

Hepatic Parenchymal Preservation Surgery: Decreasing Morbidity and Mortality Rates in 4,152 Resections for Malignancy

BackgroundMicrowave (MWA) and radiofrequency ablation (RFA) are the most commonly used techniques for ablating colorectal-liver metastases (CRLM). The technical and oncologic differences between these modalities are unclear.MethodsWe conducted a matched-cohort analysis of patients undergoing open MWA or RFA for CRLM at a tertiary-care center between 2008 and 2011; the primary endpoint was ablation-site recurrence. Tumors were matched by size, clinical-risk score, and arterial-intrahepatic or systemic chemotherapy use. Outcomes were compared using conditional logistic regression and stratified log-rank test.ResultsWe matched 254 tumors (127 per group) from 134 patients. MWA and RFA groups were comparable by age, gender, median number of tumors treated, proximity to major vessels, and postoperative complication rates. Patients in the MWA group had lower ablation-site recurrence rates (6% vs. 20%; P < 0.01). Median follow-up, however, was significantly shorter in the MWA group (18 months [95% confidence interval 17–20] vs. 31 months [95% confidence interval 28–35]; P < 0.001). Kaplan–Meier estimates of ablation-site recurrence at 2 years were significantly lower for the lesions treated with MWA (7% vs. 18%, P: 0.01).ConclusionsAblation-site recurrences of CRLM were lower with MWA compared with RFA in this matched cohort analysis. Longer follow-up time in the MWA may increase the recurrence rate; however, actuarial local failure estimations demonstrated better local control with MWA.