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The purpose of this study was to describe a single institution's experience with adult intussusception and determine how this was influenced by evolving computed tomography (CT) technology. Adults treated between 1978 and 2013 for intussusception were reviewed. CT utilization and utilization of multislice technology over time were determined. Sensitivity of CT was calculated. A total of 318 patients were identified. CT utilization was 72% and it increased over time. The number of channels ranged from 1 to 128. CT sensitivity was greater than 85% for single and multislice scanners. A lead point was identified in 69% of patients and a malignancy in 40%. Surgical exploration was required in 60% of patients and 40% were managed nonoperatively. The diagnosis of intussusception in adults is increasing over time, particularly idiopathic intussusception. This is associated with increased utilization of highly sensitive CT technology, which facilitates the safe nonoperative management in many patients.

Background Peritoneal metastasis (PM) is the most common site of dissemination of gastric cancer (GC) and is associated with a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for GC with PM remains controversial due to modest survival and significant morbidity. Methods We conducted a retrospective analysis of patients with GC and PM treated with CRS and HIPEC with cisplatin and paclitaxel for 90 min from June 2019 to December 2022. Results Twenty-two patients were included and received a median of 7 (interquartile range [IQR] 4–8) cycles of neoadjuvant systemic therapy. Seventeen patients (77%) underwent a single neoadjuvant laparoscopic HIPEC, and six (27%) patients received chemoradiation. The median Peritoneal Carcinomatosis Index at the time of CRS was 1 (IQR 0–4), and 21 patients (95%) underwent complete cytoreduction (CC-0). An R0 resection was achieved in 20 (91%) patients, and the median length of stay was 5.5 (IQR 4–7.5) days. There were six (27%) 90-day major complications (Clavien–Dindo grade ≥ 3), one (4%) Common Terminology Classification for Adverse Events (CTCAE) grade 4 cytopenia, and one (4%) acute kidney injury. The rate of anastomotic leak (all grades) was 14%, the 30-day readmission rate was 18%, and the 90-day mortality rate was 0%. At a median follow-up of 24 months, the median progression-free survival (PFS) and overall survival (OS) were not reached. The 1-, 2-, and 3-year PFS rates were 65%, 56%, and 40%, respectively, and the 1-, 2-, and 3-year OS rates were 96%, 78%, and 55%, respectively. Conclusions CRS and HIPEC with paclitaxel and cisplatin is well tolerated and is associated with favorable oncologic and perioperative outcomes.

Pseudomyxoma peritonei (PMP) is a rare abdominal malignancy. We hypothesized that next-generation exomic sequencing would identify recurrent mutations that may have prognostic or therapeutic implications. Ten patients were selected on the basis of availability of tissue and adequate follow-up. They were treated at our institution between September 2002 and August 2004. Using next-generation exomic sequencing, we tested for mutations in 236 cancer-related genes in formalin-fixed paraffin-embedded slides. MCL1 amplification was additionally tested with immunohistochemical staining. Detectable mutations were found in 8 patients (80%). Seven patients harbored a KRAS mutation, most commonly involving codon 12. Four GNAS mutations (R201H/R201C substitutions) were also detected. MCL1 and JUN were concurrently amplified in three patients. One patient with MCL1 and JUN amplification had concurrent amplification of MYC and NFKBIA. ZNF703 was amplified in one patient. Patients with MCL1 amplification were also found to express MCL1 with immunohistochemistry, but MCL1 expression was also detected in some patients without amplification. To our knowledge, we are the first to report MCL1 and JUN coamplification in PMP. Expression of MCL1 may not be completely dependent on amplification. The prognostic and therapeutic implications of these recurrent mutational events are the subject of ongoing investigation.

Background While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown. Methods ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP – distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher’s exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types. Results Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p  < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p  < 0.001), return to OR (14.0% vs. 5.6%, p  < 0.001), organ-space infection (14.6 vs. 10.5, p  = 0.002), unplanned intubation (9.% vs. 4.1%, p  < 0.001), pneumonia (9.6% vs. 4.2%, p  < 0.001), length of stay (14 days vs. 8 days, p  < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p  < 0.001) and highest for emergent TP (20%). Conclusion Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.

Background: Proximal gastrectomy (PG) with double tract reconstruction (DTR) offers organ preservation for early gastric cancers, leading to reduced vitamin B12 deficiency, less weight loss, and improved quality of life. The JCOG1401 study confirmed excellent long-term outcomes for PG in stage I gastric cancer. However, in locally advanced proximal gastric cancer (LAPGC), preserving the gastric body and lymph node station 4d may compromise margin clearance and adequate lymphadenectomy. Methods: We propose a modified PG that removes the distal esophagus, gastroesophageal junction (GEJ), cardia, fundus, and gastric body, preserving only the antrum and performing DTR. Lymphadenectomy is also adapted, removing stations 1, 2, 3a, 4sa, 4sb, 4d, 7, 8, 9, 10 (spleen preserving), 11, and lower mediastinal nodes (stations 19, 20, and 110), while preserving stations 3b, 5, and 6. Indications for this procedure include GEJ (Siewert type II and III) and proximal gastric cancers with ≤2 cm distal esophageal involvement and ≤5 cm gastric involvement. Results: In our initial experience with 14 patients, we achieved R0 resection in all patients, adequate lymph node harvest (median 24 nodes, IQR 18–38), and no locoregional recurrences at a median follow-up of 18 months. We also found favorable postoperative weight loss, reflux, and anemia in the PG cohort. Conclusion: While larger studies and long-term data are still needed, our early results suggest that modified PG—despite sparing only the antrum—retains the key benefits of PG over total gastrectomy, including better weight maintenance and improved hemoglobin levels, while maintaining oncologic outcomes for LAPGC.

BackgroundNeoadjuvant chemotherapy (NAC) is an integral part of preoperative treatment for patients with borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). The identification of a chemotherapeutic regimen that is both effective and tolerable is critical for NAC to be of oncologic benefit. After initial first-line (FL) NAC, some patients have lack of response or therapeutic toxicities precluding further treatment with the same regimen; optimal decision making regarding this patient population is unclear. Chemotherapy switch (CS) may allow for a larger proportion of patients to undergo curative-intent resection after NAC.MethodsWe reviewed our surgical database for patients undergoing combinatorial NAC for BR/LA PDAC. Variant histologic exocrine carcinomas, intraductal papillary mucinous neoplasm-associated PDAC, and patients without research consent were excluded.ResultsOverall, 468 patients with BR/LA PDAC receiving FL chemotherapy were reviewed, of whom 70% (329/468) continued with FL chemotherapy followed by surgical resection. The remaining 30% (139/468) underwent CS, with 72% (100/139) of CS patients going on to curative-intent surgical resection. Recurrence-free survival (RFS) and overall survival (OS) were not significantly different between the resected FL and CS cohorts (30.0 vs. 19.1 months, p = 0.13, and 41.4 vs. 36.4 months, p = 0.94, respectively) and OS was significantly worse in those undergoing CS without subsequent resection (19 months, p < 0.0001). On multivariable analysis, carbohydrate antigen (CA) 19-9 and pathologic treatment responses were predictors of RFS and OS.ConclusionCS in patients undergoing NAC for BR/LA pancreatic cancer does not incur oncologic detriment. The incorporation of CS into NAC treatment sequencing may allow a greater proportion of patients to proceed to curative-intent surgery.

Introduction Although surgical resection is necessary, it is not sufficient for long‐term survival in pancreatic ductal adenocarcinoma (PDAC). We sought to evaluate survival after up‐front surgery (UFS) in anatomically resectable PDAC in the context of three critical factors: (A) margin status; (B) CA19‐9; and (C) receipt of adjuvant chemotherapy. Methods The National Cancer Data Base (2010–2015) was reviewed for clinically resectable (stage 0/I/II) PDAC patients. Surgical margins, pre‐operative CA19‐9, and receipt of adjuvant chemotherapy were evaluated. Patient overall survival was stratified based on these factors and their respective combinations. Outcomes after UFS were compared to equivalently staged patients after neoadjuvant chemotherapy on an intention‐to‐treat (ITT) basis. Results Twelve thousand and eighty‐nine patients were included (n = 9197 UFS, n = 2892 ITT neoadjuvant). In the UFS cohort, only 20.4% had all three factors (median OS = 31.2 months). Nearly 1/3rd (32.7%) of UFS patients had none or only one factor with concomitant worst survival (median OS = 14.7 months). Survival after UFS decreased with each failing factor (two factors: 23 months, one factor: 15.5 months, no factors: 7.9 months) and this persisted after adjustment. Overall survival was superior in the ITT‐neoadjuvant cohort (27.9 vs. 22 months) to UFS. Conclusion Despite the perceived benefit of UFS, only 1‐in‐5 UFS patients actually realize maximal survival when known factors highly associated with outcomes are assessed. Patients are proportionally more likely to do worst, rather than best after UFS treatment. Similarly staged patients undergoing ITT‐neoadjuvant therapy achieve survival superior to the majority of UFS patients. Patients and providers should be aware of the false perception of ‘optimal’ survival benefit with UFS in anatomically resectable PDAC. Survival of resectable pancreatic cancer patients treated with surgery and stratified by margin status, CA19‐9 levels, and chemotherapy receipt shows survival is highly predicted by these factors and is proportionally not ideal in the majority of undergoing an upfront resection strategy. Neoadjuvant chemotherapy offers significant benefit to upfront surgery in the context of acheiving optimal survival in the context of these factors.

Background The management of invasive intraductal papillary mucinous cystic neoplasm (I-IPMN) does not differ from de novo pancreatic ductal adenocarcinoma (PDAC); however, I-IPMNs are debated to have better prognosis. Despite being managed similarly to PDAC, no data are available on the response of I-IPMN to neoadjuvant chemotherapy. Methods All patients undergoing pancreatic resection for a pancreatic adenocarcinoma from 2011 to 2022 were included. The PDAC and I-IPMN cohorts were compared to evaluate response to neoadjuvant therapy (NAT) and overall survival (OS). Results This study included 1052 PDAC patients and 105 I-IPMN patients. NAT was performed in 25% of I-IPMN patients and 65% of PDAC patients. I-IPMN showed a similar pattern of pathological response to NAT compared with PDAC ( p  = 0.231). Furthermore, positron emission tomography (PET) response (71% vs. 61%; p  = 0.447), CA19.9 normalization (85% vs. 76%, p  = 0.290), and radiological response (32% vs. 37%, p  = 0.628) were comparable between I-IPMN and PDAC. A significantly higher OS and disease-free survival (DFS) of I-IPMN was denoted by Kaplan–Meier analysis, with a p -value of < 0.001 in both plots. In a multivariate analysis, I-IPMN histology was independently associated with lower risk of recurrence and death. Conclusions I-IPMN patients have a longer OS and DFS after surgical treatment when compared with PDAC patients. The more favorable oncologic outcome of I-IPMNs does not seem to be related to early detection, as I-IPMN histological subclass is independently associated with a lower risk of disease recurrence. Moreover, neoadjuvant effect on I-IPMN was non-inferior to PDAC in terms of pathological, CA19.9, PET, and radiological response and thus can be considered in selected patients.

Signet Ring Cell Adenocarcinoma (SRCA) of the appendix is a rare tumor with a poor prognosis and limited information to help guide treatment. We reviewed patients diagnosed with SRCA between 1998 and 2024 ​at all Mayo Clinic sites. Among 84 patients, the most common presentation was non-specific abdominal pain (31 ​%). The majority of tumors were high grade (81 ​%), and most patients had metastatic disease (69 ​%). The best overall survival at 5 years was 25 ​% with complete cytoreduction, which was not significantly improved with the addition of systemic therapy. The addition of HIPEC to cytoreduction surgery showed a clinically significant but not a statistically significant improvement in 5-year survival (20 ​% vs 5 ​%, p ​= ​0.059). Cytoreductive surgery with HIPEC showed the best survival outcomes for SRCA, with no demonstrated efficacy for systemic chemotherapy. Overall outcomes remain poor and new treatment modalities are needed. •Signet ring cell carcinoma of the appendix is associated with a poor prognosis and low 5-year survival.•The standard treatment approach of cytoreductive surgery with HIPEC (CRS/HIPEC) provided a survival advantage.•Systemic chemotherapy offered no survival benefits in patients with or without CRS/HIPEC.