Survival and cancer recurrence after short-course perioperative probiotics in a randomized trial

BACKGROUND & AIMS

The long-term impact of perioperative probiotics remains understudied while mounting evidence links microbiome and oncogenesis. Therefore, we analyzed overall survival and cancer recurrence among patients enrolled in a randomized trial of perioperative probiotics.

METHODS

6-year follow-up of surgical patients participating in a randomized trial evaluating short-course perioperative oral probiotic VSL#3 (n = 57) or placebo (n = 63).

RESULTS

Study groups did not differ in age, preoperative hemoglobin, ASA status, and Charlson comorbidity index. There was a significant difference in preoperative serum albumin (placebo group 4.0 ± 0.1 vs. 3.7 ± 0.1 g/dL in the probiotic group, p = 0.030). Thirty-seven deaths (30.8 %) have occurred during a median follow-up of 6.2 years. Overall survival stratified on preoperative serum albumin and surgical specialty was similar between groups (p = 0.691). Age (aHR = 1.081, p = 0.001), serum albumin (aHR = 0.162, p = 0.001), and surgical specialty (aHR = 0.304, p < 0.001) were the only predictors of overall survival in the multivariate model, while the placebo/probiotic group (aHR = 0.808, p = 0.726) was not predictive. The progression rate among cancer patients was similar in the probiotic group (30.3 %, 10/33) compared to the placebo group (21.2 %, 7/33; p = 0.398). The progression-free survival was not significantly different (unstratified p = 0.270, stratified p = 0.317).

CONCLUSIONS

Perioperative short-course use of VSL#3 probiotics does not influence overall or progression-free survival after complex surgery for visceral malignancy.

Signet ring cell carcinoma of the gastrointestinal tract: National trends on treatment effects and prognostic outcomes

BACKGROUND

Signet ring cell carcinoma (SRCC) is a distinct malignancy occurring across the tubular gastrointestinal tract (tGIT). We comprehensively examined the outcomes of patients diagnosed with SRCC across tGIT.

METHODS

SRCC and not-otherwise-specified adenocarcinoma (NOS) patients reported to the National Cancer Database from 2004 to 2015 were included. Baseline characteristics, outcomes and site-specific adjusted hazard ratios (aHR) derived from Cox models of SRCC patients were compared to those of NOS patients. Overall survival (OS) was primary endpoint.

RESULTS

A total of 41,686 SRCC (4.6%) and 871,373 NOS patients (95.4%) were included. SRCC patients were younger (63.1 ± 14.7 vs. 67.0 ± 13.4 y, p < 0.001) and more likely to present with Stage IV disease than NOS patients (42.5% vs. 24.5%, p < 0.001). Stomach (n = 24,433) and colon (n = 9,914) contributed highest frequency of SRCC. SRCC histology was associated with shorter OS (aHR = 1.377, p < 0.001) in multivariate model. There was an interaction between SRCC and chemotherapy effects on risk of death (interaction aHR = 1.072, p_interaction< 0.001) and between SRCC histology and disease site, suggesting that the effect of SRCC on OS is site-dependent, with a higher increased risk of death in patients with rectal SRCC (aHR = 2.378, p_interaction< 0.001).

CONCLUSION

Significant negative prognostic effect associated with SRCC is site-dependent across the GIT. Surgical and or systemic therapy was associated with improved OS among SRCC patients, but remained lower than NOS patients. Further understanding of gastrointestinal SRCC molecular profile is needed to better inform future treatment strategies.

Rising Incidence of Peri-Operative Bactibilia among Patients Undergoing Complex Biliopancreatic Surgery

Background: Biliary instrumentation is associated with bactibilia and post-operative infection. Bactibilia incidence over time remains unknown. Patients and Methods: Consecutive patients with bilioenteric anastomosis surgery and available surveillance intra-operative bile duct cultures were evaluated for post-operative infection. The study period (2008-2019) was divided into quartiles to examine time-based trends. Results: Among 101 cases, 60 intra-operative bile duct cultures had no growth and 41 patients had documented at least one culture-positive isolate in their bile. Frequency of patients with culture-positive intra-operative bile increased over the study period (period 1, 1/28, 3.6% vs. period 2, 7/21, 33.3% vs. period 3, 15/26, 57.7% vs. period 4, 18/26, 69.2%; p < 0.001). Culture-positive post-operative infection (17/101; 16.8%) was not associated with intra-operative bile duct culture (p = 0.552), however, the same micro-organism isolate was identified on post-operative infection and intra-operative culture of bile duct bile among six of 17 patients (35.3%). Conclusions: We found an increasing incidence of bactibilia and post-operative culture-positive infections over the last decade. One-third of patients with a positive intra-operative bile duct culture experienced post-operative infection with the same organism, yet a clear link between bile colonization and post-operative infection was not established.

Robotic Resection of Type I Hilar Cholangiocarcinoma with Intrapancreatic Bile Duct Dissection

BACKGROUND

Type I hilar cholangiocarcinoma is a malignancy of the extrahepatic bile duct for which margin-negative resection with sufficient lymphadenectomy may provide curative treatment. The aim of this video is to highlight the advantages of optical magnification, articulating instruments, and indocyanine green fluorescent cholangiography to demonstrate extrahepatic bile duct resection from the biliary confluence to the intrapancreatic bile duct with comprehensive hilar lymphadenectomy for pathologic staging.

METHODS

A 58-year-old male presented with obstructive jaundice and was found to have a biliary stricture arising from the cystic duct and bile duct junction. Endoscopic biopsy of the bile duct confirmed adenocarcinoma. His case was presented at a multidisciplinary tumor conference where consensus was to proceed with upfront robotic en bloc extrahepatic bile duct resection with hilar lymphadenectomy and Roux-en-Y hepaticojejunostomy.

RESULTS

Final pathology demonstrated margin-negative resection of moderately differentiated adenocarcinoma, 1 out of 12 lymph nodes involved with disease, and pathologic stage T2N1M0 (stage IIIC). The patient had no postoperative complications and was discharged home on postoperative day 5. At 6 weeks from his operative date, he was initiated on four cycles of adjuvant gemcitabine/capecitabine, followed by 50 Gray external beam radiation therapy with capecitabine, then four cycles of gemcitabine/capecitabine, completed after 6 months of therapy.

CONCLUSIONS

Robotic extrahepatic bile duct resection, hilar lymphadenectomy, and biliary enteric reconstruction is feasible and should be considered for selected cases of bile duct resection.

Effect of wound protectors on surgical site infection in patients undergoing whipple procedure

BACKGROUND

Conflicting data persists for use of wound protectors in pancreatoduodenectomy (PD) to prevent surgical site infection (SSI). We aimed to examine, at a multi-institutional level, the effect of wound protectors on superficial or deep SSI following elective open PD.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program pancreatectomy procedure targeted participant use file was queried from 2016 to 2018. Planned open PD procedures were extracted. Univariable, multivariable, and propensity score matched analyses were conducted.

RESULTS

11,562 patients undergoing PD were evaluated, 27% of which used wound protectors. Wound protectors decreased superficial or deep SSI risk in all patients (5.7% vs. 9.5%, P < 0.001), patients who have (6.6% vs. 12.2%, P < 0.001) and who did not have (4.6% vs. 6.5%, P = 0.011) a biliary stent. Propensity score matched analysis confirms such results (OR = 0.56, 95% CI: 0.46-0.69, P < 0.001 overall, OR = 0.66, 95% CI: 0.46-0.95, P = 0.03 without biliary stent, OR = 0.57, 95% CI: 0.44-0.73, P < 0.001 with biliary stent).

CONCLUSIONS

Wound protectors reduce risk of superficial or deep SSI in patients undergoing PD, yet only a quarter of PD were associated with their use. This protective effect is seen whether patients have or have not had preoperative biliary stenting.

Robotic Isolated Caudate Lobectomy for Solitary Colorectal Liver Metastasis

BACKGROUND

Safety of liver resection for colorectal adenocarcinoma continues to improve due to decreased morbidity of resection. Minimally invasive techniques contribute greatly to this morbidity reduction. Isolated caudate lobectomy presents a unique technical challenge because of proximity to major vasculature. The video aims to review nuances of robotic isolated caudate lobectomy for metastatic colon adenocarcinoma.

Rare case of pancreatic neuroendocrine tumour presenting as paraneoplastic hypercalcaemia

An asymptomatic 68-year-old woman who presented with an isolated hypercalcaemia was diagnosed with a rare, previously unsuspected parathyroid hormone-related peptide (PTHrP)-producing pancreatic neuroendocrine tumour. She underwent an extensive operation including vascular resection and reconstruction, resulting in successful removal of the tumour with negative margins. Medical and surgical management of pancreatic neuroendocrine tumours and PTHrP-mediated paraneoplastic hypercalcaemia is discussed.

Indications and Perioperative Outcomes for Pancreatectomy with Arterial Resection

BACKGROUND

Pancreatectomy with arterial resection (AR) is performed infrequently. As indications evolve, we evaluated indications, outcomes, and predictors of mortality, morbidity, and survival after AR.

STUDY DESIGN

We performed a single-institution review of elective pancreatectomies with AR (from July1990 to July 2017). Univariate and multivariate analyses were performed for predictors of outcomes and survival.

RESULTS

A total of 111 patients underwent pancreatectomy with AR including any hepatic (54%), any celiac (44%), any superior mesenteric (14%), or multiple ARs (14%), with revascularization in 55%. The majority of cases were planned (77%) and performed post-2010 (78%). Overall 90-day major morbidity (≥grade III) and mortality were 54% and 13%, respectively, due to post-pancreatectomy hemorrhage (PPH), postoperative pancreatic fistula (POPF), or ischemia in the majority of cases. There was a significant decrease in mortality post-2010 (9% vs 29%, p = 0.02), and this was protective on multivariate analysis (odds ratio [OR] 0.1, p = 0.004); PPH increased mortality (OR 6.1, p < 0.001). Post-pancreatectomy hemorrhage was associated with major morbidity (OR 5.1, p = 0.005), reoperation (OR = 23.0, p = 0.004), ICU (OR 5.5, p < 0.001), and readmission (OR 2.6, p = 0.004). Other morbidity predictors were AR with graft (OR 4.0, p = 0.031) and POPF (OR 3.1, p = 0.003). Median survival was 28.5 months and improved for ductal adenocarcinoma after neoadjuvant chemotherapy (p = 0.038). There were no differences in survival based on AR type.

CONCLUSIONS

Regardless of indication or type, pancreatectomy with AR is associated with risks greater than standard resections. Mortality has decreased in the modern era; however, morbidity remains high from hemorrhagic, fistula, or ischemia-related complications. Mitigation measures are needed if advanced resections are considered with increasing frequency given the potential oncologic benefit of AR in selected cases after modern chemotherapy.

Implications of CA19-9 elevation for survival, staging, and treatment sequencing in intrahepatic cholangiocarcinoma: A national cohort analysis

BACKGROUND

Optimal management of patients with intrahepatic cholangiocarcinoma (ICCA) and elevated CA19-9 remains undefined. We hypothesized CA19-9 elevation above normal indicates aggressive biology and that inclusion of CA19-9 would improve staging discrimination.

METHODS

The National Cancer Data Base (NCDB-2010-2012) was reviewed for patients with ICCA and reported CA19-9. Patients were stratified by CA19-9 above/below normal reference range. Unadjusted Kaplan-Meier and adjusted Cox-proportional-hazards analysis of overall survival (OS) were performed.

RESULTS

A total of 2,816 patients were included: 938 (33.3%) normal; 1,878 (66.7%) elevated CA19-9 levels. Demographic/pathologic and chemotherapy/radiation were similar between groups, but patients with elevated CA19-9 had more nodal metastases and less likely to undergo resection. Among elevated-CA19-9 patients, stage-specific survival was decreased in all stages. Resected patients with CA19-9 elevation had similar peri-operative outcomes but decreased long-term survival. In adjusted analysis, CA19-9 elevation independently predicted increased mortality with impact similar to node-positivity, positive-margin resection, and non-receipt of chemotherapy. Proposed staging system including CA19-9 improved survival discrimination over AJCC 7th edition.

CONCLUSION

Elevated CA19-9 is an independent risk factor for mortality in ICCA similar in impact to nodal metastases and positive resection margins. Inclusion of CA19-9 in a proposed staging system increases discrimination. Multi-disciplinary therapy should be considered in patients with ICCA and CA19-9 elevation. J. Surg. Oncol. 2016;114:475-482. © 2016 Wiley Periodicals, Inc.

Laparoscopic pancreatoduodenectomy does not completely mitigate increased perioperative risks in elderly patients

BACKGROUND

Elderly patients undergoing open pancreatoduodenectomy (OPD) are at increased risk for surgical morbidity and mortality. Whether totally laparoscopic pancreatoduodenectomy (TLPD) mitigates these risks has not been evaluated.

METHODS

A retrospective review of outcomes in patients submitted to pancreatoduodenectomy during 2007-2014 was conducted (n = 860). Outcomes in elderly patients (aged ≥70 years) were compared with those in non-elderly patients with respect to risk-adjusted postoperative morbidity and mortality. Differences in outcomes between patients submitted to OPD and TLPD, respectively, were evaluated in the elderly subgroup.

RESULTS

In elderly patients, the incidences of cardiac events (odds ratio [OR] 3.21, P < 0.001), respiratory events (OR 1.68, P = 0.04), delayed gastric emptying (DGE) (OR 1.73, P = 0.003), increased length of stay (LoS, 1 additional day) (P < 0.001), discharge disposition other than home (OR 8.14, P < 0.001) and blood transfusion (OR 1.48, P = 0.05) were greater than in non-elderly patients. Morbidity and mortality did not differ between the OPD and TLPD subgroups of elderly patients. In elderly patients, OPD was associated with increased DGE (OR 1.80, P = 0.03), LoS (1 additional day; P < 0.001) and blood transfusion (OR 2.89, P < 0.001) compared with TLPD.

CONCLUSIONS

Elderly patients undergoing TLPD experience rates of mortality, morbidity and cardiorespiratory events similar to those in patients submitted to OPD. In elderly patients, TLPD offers benefits by decreasing DGE, LoS and blood transfusion requirements.

Incremental value and clinical impact of neck sonography for primary hyperparathyroidism: a risk-adjusted analysis

BACKGROUND

Despite the different preoperative imaging modalities available for parathyroid adenoma localization, there is currently no uniform consensus on the most appropriate preoperative imaging algorithm that should be routinely followed prior to the surgical management of primary hyperparathyroidism (PHPT). We sought to determine the incremental value of adding neck ultrasonography to scintigraphy-based imaging tests.

METHODS

In a single institution, surgically naive patients with PHPT underwent the following localization studies before parathyroidectomy: 1) Tc-99m sestamibi imaging with single photon emission computed tomography/computed tomography (SPECT/CT) or Tc-99m sestamibi imaging with SPECT alone, or 2) ultrasonography in addition to those tests. We retrospectively collected data and performed a multivariate analysis comparing group I (single study) to group II (addition of ultrasonography) and risk of bilateral (BNE) compared with unilateral (UNE) neck exploration.

RESULTS

Our study included 208 patients. Group II had 0.45 times the odds of BNE versus UNE compared with group I (unadjusted odds ratio [OR] 0.45, 95% confidence interval [CI] 0.25-0.81, p = 0.008). When adjusting for patient age, sex, preoperative calcium level, use of intraoperative PTH monitoring, preoperative PTH level, adenoma size, and number of abnormal parathyroid glands, Group II had 0.48 times the odds of BNE versus UNE compared with group I (adjusted OR 0.48, 95% CI 0.23-1.03, p = 0.06). In a subgroup analysis, only the addition of ultrasonography to SPECT decreased the risk of undergoing BNE compared with SPECT alone (unadjusted OR 0.40, 95% CI 0.19-0.84, p = 0.015; adjusted OR 0.38, 95% CI 0.15-0.96, p = 0.043).

CONCLUSION

The addition of ultrasonography to SPECT, but not to SPECT/CT, has incremental value in decreasing the extent of surgery during parathyroidectomy, even after adjusting for multiple confounding factors.

Effect of bariatric surgery on oncologic outcomes: a systematic review and meta-analysis

BACKGROUND

Obesity is a major public health issue and is associated with increased risk of several cancers, currently a leading cause of mortality. Obese patients undergoing bariatric surgery may allow for evaluation of the effect of intentional excess weight loss on subsequent risk of cancer. We aimed to evaluate cancer risk, incidence, and mortality after bariatric surgery.

METHODS

A comprehensive literature search was conducted using PubMed/MEDLINE and Embase with literature published from the inception of both databases to January 2012. Inclusion criteria incorporated all human studies examining oncologic outcomes after bariatric surgery. Two authors independently reviewed selected studies and relevant articles from their bibliographies for data extraction, quality appraisal, and meta-analysis.

RESULTS

Six observational studies (n = 51,740) comparing relative risk (RR) of cancer in obese patients undergoing bariatric surgery versus obese control subjects were analyzed. Overall, the RR of cancer in obese patients after undergoing bariatric surgery was 0.55 [95% confidence interval (CI) 0.41-0.73, p < 0.0001, I(2) = 83%]. The effect of bariatric surgery on cancer risk was modified by gender (p = 0.021). The pooled RR in women was 0.68 (95% CI 0.60-0.77, p < 0.0001, I(2) < 0.1%) and in men was 0.99 (95% CI 0.74-1.32, p = 0.937, I(2) < 0.1%).

CONCLUSIONS

Bariatric surgery reduces cancer risk and mortality in formerly obese patients. When stratifying the meta-analysis by gender, the effect of bariatric surgery on oncologic outcomes is protective in women but not in men.

Images of cecal volvulus from a strangulating fallopian tube: a case report

An unusual case of cecal volvulus arising from a strangulating fallopian tube is presented. The etiology, diagnosis, and management guidelines of this infrequent cause of large bowel obstruction are reviewed. Computed tomography images are included, which demonstrate key features that are pathognomonic for this condition. To our knowledge, this is the first report of gynecologic adnexa giving rise to cecal volvulus.