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BACKGROUND: Duodenal margin positivity is a poor prognostic factor following gastrectomy for resectable gastric cancer. Intraoperative frozen section (IFS) analysis allows radical resection to be achieved in a single operation but is time- and resource-consuming. Hence resection is usually performed based on surgeon's judgment and palpation. AIM OF STUDY: To determine risk factors for duodenal resection margin (RM) positivity following gastrectomy for resectable gastric cancer. MATERIALS AND METHODS: We retrospectively analyzed prospectively maintained data of 376 patients admitted with diagnosis of gastric cancer from August 2011 to January 2020 in JIPMER, a tertiary center in Puducherry, India. Of these, 146 patients underwent gastric resection with curative intent and were the subject of this study. RM status was assessed by definitive histopathology examination. The potential risk factors were compared between patients with positive margin on definitive histopathology examination and a control cohort of similar patients with negative margins. RESULTS: Of the 146 patients, 16 patients (10.9%), 11 men and 5 women, had positive duodenal margin. The mean age of study group was 59 years. None of the patient characteristics like age, sex, comorbidities, or addictions were statistically significant with regard to duodenal margin positivity. Among tumor characteristics, locally advanced tumors and pyloroantral tumors were found more frequently in the margin-positive group. High-risk features for duodenal margin positivity were extensive nodal disease, oligometastatic disease, lymphovascular invasion, and perineural invasion. Neoadjuvant chemotherapy and types of surgical access did not have significant impact on RM. Interestingly, both proximal and circumferential resection margin positivity had a linear association with distal margin positivity suggesting that tumor biology may have a significant role in margin positivity. However, none of these factors were statistically significant on multivariate analysis using logistic regression model. Among oligometastatic patients, survival was dependent on R0 resection and was not different from patients without metastases though our study was not powered for survival analysis (mean survival of 11.040 months) and expectedly, duodenal margin positive patients had lower overall survival compared to margin negative patients (mean survival of 5.188 vs. 11.763 months, p = 0.12). CONCLUSIONS: Locally advanced tumors and pyloroantral tumors are associated with an increased risk of duodenal margin positivity after gastrectomy for carcinoma stomach and may benefit from intraoperative frozen section analysis as survival is negatively affected by positive RM. Patients with high-risk features like extensive nodal and oligometastatic disease have a greater propensity for positive duodenal margin. A prospective study with a large sample size is needed to further validate these results.

Asunto(s)

Neoplasias Gástricas , Masculino , Humanos , Femenino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Neoplasias Gástricas/patología , Márgenes de Escisión , Estudios Prospectivos , Gastrectomía/efectos adversos , Factores de Riesgo , Análisis Factorial , Estadificación de Neoplasias

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Backgrounds/Aims: Proximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis. Methods: This was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014-2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann-Whitney U test and χ2 test. Results: Eighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group. Conclusions: CP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.

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Purpose@#Robotic surgery for pancreatic diseases is currently on the rise, feasible, well-accepted, and safe. Frequently performed procedures in relation to pancreatic diseases include distal pancreatectomy and pancreatoduodenectomy. The literature commonly describes robotic lateral pancreaticojejunostomy;however, data on robot-assisted Frey’s is scarce. @*Methods@#We herein, describe our series and technique of robot-assisted Frey’s procedure at our tertiary care center between November 2019 and March 2022, and its short-term outcomes in comparison to the open Frey’s. Patients with chronic pancreatitis having intractable pain, dilated duct, and no evidence of inflammatory head mass or malignancy were included in the study for robot-assisted Frey’s. @*Results@#In our study, out of 32 patients, nine patients underwent robot assisted Frey’s procedure. The duration of surgery was significantly longer in robotic group (570 minutes vs. 360 minutes, p = 0.003). The medians of intraoperative blood loss and postoperative analgesic requirement were lower in robotic group, but the difference was not statistically significant (250 mL vs. 350 mL, p = 0.400 and 3 days vs. 4 days, p = 0.200, respectively). The median length of hospital stay was shorter in the robotic group, though not significant (6 days vs. 7 days, p = 0.540). At a median follow-up of 28 months, there was no significant difference in the postoperative complications and short-term outcomes between the two groups. @*Conclusion@#Robotic surgery offers benefits of laparoscopic surgery in addition it has better visualization, magnification, dexterity, and ergonomics. Frey’s procedure is possible robotically with acceptable outcomes in selected patients.

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BACKGROUND: In the light of increased requirement for liver transplantation procedures, it is pertinent to develop bankable human expertise in the areas of liver resection and anastomoses. The alternative simulator sources available for learning surgical skills might not always provide the realistic learning gains as provided by human cadavers, especially in terms of haptic and tactile fidelity. For the first time, we have used Genelyn® embalmed cadavers (GEC) for training the surgical gastroenterologists in liver resection and transplantation procedures and we wish to document our experience of using them to facilitate the learning of liver resection procedures. MATERIALS AND METHODS: A cross-sectional satisfaction survey fitting to the first level of the Kirkpatrick model for training evaluation was performed among participating surgical gastroenterologists of liver resection and transplantation training workshop using GEC. Visual, haptic and tactile characteristics of the liver and related structures were assessed along with overall satisfaction of the workshop. RESULTS: Eleven surgical gastroenterologists had participated in the workshop conducted using three GEC. Nine participants agreed that the transection of liver parenchyma was similar to reality. However, two opined that the liver parenchyma was a bit harder to resect. Identification of portal pedicle, dissection of the peri-portal area and securing vascular anastomoses also had an acceptable level of similarity to real life. The two parameters that received a unanimous degree of the agreement are mobilization of liver and cannulation of key vessels for perfusion. CONCLUSION: Participants of the cadaveric surgical skills training workshop opined that the soft-embalmed cadaver using Genelyn® is an excellent realistic model for practicing liver resection and transplantation surgery.

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Removal of a transesophageal migrated foreign body is recommended to prevent injury to adjacent structures. As the endoscopic approach is not feasible for a transesophageal foreign body migrated into the mediastinum, the thoracoscopic approach is recommended. The thoracoscopic approach often requires single lung ventilation and is associated with more pulmonary complications. The use of a laparoscopic approach to remove a mediastinal foreign body has not been reported earlier. In this report, the authors describe a laparoscopic approach for the removal of a transesophageal migrated foreign body into the lower mediastinum.