Salvador Rodriguez Franco

Purpose Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is a cornerstone treatment for resectable peritoneal carcinomatosis. Urologic reconstructive surgery is required in 7–20% of cytoreductive surgeries due to urinary tract involvement or injury, yet current literature on outcomes remains limited. This study presents one of the largest single-institution cohorts examining outcomes of urologic reconstruction in CRS/HIPEC cases, and is the first to investigate the impact of preoperative planning and intraoperative timing of urologic reconstruction on postoperative outcomes. Methods A retrospective analysis of 314 cases was performed from June 2010 to August 2023. Data from cases involving urologic reconstruction were analyzed, including demographics, surgical details, and outcomes. Statistical analyses evaluated associations between surgical variables and short and long-term urologic complications. Results Urologic reconstruction was performed in 35 cases (11.1%), with the majority occurring after HIPEC administration. Postoperative urologic complications occurred in 57% of cases. 40% of the urologic reconstruction cases resulted in low-grade, short-term urologic complications (AKI, UTI) while 20% were deemed high-grade (sepsis, urine leak). 29% developed long-term sequelae such as ureteral stricture or urinary retention. Longer operative times were significantly associated with long-term complications. No significant differences were found in long-term complication rates based on the timing of urologic repair (pre-HIPEC or post-HIPEC) or whether urologic intervention was planned prior to surgery. Interestingly, there was a significant association between fewer prior abdominal surgeries and higher complication rates. Conclusions Surgical complexity and prior surgical history are key determinants of postoperative outcomes following urologic reconstruction at the time of cytoreductive surgery. Timing of urologic intervention and specific preoperative variables, such as age and peritoneal cancer index score, did not significantly impact long-term outcomes. Higher complication rates were also seen among patients with fewer prior abdominal surgeries, which may in part be due to selection bias or other unaccounted variables present in the patients with fewer abdominal surgeries. These findings highlight the importance of individualized surgical planning and inform preoperative discussions about the risks and benefits of CRS with HIPEC.

Background/Objectives. Lymph Node Ratio (LNR) is increasingly recognized as an important prognostic factor in various cancer types, with the potential to enhance patient stratification for intrahepatic (ICC) and extrahepatic (ECC) cholangiocarcinoma. The study aimed to assess the impact of LNR on survival in surgically resected patients with ICC and ECC. Methods. This was a retrospective analysis of National Cancer Database (2004–2020) included ICC and ECC (excluding distal bile duct) patients who underwent primary site resection with adequate lymphadenectomy (≥4 LNs excised). Exclusions comprised age < 18 years, distant metastasis, or incomplete key data. LNR was calculated as the ratio of positive LNs to total examined LNs. Survival probabilities were estimated using Kaplan–Meier analysis and Cox regression. Results. The inclusion criteria were met by 954 patients with ICC and 1607 patients with ECC. In patients with ICC, the median OS time was 62.7 months in LNR0 group, 40.8 months in LNR < 30%, and 25.2 months in LNR ≥ 30% (p < 0.001). In ICC, 3-year OS was 69.3%, 54.6%, and 34% for LNR 0, LNR < 30%, and LNR ≥ 30%, respectively (p < 0.05). When adjusted for age, sex, Charlson–Deyo score, histology, surgical margins, chemo- and radiotherapy using Cox regression, LNR < 30% and LNR ≥ 30% were associated with worse OS in patients with ICC (HR 2.1 (95% CI 1.6–2.7) and HR 2.94 (95% CI 2.3–3.8)) and ECC (HR 2.1 (95% CI 1.8–2.5) and HR 3 (95% CI 2.4–3.7)). Conclusions. It is well-known that LN-negative patients have significantly better survival than LN-positive patients with ICC and ECC. This study strongly demonstrates that survival prognosis can be further stratified based on LNR for ICC and ECC patients and that it is not simply a binary factor.

This study aimed to evaluate the role of pathological features beyond tumor size in the risk of lymph node metastasis in appendiceal neuroendocrine tumors. Analyzing data from the national cancer database, we found that among 5353 cases, 18.8% had lymph node metastasis. Focusing on tumors smaller than 2 cm, a subject of considerable debate in treatment strategies, we identified lymphovascular invasion as one of the strongest predictors of lymph node disease. Interestingly, extension into the subserosa and beyond, a current factor in the staging system, was not a strong predictor. These findings suggest that careful interpretation of pathological features is needed when selecting therapeutic approaches using current staging systems.

Recent advances in available percutaneous device technology require accurate measurements and quantification of relationships between right ventricular outflow tract (RVOT) structures in children with and without congenital heart disease to determine device suitability. To date, no population study has described normal reference ranges of these measurements by computed tomography (CT). We aimed to establish normative values for four CT-derived measurements between RVOT structures from a heterogeneous population without heart disease and develop z scores useful for clinical practice. Patients without heart disease who underwent cardiac CT between April 2014 and February 2021 at Children’s Hospital Colorado were included. Distance between the right ventricular (RV) apex to pulmonary valve (PV), PV to pulmonary trunk bifurcation, and bifurcation to the right and left pulmonary artery was measured. Previously validated models were used to normalize the measurements and calculate Z scores. Each measurement was plotted against BSA and Z scores distributions were used as reference lines. Three-hundred and sixty-four healthy patients with a mean age of 8.8 years (range 1–21), 58% male, and BSA of 1 m² (range 0.4–2.1) were analyzed. The Haycock formula was used to present data as predicted values for a given BSA and within equations relating each measurement to BSA. Predicted values and Z-score boundaries for all measurements are presented.We report CT-derived normative data for four measurements between RVOT structures from a heterogeneous cohort of healthy children. Knowledge of this normative data will be useful in both determining device fit and customizing future devices to accommodate the diverse pediatric size range.

Background: In recent years, self‐expanding technology to treat pulmonary regurgitation in the native right ventricular outflow tract became Food and Drug Administration approved in the United States and is now routinely used. The current practice for selection of patients who are candidates for these devices includes screening for “anatomic fit,” performed by each of the manufacturing companies. Our study aims to validate the use of virtual reality (VR) as a tool for local physician‐led screening of patients. Methods and Results: This retrospective study from Children's Hospital Colorado included patients who underwent pulmonary valve replacement and had screening for a Harmony TPV or Alterra Prestent performed between September 2020 and January 2022. The data from the commercial companies’ dedicated analysis for self‐expanding transcatheter pulmonary valve frames evaluation with perimeter analysis were collected. VR simulation was performed blinded by 2 congenital interventional cardiologists using Elucis VR software and an Oculus Quest 2 headset. Among the 27 evaluated cases, the use of a self‐expandable valve was recommended by companies’ dedicated analysis in 23 cases (85.2%), by VR assessment in 26 cases (96.3), and finally implanted in 25 cases (92.6%). Regarding the level of agreement, both modalities (manufacturer and VR) were good at screening‐in patients who received a self‐expanding valve (100% versus 96.1%). When it came to screening‐out the patients, VR presented good capacity to accurately classify nonsuitable patients (50% versus 100%). Conclusions: Our institutional experience with VR transcatheter pulmonary valve implantation planning accurately predicted clinical outcomes. This paves the way for routine use of VR in patient selection for self‐expanding valve technologies.

Background: In recent years, self-expanding technology to treat pulmonary regurgitation in the native RVOT became FDA approved in the U.S. and is now routinely used. The current practice for selection of patients who are candidates for these devices includes screening for “anatomic fit”, performed by each of the manufacturing companies. Our study aims to validate the use of virtual reality as a tool for local physician-led screening of patients. Methods: This retrospective study from Children’s Hospital Colorado included patients who underwent pulmonary valve replacement and had screening for a Harmony TPV or Alterra Pre Stent performed between September 2020 and January 2022. The data from the commercial companies dedicated analysis for self-expanding TPVR evaluation with perimeter analysis was collected. Virtual Reality simulation was performed blinded by two congenital interventional cardiologists using Elucis virtual reality software and an Oculus Quest 2 headset. Results: Among the 27 evaluated cases, the use of a self-expandable valve was recommended by companies dedicated analysis in 23 cases (85.2%), by VR assessment in 26 cases (96.3) and finally implanted in 25 cases (92.6%). Regarding the level of agreement, both modalities (Manufacturer and VR) were good at screening in patients who received a self-expanding valve (100% vs. 96.1%). When it came to screening the patients out , VR presented good capacity to accurately classify non-suitable patients (50% vs. 100%). Conclusion: Our institutional experience with virtual reality TPVR planning, accurately predicted clinical outcomes. This paves the way for routine use of VR in patient selection for self-expanding valve technologies.

Background: Recent advances in available percutaneous device technology require accurate measurements and quantification of relationships between right ventricular outflow tract (RVOT) structures in children with and without congenital heart disease to determine device suitability. To date, no population study has described normal reference ranges of these measurements by computed tomography (CT). We aimed to establish normative values for four CT-derived measurements between RVOT structures from a heterogeneous population without heart disease and develop z-scores useful for clinical practice. Methods: Patients without heart disease who underwent cardiac CT between April 2014 and February 2021 at Children’s Hospital Colorado were included. Distance between the right ventricular (RV) apex to pulmonary valve (PV), PV to pulmonary trunk bifurcation, and bifurcation to the right and left pulmonary artery were measured. Previously validated models were used to normalize the measurements and calculate Z-scores. Each measurement was plotted against BSA and Z-scores distributions were used as reference lines. Results: Three-hundred sixty-four healthy patients with a mean age of 8.8 years (range 1–21), 58% male, and BSA of 1 m ² (range 0.4–2.1) were analyzed. The Haycock formula was used to present data as predicted values for a given BSA and within equations relating each measurement to BSA. Predicted values and Z-score boundaries for all measurements are presented. Conclusion: We report CT-derived normative data for four measurements between RVOT structures from a heterogenous cohort of healthy children. Knowledge of this normative data will be useful in both determining device fit and customising future devices to accommodate the diverse pediatric size range. Clinical Perspective: Recent advances in advanced percutaneous technology require accurate measurements and quantification of relationships between RVOT structures to determine patient selection and device suitability. The availability of a robust range of normal reference values can provide valuable information for current device selection and future development of customized devices for the RVOT tailored to accommodate the broad size, anatomic and physiologic heterogenicity seen in the pediatric population. We report CT-derived normative data for four measurements between cardio-pulmonary structures from a heterogenous cohort of healthy children and young adults. This data may be useful in planning surgical or catheter-guided interventions in the management of children with congenital heart disease.