Novel Techniques in the Surgical Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy with cirrhosis preceding its development in most cases. Surgical resection remains the primary therapeutic option despite the recent emergence of locoregional therapies. Novel surgical techniques are being proposed to overcome the limitations of traditional anatomical open liver resection. Laparoscopic resection is a safe and effective alternative to open liver resection, especially for left lateral or peripheral segment tumors. It is associated with less postoperative morbidity, intraoperative blood loss, and medial hospital stay with no difference in oncological outcomes. Robotic-assisted liver resection overcomes the technically difficult resection of tumors located at the posterosuperior segments with similar outcomes to laparoscopic resection. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure allows resection in patients with HCC, and associated major vascular resection or small future liver remnant (FLR) with long-term results yet to be announced. For patients with small solitary tumors or poor liver function, nonanatomical liver resection is a feasible therapeutic option due to minimal postoperative morbidity and similar oncological results of anatomical resection

Impact of iliac crest bone graft harvesting on fusion rates and postoperative pain during instrumented posterolateral lumbar fusion

This study aims to evaluate the influence of bone harvesting on postoperative pain and fusion rates. Group 1 patients received iliac crest bone graft (ICBG) either alone or augmented with local bone. Group 2 received only local bone. No statistical significance was found in radiological union or in the Oswestry Disability Index scores. Visual Analogue Scale scores showed less pain in group 2. Logistic regression showed no correlation between residual pain and occurrence of fusion. Harvesting ICBG did not appear to increase fusion rates and no relation was found between radiological non-union and pai

Nutritional Management of Esophageal Cancer Patients

Esophageal cancer is associated with malnutrition in the vast majority of patients. This phenomenon is partly attributed to the disease process itself, the location of the tumor and other factors, such as dysphagia which is often accentuated due to chemotherapy/radiotherapy treatment or surgical intervention. The poor nutritional status of these patients is often related to the presence of cancer cachexia, altered metabolism, and tissue wasting. Malnutrition in this patient population affects quality of life, worsens patient’s tolerance to chemotherapy and accounts for lower survival. Nutritional management of these patients includes both proper nutritional assessment and support and might prevent, to a certain extent, the manifestation of malnutrition‐related consequences. The purpose of this article is to review the current literature in order to focus on the etiology and diagnosis of malnutrition in esophageal cancer patients, emphasizing also on the optimal nutritional support during multimodality treatment

Pancreatic intraductal papillary mucinous neoplasm with concomitant heterotopic pancreatic cystic neoplasia of the stomach: a case report and review of the literature

A 60-year-old Caucasian male underwent a total pancreatectomy for a mixed type pancreatic intraductal papillary mucinous neoplasm (IPMN) arising in the main and secondary pancreatic ducts. During surgery, a subserosal polypoid mass was noted at the greater curvature of the gastric antrum and was enucleated. This mass was proven to be heterotopic pancreatic tissue with cystic neoplasia of the IPMN histologic subtype. Through an extensive search of the literature, we found that this is the first case ever reported with simultaneous existence of IPMN changes, in the main and secondary ducts of the orthotopic pancreas and in the heterotopic pancreatic tissue of the gastric wall

Posterolateral lumbar spine fusion using a novel demineralized bone matrix: a controlled case pilot study

Introduction: Intertransverse posterolateral fusion along with instrumentation is a common technique used for spinal fusion. Iliac crest bone graft (ICBG) offers good fusion success rates with a low risk for disease transmission but is, however, linked with certain morbidity. In an effort to eliminate or reduce the amount of iliac graft needed, bone substitutes including demineralized bone matrix (DBM) have been developed. This study evaluates a novel DBM (Accell Connexus®) used in one or two-level instrumented posterolateral lumbar fusion. Materials and methods: A total of 59 consecutive patients were studied as two groups. Group 1 consisted of 33 patients having Accell Connexus® used to augment either ICBG or local decompression material. Group 2 consisted of 26 consecutive patients, operated prior to the introduction of this novel DBM, having either ICBG alone or local decompression material. Fusion was assessed by two independent observers, blinded to graft material, using standardized criteria found in the literature. All adverse events were recorded prospectively. Results: The results show no statistically significant differences between the two groups in fusion rates, complications, surgery duration, ODI, or pain on VAS. Logistical regression showed no relation between fusion and age, smoking status or comorbidities. Furthermore, no adverse events related to the use of the novel DBM were observed. Conclusion: The results from this study demonstrate that the novel DBM presented performs equally as well as that of autologous bone, be it either ICBG or a local decompression material, and can therefore be used as a graft extende

Multicenter investigation of moral distress among physicians and its impact on the intention to leave working position

Introduction: The evidence concerning Moral Distress (MD) among physicians is limited, while such data are absent for physicians working in the Greek National Health System (GNHS). The purpose of this study is the investigation of MD among physicians in Greece and the validation Moral Distress Scale-Revised (MDS-R) as a reliable method for the measurement of MD in the Greek language. Methods: This is a multicenter study in which 200 physicians of all specialties and degrees participated. A self-reporting questionnaire was used. The MDS-R questionnaire is constituted of 21 items that describe conditions met in clinical practice, aiming to investigate the frequency and intensity of such cases. The questionnaire was translated and validated in the Greek language. Results: The test-retest procedure was undergone in a sample of 18 physicians and it was found significant and high agreement in all of the MD scale items. Therefore, all 21 items of the MDS-R questionnaire were found suitable for inclusion in the Greek version of MDS-R. A model of four main factors emerged after the analysis of the results with a total variance of 46,8% and all these factors were correlated with each other. MD was detected to a significant degree in more than half participants. The incidence and intensity of MD were higher in physicians who worked in general hospitals compared to those working in cancer hospitals, which is reported for the first time. Conclusions: The Greek version of MDS-R is a valid and reliable instrument for the investigation of MD among Greek physicians. Moral distress impacts the Greek physicians but the degree depends on the working position. Moral distress is also associated with leaving a working position among Greek physicians

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas: An individual participant data meta-analysis

Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGCs) of the pancreas is a rare neoplasm that accounts for less than 1% of all pancreatic malignancies. The aim of this study was to review the literature regarding UC-OGC, and to highlight its biological behavior, clinicopathologic characteristics, prognosis, and therapeutic options. A systematic review of the literature in PubMed/Medline and Scopus databases was performed (last search October 31st, 2023) for articles concerning pancreatic UC-OGC in the adult population. Fifty-seven studies met the inclusion criteria, involving 69 patients with a male-to-female ratio of 1.1:1 and a mean age of 62.96. Main symptoms included abdominal pain (33.3%), jaundice (14.5%), weight loss (8.7%), while fourteen patients (20.3%) were asymptomatic. Surgical resection was performed in 88.4% of cases. Survival rates at one, three, and five years were 58%, 44.7%, and 37.3% respectively. Sex, age, size (cut-off of 4 cm), location, and adjuvant treatment did not significantly affect patient survival. UC-OGC of the pancreas is a rare subtype of undifferentiated pancreatic carcinoma with a better prognosis than conventional pancreatic ductal adenocarcinoma or undifferentiated carcinoma without giant cells. The establishment of a dedicated patient registry is imperative to further delineate the optimal treatment for this uncommon clinical entity

Impact of obesity on the outcomes after gastrectomy for gastric cancer: A meta-analysis.

Summary: The impact of body mass index (BMI) on surgical outcomes has previously been studied in relation to several oncological procedures. Regarding gastric cancer surgery, published results have been contradicting in terms of degree of technical difficulty, risk of postoperative complications and survival. In an attempt to clarify these issues, we performed a meta-analysis to evaluate the impact of obesity (defined as BMI ≥ 30 kg/m2) on outcomes after gastrectomy for gastric cancer. The meta-analysis was performed according to the PRISMA guidelines. Eligible studies were identified through search of PubMed, EMBASE, Web of Science and Cochrane Library databases. Quality assessment was performed using the Newcastle-Ottawa scale. The meta-analysis was conducted using random-effects modeling. A total of 11 studies with 13 538 patients were eligible for analysis. Obesity was associated with a significantly longer operation time (WMD = 19.38 min, 95% CI 12.72–26.04; p < 0.001), increased risk of overall complications (RR = 1.23, 95% CI 1.06–1.42; p = 0.005) and pulmonary complications (RR = 3.81, 95% CI 2.24–6.46; p < 0.001). These findings remained irrespective type of surgery (laparoscopic vs. open) and type of gastrectomy. No differences were found regarding blood loss, number of resected lymph nodes, anastomotic leakage, hospital stay, 30-day mortality and 5-year overall survival. The conclusion of the current meta-analysis is that high BMI in gastric cancer patients is associated with longer operative time and more frequent overall postoperative complications. However, it has no negative impact on survival, indicating that gastrectomy is a safe procedure for this group of patients