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Showing papers in "Annals of Surgery in 2015"


Journal ArticleDOI
TL;DR: The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development.
Abstract: The use of laparoscopy for liver surgery is increasing rapidly. The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development. Seventeen questions were addressed. The first 7 questions focused on outcomes that reflect the benefits and risks of LLR. These questions were addressed using the Zurich-Danish consensus conference model in which the literature and expert opinion were weighed by a 9-member jury, who evaluated LLR outcomes using GRADE and a list of comparators. The jury also graded LLRs by the Balliol Classification of IDEAL. The jury concluded that MINOR LLRs had become standard practice (IDEAL 3) and that MAJOR liver resections were still innovative procedures in the exploration phase (IDEAL 2b). Continued cautious introduction of MAJOR LLRs was recommended. All of the evidence available for scrutiny was of LOW quality by GRADE, which prompted the recommendation for higher quality evaluative studies. The last 10 questions focused on technical questions and the recommendations were based on literature review and expert panel opinion. Recommendations were made regarding preoperative evaluation, bleeding controls, transection methods, anatomic approaches, and equipment. Both experts and jury recognized the need for a formal structure of education for those interested in performing major laparoscopic LLR because of the steep learning curve.

1,064 citations


Journal ArticleDOI
TL;DR: The proposed system for defining and recording perioperative complications associated with esophagectomy provides an infrastructure to standardize international data collection and facilitate future comparative studies and quality improvement projects.
Abstract: Introduction: Perioperative complications influence long- and short-term outcomes after esophagectomy. The absence of a standardized system for defining and recording complications and quality measures after esophageal resection has meant that there is wide variation in evaluating their impact on these outcomes. Methods: The Esophageal Complications Consensus Group comprised 21 high-volume esophageal surgeons from 14 countries, supported by all the major thoracic and upper gastrointestinal professional societies. Delphi surveys and group meetings were used to achieve a consensus on standardized methods for defining complications and quality measures that could be collected in institutional databases and national audits. Results: A standardized list of complications was created to provide a template for recording individual complications associated with esophagectomy. Where possible, these were linked to preexisting international definitions. A Delphi survey facilitated production of specific definitions for anastomotic leak, conduit necrosis, chyle leak, and recurrent nerve palsy. An additional Delphi survey documented consensus regarding critical quality parameters recommended for routine inclusion in databases. These quality parameters were documentation on mortality, comorbidities, completeness of data collection, blood transfusion, grading of complication severity, changes in level of care, discharge location, and readmission rates. Conclusions: The proposed system for defining and recording perioperative complications associated with esophagectomy provides an infrastructure to standardize international data collection and facilitate future comparative studies and quality improvement projects.

733 citations


Journal ArticleDOI
TL;DR: After neoadjuvant FOLFIRINOX imaging no longer predicts unresectability, traditional pathologic predictors of survival are improved, and morbidity is decreased in comparison to patients with clearly resectable cancers at the time of presentation.
Abstract: The prevalence of pancreatic adenocarcinoma (PDAC) continues to increase. The American Cancer Society predicts 46,420 new cases and 39,590 deaths in the United States in 2014. The majority of patients present with metastatic disease, whereas 30% present with locally advanced (LA) cancers.1 Unfortunately, overall survival (OS) of pancreatic cancer patients remains low, with surgical resection offering the only chance for potential cure. However, even then the OS is reported to be less than 20%.2–4 In the hopes of rendering LA PDAC patients resectable, combination chemotherapy often followed by 50.4 Gy of radiation with low-dose chemotherapy is administered.5,6 However, historically only 19% to 30% of patients are rendered resectable.7–10 If an R0 resection can be achieved, OS is similar to patients who are considered resectable at presentation.9 Unfortunately, these heavily treated patients with LA PDAC have an increased surgical morbidity and mortality.9,11 A significant breakthrough for patients with metastatic PDAC was achieved in 2011 with the ACCORD trial.12 This trial demonstrated that the OS with fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX) was improved when compared with gemcitabine for patients with metastatic pancreatic cancer (6.8 vs 11.1 months, P < 0.001).12 On the basis of these encouraging results, FOLFIRINOX became a rational choice to render patients with LA PDAC resectable.13 Resectability of PDAC is determined by radiologic imaging. The most commonly used imaging modality to stage PDAC is a triple-phase contrast-enhanced thin-slice (multidetector row) helical computed tomography with 3-dimensional reconstructions. Unfortunately, the definitions for LA and borderline lesions vary significantly. This ambiguity prompted 4 guideline statements from the National Comprehensive Cancer Network, the University of Texas MD Anderson Cancer Center, the Americas Hepato-Pancreato-Biliary Association (AHPBA)/Society of Surgical Oncology (SSO)/Society for Surgery of the Alimentary Tract (SSAT).14–17 These guidelines address vascular involvement, which is a major determinant of unresectability. This study provides the largest series of neoadjuvantly treated FOLFIRINOX patients who underwent surgical resection. Radiologic and clinicopathologic features of patients with either LA or borderline resectable pancreatic cancer who received neoadjuvant FOLFIRINOX were compared with resectable patients who underwent exploration without neoadjuvant treatment. The first aim of this study is to critically evaluate the accuracy of imaging in determining resectability after FOLFIRINOX with or without chemoradiation. The second aim is to compare the surgical outcomes and clinicopathologic results of pancreatic resections in this cohort of FOLFIRINOX-treated patients with patients who received no neoadjuvant therapy.

666 citations


Journal ArticleDOI
TL;DR: It is demonstrated that in a large, international cohort of patients, increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome.
Abstract: Background: The ERAS (enhanced recovery after surgery) care has been shown in randomized clinical trials to improve outcome after colorectal surgery compared to traditional care. The impact of different levels of compliance and specific elements, particularly out with a trial setting, is poorly understood.Objective: This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection.Methods: The international, multicenter ERAS registry data, collected between November 2008 and March 2013, was reviewed. Patient demographics, disease characteristics, and perioperative ERAS protocol compliance were assessed. Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication.Findings: A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries. Median length of stay for colorectal resections was 6 days, with readmissions in 216 (9.2%), complications in 948 (40%), and reoperation in 167 (7.1%) of 2352 patients. Laparoscopic surgery was associated with reduced complications [odds ratio (OR) = 0.68; P < 0.001] and length of stay (OR = 0.83, P < 0.001). Increasing ERAS compliance was correlated with fewer complications (OR = 0.69, P < 0.001) and shorter primary hospital admission (OR = 0.88, P < 0.001). Shorter hospital stay was associated with preoperative carbohydrate and fluid loading (OR = 0.89, P = 0.001), and totally intravenous anesthesia (OR= 0.86, P < 0.001); longer stay was associated with intraoperative epidural analgesia (OR = 1.07, P = 0.019). Reduced postoperative complications were associated with restrictive perioperative intravenous fluids (OR = 0.35, P < 0.001).Conclusions: This analysis has demonstrated that in a large, international cohort of patients, increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome.

519 citations


Journal ArticleDOI
TL;DR: Most of the variables associated with outcome after recurrence are linked to the primary tumor at initial presentation, Nevertheless, meaningful survival can be achieved with appropriate treatment of recurrent tumors.
Abstract: Objective:We sought to determine the factors associated with survival after recurrence of hepatocellular cancer (HCC) after resection and the outcome of our prospectively applied treatment protocol.Background:Very little is known about the prognosis of HCC that recurs after resection and the outcome

513 citations


Journal ArticleDOI
TL;DR: Functional compromise in colorectal cancer surgery is associated with adverse postoperative outcome and assessment of functional compromise by means of a nutritional questionnaire, a frailty questionnaire, and sarcopenia measurement can accurately predict postoperative sepsis.
Abstract: Objective: To determine the association of sarcopenia with postoperative morbidity and mortality after colorectal surgery. Background: Functional compromise in elderly colorectal surgical patients is considered as a significant factor of impaired postoperative recovery. Therefore, the predictive value of preoperative functional compromise assessment was investigated. Sarcopenia is a hallmark of functional compromise. Methods: A total of 310 consecutive patients who underwent oncologic colorectal surgery were included in a prospective digital database. Sarcopenia was assessed using the L3 muscle index utilizing Osirix on preoperative computed tomography. Groningen Frailty Indicator and Short Nutritional Assessment Questionnaire scores were used to assess frailty and nutritional compromise. Predictors for anastomotic leakage, sepsis, and mortality were analyzed by logistic regression analysis. Results: Age was an independent predictor of mortality [P = 0.04; odds ratio, 1.17; 95% confidence interval (CI), 1.01–1.37]. Thirty-day/in-hospital mortality rate in sarcopenic patients was 8.8% versus 0.7% in nonsarcopenic patients (P = 0.001; odds ratio, 15.5; 95% CI, 2.00–120). Sarcopenia was not predictive for anastomotic leakage or sepsis. Combination of high Short Nutritional Assessment Questionnaire score, high Groningen Frailty Indicator score, and sarcopenia strongly predicted sepsis (P = 0.001; odds ratio, 25.1; 95% CI, 5.11–123), sensitivity, 46%; specificity, 97%; positive likelihood ratio, 13 (95% CI, 4.4–38); negative likelihood ratio, 0.57 (95% CI, 0.33– 0.97). Conclusions: Functional compromise in colorectal cancer surgery is associated with adverse postoperative outcome. Assessment of functional compromise by means of a nutritional questionnaire (Short Nutritional Assessment Questionnaire), a frailty questionnaire (Groningen Frailty Indicator), and sarcopenia measurement (L3 muscle index) can accurately predict postoperative sepsis.

395 citations


Journal ArticleDOI
TL;DR: These data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection, and MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colOREctal surgery.
Abstract: Objectives:To clarify whether bowel preparation use or its individual components [mechanical bowel preparation (MBP)/oral antibiotics] impact specific outcomes after colorectal surgery.Methods:National Surgical Quality Improvement Program–targeted colectomy data initiated in 2012 capture information

324 citations


Journal ArticleDOI
TL;DR: This study shows that marking and selectively removing metastatic lymph nodes after neoadjuvant systemic treatment has a high identification rate and a low false negative rate and the tumor response in the marked lymph node may be used to tailor further axillary treatment after NST.
Abstract: Objective:The MARI procedure [marking the axillary lymph node with radioactive iodine (125I) seeds] is a new minimal invasive method to assess the pathological response of nodal metastases after neoadjuvant systemic treatment (NST) in patients with breast cancer. This method allows axilla-conserving

321 citations


Journal ArticleDOI
TL;DR: For patients with LAPC (stage III), the addition of IRE to conventional chemotherapy and radiation therapy results in substantially prolonged survival compared with historical controls, suggesting that ablative control of the primary tumor may prolong survival.
Abstract: Objectives:Ablative therapies have been increasingly utilized in the treatment of locally advanced pancreatic cancer (LAPC). Irreversible electroporation (IRE) is an energy delivery system, effective in ablating tumors by inducing irreversible membrane destruction of cells. We aimed to demonstrate e

321 citations


Journal ArticleDOI
TL;DR: For NDM patients, but not DM patients, the risk of adverse events was linked to hyperglycemia, and underlying this paradoxical effect may be the underuse of insulin, but also that hyper glycemia indicates higher levels of stress in NDM Patients than in DM patients.
Abstract: Objective:To study the association between diabetes status, perioperative hyperglycemia, and adverse events in a statewide surgical cohortBackground:Perioperative hyperglycemia may increase the risk of adverse events more significantly in patients without diabetes (NDM) than in those with diabetes

303 citations


Journal ArticleDOI
TL;DR: Among US hospitals that perform major surgical procedures, hospitals with high patient satisfaction provided more efficient care and were associated with higher surgical quality, suggesting there need not be a trade-off between good quality of care for surgical patients and ensuring a positive patient experience.
Abstract: Objective:The relationship between patient satisfaction and surgical quality is unclear for US hospitals. Using national data, we examined if hospitals with high patient satisfaction have lower levels of performance on accepted measures of the quality and efficiency of surgical care.Background:Feder

Journal ArticleDOI
TL;DR: Sarcopenia was found to be a strong and independent prognostic factor for mortality after hepatectomy for HCC in European patients and could be used to evaluate eligibility of patients with HCC before surgery.
Abstract: Objective:To evaluate the prevalence of sarcopenia among European patients with resectable hepatocellular carcinoma (HCC) and to assess its prognostic impact on overall and disease-free survival.Background:Identification of preoperative prognostic factors in liver surgery for HCC is required to bett

Journal ArticleDOI
TL;DR: No graft failure due to intrahepatic cholangiopathy or nonfunction occurred in HOPE-treated livers, whereas 18% of unperfused DCD livers needed retransplantation.
Abstract: BACKGROUND: Exposure of donor liver grafts to prolonged periods of warm ischemia before procurement causes injuries including intrahepatic cholangiopathy, which may lead to graft loss. Due to unavoidable prolonged ischemic time before procurement in donation after cardiac death (DCD) donation in 1 participating center, each liver graft of this center was pretreated with the new machine perfusion "Hypothermic Oxygenated PErfusion" (HOPE) in an attempt to improve graft quality before implantation. METHODS: HOPE-treated DCD livers (n = 25) were matched and compared with normally preserved (static cold preservation) DCD liver grafts (n = 50) from 2 well-established European programs. Criteria for matching included duration of warm ischemia and key confounders summarized in the balance of risk score. In a second step, perfused and unperfused DCD livers were compared with liver grafts from standard brain dead donors (n = 50), also matched to the balance of risk score, serving as baseline controls. RESULTS: HOPE treatment of DCD livers significantly decreased graft injury compared with matched cold-stored DCD livers regarding peak alanine-aminotransferase (1239 vs 2065 U/L, P = 0.02), intrahepatic cholangiopathy (0% vs 22%, P = 0.015), biliary complications (20% vs 46%, P = 0.042), and 1-year graft survival (90% vs 69%, P = 0.035). No graft failure due to intrahepatic cholangiopathy or nonfunction occurred in HOPE-treated livers, whereas 18% of unperfused DCD livers needed retransplantation. In addition, HOPE-perfused DCD livers achieved similar results as control donation after brain death livers in all investigated endpoints. CONCLUSIONS: HOPE seems to offer important benefits in preserving higher-risk DCD liver grafts.

Journal ArticleDOI
TL;DR: Hospital costs and mortality are strongly associated with postoperative AKI, are correlated with the severity ofAKI, and are much higher for patients with other postoperative complications in addition to AKI.
Abstract: Objective To determine the incremental hospital cost and mortality associated with the development of postoperative acute kidney injury (AKI) and with other associated postoperative complications. Background Each year 1.5 million patients develop a major complication after surgery. Postoperative AKI is one of the most common postoperative complications and is associated with an increase in hospital mortality and decreased survival for up to 15 years after surgery. Methods In a single-center cohort of 50,314 adult surgical patients undergoing major inpatient surgery, we applied risk-adjusted regression models for cost and mortality using postoperative AKI and other complications as the main independent predictors. We defined AKI using consensus Risk, Injury, Failure, Loss and End-Stage Renal Disease criteria. Results The prevalence of AKI was 39% among 50,314 patients with available serum creatinine. Patients with AKI were more likely to have postoperative complications and had longer lengths of stay in the intensive care unit and the hospital. The risk-adjusted average cost of care for patients undergoing surgery was $42,600 for patients with any AKI compared with $26,700 for patients without AKI. The risk-adjusted 90-day mortality was 6.5% for patients with any AKI compared with 4.4% for patients without AKI. Serious postoperative complications resulted in increased cost of care and mortality for all patients, but the increase was much larger for those patients with any degree of AKI. Conclusions Hospital costs and mortality are strongly associated with postoperative AKI, are correlated with the severity of AKI, and are much higher for patients with other postoperative complications in addition to AKI.

Journal ArticleDOI
TL;DR: The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors, and the impact on long- term outcome is primarily driven by infectious complications, particularly severe postoperative infections.
Abstract: Objective:We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection.Background:The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial.Methods:The Veterans Affairs Surgical Qua

Journal ArticleDOI
TL;DR: Anastomotic leak after colon resection for cancer is a frequent, relevant complication and patients, surgical technique, and hospital are all important determining factors of anastomosis leak risk.
Abstract: Objective:To determine pre-/intraoperative risk factors for anastomotic leak after colon resection for cancer and to create a practical instrument for predicting anastomotic leak risk.Background:Anastomotic leak is still the most dreaded complication in colorectal surgery. Many risk factors have bee

Journal ArticleDOI
TL;DR: Combined bowel preparation with mechanical cleansing and oral antibiotics results in a significantly lower incidence of incisional surgical site infection, anastomotic leakage, and hospital readmission when compared to no preoperative bowel preparation.
Abstract: Objective:To determine the association between preoperative bowel preparation and 30-day outcomes after elective colorectal resection.Methods:Patients from the 2012 Colectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who underwent electi

Journal ArticleDOI
TL;DR: In this paper, the authors compared short-term results obtained with transanal total mesorectal excision (TME) and laparoscopic surgery and found that TME appeared as an alternative in the treatment of rectal cancer and other rectal disease.
Abstract: Objective:The aim of this study was to compare short-term results obtained with transanal total mesorectal excision (TME) and laparoscopic surgery.Background:Transanal TME appears as an alternative in the treatment of rectal cancer and other rectal disease. Natural orifices transluminal endoscopic s

Journal ArticleDOI
TL;DR: This pilot trial suggests that nonoperatively treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted.
Abstract: Methods: A pilot randomized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children. Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were randomized either to treatment with antibiotics or to surgery. Follow-up was for 1 year. Results: Fifty patients were enrolled; 26 were randomized to surgery and 24 to nonoperative treatment with antibiotics. All children in the surgery group had histopathologically confirmed acute appendicitis, and there were no significant complications in this group. Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis. Another 6 patients have had an appendectomy due to recurrent abdominal pain (n = 5) or parental wish (n = 1) during the follow-up period; none of these 6 patients had evidence of appendicitis on histopathological examination. Conclusions: Twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted.

Journal ArticleDOI
TL;DR: These results support ch-EVAR as a valid off-the-shelf and immediately available alternative in the treatment of complex abdominal EVAR and provide impetus for the standardization of these techniques in the future.
Abstract: OBJECTIVES: We sought to analyze the collected worldwide experience with use of snorkel/chimney endovascular aneurysm repair (EVAR) for complex abdominal aneurysm treatment. BACKGROUND: EVAR has largely replaced open surgery worldwide for anatomically suitable aortic aneurysms. Lack of availability of fenestrated and branched devices has encouraged an alternative strategy utilizing parallel or snorkel/chimney grafts (ch-EVAR). METHODS: Clinical and radiographic information was retrospectively reviewed and analyzed on 517 patients treated by ch-EVAR from 2008 from 2014 by prearranged defined and documented protocols. RESULTS: A total of 119 patients in US centers and 398 in European centers were treated during the study period. US centers preferentially used Zenith stent-grafts (54.2%) and European centers Endurant stent-grafts (62.2%) for the main body component. Overall 898 chimney grafts (49.2% balloon expandable, 39.6% self-expanding covered stents, and 11.2% balloon expandable bare metal stents) were placed in 692 renal arteries, 156 superior mesenteric arteries (SMA), and 50 celiac arteries. At a mean follow-up of 17.1 months (range: 1-70 months), primary patency was 94%, with secondary patency of 95.3%. Overall survival of patients in this high-risk cohort for open repair at latest follow-up was 79%. CONCLUSIONS: This global experience represents the largest series in the ch-EVAR literature and demonstrates comparable outcomes to those in published reports of branched/fenestrated devices, suggesting the appropriateness of broader applicability and the need for continued careful surveillance. These results support ch-EVAR as a valid off-the-shelf and immediately available alternative in the treatment of complex abdominal EVAR and provide impetus for the standardization of these techniques in the future.

Journal ArticleDOI
TL;DR: Laroscopic liver resection for HCC is associated with less blood loss, shorter hospital stay, and fewer postoperative complications in selected patients with no compromise in survival.
Abstract: INTRODUCTION Laparoscopic liver resection has been reported as a safe and effective approach to the management of liver cancer. However, studies of long-term outcomes regarding tumor recurrence and patient survival in comparison with the conventional open approach are limited. The aim of this study was to analyze the survival outcome of laparoscopic liver resection versus open liver resection. PATIENTS AND METHODS Between October 2002 and September 2009, 32 patients underwent pure laparoscopic liver resection for hepatocellular carcinoma (HCC). Case-matched control patients (n = 64) who received open liver resection for HCC were included for comparison. Patients were matched in terms of cancer stage, tumor size, location of tumor, and magnitude of resection. Immediate operation outcomes, operation morbidity, disease-free survival, and overall survival were compared between groups. RESULTS With the laparoscopic group compared with the open resection group, operation time was 232.5 minutes versus 204.5 minutes (P = 0.938), blood loss was 150 mL versus 300 mL (P = 0.001), hospital stay was 4 days versus 7 days (P < 0.0001), postoperative complication was 2 (6.3%) versus 12 (18.8%) (P = 0.184), disease-free survival was 78.5 months versus 29 months (P = 0.086), and overall survival was 92 months versus 71 months (P = 0.142). The disease-free survival for stage II HCC was 22.1 months versus 12.4 months (P = 0.075). CONCLUSIONS Laparoscopic liver resection for HCC is associated with less blood loss, shorter hospital stay, and fewer postoperative complications in selected patients with no compromise in survival.

Journal ArticleDOI
TL;DR: This large multicenter study provides strong evidence that SEAL adversely impacts cancer prognosis and the mechanism through which SEAL increases local recurrence is an important area for future research.
Abstract: Objective The aim of this study was to the determine impact of severe esophageal anastomotic leak (SEAL) upon long-term survival and locoregional cancer recurrence Background The impact of SEAL upon long-term survival after esophageal resection remains inconclusive with a number of studies demonstrating conflicting results Methods A multicenter database for the surgical treatment of esophageal cancer collected data from 30 university hospitals (2000-2010) SEAL was defined as a Clavien-Dindo III or IV leak Patients with SEAL were compared with those without in terms of demographics, tumor characteristics, surgical technique, morbidity, survival, and recurrence Results From a database of 2944 operated on for esophageal cancer between 2000 and 2010, 209 patients who died within 90 days of surgery and 296 patients with a R1/R2 resection were excluded, leaving 2439 included in the final analysis; 208 (85%) developed a SEAL and significant independent association was observed with low hospital procedural volume, cervical anastomosis, tumoral stage III/IV, and pulmonary and cardiovascular complications SEAL was associated with a significant reduction in median overall (358 vs 548 months; P = 0002) and disease-free (34 vs 479 months; P = 0005) survivals After adjustment of confounding factors, SEAL was associated with a 28% greater likelihood of death [hazard ratio = 128; 95% confidence interval (CI): 104-159; P = 0022], as well as greater overall (OR = 135; 95% CI: 115-173; P = 0011), locoregional (OR = 156; 95% CI: 105-224; P = 0030), and mixed (OR = 181; 95% CI: 120-271; P = 0014) recurrences Conclusions This large multicenter study provides strong evidence that SEAL adversely impacts cancer prognosis The mechanism through which SEAL increases local recurrence is an important area for future research

Journal ArticleDOI
TL;DR: This analysis of the largest cohort of ALPPS patients so far identifies those patients in whom stage-2 ALPPS surgery should be delayed or even denied, and may help to make ALPPS safer.
Abstract: OBJECTIVES: The aim of this study was to identify predictors of 90-day mortality after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS), available after stage-1, either to omit or delay stage-2. BACKGROUND DATA: ALPPS is a two-stage hepatectomy for patients with extensive liver tumors with predicted small liver remnants, which has been criticized for its high mortality rate. Risk factors for mortality are unknown. METHODS: Patients in the International Registry undergoing ALPPS from April 2011 to July 2014 were analyzed. Primary outcome was 90-day mortality. Liver function after stage-1 was assessed using the criteria of the International Study Group for Liver Surgery (ISGLS) after stage-1 among others. A multivariable model was used to identify independent predictors of 90-day mortality. RESULTS: Three hundred twenty patients registered by 55 centers worldwide were evaluated. Overall 90-day mortality was 8.8% (28/320). The predominant cause for 90-day mortality was postoperative liver failure in 75% of patients. Fourteen percent of patients developed liver failure according to ISGLS criteria already after stage-1 ALPPS. Those and patients with a model of end-stage liver disease (MELD) score more than 10 before stage-2 were at significantly higher risk for 90-day mortality after stage-2 with an odds ratio (OR) 3.9 [confidence interval (CI) 1.4-10.9, P = 0.01] and OR 4.9 (CI 1.9-12.7, P = 0.006), respectively. Other factors, such as size of future liver remnant (FLR) before stage-2 and time between stages, were not predictive. CONCLUSIONS: This analysis of the largest cohort of ALPPS patients so far identifies those patients in whom stage-2 ALPPS surgery should be delayed or even denied. These findings may help to make ALPPS safer.

Journal ArticleDOI
TL;DR: Evaluating how the World Health Organization surgical safety checklist was implemented across hospitals in England identified common themes that have aided or hindered the introduction of the WHO checklist in England and have translated into recommendations to guide the implementation of improvement initiatives in surgery and wider health care systems.
Abstract: Objectives: To evaluate how the World Health Organization (WHO) surgical safety checklist was implemented across hospitals in England; to identify barriers and facilitators toward implementation; and to draw out lessons for implementing improvement initiatives in surgery/health care more generally. Background: The WHO checklist has been linked to improved surgical outcomes and teamwork, yet we know little about the factors affecting its successful uptake. Methods: A longitudinal interview study with operating room personnel was conducted across a representative sample of 10 hospitals in England between March 2010 and March 2011. Interviews were audio recorded over the phone. Interviewees were asked about their experience of how the checklist was introduced and the factors that hindered or aided this process. Transcripts were submitted to thematic analysis. Results: A total of 119 interviews were completed. Checklist implementation varied greatly between and within hospitals, ranging from preplanned/phased approaches to the checklist simply “appearing” in operating rooms, or staff feeling it had been imposed. Most barriers to implementation were specific to the checklist itself (eg, perceived design issues) but also included problematic integration into preexisting processes. The most common barrier was resistance from senior clinicians. The facilitators revealed some positive steps that can been taken to prevent/address these barriers, for example, modifying the checklist, providing education/training, feeding-back local data, fostering strong leadership (particularly at attending level), and instilling accountability. Conclusions: We identified common themes that have aided or hindered the

Journal ArticleDOI
TL;DR: It is suggested that MIPD is a complex procedure for which comprehensive protocols outlining criteria for implementation might be warranted to optimize patient safety, and its use is associated with increased 30-day mortality.
Abstract: Objectives:To describe national practice patterns regarding utilization of minimally invasive pancreaticoduodenectomy (MIPD) and compare short-term outcomes with those following open pancreaticoduodenectomy for cancer.Background:There is increasing interest in use of MIPD; however, published data ar

Journal ArticleDOI
TL;DR: Implementation of the World Health Organization's Surgical Safety Checklist was associated with robust reduction in morbidity and length of in-hospital stay and some reduction in mortality.
Abstract: Objectives:We hypothesized reduction of 30 days' in-hospital morbidity, mortality, and length of stay postimplementation of the World Health Organization's Surgical Safety Checklist (SSC).Background:Reductions of morbidity and mortality have been reported after SSC implementation in pre-/postdesigne

Journal ArticleDOI
TL;DR: The aim of this study was to evaluate the use of laser-assisted fluorescent-dye angiography to assess perfusion in gastric grafts and determine the relationship between perfusion and anastomotic leaks.
Abstract: Objective:The aim of the study was to evaluate laser-assisted fluorescent-dye angiography (LAA) to assess perfusion in the gastric graft and to correlate perfusion with subsequent anastomotic leak.Background:Anastomotic leaks are a major source of morbidity after esophagectomy with gastric pull-up (

Journal ArticleDOI
TL;DR: The barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients are explored.
Abstract: Objective:Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients.Background:ERAS programs include perioperative interventions that when used toget

Journal ArticleDOI
TL;DR: In this paper, the authors evaluated long-term oncologic outcomes of robotic surgery for rectal cancer compared with laparoscopic surgery at a single institution and found that robotic surgery is regarded as a new modality to surpass the technical limitations of conventional surgery.
Abstract: Objective:The aim of this study is to evaluate long-term oncologic outcomes of robotic surgery for rectal cancer compared with laparoscopic surgery at a single institution.Background:Robotic surgery is regarded as a new modality to surpass the technical limitations of conventional surgery. Short-ter

Journal ArticleDOI
TL;DR: Comprehensive surgical coaching enhances surgical training and results in skill acquisition superior to conventional training.
Abstract: available at http://www.ncbi.nlm.nih.gov/pubmed/25822691 Editorial Comment: The concept of surgical coaching is a relatively new idea to help improve training and education for surgeons and surgical residents. In this study 20 residents were ran- domized to undergo either 1) intense coaching during surgery, including ward and operating room duties, regular departmental sessions, performance analysis, debriefing, feedback and behavior modeling, or 2) standard conventional training. Video analysis of surgical resident performance was assessed in a blinded fashion. Residents with intensive surgical training scored higher in terms of procedural skills and made fewer technical errors during surgery. Thus surgical coaching, like coaching in sports and music, seems to benefit the surgeon in training, and one wonders if this is a model for future training.