Natural orifice transluminal endoscopic surgery (NOTES): the future of surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an exciting and rapidly evolving area of surgery that may eventually provide the previously unattainable goal of scarless, and potentially pain free, surgery. Although a patent detailing the prospective therapy was filed in 1994, it was not until 2004 that interest flourished in this area, progressing quickly from largely investigative techniques in porcine models to the first two human NOTES cholecystectomies, which were performed almost simultaneously in Europe and the USA in April 2007.</p

The safety and acceptability of using telehealth for follow-up of patients following cancer surgery: a systematic review

Introduction: Although virtual consultations have played an increasing role in delivery of healthcare, the COVID-19 pandemic has hastened their adoption. Furthermore, virtual consultations are now being adopted in areas that were previously considered unsuitable, including post-operative visits for patients undergoing major surgical procedures, and surveillance following cancer operations. This review aims to examine the feasibility, safety, and patient satisfaction with virtual follow-up appointments after cancer operations. Methods: A systematic review was conducted along PRISMA guidelines. Studies where patients underwent surgical resection of a malignancy with at least one study arm describing virtual follow-ups were included. Studies were assessed for quality. Outcomes including adverse events, detection of recurrence and patient and provider satisfaction were assessed and compared for those undergoing virtual or in-person post-operative visits. Results: Eleven studies, with 3369 patients were included. Cancer types included were gynecological, colorectal, esophageal, lung, thyroid, breast, prostate and major HPB resections. Detection of recurrence and readmission rates were similar when comparing virtual consultations with in-person visits. Most studies showed high patient and healthcare provider satisfaction with virtual consultations following cancer resection. Concerns were raised about the integration of virtual consultations into workflows in fee-for-service settings, where reimbursement for virtual care may be an issue. Conclusion: Virtual follow-up care can provide timely and safe consultations in surgical oncology. Virtual consultations are as safe as in-person visits for assessing complications and recurrence. Where appropriate, virtual consultations can safely be integrated into the post-operative care pathway for those undergoing resection of malignancy.</p

Omission of intraoperative pyloric procedures in minimally invasive esophagectomy: assessing the impact on patients

Pyloroplasty or pyloromyotomy is often undertaken during esophagectomy to aid gastric emptying postoperatively. Minimally invasive esophagectomy (MIE) frequently omits a pyloric procedure. The impact on perioperative outcomes and the need for subsequent interventions is unclear. This study assesses the requirements for endoscopic balloon dilation of the pylorus (EPD) following MIE. Patients undergoing MIE from 2016 to 2020 were reviewed. Patients undergoing open resection, or an intraoperative pyloric procedure were excluded. Demographic, clinical and pathological data were reviewed. Univariable and multivariable analysis were performed as appropriate. In total, 171 patients underwent MIE. There were no differences in age (median 65 vs. 65 years, P = 0.6), pathological stage (P = 0.10) or ASA status (P = 0.52) between those requiring and not requiring endoscopic pyloric dilation (EPD). Forty-three patients (25%) required EPD, with a total of 71 procedures. Twenty-seven patients (16%) had EPD on their index admission. Seventy-five patients (43%) had a postoperative complication. Higher ASA status was associated with increased requirement for EPD (odds ratio 10.8, P = 0.03). On multivariable analysis, there was no association between the need for a pyloric procedure and overall survival (P = 0.14). Eight patients (5%) required insertion of a feeding jejunostomy in the postoperative period, with no difference between those with or without EPD (P = 0.11). Two patients required subsequent surgical pyloromyotomy for delayed gastric emptying. Although pyloroplasty or pyloromyotomy can safely be excluded during MIE, a quarter of patients will require postoperative EPD procedures. The impact of excluding pyloric procedures on gastric emptying requires further study. </p

PAR-4 – a novel marker of luminal A breast cancer – is down-regulated by the steroid receptor co-activator SRC-1

Introduction: Prostate apoptosis response-4 (PAR-4, PAW-R, PKC apoptosis WT1 regulator) is a gene coding for a tumour suppressor protein involved in the selective apoptosis of cancer cells. Although well described in renal cell carcinomas and prostate cancer, little is known about its role and regulation in breast cancer. Methods: Western blotting techniques looked at the association between PAR-4 expression and breast cancer sub-type, and at the effects of steroid receptor co-activator-1 (SRC-1) on PAR-4 expression. Functional assays (3D cell culture and adhesion independent growth) investigated the role of PAR-4 in breast cancer cells and immunohistochemistry looked at the clinical correlations of PAR-4 positivity in our patient cohort. Results: The results show that PAR-4 is down-regulated by SRC-1 in endocrine-resistant cell lines and they validate its use as a marker of good disease-free survival, both in vitro and in vivo. In addition, the functional assays provide evidence that PAR-4 may play a role in maintaining a well-differentiated phenotype in breast cancer cell lines. Conclusion: The results suggest that PAR-4 expression is a marker of good disease-free survival, or conversely, that the loss of PAR-4 expression would signal tumour progression to a more aggressive phenotype. The identification of such markers is important in the development of more personalised forms of treatments.</p

Nodal yield <15 is associated with reduced survival in esophagectomy and is a quality metric

Background: Surgical resection after neoadjuvant therapy remains the cornerstone of curative management of esophageal adenocarcinoma and is frequently used for squamous cell carcinoma. The optimal extent of lymphadenectomy and whether increasing lymph node yields confer a survival benefit remains unclear. Guidelines suggest resecting and examining a minimum of 15 lymph nodes at esophagectomy. This study assessed the impact of lymph node yield and lymph node ratio (LNR) on survival, identifying factors influencing nodal yield and radicality of resection. Methods: All patients undergoing esophagectomy with curative intent at a single institution (stage 1-4 inclusive) from January 1, 2010, to December 31, 2020, were reviewed. Clinical and pathologic variables were interrogated. LNR was calculated by dividing positive lymph nodes by the total nodes resected. Results: Esophagectomy was performed in 397 patients, with 288 undergoing minimally invasive esophagectomy (MIE). Margin status (hazard ratio [HR], 1.80; 95% CI, 1.15-2.83; P Conclusions: Textbook lymphadenectomy is associated with improved survival. Low lymph node yield and a high LNR are associated with reduced overall survival. A LNR of <0.05 is associated with significant survival benefit. A minimum nodal yield of 15 should remain the standard of care.</p

Nodal yield <15 is associated with reduced survival in esophagectomy and is a quality metric

Background: Surgical resection after neoadjuvant therapy remains the cornerstone of curative management of esophageal adenocarcinoma and is frequently used for squamous cell carcinoma. The optimal extent of lymphadenectomy and whether increasing lymph node yields confer a survival benefit remains unclear. Guidelines suggest resecting and examining a minimum of 15 lymph nodes at esophagectomy. This study assessed the impact of lymph node yield and lymph node ratio (LNR) on survival, identifying factors influencing nodal yield and radicality of resection. Methods: All patients undergoing esophagectomy with curative intent at a single institution (stage 1-4 inclusive) from January 1, 2010, to December 31, 2020, were reviewed. Clinical and pathologic variables were interrogated. LNR was calculated by dividing positive lymph nodes by the total nodes resected. Results: Esophagectomy was performed in 397 patients, with 288 undergoing minimally invasive esophagectomy (MIE). Margin status (hazard ratio [HR], 1.80; 95% CI, 1.15-2.83; P Conclusions: Textbook lymphadenectomy is associated with improved survival. Low lymph node yield and a high LNR are associated with reduced overall survival. A LNR of <0.05 is associated with significant survival benefit. A minimum nodal yield of 15 should remain the standard of care.</p

Surgery by a minimally invasive approach is associated with improved textbook outcomes in oesophageal and gastric cancer

Introduction: Textbook outcome (TBO) is a composite measure of a number of peri-operative and clinical outcomes in oesophagogastric malignancy. It has previously been shown that TBOs are associated with improved overall survival in both oesophageal and gastric cancer. The influence of a minimally invasive approach (MIA) on TBO is not well defined. The purpose of this study is to validate TBO in our population, examine the influence of a MIA on achieving a TBO, and the impact of TBO on long-term survival. Methods: 269 patients undergoing oesophagectomy and 258 patients undergoing subtotal or total gastrectomy were included in this study. Demographic, clinical and pathological differences between patients with and without a TBO were compared using univariable and multivariable analysis. Overall survival for those with and without a TBO was examined. The influence of MIA on overall survival and TBO was determined using Cox proportional hazard models. Results: Patients undergoing oesophagectomy and gastrectomy were significantly more likely to achieve a TBO when MIA was used (p = 0.01 and 0.001 respectively). When MIA is included as an outcome measure patients achieving a TBO show improved overall survival in both oesophageal and gastric cancer. MIA, clear resection margins and no unplanned admission to critical care are the strongest predictors of overall survival from the putative bundle of TBO parameters. Conclusion: Minimally invasive surgery is associated with improved TBO. Completion of a minimally invasive approach should be considered for inclusion as a textbook parameter.</p

Surgery by a minimally invasive approach is associated with improved textbook outcomes in oesophageal and gastric cancer

Introduction: Textbook outcome (TBO) is a composite measure of a number of peri-operative and clinical outcomes in oesophagogastric malignancy. It has previously been shown that TBOs are associated with improved overall survival in both oesophageal and gastric cancer. The influence of a minimally invasive approach (MIA) on TBO is not well defined. The purpose of this study is to validate TBO in our population, examine the influence of a MIA on achieving a TBO, and the impact of TBO on long-term survival. Methods: 269 patients undergoing oesophagectomy and 258 patients undergoing subtotal or total gastrectomy were included in this study. Demographic, clinical and pathological differences between patients with and without a TBO were compared using univariable and multivariable analysis. Overall survival for those with and without a TBO was examined. The influence of MIA on overall survival and TBO was determined using Cox proportional hazard models. Results: Patients undergoing oesophagectomy and gastrectomy were significantly more likely to achieve a TBO when MIA was used (p = 0.01 and 0.001 respectively). When MIA is included as an outcome measure patients achieving a TBO show improved overall survival in both oesophageal and gastric cancer. MIA, clear resection margins and no unplanned admission to critical care are the strongest predictors of overall survival from the putative bundle of TBO parameters. Conclusion: Minimally invasive surgery is associated with improved TBO. Completion of a minimally invasive approach should be considered for inclusion as a textbook parameter.</p

Patient-derived organoids for prediction of treatment response in oesophageal adenocarcinoma

Oesophageal cancer, comprising adenocarcinoma (OAC) and squamous cell carcinoma subtypes, accounts for approximately 450 000 deaths annually worldwide1,2. For locally advanced OAC, the current standard of care is neoadjuvant chemoradiation (CROSS) or perioperative chemotherapy (FLOT)3,4. Although both confer a survival benefit, 40% of patients undergoing FLOT and 25% of patients undergoing CROSS demonstrate minimal pathological response, suggesting alternative regimens could be more effective2–4. The superiority of either regimen is not clear, with a recent randomized controlled trial demonstrating clinical equipoise between perioperative chemotherapy and CROSS5. </p

Patient-derived organoids for prediction of treatment response in oesophageal adenocarcinoma

Oesophageal cancer, comprising adenocarcinoma (OAC) and squamous cell carcinoma subtypes, accounts for approximately 450 000 deaths annually worldwide1,2. For locally advanced OAC, the current standard of care is neoadjuvant chemoradiation (CROSS) or perioperative chemotherapy (FLOT)3,4. Although both confer a survival benefit, 40% of patients undergoing FLOT and 25% of patients undergoing CROSS demonstrate minimal pathological response, suggesting alternative regimens could be more effective2–4. The superiority of either regimen is not clear, with a recent randomized controlled trial demonstrating clinical equipoise between perioperative chemotherapy and CROSS5. </p