Risk Factors and Effect of Intrathoracic Anastomotic Leakage after Esophagectomy for Underlying Malignancy-A Ten-Year Analysis at a Tertiary University Centre.

Aim: Surgical resection remains the treatment of choice for curable esophageal cancer patients. Anastomotic leakage after esophagectomy with an intrathoracic anastomosis is the most feared complication, and is the main cause of postoperative morbidity and mortality. The aim of this study was to identify risk factors associated with anastomotic leakage and its effect on the postoperative outcome. Methods: Between 2012 and 2022, all patients who underwent Ivor Lewis esophagectomy for underlying malignancy were included in this study. We performed a retrospective analysis of 174 patients. The dataset was analyzed to identify risk factors for the occurrence of anastomotic leakage. Results: A total of 174 patients were evaluated. The overall anastomotic leakage rate was 18.96%. The 30-day mortality rate was 8.62%. Multivariate logistic regression analysis identified diabetes (p = 0.0020) and obesity (p = 0.027) as independent risk factors associated with anastomotic leakage. AL had a drastic effect on the combined ICU/IMC and overall hospital stay (p < 0.001. Conclusion: Anastomotic leakage after esophagectomy with intrathoracic anastomosis is the most feared complication and major cause of morbidity and mortality. Identifying risk factors preoperatively can contribute to better patient management.

Nanoparticle-based immunotherapy of pancreatic cancer.

Pancreatic cancer (PC) has a complex and unique tumor microenvironment (TME). Due to the physical barrier formed by the desmoplastic stroma, the delivery of drugs to the tumor tissue is limited. The TME also contributes to resistance to various immunotherapies such as cancer vaccines, chimeric antigen receptor T cell therapy and immune checkpoint inhibitors. Overcoming and/or modulating the TME is therefore one of the greatest challenges in developing new therapeutic strategies for PC. Nanoparticles have been successfully used as drug carriers and delivery systems in cancer therapy. Recent experimental and engineering developments in nanotechnology have resulted in increased drug delivery and improved immunotherapy for PC. In this review we discuss and analyze the current nanoparticle-based immunotherapy approaches that are at the verge of clinical application. Particularly, we focus on nanoparticle-based delivery systems that improve the effectiveness of PC immunotherapy. We also highlight current clinical research that will help to develop new therapeutic strategies for PC and especially targeted immunotherapies based on immune checkpoint inhibitors.

Expression of MicroRNA in Locoregional Recurrent Rectal Cancer.

BACKGROUND/AIM: miRNA expression patterns vary within primary rectal cancers and play a pivotal role in carcinogenesis. It is unknown, however, if these regulatory changes also play a role in local recurrent rectal cancers. In this study, the expression of various angiogenetic small non-coding ribonucleic acids, namely miRNA-21, miRNA-215, miRNA-221, and miRNA-222 were analysed in cancerous and healthy rectal tissues. PATIENTS AND METHODS: miRNA expression was analyzed via quantitative polymerase chain reaction (qPCR). Samples were obtained from 20 patients who were treated for local recurrent rectal cancer at the Department for general and visceral surgery, Klinikum Oldenburg, Germany. RESULTS: No significant differences in the expression of miRNA-221, miRNA-222 and miRNA-215 were observed between cancerous and healthy rectal tissues. However, a significant differential expression was detected for miRNA-21. CONCLUSION: miRNA-21 is differentially expressed in recurrent rectal cancer tissue and healthy tissues. However, miRNA-215, miRNA-221 and miRNA-222 are not significantly differentially expressed.

Routine Use of Contrast Swallow After Total Gastrectomy and Esophagectomy: Is it Justified?

BACKGROUND: After gastrectomy or esophagectomy, esophagogastrostomy and esophagojejunostomy are commonly used for reconstruction. Water-soluble contrast swallow is often used as a routine screening to exclude anastomotic leakage during the first postoperative week. In this retrospective study, the sensitivity and specificity of oral water-soluble contrast swallow for the detection of anastomotic leakage and its clinical symptoms were analysed. MATERIAL/METHODS: Records of 104 consecutive total gastrectomies and distal esophagectomies were analysed. In all cases, upper gastrointestinal contrast swallow with the use of a water-soluble contrast agent was performed on the 5th postoperative day. Extravasation of the contrast agent was defined as anastomotic leakage. When anastomotic insufficiency was suspected but no extravasation was present, a computed tomography (CT) scan and upper endoscopy were performed. RESULTS: Oral contrast swallow detected 7 anastomotic leaks. Based on CT-scans and upper endoscopy, the true number of anastomotic leakage was 15. The findings of the oral contrast swallow were falsely positive in 4 and falsely negative in 12 patients, respectively. The sensitivity and specificity of the oral contrast swallow was 20% and 96%, respectively. CONCLUSIONS: Routine radiological contrast swallow following total gastrectomy or distal esophagectomy cannot be recommended. When symptoms of anastomotic leakage are present, a CT-scan and endoscopy are currently the methods of choice.

Incidence of Metachronous Distant Metastasis and ypN Classification Influence Patient Survival in Endosonographically Confirmed uT3 Rectal Cancer after Neoadjuvant Therapy and R0 Resection: A Historical Cohort Analysis.

BACKGROUND: Tumor response after neoadjuvant radiochemotherapy (NRC) prior to surgery and other parameters are likely to have an influence on the survival rate of patients suffering from T3 rectal cancer. METHODS: 51 patients (17 female, 34 male; 59.0 years; Apache < 9 points: 95.1%; ASA I-II 88.3% and ASA III 11.8%) were treated with NRC (50.4 Gy; 5-fluorouracil/folinic acid) 4-6 weeks prior to surgery because of uT3 rectal cancer (G2: 96%; adenocarcinoma 86.3%; cUICC II 62.7%). NRC led to a tumor response (TR) (ypT0-ypT2) in 45.1% (ypT0N0M0 7.8%). RESULTS: Neither the age of patients nor Apache/ASA score, histology, UICC staging, ypTNM, Dukes staging, infiltration of vessels, surgical procedure, local recurrence nor TR had a significant influence on the patients' survival time. Patients with metachronous distant metastasis (MDM) during the follow-up period (mean: 8.2 years; 1 month to 14.5 years) and patients with ypN1-ypN2 had a significantly shorter survival time. CONCLUSIONS: NRC prior to surgery leads to a remarkable TR rate but has no significant impact of TR on the patients' survival time. Occurrence of MDM during the follow-up period and ypN1/N2 status do have a greater influence. It is necessary to investigate larger cohorts of patients in the future to obtain more conclusive results and to define factors with influence on survival.

Transsphincteric tumor resection in case of a pararectal solitary fibrous tumor.

Transsphincteric resection of rectal tumors was first described about 120 years ago. Nowadays, this approach faded into obscurity due to standardized guidelines and practice in surgical oncology including lymphadenectomy, mesorectal excision and radical dissection of veins. However, transsphincteric resection seems reasonable in some cases, especially if an abdominal approach can be avoided. In the following, we will present and describe the technique of the transsphincteric approach with its variations in rectal surgery in the case of a rare pararectal tumor.

Free latissimus dorsi myocutaneous flap for pelvic floor reconstruction following pelvic exenteration.

INTRODUCTION: Pelvic floor defects following pelvic exenteration constitute a challenge to the reconstructive surgeon. Whenever the common reconstruction options such as the gluteus maximus myocutaneous flap (GLM) and the vertical rectus abdominis myocutaneous flap (VRAM) are not feasible, free tissue transfer will be the only remaining option. Being one of the most reliable and versatile flaps used for microsurgical reconstruction, the free latissimus dorsi (LD) muscle flap provides an adequate solution to this problem. PATIENTS AND METHODS: We describe our experience with 12 consecutive patients who underwent the free transfer of LD free flap for secondary reconstruction of the pelvic floor and perineum following pelvic exenteration for management of locally advanced pelvic malignancies in Klinikum Oldenburg from 2007 to 2014. RESULTS: Recurrent cancer of the anal canal was the most common pathology necessitating the performance of pelvic exenteration. Thrombosis of the vascular anastomosis was reported in two cases and ended with total flap loss in one of them. Functional limitations arose in two patients postoperatively. The mean hospital stay was 25 days. CONCLUSION: Free LD myocutaneous flap provides an adequate solution for reconstruction of pelvic defects resulting from radical oncological resections in cases where the use of locoregional flaps, such as the gluteus maximus flap and the vertical rectus abdominis flap, is not feasible because of an extensive defect, disruption of the vascular pedicle, or due to planning for bilateral stomas placement.

Management of Spontaneous Hepatic Rupture on Top of HELLP Syndrome: Case Report and Review of the Literature.

INTRODUCTION: We report the case of a patient with antepartum HELLP syndrome and simultaneous rupture of the right liver lobe. An emergency caesarean section was performed and the liver rupture was managed surgically via perihepatic packing. The mother and her child recovered well and were discharged 19 days after admission. CASE REPORT: We describe a case report and review the literature. Based on our own experience and the most common clinical presentations of such patients, we were able to establish an algorithm for managing such cases. CONCLUSION: An association between liver rupture and HELLP syndrome is rare but was previously described in several case reports. In pregnant women with HELLP syndrome and acute onset abdominal pain, a potential spontaneous hepatic rupture should be taken into consideration.

Simultaneous cholecystectomy during gastric and oesophageal resection: a retrospective analysis and critical review of literature.

The higher incidence of gallstone formation after gastrectomy for cancer has been reported as a common complication in many studies but the management strategies are still controversial and need further evaluation. We retrospectivaly analysed between 2007 and 2013, 206 patients who underwent gastric and or oesophageal resection. In 29/93 patients receiving an oesophagectomy a simultaneous cholecystectomy was performed, respectively 31 from 111 patients who underwent a gastrectomy received an incidental cholecystectomy. In 2 patients with an extended gastrectomy, the gallblader removing was performed simultaneously in one case. A subsequent cholecystectomy was performed in 11 cases. The increased surgical mortality was significant higher correlated with an intervention at a later stage point. That suggest that the prohylactic cholecystectomy can be safely performed during a major intervention in order to reduce complication and a reoperation.

ALPPS and similar resection procedures in treating extensive hepatic metastases: our own experiences and critical discussion.

BACKGROUND: The combination of right sided portal vein ligation and hepatic parenchymal transection thus inducing a hypertrophy of the left or left lateral sector is an innovative treatment option in treating locally advanced hepatic tumors or hepatic metastases. The available published data regarding this procedure is weak. We analyzed our own data regarding tumor recurrence and complications. The data was then used to be critically analyzed using the available published literature. METHODS: We treated n = 5 patients with an ALPPS (associating liver partition and portal vein ligation for staged hepatectomy). The follow-up was 3 years. We analyzed the perioperative period, complications, mortality and oncological survival rate. RESULTS: In all patients (n = 5) a R0-resection was achieved. N = 1 patient died postoperatively. N = 1 patient died 6 month later due to a pulmonary embolism. N = 3 patients had a tumor recurrence within 6 months. CONCLUSION: Selected patients can be successfully treated by ALPPS in terms of an R0-resection. However, risk of tumor recurrence and rate of complications are high.

Gastric Metastasis of Malignant Melanoma: Report of a Case and Review of Available Literature.

BACKGROUND: Malignant melanoma is a tumor with common lymphogenic or hematogenic metastasis. Metastasis to the gastric mucosa is uncommon. CASE REPORT: We present the case of a 43-year-old female patient with metastases of a malignant melanoma to the lesser curvature of the stomach. The primary malignant melanoma of the right breast was resected 2 years previously. CONCLUSION: Metastases to the gastric mucosa are rarely seen. Esophagogastroduodenoscopy should be performed in symptomatic patients to rule out metastatic disease. When R0 resection can be achieved, it should be undertaken in order to increase the overall prognosis of the patient.

Limitation of surgical radicality in rectal cancer responding to neoadjuvant therapy.

The basic principle in the treatment of rectal cancer is the complete surgical removal of the tumor together with the lymphatic drainage region, i.e. the mesorectum encased by the mesorectal 'fascia pelvis visceralis' according to Westhues. It was shown in the 1990s that the results of surgery alone could be improved by additional adjuvant and neoadjuvant therapy. Because of less toxicity and a lower rate of local recurrence, neoadjuvant therapies in International Union Against Cancer (UICC) stage II and III disease are now preferred over adjuvant strategies. The German Rectal Cancer study CAO/ARO/AIO-94 showed a full remission rate of 8% after a 5-fluorouracil (5-FU)based chemotherapy added to a conventional fractional radiation therapy (50.4 Gy). This figure, together with similar results of others, leads to the question whether surgical radicality in rectal cancer treatment could be limited in case of a good remission after neoadjuvant therapy. There are several promising possibilities under investigation, e.g. local excision instead of radical resection, or even no resection at all. Nevertheless, up to now these strategies did not prove to give comparable results to standard surgical procedures. Therefore, reduction of radicality in curable rectal cancer should be limited to accurately designed randomized clinical trials.