Clinical Surgical Oncology最新文献

Treatment options for metastatic pancreatic ductal adenocarcinoma (mPDAC) patients remain limited, meaning that death within weeks of diagnosis unfortunately remains a common occurrence. Whilst metastases from other malignancy sites, such as colorectal and breast, are amenable to resection in selected patients, consensus remains largely against resection of mPDAC. Without surgical resection, chemotherapy remains the main treatment option and despite advances in regimens, a large proportion of mPDAC patients do not respond to these treatments. Understandably, investigation into whether different genetic subtypes of PDAC can explain the changes in response to chemotherapy have been carried out but as yet has not demonstrated any marked differences between those that do and do not respond to chemotherapy treatment.

This review outlines the emerging role that both the gut and tumour microbiome play in modulating the progression of PDAC, ranging from chemosensitivity to immune infiltration of the tumour This puts the gut microbiome in a promising position as a potential future therapeutic route for mPDAC patients. Possible methods to modulate the gut and tumour microbiome include antibiotics, probiotics and faecal microbiota transplantation (FMT). The next steps should therefore be to focus upon how we can effectively and safely introduce these beneficial bacteria into the gut and tumour microbiome of mPDAC patients through clinical trials.

Introduction

& Aims: Hindquarter amputation (HQA) has a high incidence of post-operative wound complications. We aim to use the HQA procedure as a model to investigate the potential advantages of negative pressure wound therapy (NPWT) on wound healing complications in high-risk pelvic oncology wounds.

Methods

We conducted a retrospective analysis of all patients undergoing HQA between January 2009 and November 2020 ​at a single tertiary centre. 106 patients underwent HQA for sarcoma. 43.4% (46 patients) had NPWT therapy following HQA. We compared the incidence of wound complications necessitating a return to the operating theatre, total incidence of wound infection (according to CDC Surgical site infection guidelines) and local recurrence between patients with and without NPWT.

Results

In the absence of neo-adjuvant radiotherapy, there was no difference in the incidence of wound complications requiring re-operation between the NPWT group and the conventional dressing group (odds ratio [OR], 1.01; p ​= ​0.983, 95% confidence interval [CI], 0.365–2.8). However, the use of NPWT decreased the incidence of reoperation after neo-adjuvant radiotherapy versus conventional dressings [OR], 0.087; p ​= ​0.033, 95% CI, 0.009–0.818). The incidence of wound infection has declined with the increasing use of NPWT between 2009 and 2020. There was no difference in the incidence of local recurrence after two years between patient groups with and without NPWT.

Conclusion

The application of NPWT reduces the incidence of wound complications in high-risk pelvic oncology wounds after neo-adjuvant radiotherapy. We demonstrated a reduction in the incidence of reoperation due to wound complications in patients who received NPWT following HQA.

The liver is the main target organ for hematogenous metastases of colorectal cancer, and colorectal liver metastasis is one of the most difficult and challenging situations in the treatment of colorectal cancer. In order to improve the diagnosis and comprehensive treatment in China, the Guidelines have been edited and revised for several times since 2008, including the overall evaluation, personalized treatment goals and comprehensive treatments, to prevent the occurrence of liver metastases, increase the local damage rate of liver metastases, prolong long-term survival, and improve quality of life. The revised Guideline version 2023 includes the diagnosis and followup, prevention, multidisciplinary team (MDT), surgery and local ablative treatment, neoadjuvant and adjuvant therapy, and comprehensive treatment, with stateoftheart experience and findings, detailed content, and strong operability.

Background

Neoadjuvant therapy has been the standard care for borderline resectable or locally advanced pancreatic ductal carcinoma (BR/LA PDAC). The textbook outcome (TO) for curative resection after neoadjuvant therapy (NAT) remains understudied.

Method

Patients underwent curative resection for PDAC between 2019 and 2020 were confirmed from the multidisciplinary team (MDT) database prospectively maintained by the Department of Pancreatic Hepatobiliary Surgery of Changhai hospital. TO of patients received NAT was compared to those received upfront surgery (UFS), and multivariate analysis of clinicopathological parameters was performed to explore predictors for TO.

Results

Of 435 patients, 329(76%) patients received UFS whereas 106(24%) patients received NAT. The TO was 82.1% for the NAT cohort, 77.8% for pancreaticoduodenectomy (PD) and 86.8% for distal pancreatectomy (DP). In the UFS cohort, the TO was 73.3% overall, 70.6% for PD and 77.3% for DP. Patients in the NAT cohort had longer time of operation, more intra-operative blood loss and more vascular resection. However, TO of the NAT cohort were not statistically different compared to that in the UFS cohort (p ​= ​0.27 for PD and p ​= ​0.20 for DP). On multivariable analysis, only diabetes-free was predictive for a better TO rate after PD in the UFS cohort(p ​= ​0.003). There were no factors associated with TO after DP in the UFS cohort, nor after PD or DP in the NAT cohort.

Conclusion

As a composite indicator of desired surgical outcome, TO for curative resection after neoadjuvant therapy is similar to that in upfront surgery. All patients with stable or regressed tumors after NAT should be candidates for curative resection in an MDT setting.

Background

Pancreaticoduodenectomy data regarding the optimal technique for reconstruction of small pancreatic ducts, where duct-to-mucosa is technically difficult, are lacking. We sought to retrospectively evaluate outcomes of dunking pancreaticojejunostomy (DPJ) compared to dunking pancreaticogastrostomy (DPG) after pancreaticoduodenectomy.

Methods

Using NSQIP-targeted pancreatectomy data (2014–2019), we retrospectively identified patients undergoing elective pancreaticoduodenectomy with small pancreatic ducts (<3 ​mm) who underwent DPJ or DPG. Outcomes between patients undergoing DPJ versus DPG were compared using multivariable regression.

Results

Among 780 patients, 79.8% underwent DPJ and 20.1% DPG. Patient comorbidities were similar. More patients who underwent DPG were Black, underwent vascular reconstruction (29.0% v. 10.5%; p ​< ​0.001), and had shorter operative time (324 v. 377 ​min; p ​< ​0.001). After adjustment, DPJ reconstruction was associated with higher likelihood of clinically-relevant postoperative pancreatic fistula (CR-POPF) (OR 2.1; p ​= ​0.024), deep abscess (OR 1.9; p ​= ​0.041), and postoperative percutaneous drainage (OR 2.2; p ​= ​0.027). There was no difference in delayed gastric emptying, postoperative sepsis, transfusions, reoperation, length of stay, or 30-day readmission.

Conclusion

Among patients with small pancreatic ducts where a dunking pancreaticoenteric anastomosis is performed, DPG was associated with decreased CR-POPF incidence compared to DPJ. Future clinical trials are needed to confirm the generalizability of this result across centers with varying DPG expertise.

The management of resectable gastric cancer has changed significantly over the past several decades and continues to evolve. For surgery, East Asian and Western lymphadenectomy practices have grown more convergent, with a consensus that D2 lymphadenectomy should be standard for most patients if it can be performed safely, but that more extensive lymphadenectomy or bursectomy should not be performed. Minimally invasive gastrectomy has also been established as a safe and oncologically equivalent approach to open gastrectomy, with potential short- and long-term morbidity benefits in appropriately selected patients. Moving forward, sentinel lymph node biopsy is under investigation as a possible way to de-escalate surgery for patients with early-stage gastric cancer, and other techniques such as adjuvant HIPEC are being investigated in patients with locally advanced gastric cancer. For stage 2 and 3 patients who are at high risk for recurrence with surgery alone, pre- and post-operative chemotherapy has evolved to become the standard of care in the West, while adjuvant chemotherapy has remained the standard of care in the East. There have been slow but steady incremental improvements in outcomes over the past several decades, but the timing and composition of multimodal therapy remain to be optimized. Furthermore, as our understanding of the molecular underpinnings of gastric cancer has continued to expand, exciting new systemic therapy strategies are under investigation for specific subgroups of gastric cancer, such as the use of perioperative immunotherapy for microsatellite unstable gastric cancers.

Secondary malignancies are a late complication of radiation treatment for primary cancer through DNA damage. Specifically after breast cancer radiation, a number of tissues are vulnerable to radiation damage and have increased risk for developing secondary malignancies including lung cancer, esophageal cancer, and contralateral breast cancer. Radiation dose must be minimized to healthy tissues, and patients monitored for potential complications as secondary malignancies can occur decades after original radiation. Through evaluation and examination of current literature, this review article aims to summarize molecular mechanisms of DNA damage and radiation-induced malignancies, and discuss the types of secondary neoplasms including radiation induced breast cancer and therapy-associated myeloid neoplasms.

Surgical treatment is the classic treatment modality for focal liver diseases. In 140 years, liver surgery is constantly evolving, along with advances in understanding anatomy, physiology, and emergence of technologies. During the last 30 years, many surgical techniques used in the modern ages became available since the 1990s, and liver surgery is becoming a routine procedure in many hospitals in China because of the significant decrease in surgical mortality. Furthermore, liver surgery is playing an increasingly important role in multimodality treatment for liver cancer while the treatment pattern is also changing because of progresses in systemic treatment. The progresses in liver surgery are summarized in the article.

Objective

The use of cefazolin (CEZ) is recommended as a preoperative prophylactic antibiotic, but other antibiotics may be used for various reasons. We adopted a fluoroquinolone (levofloxacin; LVFX) as a preoperative prophylactic antibiotic because of reduced supply of CEZ worldwide, while the efficacy of LVFX in preventing infectious complications including surgical site infection (SSI), empyema, and pneumonia has not been fully investigated.

Methods

The medical records of 260 patients who underwent primary lung cancer resection between April 2018 and July 2020 were retrospectively reviewed. Eighty-nine patients before May 2019 were intravenously received a single dose of CEZ with additional administration every 3 ​h during surgery (the CEZ group) and 171 patients after that date were orally received a preoperative single dose of LVFX (the LVFX group). The efficacy of preventing infectious complications was compared between two groups. The propensity score matching (PSM) method was also applied to minimize selection bias.

Results

Infectious complications were observed in 3.1% (8/260) of patients, with no significant difference between the LVFX group (2.9%) and the CEZ group (3.4%) regardless of subtypes such as SSI and empyema. After PSM, 77 patients each were matched from the two groups, and there was also no significant difference in the incidence of infectious complications (the LVFX group; 2.6% vs. the CEZ group; 3.9%).

Conclusion

LVFX has comparable efficacy to CEZ for preventing infectious complications, and may be an alternative to preoperative antibiotics for patients with primary lung cancer who underwent pulmonary resection.