Negative margins are the goal with pancreaticoduodenectomy for pancreatic adenocarcinoma. Thereby, margins are assessed intraoperatively with frozen section analysis and negative margins are pursued. This study was undertaken to determine the impact of margin status with pancreaticoduodenectomy for pancreatic adenocarcinoma and the value of extending resections to achieve negative margins. The intraoperative frozen section analysis and final margins for 448 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma were assessed and their impact on survival was determined. Median data are presented. Two hundred ninety-eight (67%) patients had negative margins (R0), an additional 110 (25%) patients had microscopically positive and macroscopically negative margins (R1), and an additional 40 (9%) patients had initially positive microscopic margins, which became negative with further resection (R1 å R0). R0 resections were more likely to have smaller tumors, earlier T grade, earlier N grade, lower American Joint Committee on Cancer stage, and less frequent extrapancreatic extension ( P ≤ 0.03 for each). Survival was better with R0 resections than R1 resections (20 vs 12 months, P < 0.001); extending resections to achieve negative margins (i.e., R1 ! R0) did not improve survival beyond R1 resections (14 vs 12 months, P = 0.19). Survival after pancreaticoduodenectomy is disappointing. Patients with initial negative margins do best. Positive microscopic margins reflect more aggressive tumor-specific factors and lead to abbreviated survival even with extended resections to achieve negative margins (i.e., R1 ! R0). With an initial positive margin, pursuing negative margins does not improve survival and, thereby, negative margins should not be “chased.”

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Little is known about the prognostic impact of body mass index (BMI) and obesity on patients with locally advanced kidney cancer. Previous studies suggest that clinical/pathological stage, the proximal extent of the tumour thrombus, direct vascular wall invasion, and preoperative performance status may all constitute important prognostic factors within this patient population. The present study shows that a patient's metastatic status, higher level of tumour thrombus, and lower BMI all constitute adverse predictors of overall survival in patients who have RCC with inferior vena cava tumour thrombus. OBJECTIVE To determine which clinical variables, including body mass index (BMI), predict overall survival (OS) after nephrectomy with inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC) with tumour thrombus. PATIENTS AND METHODS After institutional review board approval, a retrospective analysis of all patients (N= 100) undergoing nephrectomy and IVC thrombectomy for RCC from 1989 to 2010 were reviewed. One patient was excluded owing to missing clinical information leaving 99 patients in the study cohort. Patients were placed into one of two subgroups, based on their preoperative BMI (BMI ≤30 kg/m2 or BMI >30 kg/m2). Complications, blood loss, level of tumour thrombus, side of tumour and follow‐up data were tabulated. RESULTS Fifty‐six patients had a BMI ≤30 kg/m2 and 43 patients had a BMI >30 kg/m2. Intraoperative complications occurred in 14% of those with BMI >30 kg/m2 and 5.4% of those with a BMI ≤30 kg/m2 (P= 0.171). On multivariate analysis, a higher thrombus level (III/IV vs I/II) and the presence of metastatic disease at time of diagnosis was associated with a worse OS (P= 0.041 and P < 0.001, respectively). The subgroup with a higher preoperative BMI had a significantly better OS (hazard ratio 0.42; 95% confidence interval 0.22–0.80, P= 0.009). Similarly, our Kaplan–Meier survival analysis showed an improved OS in the patient cohort with a BMI >30 kg/m2 (P= 0.016). CONCLUSION Important predictors of outcome in patients undergoing nephrectomy with IVC thrombectomy for RCC with tumour thrombus include preoperative BMI, level of IVC tumour thrombus, and metastatic status at time of surgery.

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Initial outcomes suggest laparoendoscopic single-site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. One hundred patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom resolution, additional trocars, and complications were compared among patient quartiles. Median data are presented. Preoperative frequency/severity scores were: dysphagia = 10/8 and regurgitation = 8/7. Additional trocars were placed in 12 patients (10%), of whom all were in the first two quartiles. Esophagotomy/gastrotomy occurred in three patients. Postoperative complications occurred in 9 per cent. No conversions to “open” operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia = 2/0 and regurgitation = 0/0; scores were less than before myotomy ( P < 0.001). There were no apparent scars, except where additional trocars were placed. LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar. Placement of additional trocars only occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, because proficiency is quickly attained.