OBJECTIVE:Evaluate the existing literature comparing long-term survival after minimally invasive esophagectomy (MIE) and open esophagectomy (OE), and conduct a meta-analysis based on relevant ...studies.
BACKGROUND:It is unknown whether the choice between MIE and OE influences the long-term survival in esophageal cancer.
METHODS:A systematic electronic search for articles was performed in Medline, Embase, Web of Science, and Cochrane Library for studies comparing long-term survival after MIE and OE. Additionally, an extensive hand-search was conducted. The I test and χ test were used to test for statistical heterogeneity. Publication bias and small-study effects were assessed using Egger test. A random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year mortality, and disease-specific 5-year and 3-year mortality. Meta-regression was performed for the 5-year mortality outcomes with adjustment for the covariates age, physical status, tumor stage, and neoadjuvant or adjuvant therapy. The results were presented as hazard ratios (HRs) with 95% confidence intervals (CIs).
RESULTS:The review identified 55 relevant studies. Among all 14,592 patients, 7358 (50.4%) underwent MIE and 7234 (49.6%) underwent OE. The statistical heterogeneity was limited I = 12%, 95% confidence interval (CI) 0%–41%, and χ = 0.26 and the funnel plot was symmetrical both according to visual and statistical testing (Egger test = 0.32). Pooled analysis revealed 18% lower 5-year all-cause mortality after MIE compared with OE (HR 0.82, 95% CI 0.76–0.88). The meta-regression indicated no confounding.
CONCLUSIONS:The long-term survival after MIE compares well with OE and may even be better. Thus, MIE can be recommended as a standard surgical approach for esophageal cancer.
OBJECTIVE:This meta-analysis determines whether increased lymph node yield improves survival in patients with esophageal cancer undergoing esophagectomy with or without neoadjuvant therapy.
...BACKGROUND:Esophagectomy involves resection of the esophagus and surrounding lymph nodes, which are commonly the first stations of cancer spread. The extent of lymphadenectomy during esophagectomy remains controversial, with several studies publishing conflicting results, especially in the era of neoadjuvant therapy.
METHODS:An electronic literature search was undertaken using Embase, Medline, and the Cochrane library databases (2000 to 2017). Articles with esophageal cancer patients undergoing esophagectomy with lymphadenectomy and investigating the effects of low and high lymph node yield on overall survival and disease-free survival were included. Meta-analysis of data was conducted using a random effects model. If the study divided the cohort into multiple groups based on lymph node yield, survival was compared between the lowest and highest lymph node yield groups. In addition to analysis of the entire cohort, subset analysis of only those patients receiving neoadjuvant therapy was also performed.
RESULTS:A total of 26 studies were included in this meta-analysis with a follow-up ranging from 15 to 94 months. For the analysis of overall survival, 23 studies were included. A meta-analysis showed that overall survival significantly improved in the high lymph node yield group hazard ratio (HR) = 0.81; 95% confidence interval (95% CI) = 0.74–0.87; P < 0.01. In the 10 studies describing disease-free survival, this was significantly improved in the high lymph node yield group (HR = 0.72; 95% CI = 0.62–0.84; P < 0.01). Subset analysis of neoadjuvant-treated patients demonstrated a survival benefit of high lymph node yield on overall survival (HR = 0.82; 95% CI = 0.73–0.92; P < 0.01).
CONCLUSION:This meta-analysis demonstrates the benefit of an increased lymph node yield from esophagectomy on overall and disease-free survival. In addition, a survival benefit of a high lymph node yield was demonstrated in patients receiving neoadjuvant therapy followed by esophagectomy.
OBJECTIVE:To compare clinical outcomes after laparoscopic lavage (LL) or colonic resection (CR) for purulent diverticulitis.
BACKGROUND:Laparoscopic lavage has been suggested as an alternative ...treatment for traditional CR. Comparative studies to date have shown conflicting results.
METHODS:Electronic searches of Embase, Medline, Web of Science, and Cochrane databases were performed. Weighted mean differences (WMD) were calculated for effect size of continuous variables and pooled odds ratios (POR) calculated for discrete variables.
RESULTS:A total of 589 patients recruited from 3 randomized controlled trials (RCTs) and 4 comparative studies were included; 85% as Hinchey III. LL group had younger patients with higher body mass index and lower ASA grades, but comparable Hinchey classification and previous diverticulitis rates. No significant differences were noted for mortality, 30-day reoperations and unplanned readmissions. LL had higher rates of intraabdominal abscesses (POR = 2.85; 95% confidence interval, CI, 1.52–5.34; P = 0.001), peritonitis (POR = 7.80; 95% CI 2.12–28.69; P = 0.002), and increased long-term emergency reoperations (POR = 3.32; 95% CI 1.73–6.38; P < 0.001). Benefits of LL included shorter operative time, fewer cardiac complications, fewer wound infections, and shorter hospital stay. Overall, 90% had stomas after CR, of whom 74% underwent stoma reversal within 12-months. Approximately, 14% of LL patients required a stoma; 48% obtaining gut continuity within 12-months, whereas 36% underwent elective sigmoidectomy.
CONCLUSIONS:The preservation of diseased bowel by LL is associated with approximately 3 times greater risk of persistent peritonitis, intraabdominal abscesses and the need for emergency surgery compared with CR. Future studies should focus on developing composite predictive scores encompassing the wide variation in presentations of diverticulitis and treatment tailored on case-by-case basis.
Background
Peritoneal cytology has been used as a part of the cancer staging of gastric cancer patients. The primary aim of this systematic review was to evaluate the value of peritoneal cytology as ...part of the staging of gastric cancer and survival prediction. The second aim was to establish if positive cytology may be modified by neoadjuvant therapy, to improve prognosis.
Methods
An electronic literature search was performed using Embase, Medline, Web of Science, and Cochrane library databases up to January 2016. The logarithm of the hazard ratio (HR) with 95% confidence intervals (CI) was used as the primary summary statistic. Comparative studies were used, and the outcome measure was survival in three groups: (1) positive versus negative cytology at staging laparoscopy immediately preceding surgery; (2) effect of neoadjuvant therapy on cytology and survival; and (3) positive cytology in the absence of macroscopic peritoneal disease was compared with obvious macroscopic peritoneal disease.
Results
Pooled analysis demonstrated that positive cytology was associated with significantly reduced overall survival (HR, 3.46; 95% CI, 2.77–4.31;
P
< 0.0001). Interestingly, negative cytology following neoadjuvant chemotherapy was associated with significantly improved overall survival (HR, 0.42; 95% CI, 0.31–0.57;
P
< 0.0001). The absence of macroscopic peritoneal disease with positive cytology was associated with significantly improved overall survival (HR, 0.64; 95% CI, 0.56–0.73;
P
< 0.0001).
Conclusion
This study suggests that patients with initial positive cytology may have a good prognosis following neoadjuvant treatment if the cytology results change to negative after treatment.
The detection and quantification of volatile organic compounds (VOCs) within exhaled breath have evolved gradually for the diagnosis of cancer. The overall diagnostic accuracy of proposed tests ...remains unknown.
To determine the diagnostic accuracy of VOC breath tests for the detection of cancer and to review sources of methodologic variability.
An electronic search (title and abstract) was performed using the Embase and MEDLINE databases (January 1, 2000, to May 28, 2017) through the OVID platform. The search terms cancer, neoplasm, malignancy, volatile organic compound, VOC, breath, and exhaled were used in combination with the Boolean operators AND and OR. A separate MEDLINE search that used the search terms breath AND methodology was also performed for studies that reported factors that influenced the concentration of VOCs within exhaled breath in humans.
The search was limited to human studies published in the English language. Trials that analyzed named endogenous VOCs within exhaled breath to diagnose or assess cancer were included in this review.
Systematic review and pooled analysis were conducted in accordance with the recommendations of the Cochrane Library and Meta-analysis of Observational Studies in Epidemiology guidelines. Bivariate meta-analyses were performed to generate pooled point estimates of the hierarchal summary receiver operating characteristic curve of breath VOC analysis. Included studies were assessed according to the Standards for Reporting of Diagnostic Accuracy Studies checklist and Quality Assessment of Diagnostic Accuracy Studies 2 tool.
The principal outcome measure was pooled diagnostic accuracy of published VOC breath tests for cancer.
The review identified 63 relevant publications and 3554 patients. All reports constituted phase 1 biomarker studies. Pooled analysis of findings found a mean (SE) area under the receiver operating characteristic analysis curve of 0.94 (0.01), sensitivity of 79% (95% CI, 77%-81%), and specificity of 89% (95% CI, 88%-90%). Factors that may influence variability in test results included breath collection method, patient physiologic condition, test environment, and method of analysis.
The findings of our review suggest that standardization of breath collection methods and masked validation of breath test accuracy for cancer diagnosis is needed among the intended population in multicenter clinical trials. We propose a framework to guide the conduct of future breath tests in cancer studies.
Background
Acute appendicitis is the most common surgical emergency and can represent a challenging diagnosis, with a negative appendectomy rate as high as 20 %. This review aimed to evaluate the ...clinical utility of individual biomarkers in the diagnosis of appendicitis and appraise the quality of these studies.
Methods
A systematic review of the literature between January 2000 and September 2015 using of PubMed, OvidMedline, EMBASE and Google Scholar was conducted. Studies in which the diagnostic accuracy, statistical heterogeneity and predictive ability for severity of several biomarkers could be elicited were included. Information regarding costs and process times was retrieved from the regional laboratory. European surgeons blinded to these reviews were independently asked to rank which characteristics of biomarkers were most important in acute appendicitis to inform a cost–benefit trade-off. Sensitivity testing and the QUADAS-2 tool were used to assess the robustness of the analysis and study quality, respectively.
Results
Sixty-two studies met the inclusion criteria and were assessed. Traditional biomarkers (such as white cell count) were found to have a moderate diagnostic accuracy (0.75) but lower costs in the diagnosis of acute appendicitis. Conversely, novel markers (pro-calcitonin, IL 6 and urinary 5-HIAA) were found to have high process-related costs including analytical times, but improved diagnostic accuracy. QUADAS-2 analysis revealed significant potential biases in the literature.
Conclusion
When assessing biomarkers, an appreciation of the trade-offs between the costs and benefits of individual biomarkers is needed. Further studies should seek to investigate new biomarkers and address concerns over bias, in order to improve the diagnosis of acute appendicitis.
This JAMA Patient Page describes the causes, symptoms and signs, and treatments, including medication (eg, proton pump inhibitors) and surgery (eg, fundoplication), for gastroesophageal reflux ...disease (GERD).
The unprecedented pandemic of COVID-19 has impacted many lives and affects the whole healthcare systems globally. In addition to the considerable workload challenges, surgeons are faced with a number ...of uncertainties regarding their own safety, practice, and overall patient care. This guide has been drafted at short notice to advise on specific issues related to surgical service provision and the safety of minimally invasive surgery during the COVID-19 pandemic. Although laparoscopy can theoretically lead to aerosolization of blood borne viruses, there is no evidence available to confirm this is the case with COVID-19. The ultimate decision on the approach should be made after considering the proven benefits of laparoscopic techniques versus the potential theoretical risks of aerosolization. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties and all members of the OR staff should use personal protective equipment (PPE) in all surgical procedures during the pandemic regardless of known or suspected COVID status. Pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open. All emergent endoscopic procedures performed during the pandemic should be considered as high risk and PPE must be used by all endoscopy staff.
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