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Gallbladder cancer is a rare, aggressive malignancy that has a poor overall prognosis. Effective treatment consists of early detection and surgical treatment. With the wide spread treatment of gallbladder disease with minimally invasive techniques, the rate of incidental gallbladder cancer has seen an equitable rise along with stage migration towards earlier disease. Although the treatment remains mostly surgical, newer modalities such as regional therapy as well as directed therapy based on molecular medicine has led to improved outcomes in patients with advanced disease. We aim to summarize the management of gallbladder cancer along with the newer developments in this formidable disease process.

Background. Anal canal adenocarcinoma (AA) is an uncommon tumor of the gastrointestinal tract. We seek to provide a detailed description of the incidence, demographics, and outcome of this rare tumor in the United States. Methods. The data on anal canal adenocarcinoma from SEER Program, between 1973–2015, were extracted. We analyzed the incidence rates by demographics and tumor characteristics, followed by analysis of its impact on survival. Results. The incidence of AA increased initially by 4.03% yearly from 1973 to 1985 but had a modest decline of 0.32% annually thereafter. The mean age for diagnosis of AA was 68.12 ± 14.02 years. Males outnumbered females by 54.8 to 45.2%. Tumors were mostly localized on presentation (44.4%) and moderately differentiated (41.1%). Age generally correlated with poor overall cancer survival. However, young patients (age p<0.01). Conclusions. Anal canal adenocarcinoma demonstrated a poor bimodal cancer-free survival in both younger and older patient groups. Surgery significantly improves odds of survival and should be offered to patients amenable to intervention.

Background Parasitic leiomyomas are rare extra-uterine tumors that can be seen in patients after myomectomy or morcellation of leiomyomas. Case A 63-year-old woman with a history of abdominal myomectomy 20 years prior presented with worsening abdominal distension and pain for the past eight months. The patient delayed care due to fear of the COVID-19 pandemic and was found to have a 42 cm parasitic leiomyoma attached to the small bowel causing obstruction and perforation. Conclusion Parasitic leiomyomas can cause small bowel obstruction and perforation., Highlights • Parasitic leiomyomas can range in presentation from asymptomatic to sepsis. • Parasitic leiomyomas can cause small bowel obstruction and perforation. • Care should not be delayed in the setting of the COVID-19 pandemic.

Introduction Simultaneous robot assisted colon and liver resections are being performed more frequently at present due to the expanded adoption of the robotic platform for surgical management of metastatic colon cancer. However, this approach has not been studied in detail with only case series available in the literature. The aim of this systematic review was to evaluate the current body of evidence on the feasibility of performing simultaneous robotic colon and liver resections. Methods A systematic review was performed through PubMed to identify relevant articles describing simultaneous colon and liver resections for metastatic colon cancer. Results A total of 28 patients underwent simultaneous resections robotically with an average operative time of 420.3 minutes and average blood loss of 275.6 ml. Postoperative stay was 8.6 days on average with all cases achieving negative surgical margins. Conclusions Robotic simultaneous resection of colorectal cancer with liver metastases is technically feasible and seems oncologically equivalent to open or laparoscopic surgery. Further studies are urgently needed to assess benefits of robotic surgery in the patient population.

The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall postoperative morbidity and resection margin involvement rate were the primary endpoints. Secondary endpoints included operating time, estimated blood loss (EBL), incisional surgical site infection (SSI) rate, length of hospital stay (LOS), and number of lymph nodes harvested. Twenty-four studies totaling 12,579 patients (2,175 robotic PD and 10,404 open PD were included. Overall postoperative mortality did not significantly differ [OR (95%CI) = 0.86 (0.74, 1.01); p = 0.06]. Resection margin involvement rate was significantly lower in robotic PD [15.6% vs. 19.9%; OR (95%CI) = 0.64 (0.41, 1.00); p = 0.05; NNT = 23]. Operating time was significantly longer in robotic PD [MD (95%CI) = 75.17 (48.05, 102.28); p

The use of telemedicine for mentoring and proctoring is long-standing, but only in recent years has it been applied to the many specialties in surgery. Despite being relatively new, the concept of telepresence and telesurgery and the new technological advances in robotic surgery have made possible telementoring and teleproctoring in many disciplines including such as e-ICU consultations and advise on how to manage a critically ill patient. This form of telementoring and teleproctoring is probably best known clinically relevant, yet it has been accepted as routine care. Other forms of telementoring and teleproctoring include telemedicine and telepresence applications for trauma, emergency management. In this chapter we will address telementoring, and to a lesser degree teleproctoring in just about all surgical disciplines with exception of gynecology and orthopedics.

With the expected rise in the geriatric patient population, delivery of healthcare for elderly patients will require more resources in the next several decades. The development of cancer is more common in the geriatric population since two-thirds of cancers are typically discovered in the elderly. The elderly often have associated medical comorbidities. Treatment of the geriatric patient population will encompass more personalized approaches based on their functional status. Surgical management of elderly cancer patients is complex. Not only does it require incorporation of multimodality care, the treating physician needs to balance risks and benefits from options available due to patient medical comorbidities leading to posttreatment debilitation and side effect profiles. Furthermore, there are also insufficient studies in the elderly population in terms of long-term oncologic follow-up as many studies frequently exclude the elderly in their study designs. With the development of newer modalities of treatment such as ablative procedures, minimally invasive approaches, and immunotherapy, the selection of treatment methods will need to balance optimal oncologic outcome with expected patient survival.

TPS10607 Background: Pancreatic adenocarcinoma (PC) has a persistently high mortality as it presents in the advanced stages and has largely not benefited from the genomic and immunotherapeutic revolutions in oncology. Improvements in screening to detect early stage cancers are therefore urgently needed. Screening studies such as those from the International CAPS Consortium have demonstrated improved survivals in hereditary high risk individuals. In the sporadic population, individuals with new-onset diabetes (NOD) or long-standing deteriorating diabetes (DD) are at substantially increased risk of PC in the 12 months following these diagnoses and have been proposed as target populations for screening efforts. This trial will study the benefits of PC screening in the latter populations in a community setting. Methods: Individuals ≥ 50 years of age with either NOD or DD will be eligible. Criteria for NOD (within the past 12 months) include: fasting blood glucose ≥ 126 mg/dL, random blood glucose ≥ 200 mg/dL, or HbA1c ≥ 6.5%, with confirmed prior normal values. For those without prior glycemic values, a HbA1c ≥ 7.0% is required. Transition from pre-diabetes requires an increase in HgA1c of ≥ 0.5%. DD is defined by an increase in HbA1c of ≥ 2% within the past six months that is not associated with medication non-compliance or weight gain. Study participants will undergo every 6 months: evaluation by an APRN, testing for anxiety and depression and blood donation for biobanking purposes. High resolution MRI/MRCP with gadolinium will be performed at study entry and annually for 2 years. Images will be reviewed at a multi-disciplinary tumor board consisting of body-image certified radiologists, interventional gastroenterologists, hepatobiliary surgeons and medical oncologists. MRI results will be classified according to a novel PANC-RADS system. High-risk pancreatic findings will be further interrogated by endoscopic ultrasound (EUS). Study endpoints include detection rate of high-risk lesions, referrals for EUS and surgery and detection of incidental findings leading to unnecessary procedures. Adverse psychological impacts will be assessed through HADS testing. Target accrual: 500 patients within 3 years. Clinical trial information: NCT03937453 .

Lynch syndrome is an autosomal dominant disorder in which one's DNA mismatch repair mechanism is impaired, resulting in an increased risk of developing colon and endometrial cancers, as well as other malignancies. With such an increased risk of colorectal cancer, patients diagnosed with Lynch syndrome should undergo colonoscopy screening every 1–2 years beginning at ages 20 to 25 or two to five years prior to earliest diagnosis of colorectal cancer in their family members. In patients with Lynch syndrome, colorectal cancer usually presents after the fourth decade of life. Few cases have been reported in pediatric patients with early onset colorectal cancer. We report here a 16-year-old patient who presented initially with symptoms characteristic of appendicitis. Following a CT scan suggesting perforated appendicitis, the patient was treated with intravenous antibiotics with a scheduled interval appendectomy three months later. Pathology reports from the interval appendectomy showed that the specimen contained a well-to-moderately differentiated adenocarcinoma. The patient then underwent robot assisted right hemicolectomy as definitive management, which demonstrated that the tumor originated in the cecum with invasion into the submucosa and focally infiltrating the muscularis propria. This case illustrates the need to be cognizant that cancer can present similarly to appendicitis, to be aware of the increasing incidence of colon cancer in younger patients, and to catalyze the acceptability of robotics for minimally invasive surgery. Keywords: Lynch syndrome, Pediatric colon cancer, Robotic colectomy

The volume of a disease treated by a hospital and the quality of care delivered by a hospital have a known proportionate relationship. In the design of a new hospital, or the addition of new clinical services to an existing hospital, one of the central tenets is the ability to provide high-quality care that hopefully is combined with excellent outcomes. There are certain high-risk procedures known to require high-volume multimodality care to produce quality outcomes. Best examples of quality healthcare that are related to volume are high-risk surgical cases such as coronary artery bypass grafting, abdominal aortic aneurysm repair, liver transplantation, esophagectomy, pancreatectomy, and other high-risk oncologic procedures. As a result, when creating or advancing new clinical programs, the need to research the regional patient population and to concentrate on the regional patient needs is crucial to the success of the new hospital. The ability to understand the critical clinical and organizational differences between low- and high-volume hospitals may help implement changes to improve care. Therefore, in this rapidly evolving environment with introduction of new medical and surgical technologies, implementation of electronic medical records, adherence to regulatory measures such as the Joint Commission and the Hospital Quality Alliance public reporting, changing needs of the resident patient population, the building of new clinical programs capable of adapting to the changing environment may be the best solution.

Background: Duodenal gastrointestinal stromal tumors (GISTs) are uncommon, making up only 3–5% of all GISTs. [ 1 , 2 ] Historically, the treatment of choice for duodenal GIST tumors was pancreaticoduodenectomy. [3]Currently, newer surgical intervention methods including local resection via laparotomy, endoscopic resection, and robotic resection are feasible. When doing a local resection, the defect can be closed either primarily or via a Roux-en-Y duodenojejunostomy. [ 3 ] Case presentation: Our patient is a 64-year- old female who presented initially with shortness of breath and was found to have a pulmonary embolism. She then developed upper GI bleeding from anticoagulation and was found to have an ulcerated GIST tumor in the anti-mesenteric border of the third portion of the duodenum (D3). Initial surgery was postponed due to high pulmonary artery pressure from the pulmonary embolism. The patient underwent argon beam coagulation of the bleeding mass to control the bleeding, followed by localized radiotherapy plus Gleevec. Unfortunately, the tumor grew in size during follow-up. The patient was then taken to the OR for a robot-assisted partial duodenal resection (D3) with Roux-en-Y duodenojejunostomy to reconstruct the large defect. She did well post operatively and her final pathology showed a GIST tumor, c-kit and DOG1 positive, 3.5 cm in size, with negative margins. Conclusion: Robotic duodenal resection is a new technique currently being used to resect duodenal GIST tumors. Our video demonstrates the feasibility of D3 partial resection with Roux-en-Y duodenojejunostomy. Duodenal GIST tumor robotic resection offers both decreased morbidity and adequate oncologic outcomes.

Peritoneal carcinomatosis is a late manifestation of colon cancer. Patients with right sided colon cancer have increased incidence of peritoneal carcinomatosis compared to those with left sided colon cancers. Conventional intravenous chemotherapy has traditionally been less effective in management of colorectal cancer with peritoneal carcinomatosis. Mucinous histology of the primary colon cancer, more commonly seen with right sided colon cancers, is resistant to chemotherapy and showed more favorable response with aggressive cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC). With appropriate preoperative planning, patients that can be treated with complete tumor debulking with CRS have the most favorable outcomes. Development of CRS along with HIPEC in recent years yielded another potential therapy in addition to systemic chemotherapy for management of this disease. Potentially, metastatic peritoneal carcinomatosis can now be treated with CRS and HIPEC in order to achieve long-term survival in carefully selected individuals.

Background and Objectives Vaccination with cytokine gene-modified tumor cells augments the immune response against established tumors and protects against tumor challenges. In this study, we investigated the vaccine potential of GM-CSF–transduced MCA106 fibrosarcoma (MCA-GMCSF) cells in the C57BL/6 (B6) murine hepatic metastasis model. Methods Experimental mice received one to three weekly vaccines (subcutaneous/intramuscular, s.c./i.m.) of irradiated, parental, or GM-CSF–transduced MCA106 tumor cells. One week after the last immunization, hepatic metastases were established through the intrasplenic injection of live MCA106 parental (MCA106P) tumor cells. The animals were then sacrificed 3–4 weeks after surgery for evaluation of hepatic tumor burden. Results Based on in vivo experiments, both GM-CSF–modified and parental MCA106 tumor cell vaccines induced strong protection against hepatic tumor growth with grossly visible tumors rarely identified. This protection was evident even at a single vaccine dose of as low as 1 × 105 irradiated cells. Unimmunized control mice, on the other hand, consistently developed substantial hepatic tumors. Cytotoxicity assays on splenocytes (cultured in vitro for 4–5 days) showed that both groups of vaccinated mice developed strong tumor-specific cytotoxic T-lymphocyte (CTL) responses. Immunohistochemical analysis of injection sites showed infiltration of dendritic cells (DCs) and macrophages into subcutaneously injected MCA-GMCSF cells. Mostly macrophages, however, were seen at the injection site of MCA106P cells. Furthermore, the MCA106P cells expressed high levels of MHC class I antigens and the level of expression was not significantly altered by transduction with the GM-CSF gene. The high expression of MHC class I antigens probably contributed to the strong immunogenicity of the MCA106P cell vaccine. Conclusions This study demonstrates that MCA106 parental cells are as effective as the GM-CSF–transduced cells in suppressing the growth of hepatic metastases. The cellular immune responses induced by these two vaccines, however, are probably mediated by different subsets of host effector cells. These results have important implications for the use of GM-CSF–transduced cell vaccines in the immunotherapy of tumors that have the propensity to metastasize through the lymphatic channels and the circulatory system. J. Surg. Oncol. 1999;71:36–45. © 1999 Wiley-Liss, Inc.

Neuroendocrine tumors (NETs) of the gastrointestinal tract have a propensity for hepatic metastases. Surgical resection for hepatic metastases remains the gold standard for long-term survival, but many patients present with multifocal tumors, precluding surgery with increasing use of chemoembolization. However, there are few studies examining long-term survival factors. We reviewed our 15-year experience with chemoembolization in 123 patients with unresectable NET liver metastases, whose prognosis was evaluated upon baseline clinical factors. There were 64 males (53%) and 59 females (47%). Average age at presentation was 56 years (range: 14.3-85.5 years). Abdominal pain (44%) was the most common presenting symptom, followed by diarrhea (30%) and weight lost (22%). Patients underwent an average 7.3 cycles of chemoembolization (range 1-32 cycles). Responses: 62% of patients had PR; 24% had stable disease and 14% had tumor progression. Overall 3-, 5- and 10-year survivals were 59, 36 and 20% of patients with a mean follow-up of 3.2 years (range 2 weeks-18.3 years) and mean survival of 3.3 years. Univariate analysis showed that age greater than 60 years had worse outcome (P0.01), as did baseline serum albumin of ≤ 3.5 g/dL and prothrombin time13 s. Location of the primary tumor (P = 0.68), gender (P = 0.4) and serum NET peptide levels did not influence survival. However, multivariate analysis showed that a low baseline serum albumin level was an independent factor for prognosis (P = 0.003). Chemoembolization for unresectable NETs metastatic to liver is useful for tumor size reduction, symptom palliation and can be associated with prolonged survival.

Jejunal diverticula are quite rare. Furthermore, small bowel diverticular disease resulting in enteroliths can lead to complications necessitating surgical intervention. In this manuscript, we report two presentations of jejunal diverticulum with complications from enteroliths followed by a review of the literature. The first case was that of a 79-year-old male who presented with abdominal pain and was found, on computed tomography (CT) scan, to have evidence of intestinal perforation. A laparotomy showed that he had perforated jejunal diverticulitis. The second case was that of an 89-year-old female who presented with recurrent episodes of bowel obstruction. A laparotomy showed that she had an enterolith impacted in her jejunum in the presence of significant diverticular disease. Although a rare entity, familiarity with jejunal diverticular disease, its complications, and its management, should be part of every surgeon’s base of knowledge when considering abdominal pathology.