Showing papers in "World Journal of Surgery in 2019"
Virginia Mason Medical Center1, The Royal Marsden NHS Foundation Trust2, University of Verona3, McGill University Health Centre4, Queen Mary University of London5, Karolinska Institutet6, Virginia Commonwealth University7, University of Queensland8, University Hospital of Lausanne9, Örebro University10
TL;DR: The current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.
Abstract: Enhanced recovery after surgery (ERAS) programs provide a format for multidisciplinary care and has been shown to predictably improve short term outcomes associated with surgical procedures. Esophagectomy has historically been associated with significant levels of morbidity and mortality and as a result routine application and audit of ERAS guidelines specifically designed for esophageal resection has significant potential to improve outcomes associated with this complex procedure. A team of international experts in the surgical management of esophageal cancer was assembled and the existing literature was identified and reviewed prior to the production of the guidelines. Well established procedure specific components of ERAS were reviewed and updated with changes relevant to esophagectomy. Procedure specific, operative and technical sections were produced utilizing the best current level of evidence. All sections were rated regarding the level of evidence and overall recommendation according to the evaluation (GRADE) system. Thirty-nine sections were ultimately produced and assessed for quality of evidence and recommendations. Some sections were completely new to ERAS programs due to the fact that esophagectomy is the first guideline with a thoracic component to the procedure. The current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.
294 citations
TL;DR: Prehabilitation can reduce overall and pulmonary morbidity following surgery and could be utilised routinely and further work is required to tailor optimal prehabilitation protocols for specific operative procedures.
Abstract: Prehabilitation prior to major surgery has increased in popularity over recent years and aims to improve pre-operative conditioning of patients to improve post-operative outcomes. The beneficial effect of such protocols is not well established with conflicting results reported. This review aimed to assess the effect of prehabilitation on post-operative outcome after major abdominal surgery. EMBASE, Medline, PubMed and the Cochrane database were searched in August 2018 for trials comparing outcomes of patients undergoing prehabilitation involving prescribed respiratory and exercise interventions prior to abdominal surgery. Study characteristics, overall and pulmonary morbidity, length of stay (LOS), maximum inspiratory pressure and change in six-minute walking test (6MWT) distance were obtained. The primary outcome was post-operative overall morbidity within 30 days. Dichotomous data were analysed by fixed or random effects odds ratio. Continuous data were analysed with weighted mean difference. Fifteen RCTs were included in the analysis with 457 prehabilitation patients and 450 control group patients. A significant reduction in overall (OR 0.63 95% CI 0.46–0.87 I2 34%, p = 0.005) and pulmonary morbidity (OR 0.4 95% CI 0.23–0.68, I2 = 0%, p = 0.0007) was observed in the prehabilitation group. No significant difference in LOS (WMD −2.39 95% CI −4.86 to 0.08 I2 = 0%, p = 0.06) or change in 6MWT distance (WMD 9.06 95% CI −35.68, 53.81 I2 = 88%, p = 0.69) was observed. Prehabilitation can reduce overall and pulmonary morbidity following surgery and could be utilised routinely. The precise protocol of prehabilitation has not been completely established. Further work is required to tailor optimal prehabilitation protocols for specific operative procedures.
206 citations
TL;DR: The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies to peer-reviewed journals and can also assist reviewers in evaluating the quality of ERas-related manuscripts.
Abstract: Background: Enhanced Recovery After Surgery (ERAS) programs are multimodal care pathways designed to minimize the physiologic and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature.
Methods: To improve the quality of ERAS reporting, the ERAS® USA and the ERAS® Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus.
Results: The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines.
Conclusions: The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals.
148 citations
TL;DR: Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC, with a moderate improvement in survival over time.
Abstract: Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types. Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study. The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p < 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004–2009: 8.05 months vs. 2010–2015: 9.49 months; p < 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of ≥6 lymph nodes increased over time (p < 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24–1.79, p < 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04–1.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p < 0.001). The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC.
103 citations
TL;DR: Analysis revealed that adherence to the ERAS protocol in Group 2 with ≥ 80% adherence was associated with a significantly shorter length of hospital stay, and a lower rate of postoperative complications, and improved functional recovery parameters.
Abstract: Enhanced recovery after surgery (ERAS) pathways have been proven to enhance postoperative recovery, reduce morbidity, and reduce length of hospital stay after colorectal cancer surgery However, despite the benefits of the ERAS program on short-term results, little is known about its impact on long-term results The aim of the study was to determine the association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer Between 2013 and 2016, 350 patients underwent laparoscopic colorectal cancer resection in the 2nd Department of General Surgery, Jagiellonian University Medical College, and were enrolled for further analysis The relationship between the rate of compliance with the ERAS protocol and 3-year survival was analyzed according to the Kaplan–Meier method with log-rank tests Patients were divided into two groups according to their degree of adherence to the ERAS interventions: Group 1 (109 patients), < 80% adherence, and Group 2 (241 patients), ≥ 80% adherence The primary outcome was overall 3-year survival The secondary outcomes were postoperative complications, length of hospital stay, and recovery parameters The groups were similar in terms of demographics and surgical parameters The median compliance to ERAS interventions was 852% The Cox proportional model showed that AJCC III (HR 328, 95% CI 161–659, p = 00021), postoperative complications (HR 263, 95% CI 119–552, p = 00161), and compliance with ERAS protocol < 80% (HR 338, 95% CI 223–521, p = 00102) were independent predictors for poor prognosis Additionally, analysis revealed that adherence to the ERAS protocol in Group 2 with ≥ 80% adherence was associated with a significantly shorter length of hospital stay (6 vs 4 days, p < 00001), a lower rate of postoperative complications (447% vs 233%, p < 00001), and improved functional recovery parameters: tolerance of oral diet (534% vs 815%, p < 00001) and mobilization (777% vs 961%, p < 00001) on the first postoperative day This study reports an association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer Lower adherence to the protocol, independent from stage of cancer and postoperative complications, was an independent risk factors for poorer survival rates
65 citations
TL;DR: Indocyanine green fluorescence angiography is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection and can guide more appropriate autotransplantation without compromising postoperativeParathyroid function.
Abstract: Indocyanine green fluorescence angiography (ICGA) is a new adjunct that has been used in surgical procedures to assess blood flow. This study evaluated the utility of ICGA compared to visual inspection to predict parathyroid function, guide autotransplantation and potentially decrease permanent hypoparathyroidism. This was a retrospective study of patients who underwent total or near-total thyroidectomy (T-NT) between January 2015 and March 2018. Patients with preoperative hyperparathyroidism and those undergoing reoperation were excluded. Patients who had ICGA were compared to T-NT patients without ICGA. Data were analyzed to assess the frequency of autotransplantation and incidence of hypoparathyroidism between groups. In total, 210 patients underwent T-NT: 86 with ICGA and 124 without. Autotransplantation was more common in the ICGA group at 36% compared to 12% in the control (p = 0.0001). There was no correlation with at least one normal parathyroid gland on ICGA and postoperative PTH levels (p = 0.75). There was a difference in having normal postoperative PTH when there were at least two normal parathyroid glands (n = 50) compared to patients with less than two normal ICGA glands (n = 36, p = 0.044). Visual assessment and ICGA assessment of vascularity were in agreement, 245/281 (87%). There were 19 glands (6.8%) that would have undergone autotransplant based on visual inspection that had adequate blood supply on ICGA. Transient hypoparathyroidism was present in 45 out of 124 controls (36%) and 32 out of 86 (37%) in the ICG group. ICGA is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection. ICGA can guide more appropriate autotransplantation without compromising postoperative parathyroid function. At least two vascularized glands on ICGA may predict postoperative parathyroid gland function.
56 citations
TL;DR: It is revealed that multiple definitions of loss of domain are being used and are not interchangeable, which is necessary to standardise this important concept for hernia surgeons.
Abstract: Large ventral hernias are a significant surgical challenge "Loss of domain" (LOD) expresses the relationship between hernia and abdominal volume, and is used to predict operative difficulty and success This systematic review assessed whether different definitions of LOD are used in the literature The PubMed database was searched for articles reporting large hernia repairs that explicitly described LOD Two reviewers screened citations and extracted data from selected articles, focusing on the definitions used for LOD, study demographics, study design, and reporting surgical specialty One hundred and seven articles were identified, 93 full-texts examined, and 77 were included in the systematic review Sixty-seven articles were from the primary literature, and 10 articles were from the secondary literature Twenty-eight articles (36%) gave a written definition for loss of domain These varied and divided into six broad groupings; four described the loss of the right of domain, six described abdominal strap muscle contraction, five described the "second abdomen", five describing large irreducible hernias Six gave miscellaneous definitions Two articles gave multiple definitions Twenty articles (26%) gave volumetric definitions; eight used the Tanaka method [hernia sac volume (HSV)/abdominal cavity volume] and five used the Sabbagh method [(HSV)/total peritoneal volume] The definitions used for loss of domain were not dependent on the reporting specialty Our systematic review revealed that multiple definitions of loss of domain are being used These vary and are not interchangeable Expert consensus on this matter is necessary to standardise this important concept for hernia surgeons
55 citations
TL;DR: GICS members identified priorities for children’s surgical care within four pillars: infrastructure, service delivery, training and research, and guidelines for provision of care at every healthcare level based on these pillars were created.
Abstract: Author(s): Global Initiative for Children’s Surgery | Abstract: BackgroundRecommendations by the Lancet Commission on Global Surgery regarding surgical care in low- and middle-income countries (LMICs) require development to address the needs of children. The Global Initiative for Children's Surgery (GICS) was founded in 2016 to identify solutions to problems in children's surgery by utilizing the expertise of practitioners from around the world. This report details this unique process and underlying principles.MethodsThree global meetings convened providers of surgical services for children. Through working group meetings, participants reviewed the status of global children's surgery to develop priorities and identify necessary resources for implementation. Working groups were formed under LMIC leadership to address specific priorities. By creating networking opportunities, GICS has promoted the development of LMIC-LMIC and HIC-LMIC partnerships.ResultsGICS members identified priorities for children's surgical care within four pillars: infrastructure, service delivery, training and research. Guidelines for provision of care at every healthcare level based on these pillars were created. Seventeen subspecialty, LMIC chaired working groups developed the Optimal Resources for Children's Surgery (OReCS) document. The guidelines are stratified by subspecialty and level of health care: primary health center, first-, second- and third-level hospitals, and the national children's hospital. The OReCS document delineates the personnel, equipment, facilities, procedures, training, research and quality improvement components at all levels of care.ConclusionWorldwide collaboration with leadership by providers from LMICs holds the promise of improving children's surgical care. GICS will continue to evolve in order to achieve the vision of safe, affordable, timely surgical care for all children.
54 citations
TL;DR: Opt-in versus opt-out consent increases DDR and DTR and may be useful in decreasing deaths on the waiting list in the USA and other countries.
Abstract: Significant numbers of patients in the USA and UK die while waiting for solid organ transplant. Only 1–2% of deaths are eligible as donors with a fraction of the deceased donating organs. The form of consent to donation may affect the organs available. Forms of consent include: opt-in, mandated choice, opt-out, and organ conscription. Opt-in and opt-out are commonly practiced. A systematic review was conducted to determine the effect of opt-in versus opt-out consent on the deceased donation rate (DDR) and deceased transplantation rate (DTR). Literature searches of PubMed and EMBASE between 2006 and 2016 were performed. Research studies were selected based on certain inclusion criteria which include USA, UK, and Spain; compare opt-in versus opt-out; primary data analysis; and reported DDR or DTR. Modeled effect on US transplant activity was conducted using public data from Organ Procurement and Transplantation Network and Centers for Disease Control WONDER from 2006 to 2015. A total of 2400 studies were screened and six studies were included. Four studies reported opt-out consent increases DDR by 21–76% over 5–14 years. These studies compared 13–25 opt-out countries versus 9–23 opt-in countries. Three studies reported opt-out consent increases DTR by 38–83% over 11–13 years. These studies compared 22–25 opt-out versus 22–28 opt-in countries. Modeled opt-out activity on the USA resulted in 4753–17,201 additional transplants annually. Opt-out consent increases DDR and DTR and may be useful in decreasing deaths on the waiting list in the USA and other countries. PROSPERO CRD42019098759.
53 citations
TL;DR: In this study, TORT could be safely performed in a large series of patients with PTC without serious complications and could be considered an alternative approach for remote access thyroidectomy in selected patients.
Abstract: Endoscopic transoral thyroidectomy is a recently introduced technique of remote access thyroidectomy. We previously reported the feasibility of the robotic approach (TORT). Nevertheless, experience to date is limited, with scant data on outcomes in patients with papillary thyroid carcinoma (PTC). This was a retrospective analysis of prospectively collected data. Patients with PTC, who underwent TORT at a single center between March 2016 and February 2017, were analyzed. There were a total of 100 patients (85 women, 15 men) with a mean age of 40.7 ± 9.8 years, and a mean tumor size of 0.8 ± 0.5 cm. Nine patients underwent a total thyroidectomy, and 91 underwent a lobectomy. The operative time for a total thyroidectomy and lobectomy was 270.0 ± 9.3 and 210.8 ± 32.9 min, respectively. Ipsilateral prophylactic central neck compartment dissection was performed routinely with retrieval of 5.0 ± 3.6 lymph nodes. Perioperative morbidity was present in nine patients including transient recurrent laryngeal nerve palsy (n = 1), postoperative bleeding requiring surgical intervention (n = 1), zygomatic bruising (n = 2), chin flap perforation (n = 1), oral commissure tearing (n = 2), and chin dimpling (n = 2). There was no conversion to endoscopic or conventional open thyroid surgery. In this study, TORT could be safely performed in a large series of patients with PTC without serious complications. In selected patients, TORT by experienced surgeons could be considered an alternative approach for remote access thyroidectomy.
48 citations
TL;DR: Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.
Abstract: Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties. The terms “LESS” OR “single port” OR “single site” AND “robot” OR “robotic” were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles). Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (P = 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference. Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.
TL;DR: This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time, but the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.
Abstract: Minimally invasive surgery has been considered as an alternative to open surgery by surgeons for colorectal cancer. However, the efficacy and safety profiles of robotic and conventional laparoscopic surgery for colorectal cancer remain unclear in the literature. The primary aim of this review was to determine whether robotic-assisted laparoscopic surgery (RAS) has better clinical outcomes for colorectal cancer patients than conventional laparoscopic surgery (CLS). All randomized clinical trials (RCTs) and observational studies were systematically searched in the databases of CENTRAL, EMBASE and PubMed from their inception until January 2018. Case reports, case series and non-systematic reviews were excluded. Seventy-three studies (6 RCTs and 67 observational studies) were eligible (n = 169,236) for inclusion in the data synthesis. In comparison with the CLS arm, RAS cohort was associated with a significant reduction in the incidence of conversion to open surgery (ρ < 0.001, I2 = 65%; REM: OR 0.40; 95% CI 0.30,0.53), all-cause mortality (ρ < 0.001, I2 = 7%; FEM: OR 0.48; 95% CI 0.36,0.64) and wound infection (ρ < 0.001, I2 = 0%; FEM: OR 1.24; 95% CI 1.11,1.39). Patients who received RAS had a significantly shorter duration of hospitalization (ρ < 0.001, I2 = 94%; REM: MD − 0.77; 95% CI 1.12, − 0.41; day), time to oral diet (ρ < 0.001, I2 = 60%; REM: MD − 0.43; 95% CI − 0.64, − 0.21; day) and lesser intraoperative blood loss (ρ = 0.01, I2 = 88%; REM: MD − 18.05; 95% CI − 32.24, − 3.85; ml). However, RAS cohort was noted to require a significant longer duration of operative time (ρ < 0.001, I2 = 93%; REM: MD 38.19; 95% CI 28.78,47.60; min). This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time. However, the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.
TL;DR: FCH-PET/CT is a promising tool in the challenging population of reoperative patients with pHPT and parathyroid 4D-CT appears as a confirmatory imaging modality.
Abstract: To evaluate FCH-PET/CT and parathyroid 4D-CT so as to guide surgery in patients with primary hyperparathyroidism (pHPT) and prior neck surgery. Medical records of all patients referred for a FCH-PET/CT in our institution were systematically reviewed. Only patients with pHPT, a history of neck surgery (for pHPT or another reason) and an indication of reoperation were included. All patients had parathyroid ultrasound (US) and Tc-99m-sestaMIBI scintigraphy, and furthermore, some patients had 4D-CT. Gold standard was defined by pathological findings and/or US-guided fine-needle aspiration with PTH level measurement in the washing liquid. Twenty-nine patients were included in this retrospective study. FCH-PET/CT identified 34 abnormal foci including 19 ectopic localizations. 4D-CT, performed in 20 patients, detected 11 abnormal glands at first reading and 6 more under FCH-PET/CT guidance. US and Tc-99m-sestaMIBI found concordant foci in 8/29 patients. Gold standard was obtained for 32 abnormal FCH-PET/CT foci in 27 patients. On a per-lesion analysis, sensitivity, specificity, positive and negative predictive values were, respectively, 96%, 13%, 77% and 50% for FCH-PET/CT, 75%, 40%, 80% and 33% for 4D-CT. On a per-patient analysis, sensitivity was 85% for FCH-PET/CT and 63% for 4D-CT. FCH-PET/CT results made it possible to successfully remove an abnormal gland in 21 patients, including 12 with a negative or discordant US/Tc-99m-sestaMIBI scintigraphy result, with a global cure rate of 73%. FCH-PET/CT is a promising tool in the challenging population of reoperative patients with pHPT. Parathyroid 4D-CT appears as a confirmatory imaging modality.
TL;DR: The Optimal Resources for Children's Surgery document as discussed by the authors provides a strategy for integrating surgical care for children into National Surgical, Obstetric and Anesthesia Plans (NOMA).
Abstract: Surgical care has an incontrovertible, crosscutting role in achieving child health.
Children develop different surgical diseases compared to adults, present unique anesthetic challenges, and have special perioperative needs.
The Optimal Resources for Children’s Surgery document provides a strategy for integrating surgical care for children into National Surgical, Obstetric and Anesthesia Plans.
There is an important opportunity to prevent death and reduce disability in children by scaling up surgical care in low- and middle-income countries.
TL;DR: It is demonstrated that in highly selected patients; LRLR for rHCC is feasible and safe and was associated with a shorter hospitalization but longer operation time compared to ORLR.
Abstract: This study aims to determine the safety and efficacy of laparoscopic repeat liver resection (LRLR) for recurrent hepatocellular carcinoma (rHCC). Twenty patients underwent LRLR for rHCC between 2015 and 2017. The control groups consisted of 79 open RLR (ORLR) for rHCC and 185 LLR for primary HCC. We undertook propensity score-adjusted analyses (PSA) and 1:1 propensity score matching (PSM) for the comparison of LRLR versus ORLR. Comparison of LRLR versus LLR was done using multivariable regression models with adjustment for clinically relevant covariates. Twenty patients underwent LRLR with three open conversions (15%). Both PSA and 1:1-PSM demonstrated that LRLR was significantly associated with a shorter stay, superior disease-free survival (DFS) but longer operation time compared to ORLR. Comparison between LRLR versus LLR demonstrated that patients undergoing LRLR were significantly older, had smaller tumors, longer operation time and decreased frequency of Pringle’s maneuver applied. There was no difference in other key perioperative outcomes. The results of this study demonstrate that in highly selected patients; LRLR for rHCC is feasible and safe. LRLR was associated with a shorter hospitalization but longer operation time compared to ORLR. Moreover, other than a longer operation time, LRLR was associated with similar perioperative outcomes compared to LLR for primary HCC.
TL;DR: The findings suggest that preoperative anxiety may be a new target for prevention of postoperative delirium in cancer patients.
Abstract: Postoperative delirium is a common and important complication in cancer patients. We need to identify patients at high risk of postoperative delirium such that it can be prevented preoperatively or in early postoperative phase. The aim of this study was to investigate whether preoperative anxiety predicted onset of postoperative delirium in cancer patients, not only in order to identify high-risk groups but also to help develop new preventive approaches. This was a prospective observational cohort study of cancer patients undergoing tumor resections. Postoperative delirium was assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Preoperative anxiety was evaluated with the Hospital Anxiety and Depression Scale-Anxiety (HADS-A), and we defined HADS-A > 7 as clinical anxiety. We conducted multivariate logistic regression to determine which factors were predictors of delirium. The final analysis included 91 patients, 29 of whom met the criteria for postoperative delirium. In multivariable logistic regression, age (5-year increments; odds ratio (OR) = 1.565, 95% confidence interval (CI) = 1.057–2.317, p = 0.025) and HADS-A > 7 (OR = 4.370, 95% CI = 1.051–18.178, p = 0.043) predicted delirium onset. These variables explained 74.2% of the variance. Preoperative anxiety strongly predicted postoperative delirium in cancer patients. Our findings suggest that preoperative anxiety may be a new target for prevention of postoperative delirium. Trial registration number This study was registered at UMIN000018980
TL;DR: No differences were found in blood transfusion, incidence of positive resection margins and long-term outcomes between the two techniques, suggesting RLR does not compromise short-term and oncologic outcomes in patients with liver cancers.
Abstract: A laparoscopic approach improves short-term outcomes and maintains long-term outcomes compared to an open approach. In turn, the recent development of robotic surgery raises the question whether it performs as well as laparoscopic surgery. The aim of this study was to compare the short- and long-term outcomes of laparoscopic liver resection (LLR) and robotic liver resection (RLR) for malignancies. From 2011 to 2017, the study population included 111 patients in the LLR group and 61 in the RLR group. Short- and long-term outcomes were compared before and after propensity score matching (PSM). Operative mortality rate was nil. The intraoperative blood transfusion rate was higher during RLR (15% vs. 2%, p = 0.0009). Major morbidity and hospital stay were not different between the two groups. The resection margin width (LLR 7 mm vs. RLR 10 mm, p = 0.13) and R1 resection rates (resection margin width < 1 mm; LLR 15% vs. RLR 11%, p = 0.49) were similar. After PSM (55 patients in each group), the blood transfusion, major morbidity, hospital stay and R1 resection were similar between the two groups. When considering the largest subset of patients with hepatocellular carcinoma including 114 patients (66%), the 3-year overall survival rate was 80% in the LLR group and 97% in the RLR group (p = 0.10) and remained similar after PSM (p = 0.27). The 3-year recurrence-free survival rate was 50% in the LLR group and 64% in the RLR group (p = 0.30) and remained similar after PSM (p = 0.26). No differences were found in blood transfusion, incidence of positive resection margins and long-term outcomes between the two techniques. RLR does not compromise short-term and oncologic outcomes in patients with liver cancers.
TL;DR: Authors from LMICs seemed the most proactive in addressing the global surgical disease burden, and increasing the funding for interventional studies, and therefore the quality of evidence in surgery, has the potential for greater impact for patients in LM ICs.
Abstract: There has been a growing interest in addressing the surgical disease burden in low- and middle-income countries (LMICs). Assessing the current state of global surgery research activity is an important step in identifying gaps in knowledge and directing research efforts towards important unaddressed issues. The aim of this bibliometric analysis was to identify trends in the publication of global surgical research over the last 30 years. Scopus® was searched for global surgical publications (1987–2017). Results were hand-screened, and data were collected for included articles. Bibliometric data were extracted from Scopus® and Journal Citation Reports. Country-level economic and population data were obtained from the World Bank. Descriptive statistics were used to summarise data and identify significant trends. A total of 1623 articles were identified. The volume of scientific production on global surgery increased from 14 publications in 1987 to 149 in 2017. Similarly, the number of articles published open access increased from four in 1987 to 68 in 2017. Observational studies accounted for 88.7% of the included studies. The three most common specialties were obstetrics and gynaecology 260 (16.0%), general surgery 256 (15.8%), and paediatric surgery 196 (12.1%). Over two times as many authors were affiliated to an LMIC institution than to a high-income country (HIC) institution (6628, 71.5% vs 2481, 28.5%, P < 0.001). A total of 965 studies (59.5%) were conducted entirely by LMIC authors, and 534 (32.9%) by collaborations between HICs and LMICs. The quantity of research in global surgery has substantially increased over the past 30 years. Authors from LMICs seemed the most proactive in addressing the global surgical disease burden. Increasing the funding for interventional studies, and therefore the quality of evidence in surgery, has the potential for greater impact for patients in LMICs.
TL;DR: ENETS guidelines for surgery of small pNENs are yet not well accepted in the German surgical community, since the rate of formal resections with standard lymphadenectomy is high and the minimally invasive approach is underused.
Abstract: ENETS guidelines recommend parenchyma-sparing procedures without formal lymphadenectomy, ideally with a minimally invasive laparoscopic approach for sporadic small pNENs (≤2 cm). Non-functioning (NF) small pNENs can also be observed. The aim of the study was to evaluate how these recommendations are implemented in the German surgical community. Data from the prospective StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery were analyzed regarding patient’s demographics, tumor characteristics, surgical procedures, histology and perioperative outcomes. Eighty-four (29.2%) of 287 patients had sporadic pNENs ≤2 cm. Forty-three (51.2%) patients were male, and the mean age at diagnosis was 58.8 ± 15.6 years. Twenty-five (29.8%) pNENs were located in the pancreatic head. The diagnosis pNEN was preoperatively established in 53 (65%) of 84 patients. Sixty-two (73.8%) patients had formal pancreatic resections, including partial pancreaticoduodenectomy or total pancreatectomy (21.4%). Only 22 (26.2%) patients underwent parenchyma-sparing resections and 23 (27.4%) patients had minimally invasive procedures. A lymphadenectomy was performed in 63 (75.4%) patients, and lymph node metastases were diagnosed in 6 (7.2%) patients. Eighty-two (97.7%) patients had an R0 resection. Sixty (72%) tumors were classified G1, 24 (28%) tumors G2. Twenty-seven (32.2%) of 84 patients had postoperative relevant Clavien–Dindo grade ≥3 complications. Thirty- and 90-day mortalities were 2.4% and 3.6%. ENETS guidelines for surgery of small pNENs are yet not well accepted in the German surgical community, since the rate of formal resections with standard lymphadenectomy is high and the minimally invasive approach is underused. The attitude to operate small NF tumors seems to be rather aggressive.
TL;DR: Patients who underwent repeated resections had a significant better OS compared to those receiving chemotherapy, transarterial chemoembolization, selective internal radiotherapy, radiofrequency ablation or best supportive care and should be considered as long as resection is technically possible.
Abstract: Although after R0 resection of intrahepatic cholangiocarcinoma (ICC) recurrence is frequent, most guidelines do not address strategies for this. The aim of this study was to analyze the outcome of repeated resection and to determine criteria when repeated resection is reasonable. Between 2008 and 2016, we consecutively collected all cases of ICC (n = 176) in a prospective database and further analyzed them with a focus on tumor recurrence, its surgical treatment, overall survival and recurrence-free survival. Overall, a total of 22 explorations were performed for recurrent ICC in 17 patients. Resection rate was 18 repeated resections in 13 patients. Three patients underwent repeated resection twice and one patient three times. Recurrence was solitary in 7 patients and multifocal in 11 re-resected cases. Median overall survival (OS) of patients who underwent repeated resection was 65.2 months (interquartile range 37–126.5) with a 5-year OS rate of 62%, calculated from primary resection. Patients who underwent repeated resections had a significant better OS compared to those receiving chemotherapy, transarterial chemoembolization, selective internal radiotherapy, radiofrequency ablation or best supportive care (p < 0.001). Repeated resection of recurrent ICC is reasonable and associated with an improved survival. Re-exploration should be considered as long as resection is technically possible.
TL;DR: Although the duration of therapy was longer in Group T, the lack of systemic side effects increased the compliance of the patients with the therapy, and topical steroids would be among first-line treatment options of IGM.
Abstract: Idiopathic granulomatous mastitis (IGM) is a benign disorder of the breast, for which the optimal treatment modality remains missing. A total of 124 patients with a histopathologically proven diagnosis of IGM were enrolled in a prospective, randomized parallel arm study. Patients were treated with topical steroids in Group T (n: 42), systemic steroids (0.8 mg/kg/day peroral) in Group S (n: 42), and combined steroids (0.4 mg/kg/day peroral + topical) in Group C (n: 40). Compliance with the therapy, response to the therapy, the duration of therapy, side effects and the recurrence rates were compared. Sixteen patients did not comply with the treatment, and the highest ratio of compliance with therapy was seen in Group T (p < 0.05). Complete clinical regression (CCR) was observed in 90 (83.3%) patients. Response to the treatment (RT) was evaluated radiologically and observed in 89.8% of the patients. There was no statistically significant difference between groups regarding CCR, RT and the recurrence rate. The longest duration of therapy was observed in Group T (22 ± 9.1-week), whereas the shortest was observed in Group S (11.7 ± 5.5-week) (p < 0.001). The systemic side effects were significantly lower in Group T in comparison with Groups S and C (2.4% vs. 38.2% and 30.3%, respectively) (p < 0.001). The efficiency of the treatment was similar for all groups, both clinically and radiologically. Although the duration of therapy was longer in Group T, the lack of systemic side effects increased the compliance of the patients with the therapy. Therefore, topical steroids would be among first-line treatment options of IGM.
TL;DR: An historical review of the application of needle interventions of the breast in the diagnosis and management of breast conditions and current indications for the use of vacuum assisted biopsies and vacuum assisted excisions are discussed.
Abstract: The management of breast disease has been greatly facilitated by the technology of needle biopsy interventions, and over the past 30 years, this has evolved from the use of fine-needle aspiration biopsy (FNAB) to the current methodology of vacuum assisted biopsy (VAB). This article provides an historical review of the application of needle interventions of the breast in the diagnosis and management of breast conditions, and discusses current indications for the use of vacuum assisted biopsies and vacuum assisted excisions. Whilst FNAB continues to have a limited role in breast disease diagnosis, the necessity of achieving an histological diagnosis has preferentially seen the development and wider application of automated core needle biopsies (CNB) and VAB in the assessment and management of breast lesions. The advantages of CNB and VAB include the ability to distinguish in situ and invasive disease pre-operatively, and the ability to achieve prior knowledge of immunohistochemical tumour markers particularly in the setting of neoadjuvant drug treatments. Due to its ability to obtain larger tissue samples, VAB does have diagnostic advantages over CNB and indications for the utilization of VAB are discussed. VAB additionally has an expanding role as a tool for breast lesion excision.
TL;DR: The preoperative CONUT score is a simple and promising predictor of postoperative procedure-unrelated infectious morbidity and prognosis in elderly gastric cancer patients.
Abstract: Preoperative nutritional status is considered to affect the short-term and long-term outcomes of cancer patients. The clinical value of the controlling nutritional status (CONUT) score in elderly patients undergoing gastrectomy for gastric cancer remains unknown. This study reviewed 211 elderly patients aged 75 years or over who underwent curative resection for gastric cancer from 2000 to 2015. Patients were grouped according to the preoperative CONUT score into those with normal nutrition (75 patients), light malnutrition (100 patients) and moderate or severe malnutrition (36 patients). The predictive value of the CONUT score for postoperative morbidity and survival was assessed. Impaired nutrition was associated with cardiovascular disease (P = 0.012) and chronic kidney disease (P = 0.014), and worsened malnutrition was linked to advanced age (P = 0.004), decreased body mass index (P = 0.008) and advanced disease stage (P = 0.01). Multivariate analysis showed the CONUT score as an independent predictor of procedure-unrelated infectious morbidity (odds ratio, 2.36; 95% confidence interval [CI], 0.99–5.40; P = 0.046). Patients with a higher CONUT score had significantly shorter overall survival in both stage I and stage II/III gastric cancer (P = 0.044 and P = 0.007, respectively) and reduced cancer-specific survival in stage II/III (P = 0.003) The CONUT score was a strong predictors of overall survival (hazard ratio [HR], 2.12; 95% CI, 1.18–3.69; P = 0.012) and cancer-specific survival (HR, 3.75; 95% CI, 1.30–10.43; P = 0.015) independent of disease stage. The preoperative CONUT score is a simple and promising predictor of postoperative procedure-unrelated infectious morbidity and prognosis in elderly gastric cancer patients.
TL;DR: Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia and permanent hypoparathyroidism and the impact ofParathyroid autotransplantation was evaluated.
Abstract: Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation. We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05. Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1–2 glands: 13.3%; p ˂ 0.0001) [OR for 1–2 glands in situ = 5.32, CI 95% 2.61–10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79–7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46–6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85–7.02). Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).
TL;DR: The ICG fluorescence is a real-time navigation tool which enables surgeons to enhance visualization of anatomical structures and overcome the disadvantages of minimally invasive liver resection, and its applications can reduce the postoperative complication rate in robotic liver surgery.
Abstract: The ICG fluorescence properties are progressively gaining momentum in the HPB surgery. However, the exact impact of ICG application on surgical outcomes is yet to be established. Twenty-five patients who underwent ICG fluorescence-guided robotic liver resection were case-matched in a 1:1 ratio to a cohort who underwent standard robotic liver resection. In the ICG group, six additional lesions not diagnosed by preoperative workup and intraoperative ultrasound were identified and resected. Four of the lesions were proved to be malignant. Despite the similar operative time (288 vs. 272 min, p = 0.778), the risk of postoperative bile leakage (0% vs. 12%, p = 0.023), R1 resection (0% vs. 16%, p = 0.019) and readmission (p = 0.023) was reduced in the ICG group compared with the no-ICG group. The ICG fluorescence is a real-time navigation tool which enables surgeons to enhance visualization of anatomical structures and overcome the disadvantages of minimally invasive liver resection. The procedure is not time-consuming, and its applications can reduce the postoperative complication rate in robotic liver surgery.
TL;DR: A high prevalence of limited health literacy among surgical patients with considerable heterogeneity is demonstrated and the importance of recognizing and addressing surgical patientsWith limited health Literacy and the need for standardization in measurement tools is suggested.
Abstract: Health literacy is the extent to which patients are able to understand and act upon health information. This concept is important for surgeons as their patients have to comprehend the nature, risks and benefits of surgical procedures, adhere to perioperative instructions, and make complex care decisions about interventions. Our review aimed to determine the prevalence of limited health literacy of the surgical patient population. A search of MEDLINE and EMBASE was performed from inception until January 14th 2017 for experimental and observational studies reporting surgical patients' health literacy measurement. Overall pooled proportion of surgical patients with limited health literacy was calculated using a random-effects model and methodologic quality was assessed. A total of 40 studies representing 18,895 surgical patients were included in our quantitative synthesis. Pooled estimate of limited health literacy was 31.7% (95%CI 24.7-39.2%, I2 99.0%). There was low risk of bias among the majority of the 51 studies included in the qualitative synthesis. Statistical heterogeneity could not be fully accounted for by methodologic quality or patient and surgical characteristics. However, some of the heterogeneity was accounted by measurement tool [combined proportions with the REALM and NVS of 35.6 (95%CI 31.5-39.9, I2 73.0%)]. A number of different health literacy measurement tools were used (19 overall). Our review demonstrates a high prevalence of limited health literacy among surgical patients with considerable heterogeneity. Our findings suggest the importance of recognizing and addressing surgical patients with limited health literacy and the need for standardization in measurement tools.
TL;DR: This study reports short- and long-term outcomes after AWR for incisional hernia using Permacol, finding single-stage AWR is feasible using permacol and the benefit of biologics remains to be ascertained.
Abstract: To reduce the occurrence of complications in the setting of high-risk patients with contaminated operative field, a wide range of biologic meshes has been developed. Yet, few series have reported outcomes after abdominal wall repair (AWR) using such meshes. Permacol is an acellular porcine dermal collagen matrix with a cross-linked pattern. This study reports short- and long-term outcomes after AWR for incisional hernia using Permacol. All consecutive patients undergoing single-stage open AWR using Permacol mesh at eight university hospitals were included. Mortality, complication and hernia recurrence rates were assessed. Independent risk factors for complications and hernia recurrence were identified with logistic regression and Fine and Gray analysis, respectively. Overall, 250 patients underwent single-stage AWR with Permacol. Nearly 80% had a VHWG grade 3 or 4 defect. In-hospital mortality and complication rates were 4.8% (n = 12) and 61.6% (n = 154), respectively. Reintervention for complications was required for 74 patients (29.6%). Mesh explantation rate was 4% (n = 10). Independent risk factors for complications were smoking, defect size and VHWG grade. After a mean follow-up time of 16.8 months (± 18.1 months), 63 (25.2%) experienced hernia recurrence. One-, 2- and 3-year RFS were 90%, 74% and 57%, respectively. Previous AWR, mesh location and the need for reintervention were independent predictors of hernia recurrence. Single-stage AWR is feasible using Permacol. Mortality and complication rates are high due to patients’ comorbidities and the degree of contamination of the operative field. Given the observed recurrence rate, the benefit of biologics remains to be ascertained.
TL;DR: Implementation efforts for pediatric surgical care include incorporating surgery-specific priorities into the global child health initiatives, improving global health financing for scale-up activities for children, increasing financial risk protection mechanisms for families of children with surgical needs, and including comprehensive pediatric surgical models of care into country-level plans.
Abstract: Investing in surgery has been highlighted as integral to strengthening overall health systems and increasing economic prosperity in low-income and middle-income countries (LMICs). The provision of surgical care in LMICs not only affects economies on a macro-level, but also impacts individual families within communities at a microeconomic level. Given that children represent 50% of the population in LMICs and the burden of unmet surgical needs in these areas is high, investing pediatric-specific components of surgical and anesthesia care is needed. Implementation efforts for pediatric surgical care include incorporating surgery-specific priorities into the global child health initiatives, improving global health financing for scale-up activities for children, increasing financial risk protection mechanisms for families of children with surgical needs, and including comprehensive pediatric surgical models of care into country-level plans.
TL;DR: The management of esophageal anastomotic leaks after Ivor Lewis esophagectomy with SEMS is effective, safe and technically feasible and Aggressive non-surgical management should be considered when developing a treatment plan for stenting.
Abstract: Esophageal anastomotic leakages after Ivor Lewis esophagectomy are severe and life-threatening complications. We analyzed the outcome of using self-expanding metal stents (SEMS) in the treatment of postoperative leakage after esophagogastrostomy. Seventy patients with esophageal anastomotic leakage after Ivor Lewis esophagectomy for esophageal cancer who had received SEMS treatment between January 2006 and December 2015 at our clinic were identified in this retrospective study. The patients were analyzed according to demographic characteristics, risk factors, leakage characteristics, stent characteristics, stent-related complications, sealing success rate and mortality. Over a 10-year period, 70 patients received SEMS as treatment for postoperative anastomotic leakage after esophagectomy. Technical success of esophageal stenting in anastomotic leakage was achieved in 50 out of 70 cases (71.4%). Sealing success rate was 70% (n = 49) with a median treatment of 28 days (range 7–87). In 20 patients (28.6%), stent-related complications, such as stenosis, dislocation, leakage persistence, perforation or esophagotracheal fistula occurred after the SEMS treatment. Sixty-one patients (87.1%) survived SEMS treatment of esophagogastric anastomotic leakage. Mean follow-up for all patients was 38 months (IQR 10–76), and no significant difference was found in a comparison of the long-term survival rate between patients with successful and unsuccessful SEMS treatment. The management of esophageal anastomotic leaks after Ivor Lewis esophagectomy with SEMS is effective, safe and technically feasible. Aggressive non-surgical management should be considered when developing a treatment plan for stenting.
TL;DR: A small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible and a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm.
Abstract: Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT. We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery. Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0–10.5) days versus 18.0 (14.3–24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm. Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.