Massive simultaneous hepatic and renal perivascular epithelioid cell tumor benefitted from surgery and everolimus treatment: A case report

BACKGROUND

Perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal neoplasm that predominantly affects the kidney and uterus. The occurrence of this tumor in the liver, particularly with simultaneous involvement of the liver and kidney, is exceedingly uncommon. Pathological diagnosis is the gold standard. PEComas usually show positive immunohistochemical staining for melanocytic (HMB-45, Melan-A) and myoid (SMA, muscle-specific actin) markers.

CASE SUMMARY

We presented a noteworthy case of malignant PEComa affecting both the liver and kidney in a 53-year-old man with tuberous sclerosis complex (TSC). FAT2 and TP73 mutations in the kidney were identified and positive expression of diagnostic markers including HMB-45, Melan A, and TFE3 were detected. In addition, we demonstrated that hepatic artery perfusion chemotherapy was ineffective for hepatic PEComa, while surgery remained the most effective approach. Everolimus showed an excellent efficacy in the postoperative treatment of the tumor.

CONCLUSION

Surgical treatment is preferred for malignant PEComa affecting liver and kidney, especially with TSC; everolimus is effective postoperatively.

Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy

BACKGROUND

Although antibiotic therapy has become the primary treatment for acute uncomplicated appendicitis, the management of acute complicated appendicitis necessitates careful consideration of various treatment options.

AIM

To analyze the clinical data of patients who underwent emergency appendectomy for acute complicated appendicitis with peri-appendiceal abscess or phlegmon, identify factors influencing the postoperative length of hospital stay (LOS), and improve treatment strategies.

METHODS

The clinical data of acute complicated appendicitis patients with peri-appendiceal abscess or phlegmon who underwent emergency appendectomy at The Department of Emergency Surgery, Zhongshan Hospital, Fudan University from January 2016 to March 2023 were retrospectively analyzed.

RESULTS

A total of 234 patients were included in our study. The duration of symptoms and the presence of an appendicolith were significantly correlated with the occurrence of peri-appendiceal abscess in patients with acute complicated appendicitis (P < 0.001 and P = 0.015, respectively). Patients with symptoms lasting longer than 72 h had a significantly longer postoperative LOS compared to those with symptoms lasting 72 h or less [hazard ratio (HR), 1.208; 95%CI: 1.107-1.319; P < 0.001]. Additionally, patients with peri-appendiceal abscesses had a significantly longer postoperative LOS compared to those with phlegmon (HR, 1.217; 95%CI: 1.095-1.352; P < 0.001). The patients with peri-appendiceal abscesses were divided into two groups based on the median size of the abscess: Those with abscesses smaller than 5.0 cm (n = 69) and those with abscesses 5.0 cm or larger (n = 82). Patients with peri-appendiceal abscesses measuring 5.0 cm or larger had a significantly longer postoperative LOS than those with abscesses smaller than 5.0 cm (P = 0.038).

CONCLUSION

The duration of symptoms and the presence of an appendicolith are significant risk factors for the formation of peri-appendiceal abscesses in patients with acute complicated appendicitis. Patients with peri-appendiceal abscesses experience a significantly longer postoperative LOS compared to those with peri-appendiceal phlegmon.

Modified technical protocol for single-port laparoscopic appendectomy using needle-type grasping forceps for acute simple appendicitis: A case report

BACKGROUND

Because of the mild inflammatory status in acute uncomplicated appendicitis, our team developed a novel technical protocol for single-port laparoscopic appendectomy using needle-type grasping forceps (SLAN) and achieved positive clinical outcomes. However, the intraoperative procedure lacked stability and fluency due to a series of problems highlighted by the small incision design of the protocol (only 1 cm long). Therefore, there is a growing clinical demand to further optimize the SLAN protocol.

CASE SUMMARY

An adult male patient was admitted for persistent right lower abdominal pain with preoperative computed tomography findings suggestive of appendicitis accompanied by localized peritonitis. A modified technical protocol for SLAN based on minimally invasive surgical principles was used, and the patient was confirmed to have acute simple appendicitis by postoperative pathological analysis. Postoperative recovery was uneventful, and no postoperative complications, such as incision infection or severe incision pain, were observed. The patient was discharged successfully on postoperative day 2.

CONCLUSION

The modified technical protocol of SLAN may be a new minimally invasive surgical alternative for patients with acute simple appendicitis.

Impact of fast-track surgery on perioperative care in patients undergoing hepatobiliary surgery

BACKGROUND

Fast-track surgery (FTS) is a modern nursing approach that has gained popularity in the perioperative phase of surgery.

AIM

To investigate the impact of FTS on perioperative care for hepatobiliary surgery.

METHODS

A retrospective analysis was performed on 98 patients who underwent hepatobiliary surgery and were admitted to our hospital from August 2021 to October 2023. They were divided into an observation group and a control group with 49 patients in each group according to different nursing directions. The control group was treated with standard nursing and the observation group was treated with FTS concept nursing. The length of hospital stay, visual analog scale (VAS) score, wound complications, nursing satisfaction, self-rating scale (SAS) score, and SF-36 quality of life (QoL) score were compared between the two groups before and after care.

RESULTS

The duration of hospitalization, hospitalization cost, operation time, first implantation time, exhaust time, and first defecation time were shorter than the observation group (P < 0.05). Additionally, the observation group showed a significant difference between the VAS and SAS scores on days 1, 3, and 7 (P < 0.05). The complication rate in the observation group was 4.05% was significantly lower than the 18.36% in the control group, and the comparison groups were statistically significant (χ 2 = 5.018, P = 0.025). The observation group had a significantly higher level of nurse satisfaction (94.92%) than the control group (79.59%; χ 2 = 6.078, P = 0.014). Both groups showed higher QoL scores after nursing care, with higher scores in the observation group than in the control group (P = 0.032).

CONCLUSION

FTS in patients undergoing hepatobiliary surgery can effectively improve negative mood, QoL, and nursing satisfaction; reduce wound complications; and accelerate patient rehabilitation.

Evaluation of preoperative blood markers for predicting intra-abdominal infection during colorectal cancer resection: A commentary on recent findings

This commentary evaluates the study by Liu et al. This study investigates the predictive utility of the neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, systemic immune-inflammation index, and carcinoembryonic antigen levels for post-operative intra-abdominal infection following colorectal cancer (CRC) surgery. The study highlights the critical need for analyzing diverse patient demographics and delves into the potential impact of various confounding factors on the predictive accuracy of these markers. Additionally, the commentary advocates for the initiation of prospective studies aimed at validating and enhancing the clinical utility of these biomarkers in the context of CRC treatment. The commentary aims to underscore the importance of broadening the research framework to include a wider patient demographic and more comprehensive factor analyses, thereby enriching the predictive model's applicability and relevance in clinical settings.

Comparison of efficacy and safety of nab-paclitaxel and oxaliplatin + S-1 and standard S-1 and oxaliplatin chemotherapy regimens for treatment of gastric cancer

BACKGROUND

Gastric cancer (GC) is a relatively frequent clinical phenomenon, referring to malignant tumors emerging in the gastric mucosal epithelial cells. It has a high morbidity and mortality rate, posing a significant threat to the health of patients. Hence, how to diagnose and treat GC has become a heated topic in this research field.

AIM

To discuss the effectiveness and safety of nab-paclitaxel in combination with oxaliplatin and S-1 (P-SOX) for the treatment of GC, and to analyze the factors that may influence its outcomes.

METHODS

A total of 219 eligible patients with advanced GC, who were treated at Qinghai University Affiliated Hospital Gastrointestinal Oncology between January 2018 and March 2020, were included in the study. Among them, 149 patients received SOX regimen and 70 patients received S-1 regimen. All patients underwent both preoperative and postoperative chemotherapy consisting of 2-4 cycles each, totaling 6-8 cycles, along with parallel D2 radical surgical treatment. The patients were followed up for a period of three years or until reaching the event endpoint.

RESULTS

The short-term and long-term efficacy of the P-SOX group was significantly higher than that of the SOX group, and the safety was manageable. Cox multivariate analysis revealed that progression-free survival was associated with perioperative chemotherapy efficacy, tumor diameter ≤ 2cm, high differentiation, and early cTNM (T stands for invasion depth; N stands for node metastasis; M stands for distant invasion) stage.

CONCLUSION

In comparison to the SOX regimen, the P-SOX regimen demonstrates improved short-term and long-term efficacy with tolerable adverse reactions. It is anticipated that the P-SOX regimen will emerge as a first-line chemotherapy option for GC. Patients with GC who receive effective perioperative chemotherapy (Response Evaluation Criteria in Solid Tumors 1.1, Tumor Regression Grade), have a tumor diameter ≤ 2cm, exhibit high degree of differentiation, and are at an early cTNM stage show better prognosis.

Single incision laparoscopic surgery for hepatocellular carcinoma

Single incision laparoscopic liver resection (SILLR) is the most recent development in the laparoscopic approach to the liver. SILLR for hepatocellular carcinoma (HCC) has developed much more slowly than multiport LLR. So far, 195 patients completed SILLR for HCC. In this paper, we reviewed all published papers about SILLR for HCC and discussed the feasibility of the SILLR, peri and postoperative findings, tricks of patient selection and whether SILLR compromise the oncological principles.

Impact of liver metastasis on immunotherapy in gastric carcinoma

The editorial discusses the impact of liver metastasis on immunotherapy efficacy in gastric cancer (GC) patients. Liver metastasis can hinder the effectiveness of immunotherapy by altering the immune microenvironment, leading to systemic loss of T-cells and reduced treatment response. Studies suggest that liver metastases serve as a negative baseline factor for immunotherapy efficacy, resulting in poorer progression-free survival and objective response rates. Strategies such as liver-mediated radiotherapy may help improve treatment outcomes by reshaping the liver's immune microenvironment and reducing T-cell depletion. Understanding the complex interplay between liver metastasis and immunotherapy response is crucial for optimising patient care in GC.

Advancing perioperative optimization in Crohn's disease surgery with machine learning predictions

This editorial offers commentary on the article which aimed to forecast the likelihood of short-term major postoperative complications (Clavien-Dindo grade ≥ III), including anastomotic fistula, intra-abdominal sepsis, bleeding, and intestinal obstruction within 30 days, as well as prolonged hospital stays following ileocecal resection in patients with Crohn's disease (CD). This prediction relied on a machine learning (ML) model trained on a cohort that integrated a nomogram predictive model derived from logistic regression analysis and a random forest (RF) model. Both the nomogram and RF showed good performance, with the RF model demonstrating superior predictive ability. Key variables identified as potentially critical include a preoperative CD activity index ≥ 220, low preoperative serum albumin levels, and prolonged operation duration. Applying ML approaches to predict surgical recurrence have the potential to enhance patient risk stratification and facilitate the development of preoperative optimization strategies, ultimately aiming to improve post-surgical outcomes. However, there is still room for improvement, particularly by the inclusion of additional relevant clinical parameters, consideration of medical therapies, and potentially integrating molecular biomarkers in future research efforts.

Effects of postoperative treatment with chemotherapy and cellular immunotherapy on patients with colorectal cancer

BACKGROUND

The outcome of surgical treatment for colorectal cancer (CRC) remains unsatisfactory and warrants further exploration and optimization.

AIM

To clarify the impact of chemotherapy plus cellular immunotherapy [dendritic cell-cytokine-induced killer (DC-CIK) cell immunotherapy] on patients after CRC surgery and to explore the mediating variables.

METHODS

A total cohort of 121 patients who underwent CRC surgery between January 2019 and April 2022 were selected. The sample comprised a control group of 55 patients who received the XELOX chemotherapy regimen and a research group of 66 patients who received XELOX + DC-CIK immunotherapy. We performed comparative analyses of the clinical and pathological data of the two groups, including efficacy (2-year disease-free survival [DFS] rate), the incidence of adverse events (diarrhea, myelosuppression, gastrointestinal reactions, and peripheral neuritis), serum levels of tumor markers [carcinoembryonic antigens and carbohydrate antigens (CA)19-9 and CA242], and T-cell subsets [cluster of differentiation (CD)3⁺, CD3⁺ CD4⁺, CD3⁺ CD8⁺, natural killer (NK), and NK T cells]. We also conducted preliminary univariate and multivariate analyses of the variables that affected the efficacy of the treatments.

RESULTS

We found a significantly higher 2-year DFS rate of treatment efficacy in the research group than in the control group, with a statistically lower incidence of adverse events. Both groups showed a reduction in serum tumor markers after treatment but there was no marked intergroup difference. After treatment, the various T-cell subgroup indicators in the control group were significantly lower than those in the research group. The indices of T-cell subsets in the research group showed no significant change from preoperative levels. Univariate analysis revealed a significant correlation between TNM staging, tumor differentiation, and the rates of nonresponse to treatment in CRC patients after surgery. Multivariate results indicated that the treatment approach significantly affected the efficacy of postoperative CRC treatment.

CONCLUSION

We concluded that XELOX + DC-CIK immunotherapy for postsurgical CRC patients offers reduced rates of treatment-induced adverse events, extended 2-year DFS, enhanced immunity, and increased physiological antitumor responses.

Leukopenia-a rare complication secondary to invasive liver abscess syndrome in a patient with diabetes mellitus: A case report

BACKGROUND

Thrombocytopenia is a common complication of invasive liver abscess syndrome (ILAS) by Klebsiella pneumoniae (K. pneumoniae) infection, which indicates severe infection and a poor prognosis. However, the presence of leukopenia is rare. There are rare reports on leukopenia and its clinical significance for ILAS, and there is currently no recognized treatment plan. Early and broad-spectrum antimicrobial therapy may be an effective therapy for treating ILAS and improving its prognosis.

CASE SUMMARY

A 55-year-old male patient who developed fever, chills, and abdominal distension without an obvious cause presented to the hospital for treatment. Laboratory tests revealed thrombocytopenia, leukopenia, and multiple organ dysfunction. Imaging examinations revealed an abscess in the right lobe of the liver and thrombophlebitis, and K. pneumoniae was detected in the blood cultures. Since the patient was diabetic and had multi-system involvement, he was diagnosed with ILAS accompanied by leukopenia and thrombocytopenia. After antibiotic treatment and systemic supportive therapy, the symptoms disappeared, and the patient's condition almost completely resolved.

CONCLUSION

Leukopenia is a rare complication of ILAS, which serves as an indicator of adverse prognostic outcomes and the severity of infection.

Adjuvant chemotherapy for isolated resectable colorectal lung metastasis: A retrospective study using inverse probability treatment weighting propensity analysis

BACKGROUND

The benefit of adjuvant chemotherapy (ACT) for patients with no evidence of disease after pulmonary metastasis resection (PM) from colorectal cancer (CRC) remains controversial.

AIM

To assess the efficacy of ACT in patients after PM resection for CRC.

METHODS

This study included 96 patients who underwent pulmonary metastasectomy for CRC at a single institution between April 2008 and July 2023. The primary endpoint was overall survival (OS); secondary endpoints included cancer-specific survival (CSS) and disease-free survival (DFS). An inverse probability of treatment-weighting (IPTW) analysis was conducted to address indication bias. Survival outcomes compared using Kaplan-Meier curves, log-rank test, Cox regression and confirmed by propensity score-matching (PSM).

RESULTS

With a median follow-up of 27.5 months (range, 18.3-50.4 months), the 5-year OS, CSS and DFS were 72.0%, 74.4% and 51.3%, respectively. ACT had no significant effect on OS after PM resection from CRC [original cohort: P = 0.08; IPTW: P = 0.15]. No differences were observed for CSS (P = 0.12) and DFS (P = 0.68) between the ACT and non-ACT groups. Multivariate analysis showed no association of ACT with better survival, while sublobar resection (HR = 0.45; 95%CI: 0.20-1.00, P = 0.049) and longer disease-free interval (HR = 0.45; 95%CI: 0.20-0.98, P = 0.044) were associated with improved survival.

CONCLUSION

ACT does not improve survival after PM resection for CRC. Further well-designed randomized controlled trials are needed to determine the optimal ACT regimen and duration.

Influencing factors and preventive measures of infectious complications after intestinal resection for Crohn's disease

The incidence of Crohn's disease (CD) has increased in recent years, with most patients requiring intestinal resection. Complications after intestinal resection for CD can lead to poor prognosis and recurrence, among which infectious complications are the most common. This study aimed to investigate the common risk factors, including medications, preoperative nutritional status, surgery-related factors, microorganisms, lesion location and type, and so forth, causing infectious complications after intestinal resection for CD, and to propose corresponding preventive measures. The findings provided guidance for identifying susceptibility factors and the early intervention and prevention of infectious complications after intestinal resection for CD in clinical practice.

Changes over time in treatment for obstructive jaundice

This editorial discusses an article by Peng et al. This study reviewed the efficacy and safety of a new approach for treating obstructive jaundice. Although the pathophysiology of obstructive jaundice has not yet been fully elucidated, progress has been made in its management. There are two aspects of obstructive jaundice: Cholestatic status and absence of bile in the intestinal lumen. Internal biliary drainage resolved both the conditions. Clinically, endoscopic retrograde biliary drainage (ERBD) has replaced percutaneous transhepatic biliary drainage, and ERBD is transitioning to endoscopic ultrasound guided biliary drainage. This editorial briefly explains the mechanism and treatment of obstructive jaundice and the prospects of this new internal biliary drainage technique.

Development of a novel difficulty scoring system for laparoscopic liver resection procedure in patients with intrahepatic duct stones

BACKGROUND

For intrahepatic duct (IHD) stones, laparoscopic liver resection (LLR) is currently a reliable treatment. However, the current LLR difficulty scoring system (DSS) is only available for patients with hepatocellular carcinoma.

AIM

To explore the development of a DSS for IHD stone patients with LLR and the validation of its reliability.

METHODS

We used clinical data from 80 patients who received LLR for IHD stones. Forty-six of these patients were used in multiple linear regression to construct a scoring system. Another 34 patients from different centers were used as external validation. The completeness of our DSS was then evaluated in patients with varying degrees of surgical difficulty based on documented surgical outcomes in the study group of patients.

RESULTS

The following five predictors were ultimately included and scored by calculating the weighted contribution of each factor to the prediction of operative time in the training cohort: Location of stones, number of stones ≥ 3, stones located in the bile ducts of several grades, previous biliary surgery less than twice, distal bile duct atrophy. Subsequently, the data set was validated using a DSS developed from the variables. The following variables were identified as statistically significant in external validation: Operative time, blood loss, intraoperative transfusion, postoperative alanine aminotransferase, and Clavien-Dindo grading ≥ 3. These variables demonstrated statistically significant differences in patients with three or more grades.

CONCLUSION

Patients with IHD stones have varying degrees of surgical difficulty, and the newly developed DSS can be validated with external data to effectively predict risks and complications after LLR surgery.

Risk factors and survival prediction model establishment for prognosis in patients with radical resection of gallbladder cancer

BACKGROUND

Gallbladder cancer (GBC) is the most common malignant tumor of the biliary system, and is often undetected until advanced stages, making curative surgery unfeasible for many patients. Curative surgery remains the only option for long-term survival. Accurate postsurgical prognosis is crucial for effective treatment planning. tumor-node-metastasis staging, which focuses on tumor infiltration, lymph node metastasis, and distant metastasis, limits the accuracy of prognosis. Nomograms offer a more comprehensive and personalized approach by visually analyzing a broader range of prognostic factors, enhancing the precision of treatment planning for patients with GBC.

AIM

To identify risk factors and develop a predictive model for GBC prognosis.

METHODS

A retrospective study analyzed the clinical and pathological data of 93 patients who underwent radical surgery for GBC at Peking University People's Hospital from January 2015 to December 2020. Kaplan-Meier analysis was used to calculate the 1-, 2- and 3-year survival rates. The log-rank test was used to evaluate factors impacting prognosis, with survival curves plotted for significant variables. Single-factor analysis revealed statistically significant differences, and multivariate Cox regression identified independent prognostic factors. A nomogram was developed and validated with receiver operating characteristic curves and calibration curves.

RESULTS

Among 93 patients who underwent radical surgery for GBC, 30 patients survived, accounting for 32.26% of the sample, with a median survival time of 38 months. The 1-year, 2-year, and 3-year survival rates were 83.87%, 68.82%, and 53.57%, respectively. Univariate analysis revealed that carbohydrate antigen 19-9 expression, T stage, lymph node metastasis, histological differentiation, surgical margins, and invasion of the liver, extrahepatic bile duct, nerves, and vessels (P ≤ 0.001) significantly impacted patient prognosis after curative surgery. Multivariate Cox regression identified lymph node metastasis (P = 0.03), histological differentiation (P < 0.05), nerve invasion (P = 0.036), and extrahepatic bile duct invasion (P = 0.014) as independent risk factors. A nomogram model with a concordance index of 0.838 was developed. Internal validation confirmed the model's consistency in predicting the 1-year, 2-year, and 3-year survival rates.

CONCLUSION

Lymph node metastasis, tumor differentiation, extrahepatic bile duct invasion, and perineural invasion are independent risk factors. A nomogram based on these factors can be used to personalize and improve treatment strategies.

Acute gastric volvulus combined with pneumatosis coli rupture misdiagnosed as gastric volvulus with perforation: A case report

BACKGROUND

Acute gastric volvulus represents a rare form of surgical acute abdomen, which makes it difficult to establish an early diagnosis. As the disease progresses, it can lead to gastric ischemia, necrosis, and other serious complications.

CASE SUMMARY

This paper reports a 67-year-old female patient with a history of abdominal distension and retching for 1 day. After admission, a prompt and thorough examination was performed to confirm the diagnosis of acute gastric volvulus. Notably, the patient had free air in the abdominal cavity. The first consideration was gastric volvulus with gastric perforation, but the patient had no complaints, such as abdominal pain or signs of peritoneal irritation in the abdomen, and imaging examination revealed no abdominal pelvic effusion. Following endoscopic reduction, the abdominal organs, such as the stomach and spleen, returned to their normal anatomical positions, and the free intraperitoneal air disappeared, suggesting a rare case of acute gastric torsion. The source of free air within the abdominal cavity warrants careful consideration and discussion. Combined with the findings from computed tomography, these findings are hypothesized to be associated with the rupture of colonic air cysts.

CONCLUSION

Patients with gastric torsion combined with free gas in the abdominal cavity should consider nongastrointestinal perforation factors to avoid misdiagnosis.

Surgical and non-surgical risk factors affecting the insufficiency of ileocolic anastomosis after first-time surgery in Crohn's disease patients

BACKGROUND

Crohn's disease (CD) often necessitates surgical intervention, particularly when it manifests in the terminal ileum and ileocecal valve. Despite undergoing radical surgery, a subset of patients experiences recurrent inflammation at the anastomotic site, necessitating further medical attention.

AIM

To investigate the risk factors associated with anastomotic insufficiency following ileocecal resection in CD patients.

METHODS

This study enrolled 77 patients who underwent open ileocolic resection with primary stapled anastomosis. Patients were stratified into two groups: Group I comprised individuals without anastomotic insufficiency, while Group II included patients exhibiting advanced anastomotic destruction observed endoscopically or those requiring additional surgery during the follow-up period. Surgical and non-surgical factors potentially influencing anastomotic failure were evaluated in both cohorts.

RESULTS

Anastomotic insufficiency was detected in 12 patients (15.6%), with a mean time interval of 30 months between the initial surgery and recurrence. The predominant reasons for re-intervention included stenosis and excessive perianastomotic lesions. Factors associated with a heightened risk of anastomotic failure encompassed prolonged postoperative obstruction, anastomotic bleeding, and clinically confirmed micro-leakage. Additionally, patients in Group II exhibited preoperative malnutrition and early recurrence of symptoms related to CD.

CONCLUSION

Successful surgical outcomes hinge on the attainment of a fully functional anastomosis, optimal metabolic status, and clinical remission of the underlying disease. Vigilant endoscopic surveillance following primary resection facilitates the timely identification of anastomotic failure, thereby enabling noninvasive interventions.

Can serious postoperative complications in patients with Crohn's disease be predicted using machine learning?

The routine introduction of novel anti-inflammatory therapies into the management algorithms of patients with Crohn's disease over the last 2 decades has not substantially changed the likelihood of ultimate surgery. Rather it has delayed the operative need and altered the presentation phenotype. The prospect of complications continues to remain high in this modern era but depending upon the cohort assessed, it remains difficult to make strict comparisons between individual specialist centres. Those patients who present rather late after their diagnosis with a septic complication like an intra-abdominal abscess and a penetrating/fistulizing pattern of disease are more likely to have a complicated course particularly if they have clinical features such as difficult percutaneous access to the collection or multilocularity both of which can make preoperative drainage unsuccessful. Equally, those cases with extensive adhesions where an initial laparoscopic approach needs open conversion and where there is an extended operative time, unsurprisingly will suffer more significant complications that impact their length of hospital stay. The need for a protective stoma also introduces its own derivative costs, utilizing a range of health resources as well as resulting in important alterations in quality of life outcomes. Having established the parameters of the problem can the statistical analysis of the available data identify high-risk cases, promote the notion of centralization of specialist services or improve the allocation of disease-specific health expenditure?

Reassessment of palliative surgery in conversion therapy of previously unresectable hepatocellular carcinoma: Two case reports and review of literature

BACKGROUND

Most patients with hepatocellular carcinoma (HCC) have lost the opportunity for direct surgery at the time of diagnosis. Transarterial chemoembolization (TACE) combined with immune checkpoint inhibitors or tyrosine kinase inhibitors (TKI) can partially transform some unresectable HCC and improve the prognosis effectively. However, based on the promising prospects of combined targeted and immunotherapy for the effective treatment of HCC, the positive role of palliative surgery in the conversion treatment of advanced HCC urgently needs further intensive re-assessment.

CASE SUMMARY

In this study, we describe two successful cases of "conversion therapy for unresectable HCC" achieved mainly by palliative surgery combined with TACE plus immunotherapy and TKIs. A 48-year-old patient with newly diagnosed HCC, presenting with a 6-cm mass in the segment VII/VIII of the right liver with multiple intrahepatic metastases, could not undergo one-stage radical surgical resection. He underwent palliative surgery with radiofrequency of metastatic lesions and the palliative resection of the primary mass, and received subsequent TACE treatments twice in the early postoperative period (2 weeks and 6 weeks), in addition to targeted and immune combination therapy with sintilimab injection and oral lenvatinib. No evidence of recurrence was observed during the 11-month follow-up period after surgery. The other patient was a 47-year-old patient with massive HCC (18 cm × 15 cm × 4.5 cm) in the left liver with severe cirrhosis. The left portal branch was occluded and a tumor thrombus formed, and the tumor partly involved the middle hepatic vein. The patient underwent palliative surgery of left hemihepatectomy (including resection of the middle hepatic vein) for HCC, followed by three TACE procedures and oral TKIs 2 weeks after surgery. Six months later, the re-examination via computed tomography revealed no tumour activity in the remaining right liver, while magnetic resonance imaging revealed slight local tumor enhancement in the caudate lobe of the liver considered, TACE was performed once again, and during the next follow-up of 10 months did not reveal new intrahepatic lesions or distant metastases.

CONCLUSION

These cases demonstrate that the addition of palliative surgery to conversion therapy in a selected population with a high tumor burden could benefit patients with initially unresectable HCC.

Contributing to the prediction of prognosis for treated hepatocellular carcinoma: Imaging aspects that sculpt the future

A novel nomogram model to predict the prognosis of hepatocellular carcinoma (HCC) treated with radiofrequency ablation and transarterial chemoembolization was recently published in the World Journal of Gastrointestinal Surgery. This model includes clinical and laboratory factors, but emerging imaging aspects, particularly from magnetic resonance imaging (MRI) and radiomics, could enhance the predictive accuracy thereof. Multiparametric MRI and deep learning radiomics models significantly improve prognostic predictions for the treatment of HCC. Incorporating advanced imaging features, such as peritumoral hypointensity and radiomics scores, alongside clinical factors, can refine prognostic models, aiding in personalized treatment and better predicting outcomes. This letter underscores the importance of integrating novel imaging techniques into prognostic tools to better manage and treat HCC.

Prevention and management of postoperative deep vein thrombosis in lower extremities of patients with gastrointestinal tumor

BACKGROUND

Deep vein thrombosis (DVT) is a significant postoperative concern, particularly in patients undergoing surgery for gastrointestinal (GI) cancers. These patients often present multiple risk factors, including advanced age and elevated body mass index (BMI), which can increase the likelihood of thromboembolic events. Effective prophylaxis is crucial in this high-risk population to minimize complications such as DVT and pulmonary embolism (PE). This study investigates a comprehensive DVT prevention protocol, combining mechanical and pharmacological strategies alongside early mobilization, to evaluate its effectiveness and safety in reducing postoperative thrombosis rates among GI cancer surgery patients.

AIM

To evaluate the effectiveness and safety of postoperative DVT prevention strategies in patients with GI cancer.

METHODS

A prospective cohort study was conducted involving 100 patients who underwent surgery for GI tumors between January and December 2022. All patients received a standardized DVT prevention protocol, which included risk assessment, mechanical prophylaxis, pharmacological prophylaxis, and early mobilization. The primary endpoint was the incidence of DVT within 30 days postoperatively. Secondary outcomes included the occurrence of PE, bleeding complications, and adherence to the protocol.

RESULTS

The overall incidence of DVT was 7% (7/100 patients). One patient (1%) developed PE. The adherence rate to the prevention protocol was 92%. Bleeding complications were observed in 3% of patients. Significant risk factors for DVT development included advanced age [odds ratio (OR): 1.05; 95% confidence interval (95%CI): 1.01-1.09], higher BMI (OR: 1.11; 95%CI: 1.03-1.19), and longer operative time (OR: 1.007; 95%CI: 1.001-1.013).

CONCLUSION

Implementing a comprehensive DVT prevention and management protocol for patients undergoing GI tumor surgery resulted in a lower incidence. Strict adherence and individualized risk assessment are crucial for optimizing outcomes.

Postoperative serum tumor markers-based nomogram predicting early recurrence for patients undergoing radical resections of pancreatic ductal adenocarcinoma

BACKGROUND

Early recurrence (ER) is associated with dismal outcomes in patients undergoing radical resection for pancreatic ductal adenocarcinoma (PDAC). Approaches for predicting ER will help clinicians in implementing individualized adjuvant therapies. Postoperative serum tumor markers (STMs) are indicators of tumor progression and may improve current systems for predicting ER.

AIM

To establish an improved nomogram based on postoperative STMs to predict ER in PDAC.

METHODS

We retrospectively enrolled 282 patients who underwent radical resection for PDAC at our institute between 2019 and 2021. Univariate and multivariate Cox regression analyses of variables with or without postoperative STMs, were performed to identify independent risk factors for ER. A nomogram was constructed based on the independent postoperative STMs. Receiver operating characteristic curve analysis was used to evaluate the area under the curve (AUC) of the nomogram. Survival analysis was performed using Kaplan-Meier survival plot and log-rank test.

RESULTS

Postoperative carbohydrate antigen 19-9 and carcinoembryonic antigen levels, preoperative carbohydrate antigen 125 levels, perineural invasion, and pTNM stage III were independent risk factors for ER in PDAC. The postoperative STMs-based nomogram (AUC: 0.774, 95%CI: 0.713-0.835) had superior accuracy in predicting ER compared with the nomogram without postoperative STMs (AUC: 0.688, 95%CI: 0.625-0.750) (P = 0.016). Patients with a recurrence nomogram score (RNS) > 1.56 were at high risk for ER, and had significantly poorer recurrence-free survival [median: 3.08 months, interquartile range (IQR): 1.80-8.15] than those with RNS ≤ 1.56 (14.00 months, IQR: 6.67-24.80), P < 0.001).

CONCLUSION

The postoperative STMs-based nomogram improves the predictive accuracy of ER in PDAC, stratifies the risk of ER, and identifies patients at high risk of ER for tailored adjuvant therapies.

Urgent need for prognostic markers for hepatocellular carcinoma in the light of genomic instability and non-coding RNA signatures

In this editorial, we comment on an original article by Duan et al. Despite advancements in the diagnosis and treatment of hepatocellular carcinoma (HCC), the identification of suitable prognostic factors remains challenging. In their paper, Duan et al identified long non-coding RNAs (LncRNAs) to quantify genomic instability (GI) by combining LncRNA expression and somatic mutation profiles. They confirmed that the GI-derived LncRNA signature (GI-LncSig) could be an independent prognostic factor with the area under the curve of 0.773. Furthermore, the authors stated that GI-LncSig may have a better predictive performance than TP53 mutation status alone. However, studies exploring genetic markers for predicting the prognosis of HCC are crucial for identifying therapeutic targets and enhancing diagnostic and treatment strategies to mitigate the global burden of liver cancer.

Differential diagnosis of gastric submucosal masses and external pressure lesions

Lesions of the left triangular ligament of the liver are rare, and there are even fewer cases of vascular tumors misdiagnosed as gastrointestinal stromal tumors. We comment on the two cases reported in the article. The article did not include pictures of laparoscopic surgery, making it unconvincing. For gastric submucosal lesions, enhanced computed tomography venous phase imaging may be beneficial for differential diagnosis. Although endoscopic ultrasound is an effective tool for diagnosing submucosal lesions of the stomach, due to various factors, it cannot achieve an accurate diagnosis. During endoscopic examination, a more accurate diagnosis can be made depending on the personal experience of the operators.