One specific device for the IRE procedure is the  NanoKnife  system manufactured by AngioDynamics, which received FDA 510k clearance on October 24, 2011. [ 40 ]  The NanoKnife system has also received an Investigational Device Exemption (IDE) from the FDA that allows AngioDynamics to conduct clinical trials using this device. [ 40 ]  The Nanoknife system transmits a low-energy direct current from a generator to electrode probes placed in the target tissues for the surgical ablation of soft tissue. In 2011, AngioDynamics received an FDA warning letter for promoting the device for indications for which it had not received approval. [ 41 ]


In 2013, the UK National Institute for Health and Clinical Excellence issued a guidance that the safety and efficacy of the use of irreversible electroporation of the treatment of various types of cancer has not yet been established. [ 42 ]


Newer generations of Electroporation-based ablation systems are being developed specifically to address the shortcomings of the first generation of IRE but, as of June 2020, none of the technologies are available as a medical device. [ 27 ] [ 43 ] [ 44 ]


Potential organ systems, where IRE might have a significant impact due to its properties include the pancreas, liver, prostate and the kidneys, which were the main focus of the studies listed in Table 1-3 (state: June 2020).


None of the potential organ systems, which may be treated for various conditions and tumors, are covered by randomized multicenter trials or long-term follow-ups (state. June 2020).


2016 [ 47 ]


3.0 cm


laparoscopic
(n = 20)


2013 [ 48 ]


CRLM (n = 20),
Other (n = 10);
2.5 cm


(n = 28), open
(n = 14), laparoscopic
(n = 2)


2017 [ 49 ]


CRLM (n = 23),
other (n = 7); 2.4 cm


(n = 30)


(at 6 months)


2014 [ 50 ]


2.7 cm


(n = 28)


2012 [ 51 ]


CRLM (n = 21),
other (n = 5);
1.0 cm


(n = 6), open
(n = 22)


2014 [ 52 ]


CRLM (n = 20),
CCC (n = 5);
2.7 cm


(n = 67)


2015 [ 53 ]


CRLM (n = 16),
CCC (n = 6),
other (n = 4); 1.7 cm


(n = 25)


2016 [ 54 ]


CRLM (n = 22),
CCC (n = 5),
other (n = 5); 2.4 cm


(n = 34)


2017 [ 55 ]


CRLM (n = 16),
CCC (n = 6), other
(n = 4); 2.3 cm


(n = 71)


2013 [ 56 ]


CRLM (n = 23),
CCC (n = 2),
other (n = 22);
3.8 cm


(NS) open
(NS)


2014 [ 57 ]


2.4 cm


2011 [ 58 ]


CRLM (n = 15), other
(n = 31); 2.5 cm


Hepatic IRE appears to be safe, even when performed near vessels and bile ducts [ 59 ] [ 60 ]  with an overall complication rate of 16%, with most complications being needle related (pneumothorax and hemorrhage).The COLDFIRE-2 trial with 50 patients showed 76% local tumor progression-free survival after 1 year. [ 61 ]  Whilst there are no studies comparing IRE to other ablative therapies yet, thermal ablations have shown a higher efficacy in that matter with around 96% progression free survival. Therefor Bart et al. [ 36 ]  concluded that IRE should currently only be performed for only truly unresectable and non-ablatable tumors.


Patients


and Median
Largest Tumor Diameter


Follow-up


(mo)


Overall
Survival (mo)


Recurrence
(%)


Downstaging
Caused by IRE


2017 [ 62 ]


2019 [ 63 ]


(88% after chemotherapy or radiation
therapy)


(n = 32), open (n = 1)


10.7 (IRE)


2016 [ 64 ]


2016 [ 65 ]


percutaneous (n = 2)


2018 [ 66 ]


chemotherapy)


2016 [ 67 ]


7.0 (IRE)


2019 [ 68 ]


2015 [ 69 ]


chemo- or radiation
therapy)


18 (IRE)


et al., 2016 [ 70 ]


(after chemo- or radiation therapy)


14.2 (IRE)


2015 [ 71 ]


6.4 (IRE)


2019 [ 72 ]


and local recurrence (n = 10), 4.0 cm (68% after chemotherapy)


9.6 (IRE)


2017 [ 73 ]


(52% after chemotherapy)


11.0 (IRE)


2018 [ 74 ]


percutaneous, NS


2017 [ 75 ]


2016 [ 76 ]


2017 [ 77 ]


Animal studies have shown the safety and efficacy of IRE on pancreatic tissue. [ 78 ]  The overall survival rates in studies on the use of IRE for pancreatic cancer provide an encouraging nonvariable endpoint and show an additive beneficial effect of IRE compared with standard-of care chemotherapeutic treatment with FOLFIRINOX (a combination of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) (median OS, 12–14months). [ 79 ] [ 80 ]  However, IRE appears to be more effective in conjunction with systemic therapy and is not suggested as first-line treatment. [ 68 ]  Despite that IRE makes adjuvant tumor mass reduction therapy for  LAPC  possible, IRE remains, in its current state, a high risk procedure requiring additional safety data before it can be used widely. [ 81 ]


Concurrent Treatment


(% of patients)


(no. of patients)


(2010) [ 82 ]


3+4: n = 6


4+4: n = 3


urinary incontinence 0% erectile dysfunction 0%


out-of-field occurrence, n = 1


(2016) [ 83 ]


4+3: n = 3


4+4: n = 2


4 weeks after IRE


complete fibrosis or necrosis of ablation zone


(2018) [ 84 ]


3+4: n = 38


4+3: n = 16


Grade 2: 11%


Grade 3–5: 0%


urinary incontinence 0%;


erectile dysfunction 23%


out-of-field recurrence, n = 4


(2019) [ 85 ]


n = 225


4+4: n = 68


5+3/3+5: n = 3


>4+4 = 42


prostatectomy (n = 21),


radiation therapy (n = 28),


TURP (n = 17),


HIFU (n = 8)


ADT (n = 29)


erectile dysfunction 3%


local recurrence, n = 20;


out-of-field recurrence, n = 27


(2014) [ 86 ]


3+4: n = 19


4+3: n = 5


4+4: n = 1


incontinence 0%;


erectile dysfunction 5%


only one histologic verification. Out-of-field
recurrence, NS


(2016) [ 87 ]


3+4: n = 15


4+3: n = 8


4+4: n = 0


Grade 2: 29%


erectile dysfunction, unknown


out-of-fieldrecurrence, n = 5 (with histologic verification)


3+4: n = 37


4+3: n = 6


Grade 2: 9


erectile dysfunction 6%


out-of-field recurrence, NS


Focal ablation using IRE for PCa in the distal apex appears safe and feasible.


The concept of treating prostate cancer with IRE was first proposed by Gary Onik and Boris Rubinsky in 2007. [ 89 ]  Prostate carcinomas are frequently located near sensitive structures which might be permanently damaged by thermal treatments or radiation therapy. The applicability of surgical methods is often limited by accessibility and precision. Surgery is also associated with a long healing time and high rate of side effects. [ 90 ]  Using IRE, the urethra, bladder, rectum and neurovascular bundle and lower urinary sphincter  can potentially be included in the treatment field without creating (permanent) damage. [ citation needed ]


IRE has been in use against prostate cancer since 2011, partly in form of clinical trials, compassionate care or individualized treatment approach. As for all other ablation technologies and also most conventional methods, no studies employed a randomized multi-center approach or targeted  cancer-specific mortality  as endpoint.  Cancer-specific mortality  or  overall survival  are notoriously hard to assess for prostate cancer, as the trials require more than a decade and usually several treatment types are performed during the years making treatment-specific survival advantages difficult to quantify. Therefore, the results of ablation-based treatments and focal treatments in general usually use local recurrences and functional outcome (quality of life) as endpoint. In that regard, the clinical results collected so far and listed in Table 3 shown encouraging results and uniformly state IRE as a safe and effective treatment (at least for focal ablation) but all warrant further studies. The largest cohort presented by Guenther et al. [ 85 ]  with up to 6-year follow-up is limited as a heterogeneous retrospective analysis and no prospective clinical trial. Therefore, despite that several hospitals in Europe have been employing the method for many years with one private clinic even listing more than one thousand treatments as of June 2020, [ 91 ]  IRE for prostate cancer is currently not recommended in treatment guidelines.


While nephron-sparing surgery is the gold standard treatment for small, malignant renal masses, ablative therapies are considered a viable option in patients who are poor surgical candidates. Radiofrequency ablation (RFA) and cryoablation have been used since the 1990s; however, in lesions larger than 3 cm, their efficacy is limited. The newer ablation modalities, such as IRE, microwave ablation (MWA), and high-intensity focused ultrasound, may help overcome the challenges in tumor size. [ 92 ]


The first human studies have proven the safety of IRE for the ablation of renal masses; however, the effectiveness of IRE through histopathological examination of an ablated renal tumor in humans is yet to be known. Wagstaff et al. have set out to investigate the safety and effectiveness of IRE ablation of renal masses and to evaluate the efficacy of ablation using MRI and contrast-enhanced ultrasound imaging. In accordance with the prospective protocol designed by the authors, the treated patients will subsequently undergo radical nephrectomy to assess IRE ablation success. [ 93 ]


Later phase 2 prospective trials showed good results in terms of safety and feasibility   [ 94 ] [ 95 ]  for small renal masses but the cohort was limited in numbers (7 and 10 patients respectively), hence efficacy is not yet sufficiently determined. IRE appears safe for small renal masses up to 4 cm. However, the consensus is that current evidence is still inadequate in quality and quantity. [ 36 ]


In a prospective, single-arm, multi-center, phase II clinical trial, the safety and efficacy of IRE on lung cancers were evaluated. The trial included patients with primary and secondary lung malignancies and preserved lung function. The expected effectiveness was not met at interim analysis and the trial was stopped prematurely. Complications included pneumothoraces (11 of 23 patients), alveolar hemorrhage not resulting in significant hemoptysis, and needle tract seeding was found in 3 cases (13%). Disease progression was seen in 14 of 23 patients (61%). Stable disease was found in 1 (4%), partial remission in 1 (4%) and complete remission in 7 (30%) patients. The authors concluded that IRE is not effective for the treatment of lung malignancies. [ 96 ]  Similarly poor treatment outcomes have been observed in other studies. [ 97 ] [ 98 ]


A major obstacle of IRE in the lung is the difficulty in positioning the electrodes; placing the probes in parallel alignment is made challenging by the interposition of ribs. Additionally, the planned and actual ablation zones in the lung are dramatically different due to the differences in conductivity between tumor, lung parenchyma, and air. [ 99 ]


Maor et el have demonstrated the safety and efficiency of IRE as an ablation modality for smooth muscle cells in the walls of large vessels in rat model. [ 100 ]  Therefore, IRE has been suggested as preventive treatment for coronary artery re-stenosis after  percutaneous coronary intervention . [ citation needed ]


Numerous studies in animals have demonstrated the safety and efficiency of IRE as a non-thermal ablation modality for pulmonary veins in the context of  atrial fibrillation  treatment. [ 101 ]  In 2023, irreversible electroporation is being widely used and evaluated in humans, as  cardiac ablation therapy  to kill very small areas of heart muscle. This is done to treat  irregularities of heart rhythm . A  cardiac catheter  delivers trains of high-voltage ultra-rapid electrical pulses that form irreversible pores in cell membranes, resulting in cell death. It is thought to allow better selectivity than the previous techniques, which used heat or cold to kill larger volumes of muscle. [ 102 ]


IRE has also been investigated in ex-vivo human eye models for treatment of uveal melanoma [ 103 ]  and in thyroid cancer. [ 104 ]


Successful ablations in animal tumor models have been conducted for lung, [ 105 ] [ 106 ]  brain, [ 107 ] [ 108 ]  heart, [ 109 ]  skin, [ 110 ] [ 111 ]  bone, [ 112 ] [ 113 ]  head and neck cancer, [ 114 ]  and blood vessels. [ 115 ]


The  Journal of Surgical Oncology  is a monthly  peer-reviewed   medical journal  covering  surgical oncology . It was established in 1969 and is published by  Wiley-Liss . The  editor-in-chief  is Stephen F. Sener ( Keck School of Medicine of USC ). According to the  Journal Citation Reports , the journal has a 2020  impact factor  of 3.454, ranking it 157th out of 243 journals in the category "Oncology" [ 1 ]  and 60th out of 212 journals in the category "Surgery". [ 2 ]


Laryngectomy  is the removal of the  larynx . In a total laryngectomy, the entire larynx is removed (including the  vocal folds ,  hyoid bone ,  epiglottis ,  thyroid  and  cricoid cartilage  and a few  tracheal cartilage  rings) with the separation of the airway from the  mouth ,  nose  and  esophagus . [ 1 ]  In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a  stoma . [ 2 ]  This procedure is usually performed by an  ENT surgeon  in cases of  laryngeal cancer . Many cases of  laryngeal cancer  are treated with more conservative methods (surgeries through the mouth,  radiation  and/or  chemotherapy ). A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of  head and neck cancer . [ 3 ]  Less invasive partial laryngectomies, including  tracheal shaves  and  feminization laryngoplasty  may also be performed on  transgender women  and other  female  or  non-binary  identified individuals to feminize the larynx and/or voice.  Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be  affected post-surgery. [ 1 ]


The first total laryngectomy was performed in 1873 by  Theodor Billroth . [ 4 ] [ 5 ]  The patient was a thirty-six-year-old man with a  subglottic squamous cell carcinoma . On November 27, 1873, Billroth performed a partial laryngectomy. Subsequent  laryngoscopic examination  in mid-December 1873 found tumor recurrence. On December 31, 1873, Billroth performed the first total laryngectomy. The patient was discharged four months later after he learned to use the artificial larynx, which enabled him to speak despite the removal of his vocal cords. Unfortunately, the patient developed a recurrence of the lesion, accompanied by metastatic nodes, and passed away a year following the surgery. [ 6 ]


Older references credit a Patrick Watson of Edinburgh with the first laryngectomy in 1866, [ 7 ] [ 8 ]
but this patient's larynx was only excised after death.


The first artificial larynx was constructed by  Johann Nepomuk Czermak  in 1869.  Vincenz Czerny  developed an artificial larynx which he tested in dogs in 1870. [ 9 ]


Following the pioneering efforts of Billroth, the practice of total laryngectomy gained momentum among surgeons. The early attempts at this procedure, including the second ever performed by Bernhard Heine in 1874 and subsequent operations by Hermann Maas and others, often resulted in the patient's death due to complications or recurrence of disease within months. It wasn't until Enrico Bottini in Italy achieved the first long-term survival of a laryngectomy patient that the potential for lasting success was realized. The period also saw notable failures and challenges, including the tragic case of Crown Prince Frederick of Germany (the future  Frederick III ). Misdiagnosed initially in 1887 by  Morell Mackenzie  as benign, Frederick's condition was later identified as cancerous, leading to his death after a tracheostomy. This case highlighted the controversies and difficulties in diagnosing and treating laryngeal cancer, which persisted into the early 20th century. [ 6 ]


Advancements in direct laryngoscopy and suspension laryngoscopy, credited to Killian and Lynch respectively, improved the evaluation and surgical management of the larynx. Despite significant challenges such as wound infection, anesthesia, and shock, pioneers like  George Washington Crile —which performed the first laryngectomy in U.S. in 1892—made significant contributions to reducing operative mortality and advancing techniques in neck surgery and the management of metastatic disease. [ 6 ]


According to the GLOBOCAN, 2,018 estimates of cancer incidence and mortality produced by the  International Agency for Research on Cancer , there were 177,422 new cases of laryngeal cancer worldwide in 2018 (1.0% of the global total.) Among worldwide cancer deaths, 94,771 (1.0%) were due to laryngeal cancer.
 [ 10 ]


In 2019, it is estimated that there will be 12,410 new laryngeal cancer cases in the  United States , (3.0 per 100,000). [ 11 ]  The number of new cases decreases every year at a rate of 2.4%, [ 11 ]  and this is believed to be related to decreased cigarette smoking in the general population. [ 12 ]  The number of laryngectomies performed each year in the U.S. has been declining at an even faster rate [ 13 ]  due to the development of less invasive techniques. [ 14 ]  A study using the  National Inpatient Sample  found that there were 8,288 total laryngectomy cases performed in the US between 1998 and 2008, and that hospitals performing total laryngectomy decreased by 12.3 per year. [ 15 ]  As of 2013, one reference estimates that there are 50,000 to 60,000 laryngectomees in the US. [ 14 ]


To determine the severity/spread of the laryngeal cancer and the level of vocal fold function,  indirect laryngoscopies  using mirrors,  endoscopies  (rigid or flexible) and/or  stroboscopies  may be performed. [ 1 ]  Other methods of visualization using  CT scans , MRIs and PET scans and investigations of the cancer through biopsy can also be completed. Acoustic observations can also be utilized, where certain laryngeal cancer locations (e.g. at the level of the  glottis ) can cause an individual's voice to sound hoarse. [ 1 ]


Examinations are used to determine the tumor classification ( TNM classification ) and the stage (1–4) of the tumor. The increasing classifications from T1 to T4 indicates the spread/size of the tumor and provides information on which surgical intervention is recommended, where T1-T3 (smaller tumors) may require partial laryngectomies and T4 (larger tumors) may require complete laryngectomies. [ 1 ]  Radiation and/or  chemotherapy  may also be used. [ citation needed ]


The anatomy and physiology of the airways change after laryngectomy. After a total laryngectomy, the individual breathes through a stoma where the  tracheostomy  has created an opening in the neck. There is no longer a connection between the trachea and the mouth and nose. After a partial laryngectomy, the individual breathes mainly through the stoma, but a connection still exists between the trachea and upper airways such that these individuals are able to breathe air through the mouth and nose. The extent of breathing through the upper airways in these individuals varies and a  tracheostomy  tube is present in many of them. Ventilation and resuscitation of total and partial neck breathers is performed through the stoma. However, for these individuals, the mouth should be kept closed and the nose should be sealed to prevent air escape during resuscitation. [ 16 ]


Different types of complications can follow total laryngectomy. The most frequent postoperative complication is pharyngocutaneous  fistula  (PCF), characterized by an abnormal opening between the  pharynx  and the  trachea  or the skin resulting in the leaking of saliva outside of the throat. [ 17 ] [ 18 ]  This complication, which requires feeding to be completed via  nasogastric tube , increases morbidity, length of hospitalization, and level of discomfort, and may delay rehabilitation. [ 19 ]  Up to 29% of persons who undergo total laryngectomy will be affected by PCF. [ 17 ]  Various factors have been associated with an increased risk of experiencing this type of complication. These factors include  anaemia ,  hypoalbuminaemia , poor nutrition,  hepatic  and  renal  dysfunction, preoperative  tracheostomy , smoking, alcohol use, older age,  chronic obstructive pulmonary disease  and localization and stage of cancer. [ 17 ] [ 18 ]  However, the installation of a  free-flap  has been shown to significantly reduce the risks of PCF. [ 17 ]  Other complications such as wound infection,  dehiscence  and  necrosis , bleeding, pharyngeal and stomal  stenosis , and  dysphagia  have also been reported in fewer cases. [ 17 ] [ 18 ]


Total laryngectomy results in the removal of the  larynx , an organ essential for natural sound production. [ 20 ]  The loss of voice and of normal and efficient verbal communication is a negative consequence associated with this type of surgery and can have significant impacts on the quality of life of these individuals. [ 20 ] [ 21 ]  Voice rehabilitation is an important component of the recovery process following the surgery. Technological and scientific advances over the years have led to the development of different techniques and devices specialized in voice restoration. [ citation needed ]


The desired method of voice restoration should be selected based on each individual's abilities, needs, and lifestyle. [ 22 ]  Factors that affect success and candidacy for any chosen voice restoration method could include: cognitive ability, individual physiology, motivation, physical ability, and pre-existing medical conditions. [ 23 ] [ 24 ]


Pre and post-operative sessions with a  speech-language pathologist  (SLP) are often part of the treatment plan for people undergoing a total laryngectomy. [ 25 ]  Pre-operative sessions would likely involve counselling on the function of the  larynx ,  the options for post-op voice restoration, and managing expectations for outcomes and rehabilitation. [ 23 ]  Post-operative therapy sessions with an SLP would aim to help individuals learn to vocalize and care for their new  voice prosthesis  as well as refine their use of speech depending on the chosen method of voice restoration. [ 25 ]


Available methods for voice restoration:


For individuals using tracheoesophageal or esophageal speech,  botulinum toxin  may be injected to improve voice quality when spasms or increased tone (hypertonicity) is present at the level of the pharyngoesophageal segment muscles. [ 29 ]  The amount of botulinum toxin administered unilaterally into two or three sites along the pharyngoesophageal segment varies from 15 to 100 units per injection. Positive voice improvements are possible after a single injection, however outcomes are variable. Dosages may need to be re-administered (individual-dependent) after a number of months, where effective results are expected to last for about 6 to 9 months. [ 29 ]


The laryngectomy surgery results in anatomical and physiological changes in the larynx and surrounding structures. Consequently,  swallowing  function can undergo changes as well, compromising the patient's oral feeding ability and nutrition. [ 30 ]  Patients may experience distress, frustration, and reluctance to eat out due to swallowing difficulties. [ 31 ]  Despite the high prevalence of post-operative swallowing difficulties in the first days following the laryngectomy, most patients recover swallowing function within 3 months. [ 32 ]  Laryngectomy patients do not  aspirate  due to the structural changes in the larynx, but they may experience difficulty swallowing solid food. They may also experience changes in appetite due to a significant loss in their senses of taste and smell. [ 33 ]


In order to prevent the development of pharyngocutaneous fistula, it is common practice to reintroduce oral feeding as of the seventh to tenth day post-surgery, although the ideal timeline remains controversial. [ 34 ]  Pharyngocutaneous fistula typically develops before the reintroduction of oral feeding, as the  pH  level and presence of  amylase  in saliva is more harmful to tissues than other liquids or food. Whether the reintroduction of oral feeding at an earlier post-operative date decreases the risk of fistula remains unclear. However, early oral feeding (within 7 days of the operation) can be conducive to reduced length of hospital stay and earlier discharge from the hospital, entailing a decrease in costs and psychological distress. [ 35 ]


A total laryngectomy causes the separation of the upper air respiratory tract ( pharyn ), nose, mouth) and lower air respiratory tract (lungs, lower  trachea ). [ 36 ]  Breathing is no longer done through the nose (nasal airflow), which causes a loss/decrease of the sense of smell, leading to a decrease in the sense of taste. [ 36 ]  The Nasal Airflow Inducing Manoeuvre (NAIM), also known as the "Polite Yawning" manoeuvre, was created in 2000 and is widely accepted and used by speech-language pathologists in the  Netherlands , while also becoming more widely used in  Europe . [ 37 ]  This technique consists of increasing the space in the  oral cavity  while keeping the lips closed, simulating a yawn with a closed mouth by lowering the jaw, tongue and floor of the mouth. [ 37 ]  This causes a negative pressure in the oral cavity, leading to nasal airflow. [ 38 ]  The NAIM has been recognized as an effective rehabilitation technique to improve the sense of smell. [ 37 ]


People with a partial laryngectomy are more likely to have a higher  quality of life  than individuals with a total laryngectomy. [ 36 ]  People having undergone total laryngectomy have been found to be more prone to depression and anxiety, and often experience a decrease in the quality of their social life and physical health. [ 39 ]


Voice quality, swallowing and reflux are affected in both types, with the sense of smell and taste ( hyposmia / anosmia  and  dysgeusia ) also being affected in total laryngectomies (a complaint which is given very little attention by medical professionals). [ 36 ] [ 40 ]   Partial or total laryngectomy can lead to swallowing difficulties (known as  dysphagia ). [ 1 ]  Dysphagia can have a significant effect on some patients' quality of life following surgery. [ 1 ]  Dysphagia poses challenges in eating and social involvement, often causing patients to experience increased levels of  distress . [ 1 ]  This effect holds true even after the acute phase of recovery. [ 1 ]  More than half of patients who received total laryngectomy were found to experience restrictions in their food intake, specifically in what they can eat and how they can eat it. [ 1 ]  The diet limitations imposed by dysphagia can negatively impact a patient's quality of life, as it can be perceived as a form of participation restriction. [ 1 ]  Accordingly, these perceived restrictions are more commonly experienced by dysphasic laryngectomy patients compared to non-dysphasic laryngectomy patients. [ 1 ]  Therefore, it is important to consider dysphagia in short and long-term outcomes post-laryngectomy in order for patients to uphold a higher quality of life. [ 41 ]  Often,  speech-language pathologists  are involved in the process of prioritizing swallowing outcomes. [ 41 ]


People receiving  voice rehabilitation  report best voice quality and overall quality of life when using a  voice prosthesis  as compared to  esophageal speech  or  electrolarynx . [ 39 ]  Furthermore, individuals going through non-surgical therapy report a higher quality of life than those having undergone a total laryngectomy. [ 39 ]  Lastly, it is much more difficult for those using  alaryngeal speech  to vary their pitch, [ 42 ]  which particularly affects the social functioning of those speaking a  tonal language . [ 42 ]


The  loop electrosurgical excision procedure  ( LEEP ) is one of the most commonly used approaches to treat high grade  cervical dysplasia  ( CIN  II/III,  HGSIL ) and early stage  cervical cancer  discovered on  colposcopic  examination. In the UK, it is known as  large loop excision of the transformation zone  ( LLETZ ). It is considered a type of  conization. [ 1 ]  It has been in use since the 1970s, after its invention by Dr. Sheldon Weinstein.  [ 2 ]


LEEP has many advantages including low cost and a high success rate. [ 3 ]  The procedure can be done in an office setting and usually only requires a  local anesthetic , though sometimes IV sedation or a  general anesthetic  is used. [ 4 ]  Disadvantages include reports of decreased sexual satisfaction  [ 5 ]  and potential for  preterm labor , though a meta-analysis published in 2014 suggested that in patients with existing CIN lesions as opposed to controls, the risk is not more than their baseline risk. [ 6 ]  Approximately 500,000 LEEP procedures are performed in the U.S. annually.  [ 7 ]


When performing a LEEP, the  physician  uses a wire loop through which an  electric current  is passed at variable  power  settings. Various shapes and sizes of loop can be used depending on the size and orientation of the lesion.  The  cervical  transformation zone and  lesion  are excised to an adequate depth, which in most cases is at least 8 mm, and extending 4 to 5 mm beyond the lesion. A second pass with a more narrow loop can also be done to obtain an  endocervical  specimen for further  histologic  evaluation. [ 8 ]


The LEEP technique results in some thermal artifact in all specimens obtained due to the use of electricity which simultaneously cuts and cauterizes the lesion, but this does not generally interfere with  pathological  interpretation provided depth is not exceeded. [ 9 ]  The thermal artifact can be a function of depth and time.


Complications are less frequent in comparison to a  cold-knife conization  but can include  infection  and  hemorrhage . [ 10 ]


LEEP effectively reduces the risk of cancer developing or spreading but it causes an increased risk of  premature birth  in future pregnancies. [ 11 ] [ 12 ] [ 13 ]  Following LEEP there is a 10% chance of cancer recurrence and 11% chance of preterm birth. [ 11 ] [ 12 ]  This perspective carries significant implications when it comes to pregnancy timing and decision making in women of child bearing age who have cervical dysplasia and would like to decide whether they should have the lesions removed before or after pregnancy. As pregnancy is generally understood to be an immune suppressed state, the viral mediated character of cervical lesions might also inform revisions to treatment recommendations in such instances. [ 6 ]


Some women report a small decrease in sexual arousal and satisfaction following LEEP but there is a lack of high quality research showing how LEEP affects sexual function. [ 14 ]


Lumpectomy  (sometimes known as a  tylectomy, partial mastectomy, breast segmental resection or breast wide local excision ) is a  surgical  removal of a discrete portion or "lump" of  breast  tissue, usually in the treatment of a malignant  tumor  or  breast cancer . [ 1 ]   It is considered a viable  breast conservation therapy , as the amount of tissue removed is limited compared to a full-breast  mastectomy , and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumors. Although a lumpectomy is used to allow for most of the breast to remain intact, the procedure may result in adverse affects that can include sensitivity and result in scar tissue, pain, and possible disfiguration of the breast if the lump taken out is significant. [ 2 ]  According to National Comprehensive Cancer Network guidelines, lumpectomy may be performed for  ductal carcinoma in situ  (DCIS),  invasive ductal carcinoma , or other conditions. [ 3 ]


DCIS, or intraductal carcinoma, is by definition a breast cancer that is limited to the lining of the milk ducts, [ 4 ]  and accounts for about 20% of breast cancer in the US. [ 5 ]  Although early treatment of DCIS was similar to invasive breast cancer, involving full mastectomy and sometimes lymph node dissection, an evolution in understanding about the different kinds of breast cancer prompted investigations into the adequacy of less extreme surgical treatments. The results of an eight-year randomized clinical trial in the late 1980s showed that, although lumpectomy alone was associated with significant recurrence, lumpectomy with local radiation therapy achieved similar outcomes to total mastectomy in treatment of DCIS. [ 6 ]  This was the first substantial data that showed that so-called "breast conserving therapy" was a real possibility.


After a lumpectomy is performed for DCIS, local  radiation therapy  is typically performed to help eliminate microscopic-level disease.  Axillary sentinel  lymph node biopsy , as a method of screening for metastatic disease in otherwise non-invasive DCIS, is falling out of favor because the risks of procedure outweigh any effect on outcomes. [ 7 ]  For DCIS,  chemotherapy  is not recommended, but  tamoxifen  may be recommended for tumors which contain an abundance of  estrogen receptors . [ 8 ]


For patients with invasive ductal carcinoma who have lumpectomies, lymph node biopsy and radiation therapy are usually recommended.   Adjuvant  chemotherapy is often recommended, but it may not be recommended if the tumor is small and there are no lymph node  metastases . For larger tumors,  neoadjuvant  chemotherapy may be recommended.


A lumpectomy is a surgery to remove a breast tumor along with a  resection margin  of normal breast tissue. The margin is the healthy, noncancerous tissue that is next to the tumor. A pathologist analyzes the margin excised by the lumpectomy to detect any possible cancer cells. A cancerous margin is "positive", while a healthy margin is "clean" or "negative". A re-excision lumpectomy is performed if the margin is detected to be positive or cancerous cells are very close to the margin. [ 9 ]  Sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) may be used to determine if the cancer has progressed away from the breast and into other parts of the body. [ 10 ]  Sentinel lymph node biopsy is the analysis of a few removed sentinel nodes for the presence of cancerous cells. A radioactive substance is used to dye the sentinel nodes for easy identification and removal. [ 2 ]   If cancer is detected in the sentinel node then further treatment is needed. Axillary node dissection involves the excision of lymph nodes connected to the tumor by the armpit (axilla). Radiation is usually used in conjunction with the lumpectomy to prevent recurrence. [ 11 ]  The radiation treatment can last five to seven weeks following the lumpectomy. Although the lumpectomy with radiation helps to decrease the risk of the cancer returning (local recurrence); it does not prolong survival; it is not a cure, and cancer may still come back. However, local recurrences (confined to the breast area) after lumpectomy can be treated effectively with mastectomy, and these women were still disease-free 20 years after their original lumpectomies and recurrence treatments.  [ 12 ]


Lobectomy of the lung  is a  surgical  operation where a  lobe  of the  lung  is removed. [ 1 ]  It is done to remove a portion of diseased lung, such as early  stage   lung cancer . [ 2 ]


The most common type of lobectomy is known as a  thoracotomy .  When this type of surgery is done the chest is opened up.  An incision will be made on the side of the chest where the affected area of the lung is located. The incision will be in between the two ribs located in that area.  The surgeon will then be able to have access to the chest cavity once the two involved ribs have been pried open. The surgeon will then be able to remove the lobe where the problem is contained. [ 3 ]
Another less invasive lobectomy procedure can be performed through a  video assisted surgery , where the surgeon does not need to pry the two ribs open in order to get access.  A few small incisions are made and surgical tools are inserted into the chest cavity aided by a small video camera. The video images will be projected onto a screen that the surgeon can see. Once the problem area is located the small tools that were previously inserted will be utilized to perform the surgery. [ 3 ]  Once the surgery is complete, the patient will remain in the intensive care unit of the hospital for a day. They will then remain in a regular hospital room for about 4 to 7 days. [ 4 ]


As with any surgery, complications may occur. Post lobectomy air leak is a significant clinical problem, [ 5 ]  and patients undergoing pulmonary resections often present with postoperative air leaks. [ 6 ]  Other risk factors include infections, reactions to anesthesia, bleeding,  pneumothorax  and  bronchopleural fistula . [ 7 ]  New methods for sealing tissue are evaluated in research studies, aimed to determine their efficacies in preventing air leakages. [ 8 ]


The main infection that a patient runs the risk of is  pneumonia . Pneumothorax occurs when there is air trapped between the lung and the chest wall; this can leave the patient's lung unable to fully inflate ("collapsed lung"). A bronchopleural fistula is when there is a tube-like opening that allows air to escape. [ 9 ]  Minimally invasive surgery is beneficial for patient outcome, with reduced risk of complications. [ 10 ]


Once the surgery is complete, the patient will remain in the intensive care unit of the hospital for a day. They will then remain in a regular hospital room for about 4 to 7 days. [ 4 ]   After the patient returns home they typically remain in recovery for about four to six weeks, although some patients may be able to return to work and normal activities sooner. [ medical citation needed ]   Pain is very common amongst patients for quite some time after a lobectomy and doctors will usually prescribe pain medication to help with this. [ 11 ]   Chest tubes are left inside the patient in order to help excess fluid drain and are removed after a few days. Before removal, doctors must ensure that there is no air or  fluid leaking from them. [ 11 ]   In addition to this, follow-up appointments will be scheduled with the patient's doctor. X-rays will be taken of the patient's lung to make sure everything is healing properly. Patients that have had a lobectomy with no major risks shall recover in no longer than three months. [ medical citation needed ]


Lymphadenectomy,   or  lymph node dissection,  is the surgical removal of one or more groups of  lymph nodes . [ 1 ]  It is almost always performed as part of the  surgical management of cancer . In a  regional lymph node dissection , some of the lymph nodes in the  tumor  area are removed; in a  radical lymph node dissection , most or all of the lymph nodes in the tumor area are removed. [ 2 ] [ 3 ] [ 4 ]


Lymphadenectomies are usually done because many types of  cancer  have a marked tendency to produce lymph node  metastasis  early in their natural histories. This is particularly true of  melanoma ,  head and neck cancer , differentiated  thyroid cancer ,  breast cancer ,  lung cancer ,  gastric cancer ,  and  colorectal cancer . Famed British surgeon  Berkeley Moynihan  once remarked that "the surgery of cancer is not the surgery of organs; it is the surgery of the lymphatic system." [ citation needed ]


The better-known examples of lymphadenectomy are  axillary lymph node  dissection  for breast cancer;  radical  neck dissection  for head and neck cancer and thyroid cancer;  D2 lymphadenectomy  for gastric cancer; and  total mesorectal excision  for rectal cancer. [ citation needed ]


For clinical stages I and II breast cancer, axillary lymph node dissection should only be performed  after first attempting a sentinel node biopsy. [ 5 ]  A sentinel node biopsy can establish  cancer staging  of the  axilla  if there are positive lymph nodes present. [ 5 ]  It is also less risky than performing a lymphadenectomy, having fewer side effects and a much lower chance of causing  lymphedema . [ 5 ]  If cancer is not present in the sentinel lymph nodes, then the axillary lymph node dissection should not be performed. [ 5 ]


If one or two sentinel nodes have cancer that is not extensive, then no axillary dissection should be performed, but the person with cancer should have  breast-conserving surgery  and  chemotherapy  appropriate for their stage of cancer. [ 5 ]


Lymphedema  may result from lymphadenectomy. Extensive resection of lymphatic tissue can lead to the formation of a  lymphocele . [ citation needed ]


It is uncertain whether inserting wound drainage after groin lymph nodes dissection can reduce complications such as seroma, haematoma, wound dehiscence, and wound infection. [ 6 ]


Mastectomy  is the medical term for the surgical removal of one or both  breasts , partially or completely. A mastectomy is usually carried out to treat  breast cancer . [ 1 ] [ 2 ]  In some cases, women believed to be at high risk of breast cancer choose to have the operation as a  preventive measure . [ 1 ]  Alternatively, some women can choose to have a  wide local excision , also known as a  lumpectomy , an operation in which a small volume of breast tissue containing the  tumor  and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as  chemotherapy ,  hormonal therapy , or  immunotherapy .


The decision to perform a mastectomy to treat cancer is based on various factors, including breast size, the number of  lesions , biologic aggressiveness of a breast cancer, the availability of  adjuvant  radiation, and the willingness of the patient to accept higher rates of tumor recurrences after lumpectomy and/or radiation. [ 3 ]  Outcome studies comparing mastectomy to lumpectomy with radiation have suggested that routine radical mastectomy surgeries will not always prevent later distant secondary tumors arising from  micro-metastases  prior to discovery, diagnosis, and operation. In most circumstances, there is no difference in both overall survival and breast cancer recurrence rate. [ 4 ] [ 5 ]  While there are both medical and non-medical indications for mastectomy, the clinical guidelines and patient expectations for before and after surgery remain the same.


Mastectomies may also be carried out to  transgender  and  non-binary  people who were  assigned female at birth  to help lessen symptoms of  gender dysphoria . [ 6 ] [ 7 ] [ 8 ]


Despite the increased ability to offer breast conservation techniques to those with breast cancer, certain groups may be better served by traditional mastectomy procedures including:


Mastectomy has non-cancer medical uses as well, including  cosmetic or reconstructive surgery . [ 12 ]  Men with  gynecomastia  may be eligible for mastectomy, but minimally invasive surgical techniques also exist. [ 13 ] [ 14 ]   Transgender  men and  non-binary  people  assigned female at birth  may undergo a mastectomy as a  gender-affirming surgery . [ 6 ] [ 7 ] [ 8 ]


Aside from the post-surgical pain and the obvious change in the shape of the chest and/or breast(s), possible side effects of a mastectomy include soreness, scar tissue at the site of the incision, short-term swelling, phantom breast pain (pain in the breast or tissue that has been removed), wound infection or bleeding, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound). If the lymph nodes are also removed, additional side effects such as lymphedema (swelling of the lymph nodes) may occur. [ 15 ]


Upper limb problems such as shoulder and arm pain, weakness, and restricted movement are a common side effect after breast cancer surgery. [ 16 ]  According to research in the UK, an exercise programme started 7–10 days after surgery can reduce upper limb problems. [ 17 ] [ 18 ]


Currently, there are several surgical approaches to mastectomy, and the type that a person decides to undergo (or whether they will decide instead to have a lumpectomy) depends on factors such as the size, location, and behavior of the tumor (if one is present), whether or not the surgery is prophylactic or preventative, and whether the person intends to undergo reconstructive surgery after the mastectomy. [ 19 ]  For trans people undergoing a  gender-affirming mastectomy , the type of procedure chosen can also vary depending on the desired results, the scarring (or lack thereof), the recovery process, the person's desire for nipple sensation, and other different factors based both on personal preference and input from medical experts. [ 20 ]


Prior to undergoing the mastectomy, it is important to meet with the surgeon to discuss the relevant risks and benefits of receiving the surgery. Depending on the indication for mastectomy, there may be other options to address the clinical condition. One important consideration to discuss with the surgeon is whether breast reconstruction will occur and when this procedure will take place. One option is to have the reconstruction immediately after the mastectomy in the same surgery, whereas other patients opt for a subsequent surgery for reconstruction. This breast reconstruction surgery will be conducted by a plastic surgeon. In addition to the surgeon, a meeting with an anesthesiologist is pertinent in order to review the patient's medical history and determine the plan of anesthesia. [ citation needed ]


Leading up to the day of the surgery, there are various considerations that patients can be cognizant of to facilitate their recovery following surgery. As with other surgeries that may lead to appreciable blood loss, it is advised not to take aspirin or aspirin-containing products for 10 days before the surgery. [ 33 ]  The reason for this is to prevent the anti-coagulative function of aspirin and other blood thinners that would make it difficult to achieve coagulation during the surgery. In addition, it is important for patients to tell the doctor about any medications, vitamins, or supplements that they are taking because some substances could interfere with the surgery. [ 34 ]  It is also pertinent for patients to not eat or drink 8 to 12 hours before surgery, however, there may be specific pre-operative instructions given by each patient's care team. [ 35 ]


Maintaining fitness and proper nutrition is also an important measure to consider prior to receiving a surgery because it has been shown that postoperative outcomes are improved in patients that exercise and maintain a healthy diet prior to surgery. In addition to nutrition and exercise, it is advised to reduce alcohol consumption and smoking. This concept of pre-rehabilitation is beneficial in mitigating post-operative complications and decreasing length of stay in the hospital. [ 36 ]  The rationale is that increasing a patient's functional status prior to surgery will allow for a smoother and faster recovery in the postoperative setting. [ 37 ]


Recent research has indicated that mammograms should not be done with any increased frequency than the normal procedure in women undergoing breast surgery, including breast augmentation,  mastopexy , and breast reduction. [ 38 ]


Prior to leaving the hospital, people who have had a mastectomy will typically be given a prescription for pain medication to ameliorate any pain or discomfort at the surgery site. [ 33 ] [ 39 ] [ 40 ]  Recognizing signs of a surgical site infection including fever, redness, swelling, or pus is important. Any signs of infection should be reported to and assessed by a medical professional. In addition, signs of  lymphedema  due if lymph node removal is performed during mastectomy may be detected by the presence of heaviness, tightness, or fullness in the hand, arm, or axillary area region. [ 39 ]


Regarding return to activity, it is advised not to engage in strenuous activity or lift objects above 5 pounds for up to six weeks after a mastectomy at the discretion of the physician. [ 39 ]  However, it is common for a member of the medical team to provide home exercises designed to maintain arm and shoulder movement and flexibility. Walking is also highly encouraged and allowed immediately after surgery. Most people who undergo a mastectomy can return to work and other regular physical activities in approximately 4 weeks after surgery. [ citation needed ]


People who have had a mastectomy will usually have a post-operative follow-up visit with their provider 1–2 weeks after surgery. [ 33 ] [ 40 ]  The time at which a person can start to wear a bra or reconstructive breast varies and is often at the discretion of the physician. [ 40 ]


Some people with breast cancer may require additional  radiotherapy  after their mastectomy procedure with the goal of reducing the risk of the cancer returning to the lymph nodes and the tissue remaining in the wall of the person's chest. [ 41 ]  The decision by the medical team for suggesting radiotherapy may differ between individual professionals. [ 41 ]  Most teams recommend radiotherapy after a masectomy for people who are at a higher risk of cancer recurrence including those with large breast tumours (5 cm and larger) and people with cancer that has spread to multiple  axillary lymph nodes  (4 or more). [ 41 ]  The necessity and usefulness of radiotherapy on people at slightly lower risk, for example, the cancer has spread to 1-3 axillary lymph nodes, is not as clear. [ 41 ]


Between 2005 and 2013, the overall rate of mastectomy increased 36 percent, from 66 to 90 per 100,000 adult women. The rate of hospital-based bilateral mastectomies (inpatient and outpatient combined) more than tripled, from 9.1 to 29.7 per 100,000 adult women, whereas the rate of unilateral mastectomies remained relatively stable at around 60 per 100,000 women. From 2005 to 2013, the rate of bilateral outpatient mastectomies increased more than fivefold and the inpatient rate nearly tripled. The rate of unilateral mastectomies nearly doubled in the outpatient setting but decreased 28 percent in the inpatient setting. By 2013, nearly half of all mastectomies were performed outpatient. [ 42 ]  However, there are concerns that these rising rates of mastectomies are most greatly seen in women with node-negative and noninvasive lesions, which are subsets of patients that do not require mastectomy. [ 43 ]


Mastectomy rates vary tremendously worldwide, as was documented by the 2004 'Intergroup  Exemestane  Study', [ 44 ]  an analysis of surgical techniques used in an international trial of adjuvant treatment among 4,700 females with early breast cancer in 37 countries. The mastectomy rate was highest in central and eastern Europe at 77%. The USA had the second highest rate of mastectomy with 56%, western and northern Europe averaged 46%, southern Europe 42% and Australia and New Zealand 34%.


Breast surgery was first described 3000 years ago. [ 45 ]  In the earliest stages, breast tumors were treated with simple cauterization. Later, alternating incision and cauterization with complete removal of tumors was suggested by  Leonides , one of the first breast oncologic surgeons recorded in history. [ 9 ]  Other surgeons recommended excision and cauterization only if the tumor could be removed completely; otherwise, avoiding surgery was recommended. Ambrose Pare (b. 1510), a well-known surgeon from Paris who was well known for his experience treating soldiers who were injured, proposed a multi-tiered approach to breast surgery. While superficial cancers could be excised, more advanced cancers were managed through compression by lead plates to reduce blood supply to the tumor. [ citation needed ]


In the 1500s, William Fabry (b.1560), a German surgeon known as the father of German surgery, created a device that compressed and fixed the base of the breast during mastectomy, which subsequently allowed for faster excision of the breast. Another technique developed during this time to improve efficiency of breast dissection was using ligatures to achieve anterior traction. Despite the development of these techniques, there were few mastectomies actually performed at the time due to lack of qualified surgeons and the high morbidity, mortality and disfigurement associated with the surgery. [ 46 ]


During the 1700s, large contributions in mapping lymph nodes for surgery were made by Pieter Camper (b. 1722) and Paolo Mascagni (b. 1752). Lymph node removal was advocated for in managing breast cancer. [ 10 ]  At this time, surgeries were still performed without proper aseptics and without anesthesia.


In the 19th century, Seishu Hanaoka, a Japanese surgeon, performed the first surgery in the world under general anesthesia. Many more advancements in anesthesia and aseptic technique were made during this century. William Roentgen discovered x-rays in 1895, which radically shifted breast cancer treatment from a solely surgical approach to the multi-pronged approach employed today, including imaging, hormonal therapy, radiation, chemotherapy and immunotherapy. [ 11 ]


During the 20th century, progress was made towards skin-sparing mastectomies for treatment of breast cancer. Recent literature suggests that these procedures allow for improved aesthetic outcomes while also not increasing risk for local recurrence compared to conventional mastectomies. [ 47 ] [ 48 ] [ 49 ] [ 50 ]


For example, in 1937, the  Tauton State Hospital  in Massachusetts reported 1 mastectomy in its operating rooms that year, listed alongside other operations including  colostomy  (1),  enterostomy  (1),  herniorrhaphy  (4),  laparotomy  (1), and  circumcision  (2). [ 51 ]


Mesenteric pseudocyst , or  pseudomesenteric cyst [ 1 ] ) is a mass in the abdomen that is devoid of any epithelial lining. [ 2 ]  They are caused either due to trauma or infection. [ 2 ] [ 3 ]  The term mesenteric pseudocyst was first used by Ros  et al  in 1987. [ 2 ] [ 4 ]  Mesenteric pseudocysts are very rare, making up only about less than one in 250,000 hospital admissions. [ 5 ] [ 6 ]


This Epidermal nevi, neoplasms, cysts article is a  stub . You can help Wikipedia by  expanding it .


In  oncology ,  metastasectomy  is the  surgical  removal of  metastases , which are secondary  cancerous   growths  that have spread from cancer originating in another organ in the body.


In many cases, metastases are not treated surgically.  There are two common reasons for this.  Often, even with a successful surgery, the patient would have a poor  prognosis . If the cancer is widely disseminated, it is likely that after the surgical removal of all known metastases, new ones will occur elsewhere. Sometimes, surgery itself has a low likelihood of success due to the location and/or extensiveness of the cancer. If complete surgical excision is feasible, however, removing both the primary cancer and its metastases may substantially improve the patient's prognosis.  Some patients may even be cured. [ 1 ] [ 2 ]


The use of metastasectomy evolved in the field of  liver resection  for metastasised  colorectal cancer , but has evolved to include resection of metastases from different primary cancers (such as  breast cancer ,  melanoma ,  renal cell carcinoma , etc.) to the  lungs ,  brain , and other organs. Not all of these applications are equally  evidence-based , although with respect to some other primary cancers, metastasectomy may be underutilized. [ citation needed ]


Among colorectal cancer patients, 15 to 25% will have liver metastases already when the colorectal cancer is discovered, and another 25 to 50% will develop them in the three years after resection of their primary cancer. [ 2 ]   Of patients who die from metastasised colorectal cancer, 20% have metastasis in the liver alone. [ 2 ]


Surgical resection of liver metastases from colorectal cancer has been found to be safe and cost-effective. [ 3 ]
Reports from several large  retrospective  patient series suggest that it has a 5-year  overall survival rate  (5y OSR) averaging 30 to 40% and a 10y OSR around 16%, [ 1 ] [ 2 ] [ 4 ] [ 5 ]  whereas the highest 5y OSR for modern  chemotherapy regimens  is only 9% (with  FOLFOX ). [ 6 ]  However, no  randomized clinical trial  has directly compared surgical management to chemotherapy or treatment with  bevacizumab . Some have argued that the excellent results of liver metastasectomy for colorectal cancer are partially confounded by  selection bias  or  reporting bias . [ 7 ] [ 8 ]  Nevertheless, surgery for resectable metastases has become the standard of care, [ 9 ]  probably making such a trial ( ethically ) infeasible. [ 2 ] [ 7 ]


Previously, liver metastasectomy was limited to patients with less than four sites of metastasis in the liver, with a tumour-free margin of at least 1 centimetre, and no cancer elsewhere. [ 10 ] [ 11 ]
These criteria have been challenged, however, and today the main criteria are a tumour-free margin and enough functional liver tissue (70%) preserved after surgery. [ 12 ] [ 13 ] [ 14 ]  Patients with initially unresectable liver metastases can be pre-treated with chemotherapy (this is called  neoadjuvant chemotherapy ). [ 9 ]   This pre-treatment causes the tumors to shrink, resulting in a larger proportion of liver tissue that is functional, with broader margins. [ citation needed ]


Preoperative evaluation involves imaging of the liver and its metastases, for example with  ultrasound ,  computed tomography  or  magnetic resonance imaging .  Positron emission tomography can be useful to check the entire body for metastases, although the test can be falsely normal with small lesions or preoperative chemotherapy. [ 15 ]  Baseline  blood tests  typically include  liver function tests  and  tumour markers . [ 12 ]  During surgery, intraoperative ultrasound can aid the surgeon to find additional metastases. [ 2 ] [ 16 ]


A clinical risk score first proposed by Fong et al. [ 17 ]  is often used to assess the risk of recurrence after hepatic resection. The score assigns one point to each of the following:


The median survival for each score is:


Despite the score being highly predictive of long-term outcome, the clinical usefulness is often called into question because the chance of long-term survival is often enough to warrant surgery even in cases with high Fong Score. Some researchers have suggested that the Fong Score has become less useful with the advent of more effective neoadjuvant therapy. [ 18 ]


Surgery is the mainstay of treatment for patients with isolated lung metastasis from colorectal cancer. [ 19 ]  Again, no randomized clinical trials exist, and the scientific evidence is weak, limited only to case series. [ 20 ]  The surgery can be performed with a low operative mortality. [ 19 ]


For patients in whom the primary tumour is controlled and metastases are limited to the lung, criteria for eligibility include the technical resectability of the metastases and the general fitness and lung function reserve of the patient. If there are both liver and lung metastases, a resection of both can be attempted. In general, only 10% of patients with pulmonary metastases from colorectal cancer are resectable. [ 2 ]


Blalock  reported the first lung resection for metastasis from colorectal cancer in 1944. [ 21 ]


Microtransplantation  ( MST ) is an advanced technology to treat malignant hematological diseases and tumors by infusing patients with  granulocyte colony-stimulating factor  (G-CSF) mobilized  human leukocyte antigen  (HLA)-mismatched allogeneic  peripheral blood stem cells  following a reduced-intensity chemotherapy or targeted therapy. The term "microtransplantation" comes from its mechanism of reaching donor cell microchimerism.


Chemotherapy is used by lower doses only to destroy cancer and partially suppress patient’s immune system, which will be reinitiated by donor’s stem cells soon after transplantation, and will play a role as recipient-versus-tumor (RVT) effect combining donor cells’ graft-versus-tumor (GVT) effect. Donor’s stem cells, which have been processed, will also accelerate functional recovery of recipient’s hematopoietic stem cells, greatly reducing infections and transplant-related mortality. Practices of microtransplantation has shown none  graft-versus-host disease  (GVHD) till present, thus  immunosuppressive drugs  for relieving GVHD wouldn't be necessary. Possible mechanisms of the successful avoidance of GVHD include donor cell microchimerism, less-toxic cells processed prior to transplantation, and the preservation of host immune system that is capable of resisting the GVH alloresponse. Moreover, as HLA-mismatched stem cells are employed, donor availability is extremely extended. [ citation needed ]


Indications for microtransplantation are as follows:


Hematologic Malignancies Tumors


The cells employed are allogeneic peripheral blood stem cells. Matched HLA between donor and recipient is not necessary. The stem cells are collected from donor’s blood through a process known as apheresis after a certain period of daily subcutaneous injections of Granulocyte-colony stimulating factor, serving to mobilize stem cells from the donor's bone marrow into the peripheral circulation. Fresh cells are infused to recipient for the first time, and then stored in a controlled-rate freezer. [ citation needed ]


Donor’s Requirements:


In a randomized controlled trial from 2004 to 2009, 58 AML patients aged 60–88 years were randomly assigned to receive chemotherapy (control group; n=28) or it plus HLA-mismatched G-CSF–mobilized donor peripheral blood stem cell (G-PBSC) (G-PBSC group/ Microtransplantation; n = 30). The complete remission rate was significantly higher in the G-PBSC group than in the control group (80.0% vs 42.8%); The median recovery times of neutrophils and platelets were 11 days and 14.5 days, respectively, in the G-PBSC group and 16 days and 20 days, respectively, in the control group after chemotherapy; The 2-year probability of disease-free survival (DFS) was significantly higher in the G-PBSC group than in the control group (38.9% vs 10.0%). [ 1 ]  No graft-versus-host disease was observed in any patient. [ 2 ]  Persistent donor microchimerism was successfully detected in all of the 4 female patients. [ 3 ]


In another long-term research from 2004–2011, 101 patients with AML-CR1 (9 to 65 years old) received Microtransplantation regimen. The 6-year leukemia-free survival (LFS) and overall survival (OS) rates were 84.4% and 89.5%, respectively, in the low-risk group, which were similar to the rates in the intermediate-risk group (59.2% and 65.2%, respectively); The 6-year LFS and OS were 76.4% and 82.1%, respectively, in patients who received a high dose of donor CD3+ T cells, which were significantly higher than the LFS and OS in patients who received a lower dose of donor CD3+ T cells (49.5% and 55.3%, respectively). [ 4 ]  No GVHD was observed in any of the patients. [ 5 ]


The positive results have also been verified by healthcare centers in Italy, [ 6 ]  America, [ 7 ]  Spain, [ 8 ]  etc.


Led by Dr. Huisheng Ai and his medical team at MST International Clinic for Leukemia in the 307th Hospital of Chinese People’s Liberation Army located in Beijing, multicenter collaborative study on Microtransplantation has started since 2013 in nine authoritative blood institutes from China, Duke University and Keck School of Medicine-University of Southern California in United States, University of Sydney in Australia and University of Montreal in Canada. [ citation needed ]


To overcome the intolerable severe reactions of high-dose chemotherapy and GVHD, as well as the challenge to find HLA-matched donors for conventional hematopoietic stem cell transplantation, Dr  Huisheng Ai ,  Guo Mei , etc. developed a new regimen of reduced-intensity chemotherapy plus G-CSF mobilized HLA-mismatched allogeneic peripheral blood stem cell infusion, which was firstly employed for a 75-year-old patient in 2002 and later named as microtransplantation. [ citation needed ]


A  nephrectomy  is the surgical removal of a  kidney , performed to treat a number of kidney diseases including  kidney cancer . It is also done to remove a normal healthy kidney from a living or deceased donor, which is part of a  kidney transplant  procedure. [ 1 ]


The first recorded nephrectomy was performed in 1861 by  Erastus B. Wolcott  in  Wisconsin . [ 2 ]  The patient had had a large tumor and the operation was initially successful, but the patient died fifteen days later. [ 3 ] [ 4 ]  The first planned nephrectomy was performed by the German surgeon  Gustav Simon  on August 2, 1869, in  Heidelberg . [ 5 ] [ 6 ]  Simon practiced the operation beforehand in animal experiments. He proved that one healthy kidney can be sufficient for urine excretion in  humans . [ 7 ]


There are various indications for this procedure, including  renal cell carcinoma , a non-functioning kidney (which may cause  high blood pressure ) and a congenitally small kidney (in which the kidney is swelling, causing it to press on nerves, which can cause pain in unrelated areas such as the back). [ 8 ]


Nephrectomy for renal cell carcinoma is rapidly being modified to allow partial removal of the kidney. Nephrectomy is also performed for the purpose of living  donor   kidney transplantation . [ 1 ]   A  nephroureterectomy  is the removal of a kidney and the entire ureter and a small cuff of the bladder for  urothelial cancer  of the kidney or ureter. [ 9 ]


The surgery is performed with the patient under  general anesthesia . A kidney can be removed through an open incision or by  laparoscopic surgery . For the open procedure, the surgeon makes an incision in the side of the  abdomen  to reach the kidney. Depending on circumstances, the incision can also be made  midline . The  ureter  and blood vessels are disconnected, and the kidney is then removed. The laparoscopic approach utilizes three or four small (5–10 mm) cuts in the abdominal and flank area. The kidney is completely detached inside the body and then placed in a bag. One of the incisions is then expanded to remove the kidney for cancer operations. If the kidney is being removed for other causes, it can be  morcellated  and removed through the small incisions. Recently, this procedure is performed through a single incision in the patient's navel. This advanced technique is called  single port laparoscopy . [ citation needed ]


A total nephrectomy is the removal of at least the entire kidney, whereas a 'radical nephrectomy' also includes at least some perinephric fat, possibly including  Gerota's fascia , and usually also the ipsilateral  adrenal gland . [ 10 ]


For some illnesses, there are alternatives today that do not require the extraction of a kidney. Such alternatives include  renal embolization [ 11 ]  for those who are poor candidates for surgery, or partial nephrectomy if possible. [ citation needed ]


Occasionally renal cell cancers can involve adjacent organs, including the  inferior vena cava  (IVC), the  colon , the pancreas or the liver. If the cancer has not spread to distant sites, it may be safely and completely removed surgically via open or laparoscopic techniques. [ 12 ]


In January 2009, a woman who had previously had a  hysterectomy  was able to donate a kidney and have it removed through her vagina. The operation took place at  Johns Hopkins Medical Center . This is the first time a healthy kidney has been removed via this method, though it has been done in the past for nephrectomies carried out due to  pathology . Removing organs through orifices prevents some of the pain of an incision and the need for a cosmetically unappealing larger scar. Any advance which leads to a decrease in pain and scarring has the potential to boost donor numbers. [ 13 ]  This operation has also taken place at the Cleveland Clinic, which first performed transvaginal Nephrectomy. [ 14 ]   Living donation has a mortality risk of 0.03% during the procedure and seems to result in similar health outcomes to controls. [ 15 ] [ 16 ]


Pain medication  is often given to the patient after the surgery because of pain at the site of the incision. An  IV  with fluids is administered.  Electrolyte  balance and fluids are carefully monitored, because these are the functions of the kidneys. It is possible that the remaining kidney does not take over all functionality. A patient has to stay in the hospital between 2 and 7 days depending on the procedure and complications. Patients who have had open surgery will have to stay in hospital longer than those who have had laparoscopic surgery. [ 17 ]  In long-term, a person with only one kidney ("solitary kidney") may be more prone to developing  chronic kidney disease  (CKD). [ 18 ]  A 2014 study suggested that lifelong risk of CKD is several-fold higher in kidney donors, although the absolute risk is still very small. [ 19 ]  A 2017 article in the  New England Journal of Medicine  suggests that persons with only one kidney including those who have donated a kidney for transplantation or those whose kidney was removed for cancer, should avoid high protein diet and limit their protein intake to less than one gram per kilogram body weight per day in order to reduce the long-term risk of CKD. [ 20 ]


Partial nephrectomy is the surgical removal of a kidney tumor along with a thin rim of normal  kidney , with the two aims of curing the cancer and preserving as much normal kidney as possible. [ citation needed ]


Czerny first described a partial nephrectomy in 1890. [ 21 ]   However, due to limited x-ray and imaging capabilities to find small kidney tumors and significant complications associated with early operations it was largely abandoned.  More recently, with improved imaging, improved surgical techniques and increased kidney tumor detection, partial nephrectomy is performed more often. [ 22 ]


A partial nephrectomy should be attempted when there is a kidney tumor in a solitary kidney, when there are kidney tumors in both kidneys, or when removing the entire kidney could result in kidney failure and the need for dialysis.


Partial nephrectomy is also the standard of care for nearly all patients with small renal masses (<4 cm in size). [ 22 ]   Most renal masses between 4-7 centimeters can also be treated by partial nephrectomy if they are located in the proper position. [ 23 ]   Renal masses larger than 7 centimeters are generally treated with radical nephrectomy unless the tumor occurs in a solitary kidney, there are tumors on both sides or kidney function is bad.  Patients who are told their tumors are too big or too hard for a partial nephrectomy may want to seek another opinion because surgeons who take care of many patients with kidney cancer are more often able to spare the kidney than those who only see a few cases. [ 24 ]


A partial nephrectomy is performed with a patient under general anesthesia as well.  A partial nephrectomy can be performed through an  open ,  laparoscopic [ 25 ]  or  robotic  approach.   The patient is typically placed on the operating room bed lying on the side opposite the kidney tumor.  The goal of the procedure is to remove the kidney tumor along with a thin rim of normal kidney tissue.  Because the kidneys clean the blood, all blood eventually flows through the kidneys and 25% of it will go into the kidneys with each heart beat.  In order to safely remove the kidney tumor, the blood flow to the kidney is often temporarily blocked off.  The tumor is then cut out and the surgeon must sew the remaining kidney back together.  Partial nephrectomy is often an alternative to complete, or radical, nephrectomy for  renal cell cancer . [ citation needed ]


Patients who undergo partial nephrectomy experience complications around 15-25% of the time. [ 25 ] [ 26 ]   The most common complications are bleeding, infection, and urinary leak. [ 25 ]


Partial nephrectomy offers the same chance of cure from the renal cell cancer as radical nephrectomy. [ 22 ] [ 23 ]   This was confirmed in a recent  meta-analysis . [ 27 ]
Partial nephrectomy has been shown to maintain kidney function better than total removal. [ 23 ]    There is some debate whether this preservation of kidney function leads to long-term benefits to the patient. [ 28 ]  Some studies have found that patients treated by partial nephrectomy live longer than patients who had their whole kidney removed. [ 23 ]   Other studies have found the opposite. [ 29 ]
Partial nephrectomy has been associated with better  quality of life  compared to radical nephrectomy. [ 30 ]


In  medicine , a  pancreatectomy  is the  surgical removal  of all or part of the  pancreas . Several types of pancreatectomy exist, including  pancreaticoduodenectomy  (Whipple procedure), distal pancreatectomy, segmental pancreatectomy, and total pancreatectomy.  In total pancreatectomy, the  gallbladder , distal  stomach , a portion of the  small intestine , associated  lymph nodes  and in certain cases the  spleen  are removed in addition to the entire pancreas. [ 1 ]   In recent years, the  TP-IAT  (Total Pancreatectomy with Islet Autotransplantation [ 2 ] [ 3 ] ) has also gained respectable traction within the medical community.  These procedures are used in the management of several conditions involving the pancreas, such as benign  pancreatic tumors ,  pancreatic cancer , and  pancreatitis .


It is performed for a variety of reasons, including:


The most common surgical procedure involving removal of a portion of the pancreas is called a  pancreaticoduodenectomy .


Among common consequences of complete or nearly complete pancreatectomy are deficiencies of pancreatic endocrine or exocrine function requiring replacement of  insulin  or  digestive enzymes . The patient immediately develops type 1 diabetes, with little hope for future type 1 diabetes treatments involving the restoration of endocrine function to a damaged pancreas, since the pancreas is either partially or completely absent. Type 1 diabetes can be treated with careful blood glucose monitoring and insulin therapy. Because the pancreas is responsible for the production of many digestive enzymes, a pancreatectomy should only be given as an option for pancreatic disease which is life-threatening, such as pancreatic cancers. Even after a pancreatectomy, pain still exists in most patients. [ citation needed ] [ original research? ]


A  distal pancreatectomy  is removal of the body and tail of the pancreas.


After a total pancreatectomy, the body no longer produces its own insulin or pancreatic enzymes, so patients have to take insulin and enzyme supplements. Those who were not already diabetic become so.  Glycemic control  is challenging even for relatively young and healthy apancreatic people, owing to the  digestive  challenges of not having endogenous insulin and pancreatic enzymes under  autonomic  control. It can be insurmountably challenging depending on age and comorbidities. But overall, quality of life in patients after total pancreatectomy is comparable with quality of life in patients who undergo a partial pancreatic resection. [ 4 ]


An experimental procedure called  islet cell transplantation , most frequently the autotransplantation of islets isolated from the explanted pancreas into the portal vein, exists to help mitigate the loss of endocrine function following total pancreatectomy. [ 5 ] [ 6 ]


A  pancreaticoduodenectomy , also known as a  Whipple procedure , is a major surgical operation most often performed to remove  cancerous  tumours from the head of the  pancreas . [ 2 ]  It is also used for the treatment of pancreatic or  duodenal  trauma, or chronic  pancreatitis . [ 2 ]  Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the  duodenum , proximal  jejunum ,  gallbladder , and, occasionally, part of the  stomach . [ 2 ]


The most common technique of a pancreaticoduodenectomy consists of the  en bloc  removal of the distal segment (antrum) of the stomach, the first and second portions of the duodenum, the head of the  pancreas , the  common bile duct , and the  gallbladder .  Lymph nodes  in the area are often removed during the operation as well (lymphadenectomy). However, not all lymph nodes are removed in the most common type of pancreaticoduodenectomy because studies showed that patients did not benefit from the more extensive surgery. [ 3 ]


At the very beginning of the procedure, after the surgeons have gained access to the abdomen, the surfaces of the  peritoneum  and the liver are inspected for disease that has metastasized. This is an important first step as the presence of active metastatic disease is a contraindication to performing the operation.


The vascular supply of the pancreas is from the  celiac artery  via the  superior pancreaticoduodenal artery  and the  superior mesenteric artery  from the  inferior pancreaticoduodenal artery . There are additional smaller branches given off by the  right gastric artery  which is also derived from the  celiac artery . The reason for the removal of the duodenum along with the head of the pancreas is that they share the same arterial blood supply (the superior pancreaticoduodenal artery and inferior pancreaticoduodenal artery). These arteries run through the head of the pancreas so that both organs must be removed if the single blood supply is severed. If only the head of the pancreas were removed it would compromise blood flow to the duodenum, resulting in tissue  necrosis .


While the blood supply to the liver is left intact, the  common bile duct  is removed. This means that while the liver remains with a good blood supply the surgeon must make a new connection to drain bile produced in the liver. This is done at the end of the surgery. The surgeon will make a new attachment between the pancreatic duct and the jejunum or stomach. During the surgery, a  cholecystectomy  is performed to remove the  gallbladder . This portion is not done en bloc, as the gallbladder is removed separately.


Relevant nearby anatomy not removed during the procedure include the major vascular structures in the area: the  portal vein , the  superior mesenteric vein , and the  superior mesenteric artery , the  inferior vena cava . These structures are important to consider in this operation especially if done for resection of a tumor located in the head of the pancreas.


Pancreaticoduodenectomy is most often performed as a curative treatment for  periampullary cancer , which includes cancer of the bile duct, duodenum, ampulla or head of the pancreas. [ 4 ]  The shared blood supply of the pancreas, duodenum and common bile duct necessitates en bloc resection of these multiple structures. Other indications for pancreaticoduodenectomy include  chronic pancreatitis ,  benign tumors of the pancreas , cancer  metastatic  to the pancreas, multiple endocrine neoplasia type 1 [ 5 ]  and  gastrointestinal stromal tumors . [ 4 ]


Pancreaticoduodenectomy is the only potentially curative intervention for  malignant tumors of the pancreas . [ 6 ]  However, the majority of patients with pancreatic cancer present with  metastatic  or locally advanced un-resectable disease; [ 7 ]  thus only 15–20% of patients are candidates for the Whipple procedure. Surgery may follow  neoadjuvant chemotherapy , which aims to shrink the tumor and increase the likelihood of complete resection. [ 8 ]  Post-operative death and complications associated with pancreaticoduodenectomy have become less common, with rates of post-operative mortality falling from 30 to 10% in the 1980s to less than 5% in the 2000s. [ 9 ]


Ampullary cancer arises from the lining of the ampulla of Vater. [ 10 ]


Duodenal cancer arises from the lining of the duodenal mucosa. Majority of duodenal cancers originate in the second part of the duodenum, where ampulla is located. [ 10 ]


Cholangiocarcinoma , or cancer of the  bile duct , is an indication for the Whipple procedure when the cancer is present in the distal biliary system, usually the common bile duct that drains into the duodenum. Depending on the location and extension of the cholangiocarcinoma, curative surgical resection may require  hepatectomy , or removal of part of the liver, with or without pancreaticoduodenectomy. [ 11 ]


Treatment of  chronic pancreatitis  typically includes pain control and management of  exocrine insufficiency . Intractable abdominal pain is the main surgical indication for surgical management of chronic pancreatitis. [ 12 ]  Removal of the head of the pancreas can relieve pancreatic duct obstruction associated with chronic pancreatitis. [ 13 ]


Damage to the pancreas and duodenum from  blunt abdominal trauma  is uncommon. In rare cases when this pattern of trauma has been reported, it has been seen as a result of a lap belt in motor vehicle accidents. [ 14 ]  Pancreaticoduodenectomy has been performed when abdominal trauma has resulted in bleeding around the pancreas and duodenum, damage to the common bile duct, pancreatic leakage, or transection of the duodenum. [ 15 ]  Due to the rarity of this procedure in the setting of trauma, there is not robust evidence regarding post-operative outcomes.


In order to be considered for surgical removal, the tumor cannot encase more than 50% of any of the following vessels: the celiac artery, superior mesenteric artery, or inferior vena cava. In cases where less than 50% of the vessel is involved,  vascular surgeons  remove the involved portion of the vessel, and repair the residual artery or vein. [ 16 ]  Tumors are still borderline resectable even if they involve the superior mesenteric or portal veins, gastroduodenal artery, superior mesenteric vein or colon.  [ 17 ]


Metastatic disease is another contradiction to surgery. It most often occurs in the peritoneum, in the liver, and in the omentum. In order to determine if there are metastases, surgeons will inspect the abdomen at the beginning of the procedure after gaining access. Alternatively, they may perform a separate procedure called a diagnostic  laparoscopy  which involves insertion of a small camera through a small incision to look inside the abdomen. This may spare the patient the large abdominal incision that would occur if they were to undergo the initial part of a pancreaticoduodenectomy that was cancelled due to metastatic disease. [ 18 ]


Further contraindications include encasement of major vessels (such as celiac artery, inferior vena cava, or superior mesenteric artery) as mentioned above.


Clinical trials have failed to demonstrate significant survival benefits of  total pancreatectomy , mostly because patients who submit to this operation tend to develop a particularly severe form of  diabetes mellitus  called  brittle diabetes . Sometimes the pancreaticojejunostomy may not hold properly after the completion of the operation and infection may spread inside the patient. This may lead to another operation shortly thereafter in which the remainder of the pancreas (and sometimes the  spleen ) is removed to prevent further spread of infection and possible  morbidity . In recent years the pylorus-preserving pancreaticoduodenectomy (also known as Traverso–Longmire procedure/PPPD) has been gaining popularity, especially among European surgeons. The main advantage of this technique is that the  pylorus , and thus normal gastric emptying, should in theory be preserved. [ 19 ]  There is conflicting data as to whether pylorus-preserving pancreaticoduodenectomy is associated with increased likelihood of gastric emptying. [ 20 ] [ 21 ]  In practice, it shows similar long-term survival as a Whipple's (pancreaticoduodenectomy + hemigastrectomy), but patients benefit from improved recovery of weight after a PPPD, so this should be performed when the tumour does not involve the stomach and the lymph nodes along the gastric curvatures are not enlarged. [ 21 ]


Compared to the standard Whipple procedure, the pylorus preserving pancreaticoduodenectomy technique is associated with shorter operation time and less intraoperative blood loss, requiring less blood transfusion. Post-operative complications, hospital mortality and survival do not differ between the two methods. [ 22 ] [ 23 ] [ 24 ]


Pancreaticoduodenectomy is considered, by any standard, to be a major surgical procedure.


Many studies have shown that hospitals where a given operation is performed more frequently have better overall results (especially in the case of more complex procedures, such as pancreaticoduodenectomy). A frequently cited study published in  The New England Journal of Medicine  found operative  mortality rates  to be four times higher (16.3 v. 3.8%) at low-volume (averaging less than one pancreaticoduodenectomy per year) hospitals than at high-volume (16 or more per year) hospitals. Even at high-volume hospitals, morbidity has been found to vary by a factor of almost four depending on the number of times the surgeon has previously performed the procedure. [ 25 ]
de Wilde et al. have reported statistically significant mortality reductions concurrent with centralization of the procedure in the Netherlands. [ 26 ]


One study reported actual risk to be 2.4 times greater than the risk reported in the medical literature, with additional variation by type of institution. [ 27 ]


Three of the most common post-operative complications are delayed gastric emptying, bile leak, and pancreatic leak. Delayed gastric emptying, normally defined as an inability to tolerate a regular diet by the end of the first post-op week and the requirement for nasogastric tube placement, occurs in approximately 17% of operations. [ 28 ] [ 29 ]  During the surgery, a new biliary connection (normally a choledochal-jejunal anastamosis connecting the common bile duct and jejunum) is made. This new connection may leak in 1–2% of operations. As this complication is fairly common, it is normal in this procedure for the surgeon to leave a drain in place at the end. [ 30 ]  This allows for detection of a bile leak via elevated bilirubin in the fluid drained. Pancreatic leak or pancreatic fistula, defined as fluid drained after postoperative day 3 that has an  amylase  content greater than or equal to 3 times the upper limit of normal, occurs in 5–10% of operations, [ 31 ] [ 32 ]  although changes in the definition of fistula may now include a much larger proportion of patients (upwards of 40%). [ 33 ]


Immediately after surgery, patients are monitored for return of bowel function and appropriate closed-suction drainage of the abdomen.


Ileus , which refers to functional obstruction or  aperistalsis  of the intestine, is a physiologic response to abdominal surgery, including the Whipple procedure. [ 34 ]  While post-operative ileus is typically self-limited, prolonged post-operative ileus occurs when patients develop nausea, abdominal distention, pain or intolerance of food by mouth. [ 35 ]  Various measures are taken in the immediate post-operative period to minimize prolonged post-operative ileus. A  nasogastric tube  is typically maintained to suction, to drain gastric and intestinal contents. Ambulation is encouraged to stimulate return of bowel function. Use of  opioid medications , which interfere with intestinal motility, is limited. [ 36 ]


This procedure was originally described by  Alessandro Codivilla , an Italian surgeon, in 1898. [ 37 ]  The first resection for a  periampullary  cancer was performed by the German surgeon  Walther Kausch  in 1909 and described by him in 1912. It is often called  Whipple's procedure  or the  Whipple procedure , after the American surgeon  Allen Whipple  who devised an improved version of the surgery in 1935 while at  Columbia-Presbyterian Medical Center  in New York [ 38 ]  and subsequently came up with multiple refinements to his technique.


Fingerhut et al. argue that while the terms  pancreatoduodenectomy  and  pancreaticoduodenectomy  are often used interchangeably in the medical literature, scrutinizing their etymology yields different definitions for the two terms. [ 1 ]  As a result, the authors prefer  pancreatoduodenectomy  over  pancreaticoduodenectomy  for the name of this procedure, as strictly speaking  pancreaticoduodenectomy  should refer to the resection of the duodenum and pancreatic duct rather than the pancreas itself. [ 1 ]


Pelvic exenteration  (or  pelvic evisceration ) is a radical  surgical  treatment that removes all organs from a person's  pelvic cavity . It is used to treat certain advanced or recurrent  cancers . The  urinary bladder ,  urethra ,  rectum , and  anus  are removed. In women, the  vagina ,  cervix ,  uterus ,  Fallopian tubes ,  ovaries  and, in some cases, the  vulva  are removed. In men, the  prostate  is removed. The procedure leaves the person with a permanent  colostomy  and  urinary diversion .


Pelvic exenteration often leads to complications, such as  infection ,  kidney damage ,  embolism ,  perineal hernia , and problems with the  stomas  created. However, it increases 5-year survival rate from certain cancers. The procedure was first described by  Alexander Brunschwig  in 1948.


Pelvic exenteration is an option in cases of very advanced or recurrent  cancer , for which less radical surgical options are not technically possible or would not be sufficient to remove all the tumor. This procedure is performed for several types of cancer including genitourinary cancer, [ 1 ]  and  colorectal cancers . [ 2 ]  It is rarely performed due to common complications. [ 3 ]


Pelvic exenteration may not cure certain  cancers . [ 3 ]  This can happen if there are  metastases  in the  liver , the sidewall of the  pelvic cavity , the aortic  lymph nodes , or through  carcinosis . [ 3 ]  In these cases, it may not be used. It may also not be used when both  ureters are obstructed . [ 3 ]


Between 60% and 90% of all people who have a pelvic exenteration have a complication. [ 1 ]  The large  surgical incision  may become  infected . [ 1 ]   Fever  and  sepsis  may occur. [ 1 ]  The  kidneys  may be damaged, usually due to reduced blood flow and  ischaemia . [ 1 ]   Embolisms  may occur. [ 1 ]  After pelvic exenteration, many patients will have  perineal hernia , often without symptoms, but only 3–10% will have perineal hernia requiring surgical repair. [ 4 ]


Many problems can occur with the  stoma . [ 1 ]   Bowel obstruction  may occur, or the  anastomosis  created by the surgery may leak. [ 1 ]  The stoma may retract, or may prolapse. [ 1 ]  Rarely, it may  necrose . [ 1 ]


Pelvic exenteration involves removal of all of the pelvic organs. [ 3 ]  These include the  urinary bladder ,  urethra ,  rectum , and  anus . In women, the  vagina ,  cervix ,  uterus ,  fallopian tubes ,  ovaries  and, in some cases, the  vulva  are removed. In men, the  prostate  is removed. Patients receive significant counselling before the procedure so that they fully understand the benefits and risks. [ 5 ]   Radiology  is used before surgery. [ 5 ]  The surgery itself is complex. [ 5 ]


Pelvic exenteration leaves a person with a permanent  colostomy  and  urinary diversion . A 2015 article reports that pelvic exenteration can provide long-term survival for patients with locally advanced primary  rectal carcinoma . The 5-year survival rate of patients undergoing pelvic exenteration following complete resection of disease was 59.3%. Factors shown to influence the survival rate following a pelvic exenteration procedure include age, the  presence of metastatic disease, lymph node status, circumferential  resection margin , local recurrence of disease, and the need for  neoadjuvant therapy . [ 6 ]


The procedure was first described by  Alexander Brunschwig  in 1948. [ 1 ] [ 7 ]


A  pneumonectomy  (or pneumectomy) is a  surgical  procedure to remove a  lung . It was first successfully performed in 1933 by Dr. Evarts Graham. This is not to be confused with a lobectomy or segmentectomy, which only removes one part of the lung.


There are two types of pneumonectomy: simple and extrapleural. A simple pneumonectomy removes just the lung. An extrapleural pneumonectomy also takes away part of the diaphragm, the parietal pleura, and the pericardium on that side. [ 1 ]


The most common reason for a pneumonectomy is to remove  tumorous  tissue arising from  lung cancer . Other reasons can arise are a traumatic lung injury, bronchiectasis, tuberculosis, a congenital defect, and fungal infections. [ 2 ]


The operation will reduce the respiratory capacity of the patient, and before conducting a pneumonectomy, survivability after the removal has to be assessed. If at all possible, a  pulmonary function test  (PFT) should be done. It has been found that forced expiratory volume in one second (FEV1) and diffusion capacity of the lungs (DLCO) provides the best indicator of survival. [ 3 ]  Other tools can be used to assess effectiveness as well, such as cardiopulmonary exercise testing to measure maximal oxygen consumption (VO 2  max), stair climbing, shuttle walk test, and a 6-minute walk test. [ 4 ]


If someone has severe valvular disease, severe pulmonary hypertension, or poor ventricular function or if cancer has spread from the lungs into the other intra-abdominal structures, ribs, or contralateral hemithorax, it is contraindicated. [ 5 ]


Posterolateral thoracotomy using the fourth or fifth intercostal space is the most common approach used for pneumonectomy. In case of inflammatory and infectious indications, excision of the fifth rib may be necessary to achieve adequate surgical exposure if there is rib crowding. [ 6 ]


Video-assisted thoracoscopic surgery (VATS) approach: VATS pneumonectomy is a safe and feasible treatment for advanced malignant and benign diseases and has lower morbidity. [ 7 ]


Robotic pneumonectomy for lung cancer is a safe procedure and a reasonable alternative to thoracotomy. With a sound technique most procedures can be completed robotically without any major complications. [ 8 ]


After a pneumonectomy is performed, changes in the thoracic cavity occur to compensate for the altered anatomy. The remaining lung hyperinflates as well as shifting over along with the  heart  towards the now empty space. This space is full of air initially after surgery, but then it is absorbed, and fluid eventually takes its place. [ 9 ]  The fluid which fills the residual space in the chest cavity slowly gelatinizes into a proteinaceous material, and the chest scaffold collapses slightly. [ citation needed ]


As with the  kidneys , it is often possible for a person to live with just one lung. Although it is not possible for the lung to re-grow like the  liver , the body is able to compensate for the reduced lung capacity by slow and gradual expansion of the other remaining lung. Post-pneumonectomy patients in due time reach about 70–80 percent of their pre-surgery lung function. [ 10 ]  People have been able to return to near-normal lives, including running marathons after a pneumonectomy, provided there has been adequate cardio-pulmonary conditioning. [ 11 ]


Most common complications after a pneumonectomy are:


A  preventive mastectomy  or  prophylactic mastectomy  or risk-reducing mastectomy (RRM) is an  elective operation  to  remove the breasts  so that the risk of  breast cancer  is reduced. [ 1 ] [ 2 ]


The procedure is a surgical option for individuals who are at high risk for the development of breast cancer. High risk women without a prior history of personal breast cancer might consider bilateral risk-reducing mastectomy (BRRM) as an option for minimising the risk of primary breast carcinoma development. [ 3 ]  The procedure includes the surgical removal of both breasts before any pathologic diagnosis has been made. Women that were previously diagnosed with a breast cancer in one breast (ipsilateral breast cancer) might elect to undergo risk-reducing mastectomy of the other unaffected (contralateral) breast, that is to say contralateral risk-reducing mastectomy (CRRM), to minimize the risk of a second breast cancer development. CRRM has been shown to reduce the incidence of contralateral breast cancer, but there is not sufficient evidence that it improves survival. [ 4 ]  Women who had a bilateral mastectomy in 2013 were about 10 years younger than those who had a unilateral mastectomy. [ 5 ]


This  preventive operation  pertains to women with these characteristics: [ 2 ]


Discussions and decision should be made with the help of specialists who can use relevant information and statistical models to predict the individual lifetime risk of development of breast cancer.


Undergoing a preventive mastectomy does not guarantee that breast cancer will not develop later, however, it reduces the risk by 90% in high risk women. [ 2 ] [ 8 ]  Also, a preventive mastectomy may not be able to remove all breast tissue as some of it may be in the arm pit, near the collar bone, or in the abdominal wall. [ 1 ]


Male carriers of BRCA1 and BRCA2 mutations have a higher risk of breast cancer than other males, approximately 1.2% and 6.8%, [ 9 ]  but their risk is much lower than in female mutation carriers (about 60%) and lower than in the general female population (12%). [ 10 ]  Thus, preventive mastectomy has not been advocated for affected men.


In most situations the operation involves both breasts and thus represents a bilateral procedure. When cancer has affected already one breast, the other breast, still healthy, may be removed in a unilateral preventive mastectomy. Typically either a simple, a subcutaneous or a nipple-sparing mastectomy is performed. With the former the areola and  nipple  are removed, while the other two approaches preserve the nipple area for cosmetic reasons. To increase the  viability  of the nipple area for preservation during mastectomy, a so-called " nipple delay " procedure can be done several weeks before the mastectomy. [ 11 ]   Reconstructive breast surgery  can be  performed in the same surgical setting, added after the mastectomy. [ 12 ]  Saline or silicone  implants  may be used in the reshaping process and may be placed in a later setting. [ 13 ]


A preventive mastectomy carries certain risks including those of anesthesia, bleeding, infection, pain, disfiguration, anxiety and disappointment.


After surgery, routine screening for breast cancer is recommended. [ 2 ]


There are other options to reduce the risk of future breast cancer. [ 2 ]
Intensified breast cancer screening for high risk women may detect cancer at an early, treatable stage. Certain medications that block the effect of  estrogen  (i.e.  tamoxifen ,  raloxifen ,  exemestane ) can reduce the risk by about 50% but also have side effects. Prophylactic salpingo- oophorectomy  reduces estrogen levels and the risk of both ovarian and breast cancer, however, the reduction in breast cancer risk is about 50% in high risk women [ 8 ]  as compared to 90% when preventive mastectomy is done.   Lifestyle  changes (in weight, diet, exercise, avoidance of smoking, limiting alcohol) may reduce the risk to some degree. [ 14 ]