Type IV Mirizzi Syndrome: Brief Report and Review of Management Options.

Mirizzi syndrome is a rare complication of chronic calculous cholecystitis. Preoperative diagnosis is challenging due to the absence of pathognomonic signs and symptoms and low sensitivity rates of imaging tests. Historically, laparotomy has been the preferred choice of surgical management. Endoscopic and laparoscopic approaches have been increasingly described as diagnostic and therapeutic options for Mirizzi type I and II, but data is limited regarding the management of more complex cases. We describe a staged endoscopic and laparoscopic approach for the management of type IV Mirizzi syndrome and review the management options.

Feasibility of remote administration of the fundamentals of laparoscopic surgery (FLS) skills test using Google wearable device.

BACKGROUND: The fundamentals of laparoscopic surgery (FLS) program is a simulation-based training program designed to teach and assess the basic skills necessary for laparoscopic surgery. Preliminary work has demonstrated the feasibility of using Skype™ as a telesimulation modality in reliably scoring the exam for remote centers. Google Glass (GG) (Mountain View, California) is referred to as a wearable computer containing a heads-up display and front-facing camera allowing point-of-view video transmission. The objective of this study was to evaluate the feasibility of GG in scoring the technical skills component of the FLS exam. METHODS: Twenty-eight participants were asked to complete the peg transfer and intracorporeal knot tasks of FLS using both GG and Skype™ setups. GG employed a third-party HIPAA-compliant video software (Pristine; Austin, TX) for video transmission. Participants were alternated between setups and evaluated by onsite and remote proctors. Times and errors were recorded by both proctors. Interrater reliability of their FLS scores was compared using Intraclass Correlation Coefficients (ICCs). GG experience was evaluated based on participant survey responses using a 5-point Likert scale. RESULTS: Interrater reliability for GG demonstrated a statistically significant correlation between onsite (OP) and remote (RP) proctors with ICCs of 0.985 (95% Confidence Interval [CI], 0.969-0.993) and 0.997 (95% CI 0.993-0.998), respectively, for peg and suture tasks. Skype™ demonstrated ICCs of 1.0 (95% CI 1.0-1.0). Average Likert scale responses found GG to be distracting (2.71), obstructive of the view (2.79), and a limitation to task execution (2.75). Overall, there was no statistical difference in scores between GG and Skype™ setups for either the peg (t = 1.446, p = 0.154) or suture task (t = - 0.710, p = 0.480), only 1 participant found the use of GG superior to Skype™. CONCLUSIONS: Our findings suggest that although GG are feasible in remote assessment of FLS with strong interrater reliability (ICC > 0.95), Skype™ was the preferred modality.

Discrepancy between gastroenterologists' and general surgeons' perspectives on repeat endoscopy in colorectal cancer.

BACKGROUND: A myriad of localization options are available to endoscopists for colorectal cancer (CRC); however, little is known about the use of such techniques and their relation to repeat endoscopy before CRC surgery. We examined the localization practices of gastroenterologists and compared their perceptions toward repeat endoscopy to those of general surgeons. METHODS: We distributed a survey to practising gastroenterologists through a provincial repository. Univariate analysis was performed using the χ² test. RESULTS: Gastroenterologists (n = 69) reported using anatomical landmarks (91.3%), tattooing (82.6%) and image capture (73.9%) for tumour localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (91.3%), high-risk polyps (95.7%) and large lesions (84.1%). They were equally likely to tattoo lesions planned for laparoscopic (91.3%) or open (88.4%) resection. Rectal lesions were less likely to be tattooed (20.3%) than left-sided (89.9%) or right-sided (85.5%) lesions. Only 1.4% agreed that repeat endoscopy is the standard of care, whereas 38.9% (n = 68) of general surgeons agreed (p < 0.001). General surgeons were more likely to agree that an incomplete initial colonoscopy was an indication for repeat endoscopy (p = 0.040). Further, 56% of general surgeons indicated that the findings of repeat endoscopy often lead to changes in the operative plan. CONCLUSION: Discrepancies exist between gastroenterologists and general surgeons with regards to perceptions toward repeat endoscopy and its indications. This is especially significant given that repeat endoscopy often leads to change in surgical management. Further research is needed to formulate practice recommendations that guide the use of repeat endoscopy, tattoo localization and quality reporting.

CONTEXTE: De nombreuses options de repérage s'offrent aux endoscopistes dans les cas de cancer colorectal; on en sait cependant peu sur l'utilisation de ces techniques et leur lien avec les endoscopies répétées avant les interventions chirurgicales de traitement de ce cancer. Nous avons étudié les pratiques de repérage employées par des gastroentérologues et comparé leurs perceptions des endoscopies répétées à celles des chirurgiens généralistes. MÉTHODES: Nous avons réalisé un sondage auprès de gastroentérologues en exercice figurant dans un répertoire provincial. Une analyse unidimensionnelle a été effectuée à l'aide du test χ². RÉSULTATS: Les gastroentérologues (n = 69) ont dit recourir à des repères anatomiques (91,3 %), au tatouage (82,6 %) et à des images (73,9 %) pour repérer les tumeurs. La majorité a dit tatouer les lésions ne pouvant être éliminées par coloscopie (91,3 %), les polypes à haut risque (95,7 %) et les lésions de grande taille (84,1 %). Ils étaient tout aussi susceptibles de tatouer les lésions devant être éliminées par résection laparoscopique (91,3 %) ou effractive (88,4 %). Ils étaient cependant moins susceptibles de tatouer les lésions rectales (20,3 %) que les lésions du côté gauche (89,9 %) ou du côté droit (85,5 %). Seul 1,4 % des gastroentérologues était d'avis que l'endoscopie répétée constitue une norme en matière de soins, contrairement à 38,9 % des chirurgiens généralistes (n = 68; p < 0,001). Les chirurgiens généralistes étaient plus nombreux à penser qu'une coloscopie initiale incomplète était susceptible d'être associée à des endoscopies répétées (p = 0,040). En outre, 56 % d'entre eux ont indiqué que les résultats d'endoscopies répétées menaient souvent à des changements sur le plan chirurgical. CONCLUSION: Il existe des divergences entre les perceptions des gastroentérologues et des chirurgiens généralistes quant aux endoscopies répétées et à leur indication. Ces divergences sont particulièrement pertinentes, étant donné que les endoscopies répétées entraînent souvent des changements aux interventions chirurgicales qui sont pratiquées ultérieurement. Des recherches approfondies seront nécessaires pour formuler des recommandations liées aux pratiques et orienter le recours aux endoscopies répétées et au repérage des lésions par tatouage ainsi que la production de rapports sur la qualité.

Remote FLS testing in the real world: ready for "prime time".

INTRODUCTION: Maintaining the existing FLS test centers requires considerable investment in human and financial resources. It can also be particularly challenging for those outside of North America to become certified due to the limited number of international test centers. Preliminary work suggests that it is possible to reliably score the FLS manual skills component remotely using low-cost videoconferencing technology. Significant work remains to ensure that testing procedures adhere to standards defined by SAGES for this approach to be considered equivalent to standard on-site testing. OBJECTIVE: To validate the integrity and validity of the FLS manual skills examination administered remotely in a real-world environment according to FLS testing protocols and to evaluate participants' experience with the setting. METHODS: Individuals with various levels of training from the University of Toronto completed a pre- and a post-test questionnaire. Participants presented to one of the two FLS testing rooms available for the study, each connected via Skype to a separate room with a FLS proctor who administered and scored the test remotely (RP). An on-site proctor (OP) was present in the room as a control. An invigilator was also present in the testing room to follow directions from the RP and ensure the integrity of test materials. RESULTS: Twenty-one participants were recruited, and 20 completed the test. There was no significant difference between scores by RP and OP. Interrater reliability between the RP and OP was excellent. One critical error was missed by the RP, but this would not have affected the test outcome. Participants reported being highly satisfied. CONCLUSION: We demonstrate that proctors located remotely can administer the FLS skills test in a secure and reliable fashion, with excellent interrater reliability compared to an on-site proctor. Remote proctoring of the FLS examination could become a strategy to increase certification rates while containing costs.

Adherence to Guidelines for Adjuvant Imatinib Therapy for GIST: A Multi-institutional Analysis.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Adjuvant imatinib therapy improves recurrence-free and overall survival following surgery for patients with high-risk GIST; however, the factors associated with use of adjuvant imatinib therapy are unclear, and adherence to adjuvant imatinib has not been investigated. We sought to determine the clinicopathologic predictors of therapy with adjuvant imatinib following surgical resection for GIST and to determine the utilization of adjuvant imatinib in patients who underwent surgical resection of primary GIST in 2009 or later as recommended by National Comprehensive Cancer network (NCCN) guidelines. METHODS: A multi-institutional cohort including 171 patients who underwent surgery for primary GIST at seven high-volume cancer centers in the USA and Canada between January 2009-December 2012 was used in this study. Receipt of adjuvant imatinib therapy was ascertained, and factors associated with imatinib therapy were analyzed. RESULTS: Following surgery for primary GIST, tumor size (<5.0 cm: ref; 5.0-9.9 cm: odds ratio (OR) 2.36, 95 % confidence interval (CI) 0.74-7.55; >10.0 cm: OR 9.15, 95 % CI 2.28-36.75; p = 0.007), mitotic rate (≤5/50 mitoses per 50 high powered field [HPF]: ref; 6-10/50 HPF: OR 24.91, 95 % CI 3.64-170.35; >10/50 HPF: OR 5.80, 95 % CI 3.64-170.35; p < 0.001), and neoadjuvant therapy (OR 9.52; 95 % CI 2.51-36.14; p = 0.001) were associated with receipt of adjuvant imatinib therapy. Overall, 75 % of patients received appropriate treatment, 23 % of patients were undertreated, and 2 % of patients were overtreated as compared to NCCN guidelines. Adjuvant imatinib therapy was administered in only 53 % of patients for which the NCCN guidelines recommended adjuvant therapy. CONCLUSION: The clinicopathologic factors associated with use of adjuvant imatinib therapy in patients following resection of primary GIST are consistent with established risk factors for recurrence. Adjuvant imatinib therapy remains underutilized in patients with intermediate and high-risk GIST and in patients who receive neoadjuvant therapy. Barriers to adjuvant imatinib therapy in this group of patients needs to be further explored.

Multivisceral resections for gastrointestinal stromal tumors: are the risks justifiable?

BACKGROUND: Surgical resection is the cornerstone of treatment for non-metastatic gastrointestinal stromal tumors (GISTs). Multivisceral resection (MVR) for locally advanced tumors is often required to achieve negative margins. The purpose of this study was to review the peri-operative and long-term oncologic outcomes for patients who required MVR versus single-organ resection (SOR) for GISTs. METHODS: All patients who underwent treatment for GISTs at a tertiary cancer center between 2001 and 2011 were identified. Patient characteristics and clinical outcomes were compared using the chi-squared/Fisher's exact test and Student's t-test. Disease-free (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier product-limit method. RESULTS: 33 patients underwent MVR and 77 underwent SOR. Tumors in the MVR group were larger and had a higher mitotic index. MVR patients had longer operative times, greater operative blood loss and more peri-operative complications. There was no significant difference in the final margin status between the two groups (R0 resection: SOR 92.2%, MVR 81.8%, p = 0.1303). 5-year DFS was significantly lower in the MVR cohort (44.4% vs. 78.9%, p = 0.0090), but there was no difference in 5-year OS (80.2% vs. 90.5%, p = 0.2547). CONCLUSIONS: MVR patients had more aggressive tumors and more complications; however, there was no difference in 5-year OS between the MVR and SOR cohorts. These findings support the use of MVR in the appropriately selected patient. Further studies are necessary to fully define its clinical application.

Conditional disease-free survival after surgical resection of gastrointestinal stromal tumors: a multi-institutional analysis of 502 patients.

IMPORTANCE: Gastrointestinal stromal tumors (GISTs) are the most commonly diagnosed mesenchymal tumors of the gastrointestinal tract. The risk of recurrence following surgical resection of GISTs is typically reported from the date of surgery. However, disease-free survival (DFS) over time is dynamic and changes based on disease-free time already accumulated following surgery. OBJECTIVES: To assess the comparative performance of established GIST recurrence risk prognostic scoring systems and to characterize conditional DFS following surgical resection of GISTs. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 502 patients who underwent surgery for a primary, nonmetastatic GIST between January 1, 1998, and December 31, 2012, at 7 major academic cancer centers in the United States and Canada. MAIN OUTCOMES AND MEASURES: Disease-free survival of the patients was classified according to 5 prognostic scoring systems, including the National Institutes of Health criteria, modified National Institutes of Health criteria, Memorial Sloan Kettering Cancer Center GIST nomogram, and American Joint Committee on Cancer gastric and nongastric categories. The concordance index (also known as the C statistic or the area under the receiver operating curve) of established GIST recurrence risk prognostic scoring systems. Conditional DFS estimates were calculated. RESULTS: Overall 1-year, 3-year, and 5-year DFS following resection of GISTs was 95%, 83%, and 74%, respectively. All the prognostic scoring systems had fair prognostic ability. For all tumor sites, the American Joint Committee on Cancer gastric category demonstrated the best discrimination (C = 0.79). Using conditional DFS, the probability of remaining disease free for an additional 3 years given that a patient was disease free at 1 year, 3 years, and 5 years was 82%, 89%, and 92%, respectively. Patients with the highest initial recurrence risk demonstrated the greatest increase in conditional survival as time elapsed. CONCLUSIONS AND RELEVANCE: Conditional DFS improves over time following resection of GISTs. This is valuable information about long-term prognosis to communicate to patients who are disease free after a period following surgery.

Predictive Ability of Blood Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Gastrointestinal Stromal Tumors.

BACKGROUND: Recent findings have shown that the neutrophil-to-lymphocyte ratio (NLR) is prognostic for gastrointestinal stromal tumors (GIST). The platelet-to-lymphocyte ratio (PLR) can predict outcome for several other disease sites. This study evaluates the prognostic utility of NLR and PLR for patients with GIST. METHODS: All patients who had undergone surgical resection for primary, localized GIST from 2001 to 2011 were identified from a prospectively maintained database. Recurrence-free survival (RFS) was calculated by the Kaplan-Meier method and compared by the log-rank test. Univariate Cox proportional hazard regression models were used to identify associations with outcome variables. RESULTS: The study included 93 patients. High PLR [≥245; hazard ratio (HR) 3.690; 95 % confidence interval (CI) 1.066-12.821; p = 0.039], neutrophils (HR 1.224; 95 % CI 1.017-1.473; p = 0.033), and platelets (HR 1.005; 95 % CI 1.001-1.009; p = 0.013) were associated with worse RFS. Patients with high PLR had 2- and 5-year RFS of 57 and 57 %, compared with 94 and 84 % for those with low PLR. High NLR (≥2.04) was not associated with reduced RFS (p = 0.214). Whereas more patients in the high PLR group had large tumors (p = 0.047), more patients in the high NLR group had high mitotic rates (p = 0.016) than in the low-ratio cohorts. Adjuvant therapy was given to 41.2 % of the patients with high PLR (p = 0.022). The patients with high PLR/NLR had worse nomogram-predicted RFS than the patients with low PLR/NLR. CONCLUSIONS: High PLR was associated with reduced RFS. The prognostic ability of PLR to predict recurrence suggests that it may play a role in risk-stratification schemes used to determine which patients will benefit from adjuvant therapy.

Preoperative endoscopy localization error rate in patients with colorectal cancer.

BACKGROUND: Preoperative repeat endoscopy in colorectal cancer (CRC) patients is considered by many to be an integral component of surgical planning. Little is known, however, about the utility of re-endoscopy. METHODS: A retrospective review of 342 consecutive patients undergoing elective surgical resection for CRC from January 2008 to December 2011 was performed. Patients were included if the initial endoscopist was different than the operating surgeon. A localization error was recorded if the final tumor location identified during surgery was in a different anatomical segment than that identified by endoscopy. The Chi-squared test was used to compare categorical variables. An error rate with a 95% confidence interval was obtained using the exact binomial distribution. RESULTS: 298 patients were identified, 118 (39.6%) of whom also underwent a preoperative re-endoscopy by the operating surgeon or partner. Nineteen patients had incorrect tumor localization at initial endoscopy, equivalent to a 6.4% error rate (95% CI 3.88-9.78). In comparison, there were two localization errors on re-endoscopy, 1.69% (95% CI 0.21-6.00). Re-endoscopy was found to be protective against localization errors (P < 0.05), correcting 10 of the 12 errors made at the initial endoscopy. The sensitivity of re-endoscopy as a diagnostic tool to detect errors was 83% with a corresponding specificity of 100%. The overall accuracy of re-endoscopy in preventing endoscopic localization errors was 92% (95% CI 81-100). CONCLUSIONS: There is a small but important localization error rate in preoperative endoscopic evaluation of colorectal tumors. Re-endoscopy appears to be safe and may potentially identify and correct these errors and help with preoperative planning at the expense of delaying surgery. Further research is necessary to find ways to improve localization and identify which patients would benefit from re-endoscopy.

The accuracy of three predictive models in the evaluation of recurrence rates for gastrointestinal stromal tumors.

BACKGROUND: Treatment decisions for gastrointestinal stromal tumors (GIST) are frequently guided by tumor characteristics. An accurate prediction of recurrence is important to determine the benefit from targeted therapy. Our goal was to compare the concordance of three validated risk stratification schemes with observed outcomes in patients undergoing resection for GISTs. METHODS: Patients who underwent surgery for GISTs from 2001 to 2011 at a tertiary centre were identified. Survival was evaluated using the Kaplan-Meier product-limit method. Cox proportional hazard models were used to obtain predicted recurrence for each system and concordance indices were calculated. RESULTS: Of 110 patients identified, 77 (70.0%) had surgery and 29 (26.4%) also received adjuvant therapy. The majority of patients had tumors that were very low (4.5%), low (32.7%), or intermediate (22.7%) in terms of malignant potential. R0 resection was achieved in 89.1% of cases. Observed 2-year and 5-year recurrence rates were significantly lower than those predicted by the Memorial Sloan Kettering Cancer Center nomogram (7.6% vs. 19.3% and 18.4% vs. 27.0%); however, it was the most favorable tool compared to the US National Institutes of Health (NIH)-consensus (P = 0.0017) and modified NIH-consensus (P < 0.001), with a concordance index of 0.811. CONCLUSION: Development of a novel predictive tool that includes additional prognostic factors may better stratify recurrence following resection for GIST.