Objective: The aim of this study was to determine outcomes of primary tumor resection in metastatic neuroendocrine tumors across all primary tumor sites. Background: Primary tumor resection (PTR) may offer a survival benefit in metastatic gastrointestinal neuroendocrine tumors (GI-NETs); however, few studies have examined the effect of primary site and grade on resection and survival. Methods: This is a retrospective study of patients with metastatic GI-NETs at presentation between 2005 and 2011 using the California Cancer Registry (CCR) dataset merged with California Office of Statewide Health Planning and Development (OSHPD) inpatient longitudinal database. Primary outcome was overall survival (OS). Univariate and multivariate (MV) analyses were performed using the Pearson Chi-squared tests and Cox proportional hazard, respectively. OS was estimated using the Kaplan-Meier method and log-rank test. Results: A total of 854 patients with GI-NET metastases on presentation underwent 392 PTRs. Liver metastases occurred in 430 patients; 240 received liver treatment(s). PTR improved OS in patients with untreated metastases (median survival 10 vs 38 months, P < 0.001). On MV analysis adjusted for demographics, tumor stage, grade, chemotherapy use, Charlson comorbidity index, primary tumor location, or treatment of liver metastases, PTR with/without liver treatment improved OS in comparison to no treatment [hazard ratio (HR) 0.50, P < 0.001 and 0.39, P < 0.001, respectively]. PTR offered a survival benefit across all grades (low-grade, HR 0.38, P = 0.002 and high-grade, HR 0.62, P = 0.025) Conclusion: PTR in GI-NET is associated with a better survival, with or without liver treatment, irrespective of grade. This study supports the resection of the primary tumor in patients with metastatic GI-NETs, independent of liver treatment.

Intrahepatic cholangiocarcinomas (ICCs) are the second most common type of primary liver cancer.¹ Approximately 10% of all cholangiocarcinomas are intrahepatic, amounting to 2000 to 3000 cases each year in the United States with an increasing incidence worldwide.^2,3 Intrahepatic cholangiocarcinomas are resistant to chemotherapy and radiotherapy, and surgical resection is considered to be the mainstay of therapy, providing the only chance of cure. However, most patients have advanced disease at diagnosis and are not candidates for surgery. Resectability is defined by the ability to completely resect ICC while leaving an adequate liver remnant. Current consensus considers noncontiguous extrahepatic disease, multiple bilobar or multicentric tumors, or lymph node metastases beyond the primary echelon as contraindications to resection.⁴ The role of surgical resection for large or multifocal ICCs or those invading adjacent organs by direct extension remains unclear. The decision to pursue resection is complex because of unclear oncologic benefit and substantial rates of operative morbidity and mortality.

Pancreatic resections are some of the most technically challenging operations performed by surgeons, and post-operative pancreatic fistula (POPF) are not uncommon, developing in approximately 13% of pancreaticoduodenectomies and 30% of distal pancreatectomies. Multiple trials of various operative techniques in the creation of the pancreatic ductal anastomosis have been conducted throughout the years, and herein we review the literature and outcomes data regarding these techniques, although no one technique of pancreatic ductal anastomosis has been shown to be superior in decreasing rate of POPF. Similarly, we review the literature regarding techniques of pancreatic closure after distal pancreatectomy. Again, no one technique has been shown to be superior in preventing POPF; however the use of buttressing material on the pancreatic staple line in the future may be a successful means of decreasing POPF. We review adjunctive techniques to decrease POPF such as pancreatic ductal stenting, the use of various topical biologic glues, and the use of somatostatin analogue medications. We conclude that future trials will need to be conducted to find optimal techniques to decrease POPF, and meticulous attention to intra-operative details and post-operative care by surgeons is necessary to prevent POPF and optimally care for patients undergoing pancreatic resection.

Rising trends in intrahepatic cholangiocarcinoma incidence and mortality: getting at the root cause

Black patients in the US experience lower rates of survival after surgery for colorectal cancer (CRC).¹ Disparity in outcomes after cancer surgery is associated with a complex interaction of patient, socioeconomic, and health-system factors, including lower rates of referral to cancer specialists,² higher risk factors for CRC, and patient reported barriers, including fear of cancer and its treatment, costs, and the burdens of transportation and childcare during therapy.³