Retroperitoneal location of bronchogenic cysts is extremely rare. Most commonly they are encountered in the posterior mediastinum. Bronchogenic cysts arise from developmental aberrations of the tracheobronchial tree in the early embryologic period. We report a 42-year-old female patient with a retroperitoneal bronchogenic cyst in the left adrenal region. She was admitted to our hospital with epigastric pain and subsequently underwent CT of the abdomen. The examination revealed a mass related to the left adrenal gland. Endocrine tests for adrenal hypersecretion were negative. Because of the uncertain entity, laparoscopic adrenalectomy was performed. Pathological examination revealed a bronchogenic cyst in proximity to an inconspicuous left adrenal gland. Although very rare, bronchogenic cysts should be considered in the differential diagnosis of retroperitoneal cystic lesions and surgical resection pursued for symptom resolution and to establish a definitive histology.

Purpose: Pancreatic ductal adenocarcinoma (PDAC) is considered a low-immunogenic (LI) tumor with a “cold” tumor microenvironment and is mostly unresponsive to immune checkpoint blockade therapies. In this study, we decipher the impact of intratumoral heterogeneity of immune determinants on antitumor responses. Experimental Design: We performed spatial proteomic and transcriptomic analyses and multiplex immunofluorescence on multiple tumor regions, including tumor center (TC) and invasive front (IF), from 220 patients with PDAC, classified according to their transcriptomic immune signaling into high-immunogenic PDAC (HI-PDAC, n = 54) and LI PDAC (LI-PDAC, n = 166). Spatial compartments (tumor: pancytokeratin+/CD45− and leukocytes: pancytokeratin−/CD45+) were defined by fluorescence imaging. Results: HI-PDAC exhibited higher densities of cytotoxic T lymphocytes with upregulation of T-cell priming–associated immune determinants, including CD40, ITGAM, glucocorticoid-induced TNF–related receptor, CXCL10, granzyme B, IFNG, and HLA-DR, which were significantly more prominent at the IF than at the TC. In contrast, LI-PDAC exhibited immune-evasive tumor microenvironments with downregulation of immune determinants and a negative gradient from TC to IF. Patients with HI-PDAC had significantly better outcomes but showed more frequently exhausted immune phenotypes. Conclusions: Our results indicate strategic differences in the regulation of immune determinants, leading to different levels of effectiveness of antitumor responses between HI and LI tumors and dynamic spatial changes, which affect the evolution of immune evasion and patient outcomes. This finding supports the coevolution of tumor and immune cells and may help define therapeutic vulnerabilities to improve antitumor immunity and harness the responsiveness to immune checkpoint inhibitors in patients with PDAC.

BACKGROUND: Curative management of deep infiltrating endometriosis requires complete removal of all endometriotic implants. Surgical approach to rectal involvement has become a topic of debate given potential postoperative bowel dysfunction and complications. OBJECTIVE: This study aims to assess long-term postoperative evacuation and incontinence outcomes after laparoscopic segmental rectal resection for deep infiltrating endometriosis involving the rectal wall. DESIGN: This is a retrospective study of prospectively collected data. SETTINGS: This single-center study was conducted at the University Hospital of Bern, Switzerland. PATIENTS: Patients with deep infiltrating endometriosis involving the rectum undergoing rectal resection from June 2002 to May 2011 with at least 24 months follow-up were included. MAIN OUTCOME MEASURES: Aside from endometriosis-related symptoms, detailed symptoms on evacuation (points: 0 (best) to 21 (worst)) and incontinence (0–24) were evaluated by using a standardized questionnaire before and at least 24 months after surgery. RESULTS: Of 66 women who underwent rectal resection, 51 were available for analyses with a median follow-up period of 86 months (range: 26–168). Forty-eight patients (94%) underwent laparoscopic resection (4% converted, 2% primary open), with end-to-end anastomosis in 41 patients (82%). Two patients (4%) had an anastomotic insufficiency; 1 case was complicated by rectovaginal fistula. Dysmenorrhea, nonmenstrual pain, and dyspareunia substantially improved (p < 0.001 for all comparisons). Overall evacuation score increased from a median of 0 (range: 0–11) to 2 points (0–15), p = 0.002. Overall incontinence also increased from 0 (range: 0–9) to 2 points (0–9), p = 0.003. LIMITATIONS: This study was limited by its retrospective nature and moderate number of patients. CONCLUSIONS: Laparoscopic segmental rectal resection for the treatment of deep infiltrating endometriosis including the rectal wall is associated with good results in endometriotic-related symptoms, although patients should be informed about possible postoperative impairments in evacuation and incontinence. However, its clinical impact does not outweigh the benefit that can be achieved through this approach. See Video Abstract at http://links.lww.com/DCR/A547 .

Objective: To assess the efficacy and safety of fully closed-loop (FCL) compared with usual care (UC) glucose control in patients experiencing major abdominal surgery-related stress hyperglycemia. Background: Major abdominal surgery-related stress and periprocedural interventions predispose to perioperative hyperglycemia, both in diabetes and non-diabetes patients. Insulin corrects hyperglycemia effectively, but its safe use remains challenging. Methods: In this two-centre randomized controlled trial, we contrasted subcutaneous FCL with UC glucose management in patients undergoing major abdominal surgery anticipated to experience prolonged hyperglycemia. FCL (CamAPS HX, Dexcom G6, mylife YpsoPump 1.5x) or UC treatment was used from hospital admission to discharge (max 20 d). Glucose control was assessed using continuous glucose monitoring (masked in the UC group). The primary outcome was the proportion of time with sensor glucose values in a target range of 5.6 to 10.0 mmol/L. Results: Thirty-seven surgical patients (54% pancreas, 22% liver, 19% upper gastrointestinal, 5% lower gastrointestinal), of whom 18 received FCL and 19 UC glucose management, were included in the analysis. The mean ± SD percentage time with sensor glucose in the target range was 80.1% ± 10.0% in the FCL and 53.7% ± 19.7% in the UC group (P < 0.001). Mean glucose was 7.5 ± 0.5 mmol/L in the FCL and 9.1 ± 2.4 mmol/L in the UC group (P = 0.015). Time in hypoglycemia (<3.0 mmol/L) was low in either group. No study-related serious adverse events occurred. Conclusions: The FCL approach resulted in significantly better glycemic control compared with UC management, without increasing the risk of hypoglycemia. Automated glucose-responsive insulin delivery is a safe and effective strategy to minimize hyperglycemia in complex surgical populations.