Expression of PD-L1 Is Associated with Inflammatory Microenvironment in Surgical Specimens of Non-Small Cell Lung Cancer.

The aim of this study was to analyse the expression of PD-L1 in non-small cell lung cancer (NSCLC) and its correlation with immune microenvironment response (IMR), clinic-pathological parameters, and outcome. The sample included 76 male and 32 female patients who underwent surgical resection. The mean age of the males was 66 years, and that of the females was 64 years. Adenocarcinoma (ADC) was diagnosed in 68 (63%) cases, squamous cell carcinoma in 35 (32%) cases, and NSCLC (not otherwise specified) in 5 (5%) cases. Metastatic lymph nodes were found in 38 (36%) patients, 18 with N1 nodes and 20 with N2 nodes. PD-L1 expression was valuated as the percentage of positive cancer cells among all cancer cells. Gender, age, and histologic type were not associated with PD-L1 expression (all p > 0.05). The subtypes of ADC were associated with PD-L1 expression (p = 0.050). The papillary subtype was 4.3 times more common among PD-L1 negative than PD-L1 positive ADC; the solid subtype was 1.9 times more common among PD-L1 positive than PD-L1 negative ADC. IMR was predominantly strong in 19 cases, weak in 36, and absent in 53 cases. The median value of PD-L1 expression in cancer cells was positively correlated with IMR (p = 0.039). PD-L1 expression was not correlated with overall survival (p = 0.643). The patients with strong, inflammatory-like IMR had an average survival time that was 12 months longer than patients with absent/low IMR (LR = 2.8; p = 0.132). In conclusion, the papillary subtype was more commonly PD-L1 negative in comparison with other subtypes of ADC. Positive PD-L1 expression in tumour cells was connected with strong, inflammatory-like IMR. Patients with strong IMR tended to experience better outcomes. Further investigations are needed on larger-scale cohorts to elucidate the insights of this descriptive study.

[VATS THYMECTOMY IN MYASTHENIA GRAVIS TREATMENT--A CASE REPORT]. / VATS TIMEKTOMIJA U LIJECENJU MIASTENIJE GRAVIS--PRIKAZ BOLESNICE.

Myasthenia gravis (MG) is a chronic autoimmune disease characterized by weakness of skeletal muscles, specifically ocular. Relationship between the thymus gland and MG is not fully understood yet. Thymectomy is recommended for individuals with thymoma, but should be considered in all patients under 60 years of age with generalized MG in cases with no thymomatous tissue. We report a 27-year-old female patient with ocular type myasthenia gravis and radiological findings of anterior mediastinal mass, treated by VATS thymectomy. The intervention was carried out by 3-portal right-sided thoracoscopic approach. Single-lung ventilation and carbon-dioxide insufflation provided working space, and harmonic scalpel was used for the dissection and ligation. The patient's postoperative course was uncomplicated and the patient was discharged on the third postoperative day. The aim of our case report is to stress the importance of VATS technique in faster recovery and better cosmetic effect than in sternotomy procedures.

Improved staging using intraoperative ultrasound for mediastinal lymphadenectomy in non-small lung cancer surgery.

BACKGROUND: Extent of lymph node involvement in patients with non-small cell lung cancer (NSCLC) is the cornerstone of staging and influences both multimodality treatment and final outcome. The aim of this study was to investigate accuracy and characteristics of intraoperative ultrasound guided systematic mediastinal nodal dissection in patients with resected NSCLC. METHODS: From January 2008 to June 2013, 244 patients undergoing intraoperative surgical staging after radical surgery for NSCLC were included in prospective study. The patients were divided in two groups according to systematic mediastinal nodal dissection: 124 patients in intraoperative ultrasound nodal dissection guided group and 120 in standard nodal dissection group. The lymph nodes were mapped by their number and station and histopathologic evaluation was performed. RESULTS: Operating time was prolonged for 10 min in patients with ultrasound guided mediastinal nodal dissection, but number and stations of evaluated lymph nodes were significantly higher (p < 0.001) in the same group. Skip nodal metastases were found in 24% of patients without N1 nodal involvement. Twelve (10%) patients were upstaged using US guided mediastinal lymphadenectomy. In US guided group 5-year survival rate was 59% and in the group of standard systematic mediastinal lymphadenectomy 43% (p = 0.001) Standard staging system seemed to be improved in ultrasound guided mediastinal lymphadenectomy patients. Complication rate showed no difference between analyzed groups. CONCLUSION: Higher number and location of analyzed mediastinal nodal stations in patients with resected NSCLC using ultrasound is suggested to be of great oncological significance. Our results indicate that intraoperative ultrasound may have important staging implications.

Preperitoneal approach for femoral hernia repair.

BACKGROUND/AIMS: Although Lichtenstein's procedure is the standard procedure in surgical hernia treatment, and the role of laparoscopic hernia repair is constantly increasing, preperitoneal approach for femoral hernia repair should be equally considered. METHODOLOGY: After the horizontal incision of transversal fascia, preperitoneal space is visualized. The hernial sac is opened and its content is placed in the abdominal cavity, or if there is a need, resection is performed. Once the peritoneum is sutured, the iliopubic tract and Cooper's ligament are bridged with two or three sutures in the medial portion of the femoral ring. RESULTS: From 1998 to 2008, 94 patients were treated for femoral hernia using the preperitoneal approach. Out of 94 participants, 86 were female. Intestinal obstruction was present in 48 cases. Resection of the small intestine or omentum was performed in 40 patients. There was no perioperative mortality. We observed early postoperative complications in 4 patients. Following the procedure, there was no recurrence of the femoral hernia. CONCLUSIONS: We found that preperitoneal repair is the method of choice in surgical treatment of femoral hernia. The surgical technique is simple and feasible, while fully acknowledging the functional anatomy of the inguinofemoral region and the etiology of the condition.

Pelvic peritonization after laparoscopic abdominoperineal resection for low-rectal carcinoma treatment: surgical technique.

Abdominoperineal resection is a standard method of low-rectum carcinoma treatment. It is associated with significant morbidity and mortality rates, which decreased with the development of preoperative diagnostic procedures, new surgical techniques and new surgical instruments. In this article, laparoscopic pelvic peritonization was used after laparoscopic rectum amputation for low-rectum carcinoma treatment. Pelvic peritonization is performed after laparoscopic recto-sigmoid extirpation, using the extended absorbable intracorporeal suture with titanic clip application after every second suture. The role of titanic clip is to grasp the extended suture and to mark the postoperative irradiation field. Laparoscopic pelvic peritonization after laparoscopic abdominoperineal rectum amputation is a simple procedure with clinical importance in possible adhesion and postirradiatic enteritis prevention. This procedure can satisfy all oncological requirements and minimally invasive surgery principles and is acceptable for every patient in which rectum amputation is indicated.

Harmonic scalpel in transanal microsurgery.

BACKGROUND/AIMS: Retrospective clinical study of patients with rectal tumors treated by transanal endoscopic microsurgery (TEM) using Ultracision. METHODS: From 1997-2006 54 patients were treated by excision of the rectal tumors situated in the middle and distal portion, using the harmonic scalpel. We treated 25 male (range 40-76 years) and 29 female (range 46-80 years) patients. Tumors were benign or well or moderately differentiated carcinomas in stage T1N0M0 or T2N0M0. Excision was done by Ultracision (UltraCision, Ethicon Endo-Surgery) to all patients. Preoperative examinations were: colonoscopy, biopsy, tumor markers, CT, transanal ultrasound, pelvic NMR, gynecological exam in females. The tumors were excised by harmonic scalpel after submucosal infiltration of adrenalin (1: 200 000) and 2% lidocaine. RESULTS: There was no morbidity or mortality in this group of patients. Histopathology was: Adenoma tubovillosum in alteratio maligna 20, adenocarcinoma (T1N0M0) 6, (T2N0M0) 8, adenocarcinoma with lymphatic vessels and perineural spaces invasion 1, adenoma villosum 12 and adenoma tubulare 7. After surgical treatment 8 patients underwent adjuvant radiotherapy. There was no local recurrence during this period. CONCLUSIONS: TEM is a method of choice in the treatment of rectal benign tumors and malignant tumors in stage T1N0M0, grade 1 and 2. Harmonic scalpel provides a safer, easier, and more precise surgical section through clean, bloodless and better visualized operative field.

Laparoscopic subtotal gastrectomy for gastric carcinoma treatment.

Laparoscopic surgery of the stomach is not well accepted in patients with malignant disease. This paper shows the first experiences with this procedure at the Clinical Hospital and Medical School, Split, in two patients with early stage gastric carcinoma. The first patient was a 57 year old man who had had some gastric symptoms for a while. The other patient was a 73 year old man who had ulcer disease 52 years ago. Laparoscopic subtotal gastrectomy with omentectomy and Roux-en-Y reconstruction of the alimentary tract was performed on both patients. Pathohystological analysis of the resected part of the stomach showed the early stage gastric adenocarcinoma without metastases to the lymph nodes around the stomach or any pathological changes in the omentum for both of the patients. There were no complications during postoperative period. The first patient was released from the hospital after 8 and other after 9 days. All oncological principles were satisfied with laparoscopic subtotal resection with good and fast postoperative recovery without complications.

Laparoscopic colon surgery: our results.

Formerly, the laparoscopic surgery was accepted as a method of choice for benign diseases, and for palliative operations in progressive stages of malignant diseases of the colon. Today, the laparoscopic surgery of the colon has been also adopted in treating malignant diseases. The first laparoscopic colon resection was performed in our Clinic on December 12, 2002, and 114 patients have been successfully operated until June 1, 2007. Among those 114 patients 56 were men and 57 were women with the average age 65 (ranging from 28-86) years. A series of various laparoscopic operations have been performed for malignant disease mainly (almost 80%). The pre-surgical treatment, preparation of patients and the types of the operations were identical to those applied in patients treated by open surgery. Patients with colon carcinoma have been operated on with the principles of oncologic radicality. In post-operative period we encountered eight complications (four minor and four major) with only one fatal outcome. According to our experience and the facts found in literature, the results of laparoscopic colon surgery are comparable with open surgery.

Acute appendicitis and ileal perforation with a toothpick treated by laparoscopy.

A 69-year-old man underwent an emergency laparoscopic procedure after the acute appendicitis diagnosis has been established. Laparoscopic exploration showed inflamed appendix and perforation of terminal ileum with a swallowed part of the wooden toothpick. The treatment consisted of typical laparoscopic appendectomy and laparoscopic removal of the foreign body, followed by laparoscopic closure of the perforation site and lavage of the abdominal cavity. The postoperative course was uneventful and the patient was discharged from the hospital on day 3 after the operation.

Quality of life analysis after open and laparoscopic inguinal hernia repair--retrospective study.

BACKGROUND/AIMS: An inguinal hernia is a usual medical problem. The golden standard for its treatment is Lichtenstein's repair. But, there are still some dilemmas about inguinal hernia repair technique, including the role of laparoscopy. The aim of this study is to analyze patient's quality of life after Lichtenstein's or laparoscopic inguinal hernia repair. METHODOLOGY: Retrospective analysis of medical documentation of 216 operated patients during the year 2006 at the Department of digestive surgery, University hospital Split, Croatia using tension free mesh repair procedures: Lichtenstein or laparoscopy (TAPP). Among the other data, the analysis includes use of antibiotic prophylaxis and thrombosis prophylaxis. The quality of life analysis was performed using the Short form 36 questionnaire (SF-36). RESULTS: We operated 212 (98.15%) males and 4 (1.85%) females. The average age of operated patients was 60.15 +/- 13.98 years. The antibiotic prophylaxis was prescribed to 22 (10.19%) patients with some of risk factors for wound infection. We did not register any secondary wound infection. Thrombosis prophylaxis was prescribed to all patients and there were no complications. The quality of life analysis showed no statistically significant differences between Lichtenstein and laparoscopic procedure with slightly better results for laparoscopic procedure in some of the SF-36's domains. CONCLUSION: There are no differences in quality of life between the patients operated with Lichtenstein or laparoscopic procedure. Despite that, we believe that laparoscopy has its place for inguinal hernia repair especially for recurrent and bilateral hernias.

A novel algorithm for the minimal invasive treatment of choledocholithiasis.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is the gold standard in choledocholithiasis treatment. Currently there is no generally accepted algorithm for choledocholithiasis treatment. A few years ago suspected or diagnosed choledocholithiasis was indication for open operation if bilious stones could not be removed with therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Today, advancements in laparoscopic equipment and operation technique render the possibility for laparoscopic treatment of choledocholithiasis. There are many different ways in which to treat choledocholithiasis, depending on the time of diagnosis. Due to the considerable variability in choledocholithiasis treatment, which depends in turn on many objective and subjective factors, we propose a unique diagnostic algorithm for the treatment of choledocholithiasis. METHODOLOGY: From January 1st until December 31st 2005, at the University Department of Surgery -Split, 131 laparoscopic cholecystectomies were performed. Thirty-three patients with suspected choledocholithiasis were treated by laparoscopic intraoperative cholangiography. After positive cholangiography, thirteen laparoscopic transcystic extractions were performed. The patients were treated in the supine position. The surgeon was positioned between the legs of the patient, the assistants on opposite sides of the patient, and the scrub nurse on the right side of the surgeon. Transcystic stone extraction was performed using a flexible choledochoscope, which was connected to the left laparoscopic monitor using Picture-in-picture system and by Nitinol tipless Dormia basket. RESULTS: The total number of operated patients includes 18 women and 15 men. The mean age of patients was 60.16 +/- 15.36. The mean length of operation was 86 +/- 21.79. Mean hospitalization length of patients with laparoscopic cholecystectomy was 2.45 +/- 1.14 days; while mean hospitalization length of patients with stone extraction was slightly longer 2.90 +/- 1.18, (p = 0.564). CONCLUSIONS: Today several different possibilities approaches exist for the treatment of choledocholithiasis and it doesn't have to be treated unconditionally using endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy before, during or after laparoscopic cholecystectomy, or by the open operation.

Giant perianal angiomyofibroblastoma--a case report.

A 45-year old female had a long history of slow growing perianal tumor at the right side of her anus. Encapsulated tumour was found intraoperatively and completely excised using the Harmonic Scalpel. Tumour was well-circumscribed and relatively firm; measuring 12x6x4 cm. Histologically it was composed of oval to spindle cells with minimal nuclear atypia, set in mucous matrix with numerous thin-walled blood vessels. Immunohistochemically, expression of smooth-muscle actin and desmin, as well as estrogen and progesterone receptor were found in the tumour cells. The diagnosis of angiomyofibroblastoma was established. This rare benign tumour typically involves vulvovaginal, pelvic and perinal region. It is important to separate this neoplasm from locally invasive aggressive angiomyxoma and low grade fibromyxoid sarcoma, which can arise in the the same localisation. The patient was discharged on the third postoperative day and no recurrence was noted in 18 months follow-up.

Laparoscopic abdominal cysts fenestration using harmonic scalpel.

The use of ultrasonically activated scalpel for tissue cutting and coagulation is a potential replacement for electrosurgery, which can be related to different complications. Its working principle is to transform the electric power into the mechanical longitudinal movement of the working part of the instrument, by a piezoelectric transducer situated in the hand piece. Between October 2000 and June 2004, six patients with abdominal cysts were treated by laparoscopy, using the harmonic scalpel. The average age was 40.8 (ranging from 15-60) years. Laparoscopic abdominal cyst fenestration was performed in five patients, and laparoscopic cholecystectomy and abdominal cyst fenestration were done in one patient during the same operation. The average duration of the operation was 40 (ranging from 25-70) minutes and hospital stay was 2.8 (ranging from 1-5) days. Laparoscopic abdominal cyst fenestration using the harmonic scalpel is a safe and successful operation, with good results including all the advantages of the minimally invasive surgery.