BACKGROUND: The incidence of liver metastases from colorectal cancer (CLM) is on the rise. Older cancer patients are frequently subject to under-treatment. METHODS: A Markov decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) of four strategies – best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA), and hepatic resection (HR). The model was designed to account for both age and comorbidities. RESULTS: In the base case analysis, BSC, SC, RFA, and HR yielded LEs of 11.9, 23.1, 34.8, and 37.0 months, respectively, and QALEs of 7.8, 13.2, 22.0, and 25.0 months, respectively. Model results were sensitive to several variables including age, comorbidity status, and length of model simulation. CONCLUSION: Hepatic resection may be the optimal treatment strategy for healthy older patients with CLM. Treatment decisions in older cancer patients should be individualized and account for patient age, comorbidities, and values.

BACKGROUND: The incidence of liver metastases from colorectal cancer (CLM) is on the rise. Older cancer patients are frequently subject to under-treatment. METHODS: A Markov decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) of four strategies – best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA), and hepatic resection (HR). The model was designed to account for both age and comorbidities. RESULTS: In the base case analysis, BSC, SC, RFA, and HR yielded LEs of 11.9, 23.1, 34.8, and 37.0 months, respectively, and QALEs of 7.8, 13.2, 22.0, and 25.0 months, respectively. Model results were sensitive to several variables including age, comorbidity status, and length of model simulation. CONCLUSION: Hepatic resection may be the optimal treatment strategy for healthy older patients with CLM. Treatment decisions in older cancer patients should be individualized and account for patient age, comorbidities, and values.

BACKGROUND: The aging population in the United States will correlate with an increased number of cancer diagnoses as cancer is primarily a disease of the elderly. Providing this ever-growing group of individuals with quality surgical management, while taking into account the unique needs and desires of this cohort, is a great challenge facing both geriatricians and surgeons going forward. The best approach to ensure that oncogeriatric patients receive the best tailored treatment is through the completion of a pre-surgical geriatric assessment. However, only a minority of oncogeriatric patients is undergoing a comprehensive pre-surgical geriatric assessment despite the majority of geriatricians and surgeons acknowledging its importance in order to properly risk stratify their patients. LITERATURE REVIEW FINDINGS: Multiple theories exist as to why geriatric assessments are not being utilized more frequently, but the most probable answer is that these assessments are very time-consuming, making it virtually impossible for incorporation into a healthcare provider’s busy schedule. Comprehensive literature review regarding geriatric assessments amongst the oncogeriatric population found that the most sensitive and specific domains of the geriatric assessments predicting morbidity and mortality include Frailty Index, Social Support Survey, Mini-Nutritional Assessment, and Geriatric Depression Screening. PROPOSED METHODS: A novel educational intervention will be proposed to teach Physician Assistant and Medical Students about the domains of the geriatric assessment most predictive of post-surgical risk during their surgical clerkship. The curriculum will utilize both simulation- and competency-based education training under the guidance of geriatricians and surgeons. Students will first learn the necessary skills in a controlled classroom environment and then proceed to incorporate these skills during their clerkship with patients on their service. CONCLUSIONS: The goal of the proposed method is to instill the confidence and skills necessary to provide an accurate geriatric assessment for oncogeriatric patients in future clinicians. The field of geriatric oncology is going to grow exponentially in the up-coming years and familiarizing future clinicians with the most predictive domains regarding surgical outcome will improve treatment outcomes for oncogeriatric patients in the immediate and foreseeable future.

Submitted by SABRINA MARIN RODIGHERI null (smrodigheri@yahoo.com.br) on 2016-07-17T23:34:54Z No. of bitstreams: 1 Tese-.pdf: 3745959 bytes, checksum: 8b3ef3d6824392053b4f445e7c3b8cc4 (MD5) / Approved for entry into archive by Ana Paula Grisoto (grisotoana@reitoria.unesp.br) on 2016-07-19T19:49:05Z (GMT) No. of bitstreams: 1 rodigheri_sm_dr_jabo.pdf: 3745959 bytes, checksum: 8b3ef3d6824392053b4f445e7c3b8cc4 (MD5) / Made available in DSpace on 2016-07-19T19:49:05Z (GMT). No. of bitstreams: 1 rodigheri_sm_dr_jabo.pdf: 3745959 bytes, checksum: 8b3ef3d6824392053b4f445e7c3b8cc4 (MD5) Previous issue date: 2016-06-17 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / O objetivo deste estudo foi avaliar a intensidade da resposta metabólica associada ao trauma induzido pela mastectomia unilateral em fêmeas da espécie canina com neoplasia mamária, assim como verificar se a ovário-histerectomia concomitante potencializa a reação orgânica ao trauma. Foram estudados sete momentos do período perioperatório de 11 cadelas com neoplasia mamária submetidas à mastectomia unilateral (Grupo 1) e 11 submetidas à mastectomia unilateral e ovário-histerectomia (Grupo 2). Os parâmetros mensurados foram: frequência cardíaca, frequência respiratória, pressão arterial sistólica, temperatura corporal e níveis sanguíneos de glicose, lactato, albumina, fibrinogênio, cortisol, interleucina 2, interleucina 6 e fator de necrose tumoral alfa. O tempo de duração das cirurgias foi significativamente maior na mastectomia unilateral associada a ovário-histerectomia, entretanto, não houve correlação entre o tempo cirúrgico e os parâmetros avaliados. Foi observada redução significativa da frequência respiratória, pressão arterial sistólica e temperatura corporal ao término de ambas cirurgias, sendo a redução da frequência respiratória mais intensa nas fêmeas submetidas a mastectomia unilateral e ovário-histerectomia. O trauma cirúrgico promoveu redução nas concentrações séricas de albumina e interleucina 2 e aumento nos níveis sanguíneos de glicose e interleucina 6 no período pós-operatório dos pacientes dos grupos 1 e 2. Constatou-se aumento dos níveis séricos de cortisol após o término da mastectomia unilateral associada a ovário-histerectomia. A análise dos resultados do presente estudo permite concluir que a mastectomia unilateral induz alterações metabólicas significativas em cadelas com neoplasias mamárias. A realização da ovário-histerectomia no mesmo tempo cirúrgico potencializa a resposta orgânica ao trauma. / The objective of this study was to evaluate the intensity of the metabolic response associated with trauma induced by unilateral mastectomy in bitches with mammary tumors, as well as verify if the realization of ovariohisterectomy during surgery enhances the organic reaction to trauma. It were evaluated seven moments in the perioperative period of 11 bitches with mammary tumors subjected to unilateral mastectomy (Group 1) and 11 to unilateral mastectomy and ovariohysterectomy (Group 2). The parameters that were measured included: heart rate, breathing rate, systolic blood pressure, body temperature and blood levels of glucose, lactate, albumin, fibrinogen, cortisol, interleukin 2, interleukin 6 and tumor necrosis factor alpha. Surgical duration was significantly higher in unilateral mastectomy associated with ovariohysterectomy, however, there was no correlation between the surgical time and the parameters evaluated. There was a significant reduction in respiratory rate, systolic blood pressure and body temperature at the end of both surgeries, and the reduction of the respiratory rate was more intense in females undergoing unilateral mastectomy and ovariohysterectomy. Surgical trauma promoted reduction in serum albumin and interleukin 2 levels and increased blood levels of glucose and interleukin 6 in the postoperative period of patients in groups 1 and 2. It found increased serum cortisol levels after the unilateral mastectomy associated with ovariohysterectomy. The analysis of this study results shows that unilateral mastectomy induces significant metabolic changes in dogs with mammary tumors. The realization of ovariohysterectomy during surgery enhances the organic response to trauma. / FAPESP: 13/02460-9

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Depuis 25 ans, la voie d’abord coelioscopique a pris une place importante dans laprise en charge des cancers pelviens, en particulier gynécologique. Cette voie miniinvasive est utilisée pour des procédures diagnostiques, de stadifications outhérapeutiques.Les évolutions technologiques et instrumentales ont permis d’étendre sesapplications à des indications réservées à la laparotomie.Si à la vue des données de la littérature la coelioscopie est devenue la voie d’abord àrecommander dans la prise en charge des cancers du col utérin et de l’endomètre,elle doit faire face à l’arrivée de l’assistance robotisée.Le robot chirurgical Da Vinci se développe depuis 10 ans et ses applications se sontmultipliées. La chirurgie gynécologique et oncologique constitue un éventaild’indications intéressantes pour cette technologie, surtout en cancérologie. De plusen dehors des avantages évidents qu’offre le robot Da Vinci pour le chirurgien, ilsemble que certains paramètres per opératoires soient améliorés, la qualité desprélèvements et la morbidité en particulier.A travers une revue de la littérature et l’exposé des travaux menés, nous démontronsl’applicabilité et l’intérêt potentiel de cette nouvelle approche coelioscopique dans laprise en charge des cancers gynécologiques.Cependant, l’impact médico économique de cette technique ainsi que le gain enterme de morbidité pour nos patientes, par rapport à la voie coelioscopiqueconventionnelle, doivent être précisés par les essais que nous avons initiés et quisont actuellement en cours. / Since 25 years, laparoscopic approach has gained an increasing role in cancertreatment, especially of colorectal - and gynecological cancers. The laparoscopicapproach is used for staging and exploratory purposes, as well as for therapeuticpurposes.Recent developments in surgical instruments and techniques allowed to extend theindication of laparoscopy to cases that were formerly reserved for open surgery.As the laparoscopic approach has become the Gold Standard, especially for uteruscancer (cervix and endometrial), the domain of robot-assisted surgery deserves ourattention.The robotic surgical system named « DaVinci » has undergone further developmentsand the indications for this system have been multiplied. The use in gynecologyseems to be an ideal indication for this surgical technique, especially for cancertreatment. Moreover, it might be postulated that the DaVinci surgical system canmodify several peri operative factors, which might result in less morbidity and earlierrecovery from surgery.Though a literature review and our publications we demonstrate the feasibility of thistechnique and its potential place in gynecologic cancers management.However, before this innovative but expensive technique is generally used andaccessible, it is necessary to thoroughly evaluate its surgical quality, its relatedcancer outcome, its economic impact and its related patients’ quality of life.

Introdução: Os tratamentos para tumores gastrointestinais incluem procedimentos endoscópicos demorados e operações invasivas. Objetivo: Avaliação da exequibilidade e resultados da técnica de ressecção gástrica de todas as camadas da parede (FTEGR) realizada através de um grampeador linear introduzido por uma gastrostomia. Método: Foram estudados dez suínos. Primeiramente, realizou-se uma gastrostomia por punção através da qual se introduziu um trocarte laparoscópico. Suturas foram realizadas na parede gástrica, próximas à área de ressecção, para tracioná-la. Para realizar estas suturas uma câmara plástica foi acoplada à ponta distal do endoscópio, com a finalidade de aspirar a região desejada e introduzir uma agulha com um T-tag (dispositivo em \"T\") montado em um fio de nylon 2-0. Esta sutura com T-tag foi então tracionada em direção à boca do animal, formando uma tenda, incluindo todas as camadas da parede do estômago. Desacoplou-se a câmara plástica do endoscópio, o qual foi reintroduzido no estômago para se visualizar, orientar e auxiliar na ressecção. Um grampeador linear foi introduzido pela gastrostomia, colocado ao redor da base da tenda e então disparado. O espécime foi removido através da boca. O grampeador foi retirado, seguido pela retirada do trocarte. Finalmente, a gastrostomia foi fechada. Ao término do procedimento sete animais foram sacrificados e submetidos a laparotomia. Os demais três animais foram observados clinicamente por 4 semanas após o que realizou se uma endoscopia seguida da laparotomia. Resultados: FTEGR foi factível e todos os espécimes incluíram a serosa com fechamento completo da área ressecada. Foram ressecados espécimes com 8,0 cm (6-10 cm) de comprimento e 5,0 cm (4,2-6,2 cm) de largura, em média. O tempo médio dos procedimentos foi de 78 min (72-85 min.). Todos os procedimentos foram efetivos e não ocorreram complicações. Conclusão: A técnica de FTEGR em modelo suíno é exequível, não expõe a cavidade peritoneal e pode ser realizada sem complicações / Background: Treatments for gastrointestinal tumors include time-consuming endoscopic procedures and invasive surgeries. Aim: To evaluate the feasibility and results of a full-thickness endoscopic gastric resection technique (FTEGR) performed using a stapler inserted through a gastrostomy. Methods: Ten pigs were used. Firstly, a push gastrostomy was performed through which a laparoscopic trocar was inserted. Sutures were placed on the stomach wall near the resection area to hold on this area. To perform these sutures plastic chamber was assembled at the distal tip of the endoscope to aspirate the aimed region and insert a needle with an assembled T-tag mounted with a 2-0 nylon thread. This T-tag stitch was then pulled toward the animal\'s mouth to form a tent including all stomach\'s layers. The plastic chamber was then disengaged from the endoscope, which was reintroduced into the stomach to visualize, guide and aid in resection. A linear stapler was inserted through the gastrostomy, placed around the base of the tent and then utilized. The specimen was removed through the mouth. The stapler was withdrawn, followed by the withdrawal of the trocar. Finally, the gastrostomy was closed. At the end of the procedure seven animals were sacrificed and submitted to laparotomy. The other three animals were observed clinically for 4 weeks after and then it was performed an endoscopy followed by euthanasia and a laparotomy. Results: FTEGR was possible and all specimens included the serosa with complete closure of the resected area. Samples 8.0 cm (6-10 cm) long and 5.0 cm (4.2-6.2 cm) wide were resected on average. The mean time to perform FTEGR was 78 min (72-85). All procedures were feasible and there were no complications. Conclusion: The FTEGR technique in pig model is feasible, it does not expose the peritoneal cavity to the contamination and can be performed without complications