Zeljka Jutric

Impact of lymph node status in patients with intrahepatic cholangiocarcinoma treated by major hepatectomy: a review of the National Cancer Database

INTRODUCTION Routine lymphadenectomy in the surgical treatment of intrahepatic cholangiocarcinoma (ICC) is not routinely performed. We aim to define predictive indicators of survival in patients with positive lymph nodes. METHODS The National Cancer Data Base (NCDB) was queried for patients who underwent major hepatectomy for ICC between 1998 and 2011. Clinical and pathologic data were assessed using uni- and multi-variate analyses. A sub-analysis was performed on the 160 patients with positive lymph nodes. RESULTS Of 849 patients with lymph node data, 57% had at least one lymph node examined. Median survival for lymph node negative patients was 37 months versus 15 months for lymph node positive patients. In lymph node positive patients, poorer survival was associated with not receiving chemotherapy (HR 1.83, p = 0.003), tumor size > 5 cm (p = 0.029), and older age (p < 0.0001). Lymph node positive patients age less than 45 had a median survival of 27 months. CONCLUSIONS Overall survival in patients with lymph node metastases from ICC is poor. Adjuvant therapy was associated with a longer survival in lymph node positive patients, although prospective data are needed. Routine lymphadenectomy should be strongly considered to provide prognostic information and guidance for adjuvant therapy.

Clinical Outcomes of Reoperation for Failed Antireflux Operations

BACKGROUND Up to 18% of patients undergoing antireflux operations will require reoperation. Authors caution that with each additional reoperation, fewer patients achieve satisfaction. The quality of life in patients who underwent revision operations was compared with patients who underwent primary antireflux operations to determine the effectiveness of revision operations. METHODS We retrospectively reviewed patients who underwent revision after failed antireflux operations from 2004 to 2014. Patients were divided into two groups: first reoperation (Reop[1]) and more than one reoperation (Reop[>1]). For comparison, a control group of patients who underwent primary antireflux operations was included. Patients underwent quality of life assessment preoperatively and postoperatively. RESULTS We identified 105 reoperative patients: 94 Reop(1), 11 Reop(>1), and 112 controls. The primary reason for failure was combined fundoplication herniation and slippage. Morbidity, mortality, and readmission rates were similar in all groups. Postoperative outcomes were improved in all groups but to a lesser degree in subsequent reoperations. Gastroesophageal Reflux Disease Health-Related Quality of Life: controls, 20.0 to 2.0; Reop(1), 26.5 to 4.0; and Reop(>1), 13.0 to 2.0. Quality of Life in Reflux and Dyspepsia: controls, 4.5 to 7.0; Reop(1), 3.7 to 6.7; and Reop(>1), 3.5 to 5.8. Dysphagia Severity Score: controls, 44.0 to 45.0; Reop(1), 36.0 to 45.0; and Reop(>1), 30.8 to 45.0. CONCLUSIONS Patients undergoing revision antireflux operations have improved quality of life, relatively normal swallowing, and primary symptom resolution at a median of 20 months postoperatively. However, patients who undergo more than one reoperation have lower quality of life scores and less improvement in dysphagia, suggesting that other procedures such as Roux-en-Y or short colon interposition, should be considered after a failed initial reoperation.

Cytoreductive surgery for head and neck squamous cell carcinoma in the new age of immunotherapy.

Cytoreductive surgery is an approach to cancer treatment that aims to reduce the number of cancer cells via resection of primary tumor or metastatic deposits, in an effort to minimize a potentially immunosuppressive tumor burden, palliate symptoms, and prevent complications. Furthermore, it provides a platform for investigation of biomarkers with the goal of optimizing immunotherapy to reverse the immunosuppressive tumor microenvironment and enhance adaptive immune responses. Ultimately, our group aims to exploit the concept that successful cancer therapy is dependent upon an effective immune response. Surgery will remain an integral part of head and neck squamous cell carcinoma (HNSCC) treatment in the future, even as checkpoint inhibitors, co-stimulatory molecules, vaccines, adoptive T cell therapy and other novel agents enter clinical routine. Cytoreductive resection may provide an effective platform for immunotherapy and biomarker directed interventions to improve outcomes for patients with HNSCC.

Early recovery pathway for hepatectomy: data-driven liver resection care and recovery

In recent years, great progress has been made toward safer hepatobiliary surgical interventions. This has resulted in more widely available treatments for patients who in the past were ineligible for curative resection of primary liver tumors, liver metastases, and advanced biliary tumors. However, the rise in procedures has seen increasingly heterogeneous perioperative management, yielding strikingly disparate outcomes. A number of groups have attempted to standardize perioperative care in an effort to create enhanced recovery pathways (ERPs) and provide clinicians with a dependable roadmap to success following hepatectomy. In the future, each aspect of perioperative care could be pre-ordained with emphasis on nutrition, anesthesia, prophylaxis, use of surgical drains, post-operative fluid and electrolyte management, and contact with physician extenders following discharge. This article reviews the data behind ERPs preceding and following hepatectomy. It includes primary data justifying practices in post-hepatectomy support. It also touches on the benefits of minimally invasive hepatectomy and offers future directions for research in peri-hepatectomy ERPs. Overall, this article seeks to formulate a pathway for practice based on data, with enough details to allow creation of rational order sets for efficient and superior practice.

Laparoscopic paraesophageal hernia repair.

Repair of the large paraesophageal hernias—types II, III, and IV is a challenging surgical problem. There are many technical modifications to the numerous aspects of surgical repair. The 2 most critical aspects of repair are: (1) aggressive mobilization of the esophagus to restore and ensure length and (2) the underestimated and understudied technique of hiatal closure. We describe the techniques and unique modifications such as a combined Hill and Nissen repair utilized at Swedish Medical Center There remains considerable opportunity through research and surgical innovation to improve on existing techniques in the repair of the paraesophageal hernia.

Novel Simulation Device for Targeting Tumors in Laparoscopic Ablation: A Learning Curve Study

Introduction. A novel 3-dimensional (3D) guidance system was developed to aid accurate needle placement during ablation. Methods. Five novices and 5 experienced hepatobiliary surgeons were recruited. Using an agar block with analog tumor, participants targeted under 4 conditions: in-line with the ultrasound plane using ultrasound, in-line using 3D guidance, 45° off-axis using ultrasound, and off-axis using 3D guidance. Time to target the tumor, number of withdrawals, and the National Aeronautics and Space Administration Task Load Index were collected. Initial and final parameters for each of the conditions were compared using a within-subjects paired t test. Results. A significant reduction was seen in the number of required withdrawals in all situations when using the 3D guidance (0.75 vs 3.65 in-line and 0.25 vs 3.6 for off-axis). Mental workload was significantly lower when using 3D guidance compared with ultrasound both for novices (29.85 vs 41.03) and experts (31.98 vs 44.57), P < .001 for both. The only difference in targeting time between first and last attempt was in the novice group during off-axis targeting using 3D guidance (115 vs 32.6 seconds, P = .03). Conclusion. Though 3D guidance appeared to decrease time to target, this was not statistically significant likely as a result of lack of power in our trial. Three-dimensional guidance did reduce the number of required withdrawals, potentially decreasing complications, as well as mental workload after proficiency was achieved. Furthermore, novices without experience in ultrasound were able to learn targeting with the 3D guidance system at a faster pace than targeting with ultrasound alone.

Regional Metastatic Behavior of Nonfunctional Pancreatic Neuroendocrine Tumors: Impact of Lymph Node Positivity on Survival

Objectives Literature addressing the significance of lymph node positivity in the management of nonfunctional pancreatic neuroendocrine tumors (PNETs) is conflicting. Methods The National Cancer Data Base was queried for patients who underwent surgical resection of nonfunctional PNETs between 1998 and 2011. Clinical data and overall survival were analyzed using &khgr;2 and Cox proportional hazards regression. Multiple imputation was used as a comparative analysis because of the high number of patients missing data on tumor grade. Results Two thousand seven hundred thirty-five patients were identified. The overall incidence of lymph node metastasis was 51%. In the subset of patients with grade 1 tumors less than 1 cm, 24% had positive lymph nodes. Overall median survival for patients with negative lymph nodes was 11 years compared with 8 years for lymph node–positive patients (P < 0.001). On multivariate survival analysis, tumor grade, distant metastases, regional lymph node involvement, positive surgical margins, male sex, and older age were predictive of decreased overall survival. Conclusions Lymph node positivity was associated with decreased overall survival. The incidence of lymph node involvement in resected low-grade tumors less than 1 cm is higher than previously reported. Patients selected for resection of PNETs should be offered lymphadenectomy for staging.

Novel Device for Targeting Tumors in Laparoscopic Radiofrequency Ablation: A Learning Curve Study

Design: A case report. Setting: Park Bell Clinic, Japan. Patients: A 45 years old nullipara woman with a body mass index of 18.67. Intervention: SS-TLH wth a morcellator. Measurements and Main Results: After using six course of GnRH agonist, her uterine height was as high as her umbilicus, we performed by SS-TLH with a morcellator. SS-TLH, which was started with three 5mm trocars in 2cm incision of umbilicus, includes uterine artery ligation at its origin and identifying ureter traveling through retroperitneal space development. After vaginal cutting, we extract this uterus from umbilicus using a morcellator device exchanged one of three 5mm trocars. The uterine weight was 782g by SS-TLH underwent with total blood loss 20ml, operation time 267min. Conclusion: SS-TLH may be feasible alternative to conventional laparoscopy for patients with huge uterus provides a great cosmetic benefit. The other hand, SS-TLH method for huge uterus need a one hand technique for ligation of uterine artery in narrow space and cost long time to extract uterus using a morcellator. 851

Primary liver sarcomas in the modern era: Resection or transplantation?

Primary liver sarcomas (PLS) are rare. Published series are limited by small numbers of patients.

Response to Comment on: Early recovery pathway for hepatectomy: data-driven liver resection care and recovery

We are grateful for the questions raised by Drs. Blasi and Beltran and appreciate the opportunity to respond (1). The comment on our article entitled Early recovery pathway for hepatectomy: data-driven liver resection care and recovery questions the recommendation that fresh frozen plasma (FFP) transfusion be used to correct coagulopathy based on international normalized ratio (INR) and clinical risk factors for coagulopathy in patients following liver resection (1,2).