To the Editor:Intraductal papillary neoplasm of the bile duct(IPNB)may occur in the setting of primary sclerosing cholangitis,choledochal cysts or hepatolithiasis[1].The entity may be a precursor of cancer or intrahep...To the Editor:Intraductal papillary neoplasm of the bile duct(IPNB)may occur in the setting of primary sclerosing cholangitis,choledochal cysts or hepatolithiasis[1].The entity may be a precursor of cancer or intrahepatic cholangiocarcinoma.Invasive carcinoma,tubular or mucinous adenocarcinoma is present in approximately 40%-80%of IPNBs[1–3].IPNB is frequently found in the resection margins of patients undergoing hepatectomy for cholangiocarcinoma[4].展开更多
Background: A wide range of therapies exist for keloids. But despite the multiple treatment modalities available, keloids still remain a significant challenge for both the clinician and the patient. Objective: To asse...Background: A wide range of therapies exist for keloids. But despite the multiple treatment modalities available, keloids still remain a significant challenge for both the clinician and the patient. Objective: To assess the effectiveness and safety of debulking of keloid with intralesional injection of 5-flurouracil and triamcinolone in comparison to intralesional injection of 5-flurouracil and triamcinolone alone. Patient and Methods: This single blinded comparative therapeutic outpatient based study was done at the Department of Dermatology, Baghdad Teaching Hospital during the period from February 2011 to February 2013. Twenty-three patients with 52 lesions were enrolled in the study and consisted of two groups: Group A (26 lesions): Treated by intralesional injection of combination of 5-flurouracil and triamcinolone acetonide and repeated every month;Group B (26 lesions): Debulking was carried out first and then injection of combination of 5-flurouracil and triamcinolone acetonide at time of operation and then repeated injection monthly. Evaluation was performed by scoring system with 5 criteria (redness, elevation, hardness, itching and tenderness). The response was graded as no response, minimal, moderate or complete response. Results: Both modalities of treatments showed significant results in treating keloid, but the intralesional therapy alone was slightly better than debulking plus intralesional and no systemic adverse effects were noticed in both groups. Conclusion: Both modalities of therapy were effective in treatment of keloid, and there was no much difference between them.展开更多
Objective:To assess the role of debulking surgery in extensive hepatic alveolar echinococcosis(HAE).Methods:Five cases of extensive HAE undergoing debulking surgery with their long-term follow-ups were reported.Additi...Objective:To assess the role of debulking surgery in extensive hepatic alveolar echinococcosis(HAE).Methods:Five cases of extensive HAE undergoing debulking surgery with their long-term follow-ups were reported.Additionally,a systematic review was carried out.Results:The average age of patients in the study was(50.8±17.1)years(range 36 to 77 years).Three cases were female.The median follow-up period was 61 months(range 12 to 84 months).Left liver resections were performed in 2 cases and right hemihepatectomies were undertaken in 2 cases.Two patients(cases 2 and 4)developed early surgical complications,while one of them(case 4)who suffered from the recurrent sub-hepatic abscess died at 12 months postoperatively.Conclusions:This study highlights the importance of debulking surgery for the management of complex symptomatic HAE lesions in patients with no curative option available.展开更多
Background: Inappropriately ovarian cancer cannot be detected until an advanced stage. Radical debulking surgery is considered the cornerstone in the management of advanced ovarian cancer pointing to complete tumor re...Background: Inappropriately ovarian cancer cannot be detected until an advanced stage. Radical debulking surgery is considered the cornerstone in the management of advanced ovarian cancer pointing to complete tumor resolution. Unless optimal debulking cannot be achieved, these patients gain little benefit from surgery. Neoadjuvant chemotherapy (NACT) has been recommended as a novel therapeutic modality to a diversity of malignant tumors when the disease is not willing to optimal surgical resection at the time of diagnosis or the patient who unfit for aggressive debulking surgery. The purpose of this study is to compare survival in the patient with advanced ovarian cancer (stage III/IV) underwent primary debulking surgery followed by adjuvant chemotherapy (PDS-ACTR) to those who received neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS). Results: Neoadjuvant chemotherapy (NACT-IDS) showed significant complete cytoreduction and decreased in surgical morbidity in comparison to primary debulking surgery (PDS-ACTR). NACT-IDS showed significant improvement in progression-free survival (P-value 0.002) and overall survival (P-value 0.03) in comparison to PDS-ACTR. Response to NACT and residual volume were the two independent prognostic factors for overall survival. Conclusion: NACT-IDS for advanced ovarian cancer (III/IV) resulted in higher frequency of complete resection with no residual tumor, less post-operative surgical morbidity and significant increase progression-free survival and overall survival. Both responses to NACT and residual tumor volume were the two independent prognostic factors for survival in ovarian cancer.展开更多
Background and objective:The value of debulking surgery for unresectable well-differentiated metastatic pancreatic neuroendocrine tumor(m-PNET)remains poorly defined.This study aimed to evaluate the outcomes of m-PNET...Background and objective:The value of debulking surgery for unresectable well-differentiated metastatic pancreatic neuroendocrine tumor(m-PNET)remains poorly defined.This study aimed to evaluate the outcomes of m-PNET following debulking surgery in our institute.Methods:Patients with well-differentiated m-PNET in our hospital between February 2014 and March 2022 were collected.Clinicopathological and long-term outcomes of patients treated with radical resection,debulking surgery,and conservative therapy were compared retrospectively.Results:Fifty-three patients with well-differentiated m-PNET were reviewed,including 47 patients with unresectable m-PNET(debulking surgery,25;conservative therapy,22)and 6 patients with resectable m-PNET(radical resection).Patients undergoing debulking surgery had a post-operative Clavien–DindoIII complication rate of 16.0%without mortality.The 5-year overall survival(OS)rate of patients treated with debulking surgery was significantly higher than that of those treated with conservative therapy alone(87.5%vs 37.8%,log-rank P=0.022).Besides,the 5-year OS rate of patients treated with debulking surgery was comparable to that of patients with resectable m-PNET undergoing radical resection(87.5%vs 100%,log-rank P=0.724).Conclusions:Patients with unresectable well-differentiated m-PNET who underwent resection had better long-term outcomes than those who received conservative therapy alone.The 5-year OS of patients undergoing debulking surgery and radical resection were comparable.Debulking surgery could be considered for patients with unresectable well-differentiated m-PNET if no contraindication exists.展开更多
Objective:The goal of this study was to find the risk factors for major intraoperative blood loss(MBL)of pr imary debulking surgery(PDS)for ovarian cancer.Methods:Patients wi th ovarian cancer who underwent PDS in our...Objective:The goal of this study was to find the risk factors for major intraoperative blood loss(MBL)of pr imary debulking surgery(PDS)for ovarian cancer.Methods:Patients wi th ovarian cancer who underwent PDS in our hospital,from 2010 to 2017,were enrolled.The association between risk factors and MBL was modeled with the use of logisde regr ession.Receiver operating characteristic(ROC)curve analysis was used to determine the predictive value of the logi stic regression model.Results:A total of 346 padients met the inclusion criteria.There were 150 patients with MBL.Tumor stage 3/4(P<0.001),American Society of Aneshesiologists(ASA)score 23(P=0.044),ascites volume≥500 ml(P=0.002),radical or ultra radical surgery(P=0.002),and diabetes(P=0.035)were independent risk factors for MBL in patients with ovarian cancer.The logistic regression combined model of these five factors is more reliable in the prediction of MBL with an area under the ROC curve of 0.729 than the tumor stage(ROC curve=0.645)and surgical complexity(ROC curve=0.568).Conclusion:In padients with ovarian cancer,five risk factors for major intraoperative bleeding were identified.Planned surgical procedures and preoperative risk factors can be used to predict perioperative blood requir ements.展开更多
Lymphoedema is a chronic debilitating disease of the lymphatic system that occurs due to either abnormal development or damage of the lymphatics resulting from cancer or infection.The optimal treatment of lymphoedema ...Lymphoedema is a chronic debilitating disease of the lymphatic system that occurs due to either abnormal development or damage of the lymphatics resulting from cancer or infection.The optimal treatment of lymphoedema is still elusive.Management is tailored according to clinical features,investigations and expectations of each patient.Lymphoedema patients should undergo a trial of conservative management with compression therapy,manual lymphatic drainage and external sequential compression devices.Early lymphoedema is treated by lymphovascular anastomosis,where the lymph vessels are connected to the subdermal veins by supermicrosurgery.In late cases when the limb is fibrotic,vascularised lymph node transfers are done,where lymph nodes are transferred from a healthy area to the affected area.In advanced cases,when the limb is fibrotic with cutaneous folds and skin changes,surgical debulking is done.In lymphoedema,along with accumulation of lymphatic tissue,there is also fat deposition,which can be removed by liposuction.One should be conversant with all treatment modalities to provide the lymphoedema patient with optimal care.展开更多
<strong>Introduction:</strong><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"> This study evaluated ...<strong>Introduction:</strong><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"> This study evaluated the difference in operative and clinica</span></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">l outc</span><span style="font-family:Verdana;">omes for patients with advanced ovarian cancer after primary debulking</span><span style="font-family:Verdana;"> surgery (PDS) versus neoadjuvant chemotherapy (NACT) followed by interval debul</span><span><span style="font-family:Verdana;">king surgery (IDS) in Bangladesh. </span><b><span style="font-family:Verdana;">Methods:</span></b><span style="font-family:Verdana;"> Sixty patients with a</span></span><span style="font-family:Verdana;">dvanced epit</span><span style="font-family:Verdana;">helial ovarian cancer presenting to the department of Gynaecologi</span><span style="font-family:Verdana;">cal Oncology at the National Institute of Cancer Research and Hospital were prospectively enrolled. Thirty patients underwent primary debulking surgery and thirty patients received NACT followed by IDS. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> In the PDS and IDS groups respectively, 56.7% and 50% of patients presented with stage IIIC and 67.7% and 56.7% respectively had ser</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">i</span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">ous papillary type histopathology. Duration of surgery, amount of blood loss and total hospital stay were significantly lower (p < 0.001) in IDS group than </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">in </span></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">the PDS group. There was a statistically significant difference in postoperative tumor residuals between IDS and PDS patients. Complete tumor resection (R0) was obtained in 24 (80%) of IDS patients versus 13 (43.3%) PDS patients. In fifteen months of follow-up, 21 (70%) in the PDS group and 5 (16.7%) in the IDS group recurred (</span><span style="font-family:Verdana;">p</span><span style="font-family:Verdana;"> = 0.021). Median progression free survival in PDS patients was twelve months while that of the IDS group was seventeen months. There was one death at 45 days in the PDS group. No other deaths were documented at fifteen months of follow-up. </span><b><span style="font-family:Verdana;">Conclusion</span></b></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><b><span style="font-family:Verdana;">:</span></b></span></span><span><span><span style="font-family:""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">Interval debulking surgery has a more favorable outcome than primary debulking surgery on progression free survival in advanced ovarian cancer patients </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">and </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">permits a less aggressive surgery to be performed in Bangladesh.</span></span></span>展开更多
AIM To examine the efficacy and safety of the 6 French(6F) Rotarex~S catheter system in patients with acute limb ischemia(ALI) involving thromboembolic occlusion of the proximal and mid-crural vessels.METHODS The fi...AIM To examine the efficacy and safety of the 6 French(6F) Rotarex~S catheter system in patients with acute limb ischemia(ALI) involving thromboembolic occlusion of the proximal and mid-crural vessels.METHODS The files of patients in our department with ALI between 2015 and 2017 were examined. In seven patients, the Rotarex~S catheter was used in the proximal segment of the crural arteries. Data related to the clinical examination, Doppler sonography, angiography and followup from these patients were further used for analysis.RESULTS Two patients(29%) had thrombotic occlusion of the common femoral artery, and the remaining five exhibited thrombosis of the superficial femoral artery and popliteal artery. Mechanical thrombectomy was performed in all cases using a 6F Rotarex~S catheter. Additional Rotarex~S catheter thrombectomy due to remaining thrombus formation with no reflow was performed in the anterior tibial artery in two of seven cases(29%), in the tibiofibular tract and posterior tibial artery in two of seven cases(29%) and in the tibiofibular tract and fibular artery in the remaining three of seven cases(43%). Ischemic symptoms resolved promptly in all, and none of the patients experienced a procedural complication, such as crural vessel dissection, perforation or thrombus embolization.CONCLUSION Mechanical debulking using the 6F Rotarex~S catheter system may be a safe and effective treatment option in case of thrombotic or thromboembolic occlusion of the proximal and mid-portion of crural arteries.展开更多
BACKGROUND: The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even whe...BACKGROUND: The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even when a radical excision cannot always be achieved. DATA SOURCES: A PubMed search of relevant articles published up to February 2011 was performed to identify current information about PET liver metastases regarding diagnosis and management, with an emphasis on surgery. RESULTS: The early diagnosis of metastases and their accurate localization, most commonly in the liver, is very important. Surgical options include radical excision, and palliative excision to relieve symptoms in case of failure of medical treatment. The goal of the radical excision is to remove the primary tumor bulk and all liver metastases at the same time, but unfortunately it is not feasible in most cases. Palliative excisions include aggressive tumor debulking surgeries in well-differentiated carcinomas, trying to remove at least 90% of the tumor mass, combined with other additional destructive techniques such as hepatic artery embolization or chemoembolization to treat metastases or chemoembolization to relieve symptoms in cases of rapidly growing tumors. The combination of chemoembolization and systemic chemotherapy results in better response and survival rates. Other local destructive techniques include ethanol injection, cryotherapy and radiofrequency ablation. CONCLUSION: It seems that the current management of PETs can achieve important improvements, even in advanced cases.展开更多
BACKGROUND Primary extra-gastrointestinal stromal tumors(E-GIST)of the liver are rare.The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect.Oncologic surgery followed by ad...BACKGROUND Primary extra-gastrointestinal stromal tumors(E-GIST)of the liver are rare.The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect.Oncologic surgery followed by adjuvant therapy with imatinib is the standard of care.However,under specific circumstances,a cytoreductive approach may represent a therapeutic option.We describe herein the case of an 84-year-old woman who presented with a tender,protruding epigastric mass.Abdominal computed tomography scan revealed a large,heterogeneous mass located across segments III,IV,V,and VIII of the liver.The initial approach was transarterial embolization of the tumor,which elicited no appreciable response.Considering the large size and central location of the tumor and the advanced age of the patient,non-anatomic complete resection was indicated.Due to substantial intraoperative bleeding and hemodynamic instability,only a near-complete resection could be achieved.Histopathology and immunohistochemical staining confirmed the diagnosis of primary E-GIST of the liver.Considering the risk/benefit ratio for therapeutic options,debulking surgery may represent a strategy to control pain and prolong survival.CASE SUMMARY Here,we present a case report of a patient diagnosed with E-GIST primary of the liver,which was indicated a cytoreductive surgery and adjuvant therapy with imatinib.CONCLUSION E-GIST primary of the liver is a rare conditional,the treatment is with systemic therapy and total resection surgery.However,a cytoreductive surgery will be necessary when a complete resection is no possible.展开更多
Although it is assumed that the combination of chemotherapy and radical surgery should be indicated in all newly diagnosed advanced-stage ovarian cancer patients, one of the main raised questions is how to select the ...Although it is assumed that the combination of chemotherapy and radical surgery should be indicated in all newly diagnosed advanced-stage ovarian cancer patients, one of the main raised questions is how to select the best strategy of initial treatment in this group of patients, neoadjuvant chemotherapy followed by interval debulking surgery or primary debulking surgery followed by adjuvant chemotherapy. The selection criteria to offer one strategy over the other as well as a stepwise patient selection for initial treatment are described. Selecting the best strategy of treatment in newly diagnosed advanced stage ovarian cancer patients is a multifactorial and multidisciplinary decision. Several factors should be taken into consideration:(1) the disease factor, related to the extension and localization of the disease as well as tumor biology;(2) the patient factor, associated with patient age, poor performance status, and co-morbidities; and(3) institutional infrastructure factor, related to the lack of prolonged operative time, an appropriate surgical armamentarium, as well as well-equipped intensive care units with well-trained personnel.展开更多
Over the last 40 years,the incidence and prevalence of gastroenteropancreatic neuroendocrine neoplasms(GEP-NENs)have continued to increase.Compared to other epithelial neoplasms in the same organ,GEP-NENs exhibit indo...Over the last 40 years,the incidence and prevalence of gastroenteropancreatic neuroendocrine neoplasms(GEP-NENs)have continued to increase.Compared to other epithelial neoplasms in the same organ,GEP-NENs exhibit indolent biological behavior,resulting in more chances to undergo surgery.However,the role of surgery in high-grade or advanced GEP-NENs is still controversial.Surgery is associated with survival improvement of well-differentiated highgrade GEP-NENs,whereas poorly differentiated GEP-NENs that may benefit from resection require careful selection based on Ki67 and other tissue biomarkers.Additionally,surgery also plays an important role in locally advanced and metastatic disease.For locally advanced GEP-NENs,isolated major vascular involvement is no longer an absolute contraindication.In the setting of metastatic GEP-NENs,radical intended surgery is recommended for patients with low-grade and resectable metastases.For unresectable metastatic disease,a variety of surgical approaches,including cytoreduction of liver metastasis,liver transplantation,and surgery after neoadjuvant treatment,show survival benefits.Primary tumor resection in GEP-NENs with unresectable metastatic disease is associated with symptom control,prolonged survival,and improved sensitivity toward systemic therapies.Although there is no established neoadjuvant or adjuvant strategy,increasing attention has been given to this emerging research area.Some studies have reported that neoadjuvant therapy effectively reduces tumor burden,improves the effectiveness of subsequent surgery,and decreases surgical complications.展开更多
Ovarian cancer is one of the leading causes of death among gynecological cancers. This is because the majority of patients present with advanced stage disease. Primary debulking surgery(PDS) followed by adjuvant chemo...Ovarian cancer is one of the leading causes of death among gynecological cancers. This is because the majority of patients present with advanced stage disease. Primary debulking surgery(PDS) followed by adjuvant chemotherapy is still a mainstay of treatment. An optimal surgery, which is currently defined by leaving no gross residual tumor, is the goal of PDS. The extent of disease as well as the operative setting, including the surgeon's skill, infl uences the likelihood of successful debulking. With extensive disease and a poor chance of optimal surgery or high morbidity anticipated, neoadjuvant chemotherapy(NACT) prior to primary surgery is an option. Secondary surgery after induction chemotherapy is termed interval debulking surgery(IDS). Delayed PDS or IDS is offered to patients who show some clinical response and are without progressive disease. NACT or IDS has become more established in clinical practice and there are numerous publications regarding its advantages and disadvantages. However, data on survival are limited and inconsistent. Only one large randomized trial could demonstrate that NACT was not inferior to PDS while the few randomized trials on IDS had inconsistent results. Without a defi nite benefi t of NACT prior to surgery over PDS, one must carefully weigh the chances of safe and successful PDS against the morbidity and risks of suboptimal surgery. Appropriate selection of a patient to undergo PDS followed by chemotherapy or, preferably, to have NACT prior to surgery is very important. Some clinical characteristics from physical examination, serum tumor markers and/or fi ndings from imaging studies may be predictive of resectability. However, no specific features have been consistently identifi ed in the literature. This article will address the clinical data on prediction of surgical outcomes, the role of NACT, and the role of IDS.展开更多
Aim:As more and more centers has published their treatment results of pseudomyxoma peritonei(PMP)with cytoreductive surgery(CRS)and hyperthermic intraperitoneal chemotherapy(HIPEC),the data from China is missing.Myxom...Aim:As more and more centers has published their treatment results of pseudomyxoma peritonei(PMP)with cytoreductive surgery(CRS)and hyperthermic intraperitoneal chemotherapy(HIPEC),the data from China is missing.Myxoma Department of Aerospace Hospital is the biggest center treating PMP in China.The purpose of this study is to report the early and long-term outcomes for PMP from this single center.Methods:801 appendix-derived PMP out of 1008 consecutive patients treated in Myxoma Department of Aerospace Hospital between 2008 and 2019 were retrospectively analyzed.Results:Complete cytoreductive surgery(CCRS)was achieved in 240(30%)patients with median PCI of 14(1~39),and the rest had maximal tumor debulking(MTD),HIPEC was implemented in 96.3%of CCRS and 78.6%of MTD.The major morbidity(grade III/IV)was 11.4%and the 30-day operative mortality is 0.7%.The 5-and 10-year OS of CCRS was 76.9%and 64.1%,which is significantly higher than MTD(5-,10-year OS as 36.1%,27.1%;p<0.001).On the univariate analysis,all prognostic factors(gender,PSS,interval time,prior chemotherapy,prior HIPEC,Peritoneal Cancer Index(PCI),completeness of cytoreduction(CC),HIPEC,pathology,present of serous ascites)were found to be associated with overall survival except for age.On multivariate analysis,only PCI>20,MTD,high pathologic grade and without HIPEC were independent factors predicting poorer prognosis.Conclusions:CCRS+HIPEC can benefit PMP well with controllable risks.MTD+HIPEC may benefit PMP as well when CCRS cannot be achieved after fully asscessment by an experienced peritoneal maglignacy center,but the surgery should be performed as limited as possible.展开更多
How strong is the evidence supporting surgery for patients with metastatic neuroendocrine tumors(NETs)?This is the chief question from Dr.Williams’comprehensive and balanced literature analysis on the surgical treatm...How strong is the evidence supporting surgery for patients with metastatic neuroendocrine tumors(NETs)?This is the chief question from Dr.Williams’comprehensive and balanced literature analysis on the surgical treatment of metastatic pancreatic NETs(1).No matter how many non-randomized studies demonstrate a survival advantage for patients undergoing cytoreductive hepatic surgery or resection of the primary pancreatic tumor,the methodological biases remain constant(2-9).Patients undergoing surgery tend to be younger and healthier,and their tumors tend to be lower grade,less aggressive,and fewer in number than patients undergoing other systemic or liver-directed therapies.In other words,the survival advantage begins when the patient is selected as a surgical candidate and before the scalpel even touches the skin.Although multivariate analyses can control for some confounding variables,it is impossible to control for all.Even a simple concept such as tumor burden is challenging to standardize:a patient with a few large tumors confined to a single hepatic lobe may have a vastly different prognosis than a patient with a similar burden of miliary tumors scattered throughout the liver(2).展开更多
Background and Objective:Pancreatic neuroendocrine tumors(PanNETs)are derived from the islet cells of the pancreas and have been increasing in incidence.Most of these tumors are nonfunctional although some can secrete...Background and Objective:Pancreatic neuroendocrine tumors(PanNETs)are derived from the islet cells of the pancreas and have been increasing in incidence.Most of these tumors are nonfunctional although some can secrete hormones and lead to hormone-specific clinical syndromes.Surgery is the mainstay of treatment for localized tumors,however,surgical resection is controversial in metastatic PanNETs.This narrative review seeks to summarize the current literature surrounding surgery,specifically in the controversial area of metastatic PanNETs,review current treatment paradigms,and understand the benefits of surgery in this group of patients.Methods:Authors searched PubMed using the terms“surgery pancreatic neuroendocrine tumor”,“metastatic neuroendocrine tumor”,and“liver debulking neuroendocrine tumor”from January 1990 to June 2022.Only English language publications were considered.Key Content and Findings:There is no consensus among the leading specialty organizations regarding surgery for metastatic PanNETs.When considering surgery for metastatic PanNETs,tumor grade and morphology,location of the primary tumor,extra-hepatic or extra-abdominal disease,as well as liver tumor burden and metastatic distribution should be considered.Because the liver is the most common site of metastasis and liver failure is the most common cause of death in patients with hepatic metastases,attention is centered here on debulking and other ablative techniques.Liver transplantation is rarely used for hepatic metastases but could be beneficial in a small subset of patients.Retrospective studies have demonstrated improvement in survival and symptoms after surgery for metastatic disease,but the lack of prospective randomized control trials significantly limits analysis of surgical benefits in patients with metastatic PanNETs.Conclusions:Surgery is the standard of care for localized PanNETs,while it remains controversial in metastatic disease.Many studies have shown a survival and symptomatic benefit to surgery and liver debulking in select groups of patients.However,most of the studies on which recommendations are based in this population are retrospective in nature and are subject to selection bias.This presents an opportunity for future investigation.展开更多
There has been a rising trend in the incidence and prevalence of non-functioning pancreatic neuroendocrine tumors(NFPanNETs).While a significant number of the newly diagnosed NFPanNETs are asymptomatic,a majority of p...There has been a rising trend in the incidence and prevalence of non-functioning pancreatic neuroendocrine tumors(NFPanNETs).While a significant number of the newly diagnosed NFPanNETs are asymptomatic,a majority of patients will present with liver metastasis(LM)at the time of diagnosis.Surgical resection remains the only curative treatment,especially for localized NFPanNETs.While a majority of small NFPanNETs are indolent,some are not.This heterogeneity in tumor biology presents the surgeon with the unique challenge of determining which patient will benefit from surgery,given the morbidity of pancreatic surgery.There has been a recent push for a more aggressive approach to the care of these patients,given the emergence of data supporting such measures.However,the risk of over or under treatment has generated immense debate amongst experts in the field.The heterogeneity of current practice guidelines and institutional practices around the world is a reflection of the disparate opinion on the management of NFPanNET.In this review,we set out to examine the evidence regarding some of the most controversial and challenging aspects of the surgical treatment of NFPanNET.We evaluate the following questions;should patients with small NFPanNETs≤2 cm in size be resected;should patients with metastatic NFPanNETs undergo surgical debulking,and should there be resection of the primary tumor in the setting of non-resectable metastatic disease?Although there are currently no Level 1 data to answer these questions conclusively,we believe that the current literature supports a more aggressive approach to the management of NFPanNET.展开更多
Aim:Genital lymphoedema(GL)is a chronic and debilitating disease,which can severely affect the patient’s quality of life with significant socio-economic impact.Nowadays,no gold standard algorithm exists for GL from d...Aim:Genital lymphoedema(GL)is a chronic and debilitating disease,which can severely affect the patient’s quality of life with significant socio-economic impact.Nowadays,no gold standard algorithm exists for GL from diagnosis to treatment.This study proposes our therapeutic flowchart based on the three senior consultants’experience in lymphatic surgery.Methods:A retrospective investigation was conducted on a prospectively maintained database(2018-2022).Inclusion criteria involved all patients who underwent surgical procedures for treating GL in three plastic surgery departments(Lausanne,Bari,and Genova).Outcomes were assessed in terms of oedema reduction,stage regression,and functional reported outcomes.Results:16 patients with GL were included:50%underwent debulking surgery,18.8%microsurgery,and 31.2%debulking+microsurgery.We recorded a significant regression of the GL stage:62.5%shifted from stage II/III to postoperative stage I.Similarly,we found an infection recurrency resolution in 50%,a scrotal oedema reduction in 62.5%,and a scrotal oedema resolution in 37.5%of the patients treated.While almost half of the patients(53.3%)with associated penile oedema described persistent postoperative penile oedema,only two patients complained of persistent lymphorrhea.Conclusion:According to our clinical experience,preoperative and postoperative physical functional therapy is always recommended.For stages I and IIA,after the failure of the conservative treatment,lymph-venous shunts and lymph node transplantation surgery are proposed at the early time.When GL is already diagnosed at stages IIB and III,the debulking surgery,together with functional procedures,represents our first approach.展开更多
文摘To the Editor:Intraductal papillary neoplasm of the bile duct(IPNB)may occur in the setting of primary sclerosing cholangitis,choledochal cysts or hepatolithiasis[1].The entity may be a precursor of cancer or intrahepatic cholangiocarcinoma.Invasive carcinoma,tubular or mucinous adenocarcinoma is present in approximately 40%-80%of IPNBs[1–3].IPNB is frequently found in the resection margins of patients undergoing hepatectomy for cholangiocarcinoma[4].
文摘Background: A wide range of therapies exist for keloids. But despite the multiple treatment modalities available, keloids still remain a significant challenge for both the clinician and the patient. Objective: To assess the effectiveness and safety of debulking of keloid with intralesional injection of 5-flurouracil and triamcinolone in comparison to intralesional injection of 5-flurouracil and triamcinolone alone. Patient and Methods: This single blinded comparative therapeutic outpatient based study was done at the Department of Dermatology, Baghdad Teaching Hospital during the period from February 2011 to February 2013. Twenty-three patients with 52 lesions were enrolled in the study and consisted of two groups: Group A (26 lesions): Treated by intralesional injection of combination of 5-flurouracil and triamcinolone acetonide and repeated every month;Group B (26 lesions): Debulking was carried out first and then injection of combination of 5-flurouracil and triamcinolone acetonide at time of operation and then repeated injection monthly. Evaluation was performed by scoring system with 5 criteria (redness, elevation, hardness, itching and tenderness). The response was graded as no response, minimal, moderate or complete response. Results: Both modalities of treatments showed significant results in treating keloid, but the intralesional therapy alone was slightly better than debulking plus intralesional and no systemic adverse effects were noticed in both groups. Conclusion: Both modalities of therapy were effective in treatment of keloid, and there was no much difference between them.
文摘Objective:To assess the role of debulking surgery in extensive hepatic alveolar echinococcosis(HAE).Methods:Five cases of extensive HAE undergoing debulking surgery with their long-term follow-ups were reported.Additionally,a systematic review was carried out.Results:The average age of patients in the study was(50.8±17.1)years(range 36 to 77 years).Three cases were female.The median follow-up period was 61 months(range 12 to 84 months).Left liver resections were performed in 2 cases and right hemihepatectomies were undertaken in 2 cases.Two patients(cases 2 and 4)developed early surgical complications,while one of them(case 4)who suffered from the recurrent sub-hepatic abscess died at 12 months postoperatively.Conclusions:This study highlights the importance of debulking surgery for the management of complex symptomatic HAE lesions in patients with no curative option available.
文摘Background: Inappropriately ovarian cancer cannot be detected until an advanced stage. Radical debulking surgery is considered the cornerstone in the management of advanced ovarian cancer pointing to complete tumor resolution. Unless optimal debulking cannot be achieved, these patients gain little benefit from surgery. Neoadjuvant chemotherapy (NACT) has been recommended as a novel therapeutic modality to a diversity of malignant tumors when the disease is not willing to optimal surgical resection at the time of diagnosis or the patient who unfit for aggressive debulking surgery. The purpose of this study is to compare survival in the patient with advanced ovarian cancer (stage III/IV) underwent primary debulking surgery followed by adjuvant chemotherapy (PDS-ACTR) to those who received neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS). Results: Neoadjuvant chemotherapy (NACT-IDS) showed significant complete cytoreduction and decreased in surgical morbidity in comparison to primary debulking surgery (PDS-ACTR). NACT-IDS showed significant improvement in progression-free survival (P-value 0.002) and overall survival (P-value 0.03) in comparison to PDS-ACTR. Response to NACT and residual volume were the two independent prognostic factors for overall survival. Conclusion: NACT-IDS for advanced ovarian cancer (III/IV) resulted in higher frequency of complete resection with no residual tumor, less post-operative surgical morbidity and significant increase progression-free survival and overall survival. Both responses to NACT and residual tumor volume were the two independent prognostic factors for survival in ovarian cancer.
文摘Background and objective:The value of debulking surgery for unresectable well-differentiated metastatic pancreatic neuroendocrine tumor(m-PNET)remains poorly defined.This study aimed to evaluate the outcomes of m-PNET following debulking surgery in our institute.Methods:Patients with well-differentiated m-PNET in our hospital between February 2014 and March 2022 were collected.Clinicopathological and long-term outcomes of patients treated with radical resection,debulking surgery,and conservative therapy were compared retrospectively.Results:Fifty-three patients with well-differentiated m-PNET were reviewed,including 47 patients with unresectable m-PNET(debulking surgery,25;conservative therapy,22)and 6 patients with resectable m-PNET(radical resection).Patients undergoing debulking surgery had a post-operative Clavien–DindoIII complication rate of 16.0%without mortality.The 5-year overall survival(OS)rate of patients treated with debulking surgery was significantly higher than that of those treated with conservative therapy alone(87.5%vs 37.8%,log-rank P=0.022).Besides,the 5-year OS rate of patients treated with debulking surgery was comparable to that of patients with resectable m-PNET undergoing radical resection(87.5%vs 100%,log-rank P=0.724).Conclusions:Patients with unresectable well-differentiated m-PNET who underwent resection had better long-term outcomes than those who received conservative therapy alone.The 5-year OS of patients undergoing debulking surgery and radical resection were comparable.Debulking surgery could be considered for patients with unresectable well-differentiated m-PNET if no contraindication exists.
基金the National Key Research and Development Program of China(No.2016YFA0201404)Natural Science Foundation of Beijing(7222204).
文摘Objective:The goal of this study was to find the risk factors for major intraoperative blood loss(MBL)of pr imary debulking surgery(PDS)for ovarian cancer.Methods:Patients wi th ovarian cancer who underwent PDS in our hospital,from 2010 to 2017,were enrolled.The association between risk factors and MBL was modeled with the use of logisde regr ession.Receiver operating characteristic(ROC)curve analysis was used to determine the predictive value of the logi stic regression model.Results:A total of 346 padients met the inclusion criteria.There were 150 patients with MBL.Tumor stage 3/4(P<0.001),American Society of Aneshesiologists(ASA)score 23(P=0.044),ascites volume≥500 ml(P=0.002),radical or ultra radical surgery(P=0.002),and diabetes(P=0.035)were independent risk factors for MBL in patients with ovarian cancer.The logistic regression combined model of these five factors is more reliable in the prediction of MBL with an area under the ROC curve of 0.729 than the tumor stage(ROC curve=0.645)and surgical complexity(ROC curve=0.568).Conclusion:In padients with ovarian cancer,five risk factors for major intraoperative bleeding were identified.Planned surgical procedures and preoperative risk factors can be used to predict perioperative blood requir ements.
文摘Lymphoedema is a chronic debilitating disease of the lymphatic system that occurs due to either abnormal development or damage of the lymphatics resulting from cancer or infection.The optimal treatment of lymphoedema is still elusive.Management is tailored according to clinical features,investigations and expectations of each patient.Lymphoedema patients should undergo a trial of conservative management with compression therapy,manual lymphatic drainage and external sequential compression devices.Early lymphoedema is treated by lymphovascular anastomosis,where the lymph vessels are connected to the subdermal veins by supermicrosurgery.In late cases when the limb is fibrotic,vascularised lymph node transfers are done,where lymph nodes are transferred from a healthy area to the affected area.In advanced cases,when the limb is fibrotic with cutaneous folds and skin changes,surgical debulking is done.In lymphoedema,along with accumulation of lymphatic tissue,there is also fat deposition,which can be removed by liposuction.One should be conversant with all treatment modalities to provide the lymphoedema patient with optimal care.
文摘<strong>Introduction:</strong><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"> This study evaluated the difference in operative and clinica</span></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">l outc</span><span style="font-family:Verdana;">omes for patients with advanced ovarian cancer after primary debulking</span><span style="font-family:Verdana;"> surgery (PDS) versus neoadjuvant chemotherapy (NACT) followed by interval debul</span><span><span style="font-family:Verdana;">king surgery (IDS) in Bangladesh. </span><b><span style="font-family:Verdana;">Methods:</span></b><span style="font-family:Verdana;"> Sixty patients with a</span></span><span style="font-family:Verdana;">dvanced epit</span><span style="font-family:Verdana;">helial ovarian cancer presenting to the department of Gynaecologi</span><span style="font-family:Verdana;">cal Oncology at the National Institute of Cancer Research and Hospital were prospectively enrolled. Thirty patients underwent primary debulking surgery and thirty patients received NACT followed by IDS. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> In the PDS and IDS groups respectively, 56.7% and 50% of patients presented with stage IIIC and 67.7% and 56.7% respectively had ser</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">i</span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">ous papillary type histopathology. Duration of surgery, amount of blood loss and total hospital stay were significantly lower (p < 0.001) in IDS group than </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">in </span></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">the PDS group. There was a statistically significant difference in postoperative tumor residuals between IDS and PDS patients. Complete tumor resection (R0) was obtained in 24 (80%) of IDS patients versus 13 (43.3%) PDS patients. In fifteen months of follow-up, 21 (70%) in the PDS group and 5 (16.7%) in the IDS group recurred (</span><span style="font-family:Verdana;">p</span><span style="font-family:Verdana;"> = 0.021). Median progression free survival in PDS patients was twelve months while that of the IDS group was seventeen months. There was one death at 45 days in the PDS group. No other deaths were documented at fifteen months of follow-up. </span><b><span style="font-family:Verdana;">Conclusion</span></b></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><b><span style="font-family:Verdana;">:</span></b></span></span><span><span><span style="font-family:""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">Interval debulking surgery has a more favorable outcome than primary debulking surgery on progression free survival in advanced ovarian cancer patients </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">and </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">permits a less aggressive surgery to be performed in Bangladesh.</span></span></span>
文摘AIM To examine the efficacy and safety of the 6 French(6F) Rotarex~S catheter system in patients with acute limb ischemia(ALI) involving thromboembolic occlusion of the proximal and mid-crural vessels.METHODS The files of patients in our department with ALI between 2015 and 2017 were examined. In seven patients, the Rotarex~S catheter was used in the proximal segment of the crural arteries. Data related to the clinical examination, Doppler sonography, angiography and followup from these patients were further used for analysis.RESULTS Two patients(29%) had thrombotic occlusion of the common femoral artery, and the remaining five exhibited thrombosis of the superficial femoral artery and popliteal artery. Mechanical thrombectomy was performed in all cases using a 6F Rotarex~S catheter. Additional Rotarex~S catheter thrombectomy due to remaining thrombus formation with no reflow was performed in the anterior tibial artery in two of seven cases(29%), in the tibiofibular tract and posterior tibial artery in two of seven cases(29%) and in the tibiofibular tract and fibular artery in the remaining three of seven cases(43%). Ischemic symptoms resolved promptly in all, and none of the patients experienced a procedural complication, such as crural vessel dissection, perforation or thrombus embolization.CONCLUSION Mechanical debulking using the 6F Rotarex~S catheter system may be a safe and effective treatment option in case of thrombotic or thromboembolic occlusion of the proximal and mid-portion of crural arteries.
文摘BACKGROUND: The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even when a radical excision cannot always be achieved. DATA SOURCES: A PubMed search of relevant articles published up to February 2011 was performed to identify current information about PET liver metastases regarding diagnosis and management, with an emphasis on surgery. RESULTS: The early diagnosis of metastases and their accurate localization, most commonly in the liver, is very important. Surgical options include radical excision, and palliative excision to relieve symptoms in case of failure of medical treatment. The goal of the radical excision is to remove the primary tumor bulk and all liver metastases at the same time, but unfortunately it is not feasible in most cases. Palliative excisions include aggressive tumor debulking surgeries in well-differentiated carcinomas, trying to remove at least 90% of the tumor mass, combined with other additional destructive techniques such as hepatic artery embolization or chemoembolization to treat metastases or chemoembolization to relieve symptoms in cases of rapidly growing tumors. The combination of chemoembolization and systemic chemotherapy results in better response and survival rates. Other local destructive techniques include ethanol injection, cryotherapy and radiofrequency ablation. CONCLUSION: It seems that the current management of PETs can achieve important improvements, even in advanced cases.
基金Supported by Fundo de IncentivoàPesquisa(FIPE)/Hospital de Clínicas de Porto Alegre and Universidade Federal do Rio Grande do Sul.
文摘BACKGROUND Primary extra-gastrointestinal stromal tumors(E-GIST)of the liver are rare.The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect.Oncologic surgery followed by adjuvant therapy with imatinib is the standard of care.However,under specific circumstances,a cytoreductive approach may represent a therapeutic option.We describe herein the case of an 84-year-old woman who presented with a tender,protruding epigastric mass.Abdominal computed tomography scan revealed a large,heterogeneous mass located across segments III,IV,V,and VIII of the liver.The initial approach was transarterial embolization of the tumor,which elicited no appreciable response.Considering the large size and central location of the tumor and the advanced age of the patient,non-anatomic complete resection was indicated.Due to substantial intraoperative bleeding and hemodynamic instability,only a near-complete resection could be achieved.Histopathology and immunohistochemical staining confirmed the diagnosis of primary E-GIST of the liver.Considering the risk/benefit ratio for therapeutic options,debulking surgery may represent a strategy to control pain and prolong survival.CASE SUMMARY Here,we present a case report of a patient diagnosed with E-GIST primary of the liver,which was indicated a cytoreductive surgery and adjuvant therapy with imatinib.CONCLUSION E-GIST primary of the liver is a rare conditional,the treatment is with systemic therapy and total resection surgery.However,a cytoreductive surgery will be necessary when a complete resection is no possible.
文摘Although it is assumed that the combination of chemotherapy and radical surgery should be indicated in all newly diagnosed advanced-stage ovarian cancer patients, one of the main raised questions is how to select the best strategy of initial treatment in this group of patients, neoadjuvant chemotherapy followed by interval debulking surgery or primary debulking surgery followed by adjuvant chemotherapy. The selection criteria to offer one strategy over the other as well as a stepwise patient selection for initial treatment are described. Selecting the best strategy of treatment in newly diagnosed advanced stage ovarian cancer patients is a multifactorial and multidisciplinary decision. Several factors should be taken into consideration:(1) the disease factor, related to the extension and localization of the disease as well as tumor biology;(2) the patient factor, associated with patient age, poor performance status, and co-morbidities; and(3) institutional infrastructure factor, related to the lack of prolonged operative time, an appropriate surgical armamentarium, as well as well-equipped intensive care units with well-trained personnel.
基金Supported by State Key Program of National Natural Science Foundation of China,No.81930016Zhejiang Provincial Natural Science Foundation of China,No.LY21H160026。
文摘Over the last 40 years,the incidence and prevalence of gastroenteropancreatic neuroendocrine neoplasms(GEP-NENs)have continued to increase.Compared to other epithelial neoplasms in the same organ,GEP-NENs exhibit indolent biological behavior,resulting in more chances to undergo surgery.However,the role of surgery in high-grade or advanced GEP-NENs is still controversial.Surgery is associated with survival improvement of well-differentiated highgrade GEP-NENs,whereas poorly differentiated GEP-NENs that may benefit from resection require careful selection based on Ki67 and other tissue biomarkers.Additionally,surgery also plays an important role in locally advanced and metastatic disease.For locally advanced GEP-NENs,isolated major vascular involvement is no longer an absolute contraindication.In the setting of metastatic GEP-NENs,radical intended surgery is recommended for patients with low-grade and resectable metastases.For unresectable metastatic disease,a variety of surgical approaches,including cytoreduction of liver metastasis,liver transplantation,and surgery after neoadjuvant treatment,show survival benefits.Primary tumor resection in GEP-NENs with unresectable metastatic disease is associated with symptom control,prolonged survival,and improved sensitivity toward systemic therapies.Although there is no established neoadjuvant or adjuvant strategy,increasing attention has been given to this emerging research area.Some studies have reported that neoadjuvant therapy effectively reduces tumor burden,improves the effectiveness of subsequent surgery,and decreases surgical complications.
文摘Ovarian cancer is one of the leading causes of death among gynecological cancers. This is because the majority of patients present with advanced stage disease. Primary debulking surgery(PDS) followed by adjuvant chemotherapy is still a mainstay of treatment. An optimal surgery, which is currently defined by leaving no gross residual tumor, is the goal of PDS. The extent of disease as well as the operative setting, including the surgeon's skill, infl uences the likelihood of successful debulking. With extensive disease and a poor chance of optimal surgery or high morbidity anticipated, neoadjuvant chemotherapy(NACT) prior to primary surgery is an option. Secondary surgery after induction chemotherapy is termed interval debulking surgery(IDS). Delayed PDS or IDS is offered to patients who show some clinical response and are without progressive disease. NACT or IDS has become more established in clinical practice and there are numerous publications regarding its advantages and disadvantages. However, data on survival are limited and inconsistent. Only one large randomized trial could demonstrate that NACT was not inferior to PDS while the few randomized trials on IDS had inconsistent results. Without a defi nite benefi t of NACT prior to surgery over PDS, one must carefully weigh the chances of safe and successful PDS against the morbidity and risks of suboptimal surgery. Appropriate selection of a patient to undergo PDS followed by chemotherapy or, preferably, to have NACT prior to surgery is very important. Some clinical characteristics from physical examination, serum tumor markers and/or fi ndings from imaging studies may be predictive of resectability. However, no specific features have been consistently identifi ed in the literature. This article will address the clinical data on prediction of surgical outcomes, the role of NACT, and the role of IDS.
基金This study was supported by funding from scientific research special project of capital health development(2020-4-6083)。
文摘Aim:As more and more centers has published their treatment results of pseudomyxoma peritonei(PMP)with cytoreductive surgery(CRS)and hyperthermic intraperitoneal chemotherapy(HIPEC),the data from China is missing.Myxoma Department of Aerospace Hospital is the biggest center treating PMP in China.The purpose of this study is to report the early and long-term outcomes for PMP from this single center.Methods:801 appendix-derived PMP out of 1008 consecutive patients treated in Myxoma Department of Aerospace Hospital between 2008 and 2019 were retrospectively analyzed.Results:Complete cytoreductive surgery(CCRS)was achieved in 240(30%)patients with median PCI of 14(1~39),and the rest had maximal tumor debulking(MTD),HIPEC was implemented in 96.3%of CCRS and 78.6%of MTD.The major morbidity(grade III/IV)was 11.4%and the 30-day operative mortality is 0.7%.The 5-and 10-year OS of CCRS was 76.9%and 64.1%,which is significantly higher than MTD(5-,10-year OS as 36.1%,27.1%;p<0.001).On the univariate analysis,all prognostic factors(gender,PSS,interval time,prior chemotherapy,prior HIPEC,Peritoneal Cancer Index(PCI),completeness of cytoreduction(CC),HIPEC,pathology,present of serous ascites)were found to be associated with overall survival except for age.On multivariate analysis,only PCI>20,MTD,high pathologic grade and without HIPEC were independent factors predicting poorer prognosis.Conclusions:CCRS+HIPEC can benefit PMP well with controllable risks.MTD+HIPEC may benefit PMP as well when CCRS cannot be achieved after fully asscessment by an experienced peritoneal maglignacy center,but the surgery should be performed as limited as possible.
文摘How strong is the evidence supporting surgery for patients with metastatic neuroendocrine tumors(NETs)?This is the chief question from Dr.Williams’comprehensive and balanced literature analysis on the surgical treatment of metastatic pancreatic NETs(1).No matter how many non-randomized studies demonstrate a survival advantage for patients undergoing cytoreductive hepatic surgery or resection of the primary pancreatic tumor,the methodological biases remain constant(2-9).Patients undergoing surgery tend to be younger and healthier,and their tumors tend to be lower grade,less aggressive,and fewer in number than patients undergoing other systemic or liver-directed therapies.In other words,the survival advantage begins when the patient is selected as a surgical candidate and before the scalpel even touches the skin.Although multivariate analyses can control for some confounding variables,it is impossible to control for all.Even a simple concept such as tumor burden is challenging to standardize:a patient with a few large tumors confined to a single hepatic lobe may have a vastly different prognosis than a patient with a similar burden of miliary tumors scattered throughout the liver(2).
文摘Background and Objective:Pancreatic neuroendocrine tumors(PanNETs)are derived from the islet cells of the pancreas and have been increasing in incidence.Most of these tumors are nonfunctional although some can secrete hormones and lead to hormone-specific clinical syndromes.Surgery is the mainstay of treatment for localized tumors,however,surgical resection is controversial in metastatic PanNETs.This narrative review seeks to summarize the current literature surrounding surgery,specifically in the controversial area of metastatic PanNETs,review current treatment paradigms,and understand the benefits of surgery in this group of patients.Methods:Authors searched PubMed using the terms“surgery pancreatic neuroendocrine tumor”,“metastatic neuroendocrine tumor”,and“liver debulking neuroendocrine tumor”from January 1990 to June 2022.Only English language publications were considered.Key Content and Findings:There is no consensus among the leading specialty organizations regarding surgery for metastatic PanNETs.When considering surgery for metastatic PanNETs,tumor grade and morphology,location of the primary tumor,extra-hepatic or extra-abdominal disease,as well as liver tumor burden and metastatic distribution should be considered.Because the liver is the most common site of metastasis and liver failure is the most common cause of death in patients with hepatic metastases,attention is centered here on debulking and other ablative techniques.Liver transplantation is rarely used for hepatic metastases but could be beneficial in a small subset of patients.Retrospective studies have demonstrated improvement in survival and symptoms after surgery for metastatic disease,but the lack of prospective randomized control trials significantly limits analysis of surgical benefits in patients with metastatic PanNETs.Conclusions:Surgery is the standard of care for localized PanNETs,while it remains controversial in metastatic disease.Many studies have shown a survival and symptomatic benefit to surgery and liver debulking in select groups of patients.However,most of the studies on which recommendations are based in this population are retrospective in nature and are subject to selection bias.This presents an opportunity for future investigation.
文摘There has been a rising trend in the incidence and prevalence of non-functioning pancreatic neuroendocrine tumors(NFPanNETs).While a significant number of the newly diagnosed NFPanNETs are asymptomatic,a majority of patients will present with liver metastasis(LM)at the time of diagnosis.Surgical resection remains the only curative treatment,especially for localized NFPanNETs.While a majority of small NFPanNETs are indolent,some are not.This heterogeneity in tumor biology presents the surgeon with the unique challenge of determining which patient will benefit from surgery,given the morbidity of pancreatic surgery.There has been a recent push for a more aggressive approach to the care of these patients,given the emergence of data supporting such measures.However,the risk of over or under treatment has generated immense debate amongst experts in the field.The heterogeneity of current practice guidelines and institutional practices around the world is a reflection of the disparate opinion on the management of NFPanNET.In this review,we set out to examine the evidence regarding some of the most controversial and challenging aspects of the surgical treatment of NFPanNET.We evaluate the following questions;should patients with small NFPanNETs≤2 cm in size be resected;should patients with metastatic NFPanNETs undergo surgical debulking,and should there be resection of the primary tumor in the setting of non-resectable metastatic disease?Although there are currently no Level 1 data to answer these questions conclusively,we believe that the current literature supports a more aggressive approach to the management of NFPanNET.
文摘Aim:Genital lymphoedema(GL)is a chronic and debilitating disease,which can severely affect the patient’s quality of life with significant socio-economic impact.Nowadays,no gold standard algorithm exists for GL from diagnosis to treatment.This study proposes our therapeutic flowchart based on the three senior consultants’experience in lymphatic surgery.Methods:A retrospective investigation was conducted on a prospectively maintained database(2018-2022).Inclusion criteria involved all patients who underwent surgical procedures for treating GL in three plastic surgery departments(Lausanne,Bari,and Genova).Outcomes were assessed in terms of oedema reduction,stage regression,and functional reported outcomes.Results:16 patients with GL were included:50%underwent debulking surgery,18.8%microsurgery,and 31.2%debulking+microsurgery.We recorded a significant regression of the GL stage:62.5%shifted from stage II/III to postoperative stage I.Similarly,we found an infection recurrency resolution in 50%,a scrotal oedema reduction in 62.5%,and a scrotal oedema resolution in 37.5%of the patients treated.While almost half of the patients(53.3%)with associated penile oedema described persistent postoperative penile oedema,only two patients complained of persistent lymphorrhea.Conclusion:According to our clinical experience,preoperative and postoperative physical functional therapy is always recommended.For stages I and IIA,after the failure of the conservative treatment,lymph-venous shunts and lymph node transplantation surgery are proposed at the early time.When GL is already diagnosed at stages IIB and III,the debulking surgery,together with functional procedures,represents our first approach.
