Pelvic exenteration surgery for locally advanced rectal cancers is a complex and extensive multivisceral operation, which is associated with high perioperative morbidity and mortality rates. Significant technical challenges may arise due to inadequate access, visualisation, and characterisation of tissue planes and critical structures in the spatially constrained pelvis. Over the last two decades, robotic-assisted technologies have facilitated substantial advancements in the minimally invasive approach to total mesorectal excision (TME) for rectal cancers. Here, we review the emerging experience and evidence of robotic assistance in beyond TME multivisceral pelvic exenteration for locally advanced rectal cancers where heightened operative challenges and cumbersome ergonomics are likely to be encountered.

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Background ObjectivesThe impact of tumor necrosis as a prognostic factor in gastrointestinal stromal tumor (GISTs) is still debated. The objective was to determine whether tumor necrosis is an independent risk factor for survival in patients with GISTs.MethodsPatients undergoing surgery for primary GIST from March 2003 to October 2018 at two sarcoma referral centers were retrospectively identified. Patients who received neoadjuvant imatinib were excluded. Multivariable Cox regression models were produced, to assess whether tumor necrosis was an independent predictor of either overall or recurrence‐free survival.ResultsForty‐one out of 195 (21.0%) patients had tumor necrosis. Tumor necrosis was associated with a significantly higher modified National Institute of Health risk score, with 29 out of 41 (70.7%) patients with necrosis classified as high risk, compared to 52 out of 153 (34.0%) without (p < .001). Tumor necrosis was found to be independently predictive of recurrence‐free survival (hazard ratio: 5.26, 95% CI: 2.62–10.56, p < .001) on multivariable analysis. At 5 years, 44.3% of patients with necrosis had either died or developed recurrence, compared to 9.9% of those without.ConclusionTumor necrosis is an independent predictor of recurrence‐free survival in patients with operable GISTs. It should be routinely reported by pathologists, and used by clinicians when counseling patients and deciding on adjuvant therapy.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Ethical approval Our institution does not require ethical approval for reporting individual cases or case series. Informed consent Written informed consent was obtained from the patient for his anonymised information to be published in this article. Guarantor YCP Contributorship DTMT and YCP researched the literature and wrote the article. MH provided histology photographs. MA oversaw the project. All authors reviewed and approved the final version of the manuscript.

Background: Pancreaticoduodenectomy is increasingly being offered as treatment for periampullary tumours in patients 80 years and older. Our aim was to evaluate clinical outcomes of pancreaticoduodenectomy in octogenarians from two high-volume tertiary HPB centres. Materials and Methods: A retrospective case-control analysis of a prospectively-maintained database, between January 2008 and December 2017, was performed. Octogenarians who underwent pancreaticoduodenectomy were matched with consecutively-operated younger patients with 1:1 ratio, based on extent of surgery (venous, arterial or additional resection). Pre-operative comorbidities, intraoperative variables, post-operative complications and mortality were compared, with statistical significance at p<0.05. Results: 88 octogenarians (median age 81 years,range:80-90) who underwent pancreaticoduodenectomy (either classical or pylorus-preserving) were compared to similar number of controls (median age 66 years,range:16-79). Gender, ASA (octogenarians median grade 2 [range:1-4] versus median grade 2 [range:1-3] for controls) and performance status (median score 0 [range:0-2] for both groups) were comparable (p=1.00,p=0.18 and p=0.11 respectively). Charlson Comorbidity Index scores were higher overall for octogenarians (median 7 [range:6-10] versus 5 [range2-9],p=0.001). Median LOS was comparable, 15 days (range:5-69) for octogenarians and 12 days (range:5-78) for controls (p=0.12), as was median ICU stay, 2 days (range:0-58) for octogenarians versus 2 days (range:0-25) (p=0.40). Negative resection margin (R0) rates were 64% for octogenarians and 59% for controls (p=0.53), with no significant difference in lymph node status (p=0.53). Overall post-operative complication rate was higher in octogenarians (60% versus 49%); however this was not statistically significant (p=0.17). Similarly, complication rates across the Clavien-Dindo classification categories were not statistically significant. 30-day and 90-day mortality were 2.3% and 8% for octogenarians versus 1.1% and 3.4% for controls (p=1.0 and p=0.33 respectively). Conclusion: Despite higher 90-day mortality, pancreaticoduodenectomy outcomes in octogenarians are comparable to their younger counterparts. Pancreaticoduodenectomy should therefore be offered as a curative surgical option in this cohort, in specialised centres after meticulous pre-operative assessment.