Introduction: Pancreaticoduodenectomy is a complex surgical procedure involving meticulous resection and reconstruction steps. Materials and Methods: We analyzed the first 15 laparoscopic pancreaticoduodenectomies performed for ampullary, periampullary, and cephalic pancreatic tumors at the Fundeni Clinical Institute, Bucharest, a high-volume center with extensive expertise in hepatopancreatobiliary surgery. Patient demographics, medical history, intraoperative parameters, early postoperative outcomes, and oncological results regarding radical resection were evaluated. Results: The mean patient age was 59.4 years, with 53.33% males. Cardiovascular comorbidities were present in 60% of patients, while 26.66% had controlled type 2 diabetes mellitus. Previous cholecystectomy was noted in 46.66% of cases, and 60% presented with jaundice at diagnosis. The mean operative time was 360 minutes. Pancreaticogastrostomy was performed in 66.66% of cases and pancreaticojejunostomy in 33.33%, with 26.66% of procedures being fully laparoscopic. Biochemical leakage occurred in 13.33% of cases, while grade B pancreatic fistula developed in 6.67% of cases and was managed conservatively. Moderate biliary fistula occurred in 13.3% of the patients, with remission under conservative treatment. All resections achieved negative margins (R0). The mean number of retrieved lymph nodes was 15.6, and the average hospital stay was 18.7 days. Discussions: Laparoscopic pancreaticoduodenectomy provides oncological outcomes comparable to the open approach and may improve postoperative recovery in experienced centers. Conclusions: Our results are encouraging, with potential for further improvement through careful patient selection and refinement of surgical technique.

Pancreaticoduodenectomy is one of the most technically demanding procedures in digestive surgery. Historically, laparoscopy in pancreatic surgery was limited to staging and palliative interventions. Since the first laparoscopic pancreaticoduodenectomy was completed in 1994, significant advances have improved perioperative safety, operative time, and lowered postoperative morbidity. Nevertheless, the complexity of pancreatic surgery paired with the technical challenges of pancreatic minimally invasive approach have restricted laparoscopic pancreatoduodenectomy to high-volume centers until recent times. The aim of this technical note presentation is to describe novel laparoscopic techniques of performing the three anastomoses - pancreaticojejunostomy and pancreaticogastrectomy, hepaticojejunostomy, and gastrojejunostomy- in an intracorporeal fashion, highlighting methods of facilitating the reconstructive process. This technical note s purpose is to also present new training models for surgeons, meant to reduce post-operative complications, such as pancreatic fistula or biliary leakage, to shorten operating times, and, ultimately, to increase the availability of laparoscopic pancreaticoduodenectomy as a safe and efficient treatment option.

Introduction: Gallbladder cancer is the most common biliary malignancy frequently diagnosed incidentally on cholecystectomy specimens for presumed benign disease. Once the diagnosis is confirmed on histopathologically, the treatment must be completed by resecting the gallbladder liver bed and regional lymph nodes. The laparoscopic approach seems to be efficient and oncologically safe. The aim of our study was to present the 9-year experience in treating gallbladder cancer in our surgery clinic by both open and laparoscopic approach completed by a literature review with the latest updates regarding the state of the laparoscopic approach in treating this type of cancer. Materials and Methods: Fifty-seven patients underwent radical surgery and 26 resections had a palliative purpose. Among radical resections, 52 were performed by using the open approach and 5 by using the laparoscopic approach. 14 cases out of 57 were completion procedures performed after a malignant histopathological finding was confirmed on a simple cholecystectomy specimen. In the majority of cases, the primary simple cholecystectomy was performed by laparoscopic approach. The laparoscopic approach was used in 3 cases of re-resection and 2 per-primam resections. Results: The median age of the patients was 64.21 years in the open group and 67.2 years in the laparoscopic group. Most patients were females. All patients had one or more comorbidities with an ASA score of 3 or 4 in 52 patients out of 57. ASA score had lower values in the laparoscopic group. The average surgery time for the laparoscopic group was 308 minutes, similar to the one for the open group that was 294 minutes. The complication rate was higher in the open group. The number of harvested lymph nodes was similar between the groups. The laparoscopic group benefited of lower postoperative pain, faster recovery and shorter hospital stay (6.2 days versus 13 days). Gallbladder cancer evolves asymptomatic in early stages and the diagnosis in advanced stages limits the therapeutic options. Still, in cases incidentally diagnosed on cholecystectomy specimens for presumed benign disease (stages T1-T3), the re-resection might be performed by laparoscopic approach. Also, in per-primam diagnosed selected cases, the laparoscopic resection might be performed by experimented teams. Conclusions: The laparoscopic approach is an ideal alternative to the open approach in treating early-stage gallbladder cancer. This surgical approach provides oncological safety, similar R0 resection rates and number of harvested lymph-nodes. The maximum benefit of this surgical approach is achieved in high-volume centers with experimented teams.

Background/Objectives: Pancreatic cancer remains one of the most aggressive and lethal malignancies, with limited effective treatment options for advanced stages. Microwave Ablation (MWA) has emerged as a minimally invasive therapeutic modality, offering potential benefits in tumor control. This review aims to critically assess the safety and efficacy of MWA in the treatment of pancreatic cancer, focusing on its application in various pancreatic lesions. Methods: We systematically reviewed studies published between 2010 and 2023 that evaluated the use of MWA in pancreatic tumors, including locally advanced pancreatic cancer (LAPC), pancreatic neuroendocrine tumors (PNETs), and pancreatic metastases from renal cell carcinoma (RCC). Due to limited data on survival rates and long-term outcomes, our analysis concentrated primarily on the technical aspects and immediate procedural outcomes of MWA. Results: MWA was technically feasible in all cases. The overall complication rate was approximately 16.7% (nine patients), with higher incidences in tumors located in the pancreatic head. Reported complications included pancreatitis and pseudocyst formation. Procedural parameters varied, with applied energy ranging from 20 to 80 watts and ablation times between 2 to 15 min, depending on the microwave generator type and approach (percutaneous, intraoperative or endoscopic). All cases demonstrated effective necrosis of the target tissue, and several studies reported notable tumor size reductions, averaging up to 70%. Conclusions: MWA shows promise as a therapeutic option for pancreatic cancer, achieving high technical success rates and significant tumor reductions. However, the procedure is associated with a moderate complication rate, particularly in tumors located in the pancreatic head.

Introduction/Background Ovarian cancer remains an aggressive malignancy with poor rates in terms of survival even in cases in which debulking surgery to no residual disease is achieved. Therefore, attention was focused on identifying other prognostic markers which might be associated with poorer outcomes in order to provide a better selection of cases submitted to per primam surgery Methodology Data of patients submitted to primary debulking surgery between 2014 -2020 in Ion Cantacuzino hospital were retrospectively reviewed. Finally a total number of 107 patients was identified. Preoperative data regarding laboratory tests, intraoperative data regarding the completeness of cytoreduction and postoperative data regarding the long term outcomes were reviewed. A serum value of 136 for natrium was considered as cut off, patients being further classified in cases with hyponatremia – 41 cases and cases with normal natrium levels – 66 cases. Results Patients diagnosed with preoperative hyponatremia proved to be diagnosed more often in advanced stages of the disease (IIIC,IV) when compared to those with normal natrium values (p=0,0012). Moreover, among patients diagnosed in advanced stages (FIGO IIIC and IV) hyponatremia was more often encountered in cases in which debulking surgery was not achieved (p=0,003). Meanwhile, hyponatremia was also found to be statistically significant associated with a higher volume of ascites (p=0,002), with lower levels of serum albumin (p=0,004) and with higher rates of postoperative complications (p=0,004). As for the long term outcomes, patients diagnosed with preoperative hyponatremia and advanced stages of the disease reported a significantly poorer overall survival when compared to those with normal sodium levels. However, this difference was not statistically significant when comparing the overall survivals between hyponatremic and normonatremic patients along all stages of the disease. Conclusion Preoperative hyponatremia might become an useful tool in order to identify caseswith poorer outcomes especially among advanced stages of the disease. Disclosures None.

Ovarian cancer remains one of the most lethal gynaecological malignancies affecting women worldwide; therefore, attention has been focused on identifying new prognostic factors which might help the clinician to select cases who could benefit most from surgery versus cases in which neoadjuvant systemic therapy followed by interval debulking surgery should be performed. The aim of the current paper is to identify whether preoperative inflammation could serve as a prognostic factor for advanced-stage ovarian cancer. Material and methods: The data of 57 patients who underwent to surgery for advanced-stage ovarian cancer between 2014 and 2020 at the Cantacuzino Clinical Hospital were retrospectively reviewed. The receiver operating characteristic curve was used to determine the optimal cut-off value of different inflammatory markers for the overall survival analysis. The analysed parameters were the preoperative level of CA125, monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and systemic inflammation index (SII). Results: Baseline CA125 > 780 µ/mL, NLR ≥ 2.7, MLR > 0.25, PLR > 200 and a systemic immune inflammation index (SII, defined as platelet × neutrophil–lymphocyte ratio) ≥ 84,1000 were associated with significantly worse disease-free and overall survival in a univariate analysis. In a multivariate analysis, MLR and SII were significantly associated with higher values of overall survival (p < 0.0001 and p = 0.0124); meanwhile, preoperative values of CA125, PLR and MLR were not associated with the overall survival values (p = 0.5612, p = 0.6137 and p = 0.1982, respectively). In conclusion, patients presenting higher levels of MLR and SII preoperatively are expected to have a poorer outcome even if complete debulking surgery is performed and should be instead considered candidates for neoadjuvant systemic therapy followed by interval surgery.

Introduction/Background Both nutritional and inflammatory status seem to play a central role in the evolution of ovarian cancer patients. The aim of the current paper is to investigate the association between C reactive protein to albumin ratio and the postoperative outcomes of ovarian cancer patients. Methodology In the current paper we introduced 107 patients diagnosed with epithelial ovarian cancer submitted to per primam debulking surgery. An optimal cutoff value of 0,75 was obtained using the receiver operation curve Results Higher levels of this parameter were significantly associated with higher values of CA125 (p=0,02), higher stages (p=0,04), incomplete debulking (p=0,02) and with more frequent postoperative complications (p=0,004). When it comes to the long term outcomes, higher values of CRP/albumin ratio were associated with significantly poorer disease free and overall survival (12,3 and 18 months respectively) when compared to cases with lower values of this parameter (15,1 months and 26 months respectively) (p=0,001 and p=0,0004 respectively). Conclusion CRP/albumin ratio represents a significant prognostic marker which seems to identify cases at risk to have a poorer evolution after per primamdebulking surgery. Therefore such cases might benefit more if neoadjuvant chemotherapy is administrated. Disclosures None.

Introduction/Background Anemia represents a common finding among neoplastic patients and is caused by multiple mechanisms including due to the inflammatory status induced by the presence of malignant cells. The aim of the current paper is to investigate the correlation between these two entities among cases diagnosed with advanced stage ovarian ca Methodology Preoperative data of patients submitted to debulking surgery between 2014–2020 in Ion Cantacuzino hospital were retrospectively reviewed. Results A total number of 57 patients were considered as eligible for this study: By using the receiver operation curve (ROC) a cut off value of 841000 was obtained with an area under the ROC curve (AUC) of 0,787 (sensibility=0,83, 1- specificity=0,29). According to this value the study group was divided in two subgroups: the first one included patients with SII < 841.000 – 20 cases while the second one included patients with SII >841.000 - 37 cases. When it comes to the preoperative level of hemoglobin, a mean value of 12,2 g/dl was obtained, this value being significantly lower among patients with higher levels of SII (11,4g/dl) versus those with lower SII levels (and in which the mean preoperative value of hemoglobin was of 13,1 g/dl) (p=0,005). Moreover, when analyzing the preoperative data, there were 41 cases in FIGO stage IIIC and respectively 16 cases diagnosed in FIGO stage IV. Patients diagnosed with FIGO stage IIIC of disease had a mean value of SII of 789001 while cases diagnosed in FIGO stage IV of disease had a mean SII value of 1890256 (p=0,003) and respectively a mean value of hemoglobin of 12,8 g/dl versus 10,8 g/dl (p=0,002). Conclusion Preoperative levels of hemoglobin seem to be significantly correlated with preoperative SII values; meanwhile both values seem to be significantly corelated with FIGO stage in advanced stage ovarian cancer. Disclosures None.

Introduction/Background The extent of peritoneal carcinomatosis represents the most frequently encountered reason for incomplete debulking in advanced stage ovarian cancer. Therefore, attention was focused on identifying a prognostic marker which might provide a better identification of these cases preoperatively. Systemic inflammatory index, defined as the platelets*neutrophils/lymphocytes seems to provide significant information regarding the extent of the disease. Methodology Between 2014–2020 57 patients diagnosed with peritoneal carcinomatosis from ovarian cancer were submitted to surgery in Ion Cantacuzino hospital. Patients were further classified in three groups according to the extent of peritoneal carcinomatosis (defined by the peritoneal carcinomatosis index – PCI): PCI<10 – 14 cases, PCI between 10–15 – 21 cases and PCI>15 - 12 cases. Results Preoperative values of SII ranged between 871674 and 7458168, with a mean value of 2424479. Meanwhile, we determined the intraoperative volume of ascites, a mean value of 2350 ml being obtained (range 300–8000ml). Cases in the first group reported a mean SII level of 761786, those in the second group reported a mean SII level of 1276485 while those in the third group reported a mean SII level of 68760393 (p<0,0001). Meanwhile a positive correlation was established between the ascites volume and the preoperative level of SII (p=0,001). When analyzing the completeness of cytoreduction, maximal debulking was achieved in 46 out of the 57 cases; cases in which maximal debulking was feasible had a mean value of SII of 1175802 while cases in which debulking was incomplete had a preoperative value of SII of 4190031 (p<0,0001). Conclusion Preoperative SII seems to have a prognostic value in order to identify cases in which maximal debulking surgery is not feasible; therefore, such cases should be rather submitted to neoadjuvant chemotherapy followed by interval debulking surgery than to per primam attempt of debulking. Disclosures None.

Background: Gallbladder cancer (GBC) is a rare entity with a poor prognosis, usually discovered late due to nonspecific symptoms; therefore, over the last years, attention has been focused on identifying the risk factors for developing this malignancy in order to provide an early diagnosis, as well as new prognostic factors in order to modulate the long-term evolution of such cases. The aim of this review is to discuss both major risk factors and prognostic factors in GBC for a better understanding and integration of relevant and currently available information. Methods: A literature search was performed using Cochrane Library, PubMed, Google Scholar, Elsevier, and Web of Science; studies published after the year of 2000, in English, were reviewed. Results: Over time, risk factors associated with the development of GBC have been identified, which outline the profile of patients with this disease. The most important prognostic factors in GBC remain TNM staging, safety margin, and R0 status, along with perineural invasion and lymphovascular invasion. Both the technique and experience of the surgeons and a pathological examination that ensures final staging are particularly important and increase the chances of survival of the patients. Conclusions: improvements in surgical techniques and pathological analyses might provide better and more consistent guidance for medical staff in the management of patients with GBC.

Aim to determin the recurrence rate of benign recto -colonic polyps in a 5 -year interval, and compare the development rate of intrapolypoid carcinomatous lesions in polypectomized versus nonpolypectomized subjects. Materials and method a group of 77 patients diagnosed with recto -colonic polypoid lesions during the period 2014-2019 underwent colonoscopy at the time of study initiation and then annually during a five-year interval. Result The recurrence rate of polyps increased annually from 5 to 12.5%; the highest rate was noted in the last two years. The five-year cumulative risk of neoplastic lesions was 73% in patients without polypectomy and 20% among those with endoscopic resection (p< 0.05). Comparing the recurrence rate of benign lesions (60%) in patients without neoplastic findings with the recurrence rate of adenomas in patients with benign lesions (40%), a higher risk of recurrence was found in the first category, and seemed to be influenced by the personal history of pre-existing adenomatous lesions. Conclusion an increased risk of colorectal polyps recurrence was reported during five year follow up; moreover, during the first three years an increased risk of malignant transformation was observed among cases in which endoscopic resection was not feasible when compared to those in which complete excision was feasible.

We present the case of a patient with rheumatoid polyarthritis treated in our department, with a long history of chronic calcifying pancreatitis which was incidentaly diagnosed during a renal colic with a pancreatic tumor. Pancreatoduodenectomy with lateral superior mesenteric vein resection was performed, the final pathological examination revealed a malignant solid pseudopapillary neoplasm with a positive lymph node. Clinical, surgical, pathological and a review of the literature are presented.

The liver represents a frequent site for multiple secondary tumors including colorectal cancers, skin and eye cancers such as uveal melanoma. Uveal melanoma is a relatively rare cancer, with a satisfactory local disease control achieved in the last decades, but associating a guarded prognosis because of the risk for liver metastasis. The purpose of our study is to underline the therapeutic approach of liver metastasis determined by the uveal melanoma. We present the case of a 68 years old female patient with history of uveal melanoma (10 years ago), recently being investigated for loss of appetite and epigastric pain. The computed tomography scan detected an abnormal mass in the left hepatic lobe (204/ 151 mm) compressing the hepatic vessels, associating invasion in the left suprahepatic vein, suggestive for a secondary tumor of the uveal melanoma. Ultrasound-guided liver biopsy and histopathological result also supported the suspicion for a metastatic tumor. Endoscopy and colonoscopy procedures did not find any proof of a primary or secondary digestive tumor. The surgical procedure performed was left hepatectomy and there were vascular anatomical variations. The patient had a favourable evolution being discharged after 7 days of hospitalization with recommendations for oncological follow-up. Although uveal melanoma is considered a rare malignancy with possibilites of targeted theraphy in the early stages, when it is associated with metastatic disease the prognosis becomes poor. Even though, the liver metastases are often safely resected in patients with proper hepatic function, improving the prognosis.

Intrahepatic cholangiocarcinomas represent rare and aggressive malignancies developing from the second order bile ducts to the smaller biliary branches. The aim of this narrative review is to discuss about the main diagnostic and therapeutic challenges in order to help medical and surgical oncologists to gain familiarity in regard to this subject. Articles discussing about epidemiology, histology, diagnostic, perioperative management and surgery which were published from January 2000 to September 2023 included in Cochrane Library, PubMed, Embase, MedLine, Web of Science, Elsevier, Google Scholar databases were reviewed. Articles reviewed in the current paper came to demonstrate that the main problem in such cases is related to the fact that most cases remain asymptomatic for a long period of time and therefore are diagnosed in advanced stages of the disease when curative procedures are feasible after performing extended visceral sacrifice or even worse, are no longer possible; however, the most efficient therapeutic strategy in order to improve the long term outcomes remains radical surgery. In this respect, attention was focused on improving the accuracy of the diagnostic tools and on identifying non-surgical therapeutic options which might increase the chances of achieving complete resection. Intrahepatic cholangiocarcinoma represent rare aggressive tumors with poor outcomes especially if radical surgery is not feasible.

Purpose: A grade C postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) usually requires early re-laparotomy, and completion of pancreatectomy (CP) is necessary for a few patients. The study aims to assess the frequency, indications, and outcomes of CP in a single-center experience during the last 5 years.

Deficient DNA mismatch repair status (dMMR)/high microsatellite instability have been shown to be predictive biomarkers for immune checkpoint inhibitor drugs which block the programmed death protein-1/programmed death ligand-1 (PD-1/PD-L1) interaction between tumor cells and activated T cells. The aim of this study was to determine the prevalence of MMR status and quantification of PD-L1 expression in pancreatic endoscopic ultrasound-guided fine-needle biopsy (EUS FNB) specimens. Immunochemistry (IHC) was performed on consecutive archived treatment-naïve formalin-fixed paraffin-embedded EUS-FNB samples. The specimens were considered to have PD-L1 expression if PD-L1 was expressed in ≥1% of tumor cells and a high level of expression if ≥50%. Tumors with absent nuclear staining of DNA mismatch repair proteins (MLH1, MSH2, MSH6, or PMS2) were classified as dMMR. A total of 28 treatment-naïve patients who underwent EUS-FNB and had a final diagnosis of pancreatic ductal adenocarcinoma (PDAC) were included in the study. All the EUS-FNB samples were adequate for the evaluation of MMR and PD-L1 expression. None of the patients with PDAC included in the study had a dMMR tumor. PD-L1 expression was identified in 39% of the cohort (n = 11). Expression thresholds of ≥1%, ≥10%, and ≥50% in tumor cells were identified in 11 (39%), 4 (14%), and 1 (4%) patients, respectively. The evaluation of MMR status and PD-L1 can be successfully performed on EUS-FNB pancreatic specimens. Furthermore, MMR expression failed to show utility in recognizing immunotherapy vulnerability in pancreatic cancer; the only recommendation for testing remains for patients with heritable cancers. Meanwhile high PD-L1 expression was correlated with poor prognosis. This association may identify a subgroup of patients where immune checkpoints inhibitors could provide therapeutic benefits, spotlighting the role of EUS-FNB in the field of immune-oncology.

Hepatocellular carcinoma (HCC) is the fifth most common cancer, with an increasing incidence in recent years. The prognosis is unfavorable, representing the third most frequent cause of cancer-related death worldwide. This is because it generally develops in patients with pre-existing liver pathology, thus limiting therapeutic options. The role of ablative therapies is well-established in nodules smaller than 3 cm, but for nodules from 3 to 5 cm, the best therapeutic management is not well defined. Recent studies reported that combining minimally invasive procedures like transarterial chemoembolization (TACE) with microwave ablation (MWA) or radiofrequency ablation is superior to each alone. However, there is no consensus regarding the timing and the order in which each procedure should be performed. We report a case of an 86 years old male with HCV-related compensated hepatic cirrhosis and multiple cardiac comorbidities diagnosed with a 47/50 mm HCC. Pre-surgical evaluation of the associated pathologies determined that the risk for the surgical approach outweighs the benefits, so the committee decided to treat it in a less invasive manner. We performed MWA and TACE in a single session with technical success according to the modified Response Evaluation Criteria in Solid Tumors (m-RECIST). This case illustrates the first case of simultaneous MWA and TACE performed in our center. This new approach of hepatocellular carcinoma appears to be a good alternative to more invasive methods, with good results even in older people that are unfit for surgery.