Introduction
Open esophagectomy for cancer is a major oncological procedure, associated with significant morbidity and mortality. Recently, thoracoscopic procedures have offered a potentially ...advantageous alternative because of less operative trauma compared with thoracotomy. The aim of this study was to utilize meta-analysis to compare outcomes of open esophagectomy with those of minimally invasive esophagectomy (MIE) and hybrid minimally invasive esophagectomy (HMIE).
Methods
Literature search was performed using Medline, Embase, Cochrane Library, and Google Scholar databases for comparative studies assessing different techniques of esophagectomy. A random-effects model was used for meta-analysis, and heterogeneity was assessed. Primary outcomes of interest were 30-day mortality and anastomotic leak. Secondary outcomes included operative outcomes, other postoperative outcomes, and oncological outcomes in terms of lymph nodes retrieved.
Results
A total of 12 studies were included in the analysis. Studies included a total of 672 patients for MIE and HMIE, and 612 for open esophagectomy. There was no significant difference in 30-day mortality; however, MIE had lower blood loss, shorter hospital stay, and reduced total morbidity and respiratory complications. For all other outcomes, there was no significant difference between the two groups.
Conclusion
Minimally invasive esophagectomy is a safe alternative to the open technique. Patients undergoing MIE may benefit from shorter hospital stay, and lower respiratory complications and total morbidity compared with open esophagectomy. Multicenter, prospective large randomized controlled trials are required to confirm these findings in order to base practice on sound clinical evidence.
Background
Although advocated by some, minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) is controversial. Moreover, the oncologic implications for patients requiring ...conversion to an open procedure during attempted MIA for ACC are not extensively reported.
Patients and Methods
The National Cancer Database was queried for patients undergoing resection for ACC. Overall survival (OS) for patients undergoing successful MIA was compared with those requiring conversion, and additionally evaluated with a multivariable Cox regression analysis including other factors associated with OS. After propensity matching, those experiencing conversion were further compared with patients who underwent planned open resection.
Results
Among 196 patients undergoing attempted MIA for ACC, 38 (19.4%) required conversion. Independent of 90-day postoperative mortality, conversion was associated with significantly reduced OS compared with successful MIA (median 27.9 months versus not reached,
p
= 0.002). Even for tumors confined to the adrenal, conversion was associated with worse median OS compared with successful MIA (median 34.2 months versus not reached,
p
= 0.003). After propensity matching for clinicopathologic covariates to establish well-balanced cohorts (
N
= 38 per group), patients requiring conversion during MIA had significantly worse OS than those having planned open resection (27.9 months versus 50.5 months,
p
= 0.020). On multivariable analysis for predictors of OS, conversion during MIA (HR 2.32,
p
= 0.003) was independently associated with mortality.
Conclusions
ACC is a rare tumor for which adequate oncologic resection is the only chance for cure. Given the relatively high rate of conversion and its associated inferior survival, open resection should be considered standard of care for known or suspected ACC.
Background
Perioperative chemotherapy is a standard-of-care treatment for patients with gastric cancer. However, the impact of the postoperative chemotherapy (postCTX) component on overall survival ...(OS) is not well defined.
Methods
The National Cancer Database (NCDB) 2006–2014 was queried for patients who received preoperative chemotherapy (preCTX) and resection for gastric cancer. Analysis was performed to identify factors influencing receipt of postCTX. The impact of postCTX on OS was evaluated in propensity-matched groups.
Results
Among 3449 patients who received preCTX and resection for gastric cancer, 1091 (31.6%) received postCTX. Independent predictors of receiving postCTX were diagnosis after 2010 (odds ratio OR 1.985), distal tumor location (OR 1.348), and 15 or more lymph nodes examined (OR 1.214). Predictors of not receiving postCTX were older age (OR 0.985), comorbidity score higher than 1 (OR 0.592), and black race (OR 0.791). After propensity-matching (1091 per group), the median OS was 56.8 months for those who did receive postCTX versus 52.5 months for those who did not (
p
= 0.131). Subset analysis according to tumor grade, lymphovascular invasion, number of lymph nodes evaluated, T and N class, and AJCC stage identified an improvement in OS for the patients with N1 disease who received postCTX compared with those who did not (79.6 vs 41.3 months;
p
= 0.025). However, no other subgroup had a significant survival benefit.
Conclusions
Additional postCTX was administered to a minority of patients who received preCTX and gastrectomy for gastric cancer, and its influence on OS appeared to be limited. Future trials should aim to define patients who will benefit from postCTX.
Background
Venous thromboembolism (VTE) is a major cause of morbidity and mortality following distal pancreatectomy (DP). However, the influence of operative technique on VTE risk after DP is ...unknown.
Objective
The purpose of this study was to examine the association between the MIS technique versus the open technique and the development of postoperative VTE after DP.
Methods
Patients who underwent DP from 2014 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program pancreas-specific database. Multivariable logistic regression was then used to identify independent associations with the development of postoperative VTE after DP.
Results
A total of 3558 patients underwent DP during this time period. Of these cases, 47.8% (
n
= 1702) were performed via the MIS approach. After adjusting for significant covariates, the MIS approach was independently associated with the development of any VTE (odds ratio OR 1.60, 95% confidence interval CI 1.06–2.40;
p
= 0.025), as well as increasing the risk of developing a postdischarge VTE (OR 1.80, 95% CI 1.05–3.08;
p
= 0.033) when compared with the open approach. There was an association between VTE and the development of numerous postoperative complications, including pneumonia, unplanned intubation, need for prolonged mechanical ventilation, and cardiac arrest.
Conclusion
Compared with the open approach, the MIS approach is associated with higher rates of postoperative VTE in patients undergoing DP. The majority of these events are diagnosed after hospital discharge.
Abstract Background The best gastrointestinal reconstruction route after pylorus preserving pancreaticoduodenectomy remains debatable. We aimed to evaluate the incidence of delayed gastric emptying ...(DGE) after antecolic (AC) and retrocolic (RC) duodenojejunostomy in these patients. Data Sources Studies comparing AC to RC reconstruction after pylorus preserving pancreaticoduodenectomy were identified from literature databases (PubMed, MEDLINE, EMBASE, SCOPUS, and Cochrane). The meta-analysis included 10 studies with a total of 1,067 patients, where 504 patients underwent AC and 563 patients underwent RC reconstruction. The incidence of DGE was significantly lower with AC reconstruction in both randomized controlled trials (risk ratio = .44, confidence interval = .24 to.77, P = .005) and retrospective studies (risk ratio .21, confidence interval .14 to .30, P < .001) with less output and days of nasogastric tube use. AC reconstruction was associated with a decreased length of stay. There was no difference in operative time, blood loss, pancreatic fistula, and abdominal abscess/collections. Conclusions AC reconstruction seems to be associated with less DGE, with no association with pancreatic fistula or abscess formation.
Background The clinical significance of isolated calf vein thrombosis (ICVT) remains controversial. Several studies have shown that the majority of ICVT do not propagate above the knee while other ...studies have suggested ICVT propagation and recommend full anticoagulation. The purpose of this study was to determine the progression of ICVT, identify risk factors for clot propagation, and to evaluate further thrombotic events associated with it. Methods This study consisted of 156 patients and a total of 180 limbs. All patients included had ICVT involving either the tibial, peroneal, gastrocnemius, or the soleal vein. After initial diagnosis, all patients were started on prophylactic dose of low molecular weight heparin (LMWH) or unfractionated heparin, unless already anticoagulated. All limbs were monitored using duplex ultrasonography scans at intervals of 2 to 3 days, 1 to 3 months, and 6 to 8 months from the initial time of diagnosis. Outcomes examined included lysis of clot, propagation to a proximal vein, and pulmonary emboli. Results ICVT was detected in 180 limbs of 156 patients. No significant difference was noted in the gender of the patients or limb preference. Twenty-four patents had both limbs involved. The mean age was 77 years old and the mean follow-up was 5.1 months. The soleal vein was most commonly involved. The second most common vein involved was peroneal, followed by posterior tibial and then gastrocnemius. The least commonly involved vein was the anterior tibial with only one positive result on each side. Fifteen of 180 limbs (9%) had complete resolution of the thrombus within 72 hours. Of these, six were anticoagulated to a therapeutic level. All patients had a follow-up duplex scan within 1 to 3 months' time, and none had recurrence. At the 1 to 3-month follow-up, 11 of 180 patients (7%) had propagation to a proximal vein; all of whom were in a high-risk group to develop a deep vein thrombosis (DVT), either after an orthopedic procedure, stroke, or malignancy. Nine of 156 patients developed a pulmonary emboli also diagnosed within the 1 to 3-months' time period. At the 6 to 8-month follow-up, there was no further propagation of any additional limbs and no further incidences of pulmonary emboli. Conclusion ICVT can be safely observed in asymptomatic patients without therapeutic anticoagulation. In our study, patients who have had orthopedic procedures, those with malignancy, and those that were immobile seemed to have a higher incidence of clot propagation. In this group, we recommend full anticoagulation until the patient is ambulatory or the follow-up duplex scan is negative. Our data also suggest that a follow-up duplex scan is not beneficial when performed within 72 hours or after 3 months.
Abstract Background Delayed gastric emptying (DGE) remains an unsolved complication after pancreaticoduodenectomy (PD) with conflicting reports of its cause. We aimed to compare the effect of ...surgical techniques involving the stomach in PD in lowering the risk of postoperative DGE. Methods Online search and review of key bibliographies in PubMed, Medline, Embase, Scopus, Cochrane, and Google Scholar was performed. Studies comparing PD surgical techniques were identified. Primary outcome was postoperative DGE. Methodological quality was assessed using STROBE and CONSORT. Calculated pooled relative risk and odds ratios (ORs) with the corresponding 95% confidence interval (CI) were used in the meta-analyses. Results Overall, 376 studies were reviewed, of which 22 studies were selected including a total of 5172 patients. The incidence of DGE was lower in antecolic compared with retrocolic gastrojejunostomy (risk ratio RR, 0.260; CI, 0.157–0.431; P < 0.001; n = 1067 patients) and in subtotal stomach preserving PD compared with pylorus preserving PD (RR, 0.527; CI, 0.363–0.763; P < 0.001; n = 663 patients). There was no significant difference between classic PD versus pylorus preserving PD (OR, 0.64; CI, 0.40–1.00; P = 0.05; n = 1209 patients), pancreaticogastrostomy versus pancreaticojejunostomy (RR, 1.02; CI, 0.62–1.68; P = 0.94; n = 961 patients), Roux-en-Y versus Billroth II gastrojejunostomy (RR, 0.946; CI, 0.788–1.136; P = 0.5513; n = 470 patients), or minimally invasive PD versus open PD (OR, 0.99; CI, 0.62–1.56; P = 0.96; n = 802). Conclusions In PD, surgical techniques using antecolic reconstruction route and subtotal stomach preserving PD seem to be associated with a lower risk of DGE. Further randomized controlled trials are necessary to evaluate these results taking other causes into consideration.
Background
In the USA, most patients with clinical stage II/III rectal cancer receive neoadjuvant chemoradiation (chemo/XRT) over 5–6 weeks followed by a 6–10-week break before proctectomy. As ...chemotherapy is delivered at radio-sensitizing doses, there is essentially a 3-month window during which potential systemic disease is untreated. Evidence regarding the utility of restaging patients prior to proctectomy is limited.
Methods
PubMed, Scopus, Web of Science, and the Cochrane Library were searched for studies evaluating the utility of restaging patients with rectal cancer after completion of long-course chemo/XRT, and reporting associated changes in management. Studies that were non-English, included <50 patients, or examining the diagnostic accuracy of imaging modalities were excluded. Study quality was evaluated using the modified Newcastle Ottawa Scale.
Results
Eight studies were identified including a total of 1251 patients restaged between completion of chemo/XRT and proctectomy. All studies were retrospective. Restaging identified new metastatic disease in 72 (6.0%) patients, with 4 studies reporting specific sites: liver (
n
= 28), lung (
n
= 8), adrenal (
n
= 1), bone (
n
= 1), and multiple sites (
n
= 7). Overall progression (distant or local) was detected in 88 (7.0%) patients and resulted in a change in management in 77 (87.5%) of these patients. Tumor-related prognostic characteristics were inconsistently reported among studies, precluding meta-analysis.
Conclusions
Although restaging between completion of neoadjuvant chemo/XRT and proctectomy detects disease progression in only a small percentage of patients, findings alter the treatment plan in the vast majority of these patients. Multi-institutional collaboration with analysis of well-defined prognostic variables may better identify patients most likely to benefit from restaging.
Background
Delayed gastric emptying (DGE) is one of the main complications after pancreaticoduodenectomy (PD). Literature review and meta-analysis were used to evaluate whether subtotal ...stomach-preserving pancreaticoduodenectomy (SSPPD) may have less incidence than pylorus-preserving pancreaticoduodenectomy (PPPD).
Methods
Online search for studies comparing PPPD to SSPPD was done. Primary outcome was DGE. Quality of included studies was evaluated and heterogeneity was assessed. Relative risk (RR) and 95 % confidence intervals (CI) were calculated from pooled data in RCTs and retrospective studies.
Results
Eight studies met our selection criteria, with a total of 663 patients undergoing pancreaticoduodenectomy; 309 underwent PPPD and 354 underwent SSPPD. Median age was 66 years. Average male/female ratio was 57 vs. 43 %, respectively. There was lower incidence of DGE with SSPPD (RR 0.527; 95 % CI 0.363–0.763;
p
< 0.001) and less nasogastric tube days with SSPPD (RR −0.544; 95 % CI −876 to −0.008;
p
= 0.047). Operative blood loss was more in SSPPD (RR 0.285; 95 % CI 0.071–0.499;
p
= 0.009). There was no statistical difference between the two groups regarding length of hospital stay, incidence of pancreatic fistula, abscesses, overall morbidity, or postoperative mortality.
Conclusion
SSPPD was associated with less DGE than PPPD. Larger prospective randomized studies are needed to investigate the association of this result with other complications in more depth.
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