Role of thromboxane and leukotriene B4 in patients with acute respiratory distress syndrome after oesophagectomy

We have studied prospectively the clinical course and serum concentrations of thromboxane B2 (TxB2) and leukotriene B4 (LTB4) in patients developing adult respiratory distress syndrome (ARDS) after oesophagectomy. The clinical course was assessed according to a validated ARDS score, and intra- and postoperative measurements of TxB2 and LTB4 in pre- and post-pulmonary blood were performed in 18 patients undergoing oesophagectomy for oesophageal carcinoma and 11 control patients undergoing thoracotomy and pulmonary resection. Six of 18 patients undergoing oesophagectomy, but no control patient, developed ARDS. The ARDS score was highest on day 8 after operation. Only patients with ARDS had a significant postoperative increase in post- pulmonary, but not pre-pulmonary, TxB2 concentrations (P < 0.05 vs patients without ARDS). This study provides evidence that TxA2, originating from the lungs, was associated with the development of ARDS after oesophageal resection. In view of the high incidence of ARDS after oesophagectomy (10-30%), prophylactic treatment of patients undergoing oesophageal resection with clinically applicable thromboxane synthetase inhibitors may be warranted.      

Laparoscopic ischaemic conditioning of the stomach may reduce gastric-conduit morbidity following total minimally invasive oesophagectomy

Objective: Oesophagectomy, whether open or minimal access, is associated with a significant incidence of gastric-conduit-related complications. Previous animal and human studies suggest that ischaemic conditioning of the stomach prior to oesophagectomy improves perfusion of the gastric conduit. We have adopted laparoscopic ligation of the left gastric artery 2 weeks prior to minimally invasive oesophagectomy, having identified a relative high incidence of gastric-tube complications through a cumulative summation (CUSUM) analysis. Methods: This study included 77 consecutive patients who underwent a Total MIO (thoracoscopic oesophageal mobilisation, laparoscopic gastric tube formation, cervical anastomosis). The ligation group comprised 22 consecutive patients, excluding those with middle-third squamous tumours or early-stage adenocarcinoma, who underwent ligation 2 weeks prior to MIO at staging laparoscopy. The control group comprised 55 patients who did not undergo ischaemic conditioning in this way. We have defined conduit-related complications as: leak managed conservatively (L); tip necrosis requiring resection and re-anastomosis (TN) and conduit necrosis needing resection and oesophagostomy (CN). The values are reported as medians. The effect of ligation of the left gastric artery was followed with a CUSUM analysis. Results: Ligation was performed 15.5 days pre-operatively (median). There were no complications and the length of hospital stay was 1 day. Although gastric mobilisation at MIO was technically more difficult after ligation, there was no significant difference in operating time (ligation, 407 min; control, 425 min) or blood loss (ligation and control, 500 ml). There was less gastric-conduit morbidity in the ligation group (two of 22, 10%; one L, one CN) compared with the control group (11 of 55, 20%; four L, five TN, two CN), but these differences did not reach statistical significance (p = 0.211 and p = 0.176 Fisher's exact test). The CUSUM analysis showed that during ligation of the left gastric artery, conservatively treated gastric-conduit-related morbidity (leak, resection and re-anastomosis or conduit necrosis) remained within safe limits (10%). Conduit-related-morbidity increased after stopping ligation. Conclusion: In this non-randomised clinical setting, our results suggest that ischaemic conditioning of the stomach prior to MIO is safe. There is a trend to reduced morbidity related to gastric-conduit ischaemia, which was demonstrated by a CUSUM analysis. A randomised trial is needed before ligation of the left gastric artery can be routinely recommended.     

The pattern and prevalence of lymphatic spread in thoracic oesophageal squamous cell carcinoma

Background: Oesophageal squamous cell carcinoma (SCC) is a common type of cancer in China. The knowledge of its pattern of lymphatic metastasis would be of clinical value for surgical and radiation oncologists to treat this disease. Material and methods: A large series of 1850 thoracic oesophageal SCC was retrospectively analysed after extended oesophagectomy with three-field lymphadenectomy (3FL). Specimens were assessed for pattern of lymphatic spread. Result: Of the 1850 patients, 1081 (58.4%) developed mediastinal, cervical and/or abdominal node metastases. The lymphatic metastasis rates were 35.6%, 22.2%, 26.5%, 6.1% and 26.5%, respectively, for the cervical, upper, middle, lower mediastinal nodes and abdominal nodes. The adjacent mediastinal node metastasis alone occurred in 5.5% of patients, and the multiple level or skip node spread accounted for 20.9% and 73.6% of patients with node metastases. Upward lymphatic spread developed in 46.4% of patients, both up- and downward in 33.2%, and the downward, 20.5%. For the upper oesophageal SCC, the most common node metastasis was in the cervical (49.5%) and followed by the upper mediastinal (28.7%), middle mediastinal (11.4%), abdominal (8.0%) and lower mediastinal (1.4%) nodes. For the middle oesophageal SCC, the highest incidence of node spread was also in the cervical (35.0%) and similar rates in the middle mediastinal (29.8%), abdominal (27.2%) and upper mediastinal (22.4%) nodes, but the least in the lower mediastinal (6.0%) node. For the lower oesophageal SCC, more node metastasis occurred in the abdominal (51.7%), and followed by the middle mediastinal (25.6%), cervical (17.2%), lower mediastinal (13.9%) and upper mediastinal (10.0%). However, the lymphatic metastasis rates of the upper, middle and lower thoracic oesophageal SCC were similar. The unfavourable factors for lymphatic metastasis were long oesophageal lesion (p < 0.000), late T stage (p < 0.000) and poor differentiation of tumour cells (p < 0.000). Conclusion: The prevalence was: (1) lymphatic spread prone to the upward in the upper oesophageal SCC, downward in the lower one and both up- and downward in the middle one with in favour of the upward and (2) multiple level and skip node metastases were very often seen. The unfavourable factors for node spread were long oesophageal lesion, late T stage and poor differentiation of tumour cells.     

Emergency Oesophagectomy for Oesophageal Perforation after Chemoradiotherapy for Oesophageal Cancer

Introduction

Oesophageal perforation following chemoradiotherapy for oesophageal cancer is a devastating condition but there have been no studies investigating the role of emergency oesophagectomy for this life threatening situation.

Methods

This retrospective study comprised all cases of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal carcinoma at a major centre for oesophageal surgery in Germany between 2004 and 2013.

Results

A total of 13 patients (mean age: 58.9 years) were identified. During the same time period, 356 elective oesophagectomies were performed. Tumour entities were squamous cell carcinoma (n=12) and adenocarcinoma of the oesophagus (n=1). Alcoholism (odds ratio [OR]: 25.79, 95% confidence interval [CI]: 6.70–121.70, p<0.0001) and chronic pulmonary disease (OR: 3.76, 95% CI: 1.06–14.96, p=0.027) were more common among the emergency cases.Oesophageal rupture was caused by perforation of an oesophageal stent (10 cases) or perforation during implantation of a percutaneous endoscopic gastrostomy tube (3 cases). Emergency oesophagectomy was carried out either as discontinuity resection (10/13) or oesophagectomy with immediate reconstruction (3/13).Compared with the elective cases, patients undergoing emergency oesophagectomy had significantly higher odds for sustaining perioperative sepsis (OR: 4.42, 95% CI: 1.23–16.45, p=0.01), acute renal failure (OR: 6.49, 95% CI: 1.57–24.15, p=0.005) and pneumonia (OR: 24.33, 95% CI: 3.52–1,046.65, p<0.0001). Furthermore, slow respiratory weaning was more common and there was a significantly higher tracheostomy rate (OR: 4.64, 95% CI: 1.14–16.98, p=0.02). Oesophageal discontinuity was eventually reversed in eight patients.Emergency oesophagectomy patients had odds that were three times higher for fatal outcome (OR: 3.59, 95% CI: 0.77–13.64, p=0.05). The overall mortality was 4/13. The remaining nine patients had a mean survival of 25.1 months (range: 5–46 months). The two-year-survival-rate was 38.5% (5/13).

Conclusions

Despite the most unfavourable preconditions, the results of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy are not desperate. The procedure is not only justified but life saving.     

Outcome of oesophagectomy for adenocarcinoma of the oesophagus and oesophagogastric junction

BACKGROUND: Oesophageal adenocarcinoma is becoming an increasingly important problem in the Western world. Its incidence is increasing and its prognosis is poor. Because most reports of outcomes following oesophagectomy include patients with squamous cell carcinoma, the outcome following oesophagectomy for adenocarcinoma was evaluated at Flinders Medical Centre, Royal Adelaide Hospital and associated private hospitals. METHODS: The study group consisted of 121 patients with oesophageal adenocarcinoma or adenocarcinoma of the oesophagogastric junction who underwent an attempted oesophagectomy between 1985 and 2003. Thirty-two of these patients underwent surgery before 1999 at the Royal Adelaide Hospital. These patients were reviewed retrospectively. In 1999 the recording of details of all patients undergoing oesophagectomy was commenced on a prospectively maintained database. From 1999 to 2003, 89 patients underwent oesophagectomy at either the Royal Adelaide Hospital, Flinders Medical Centre or associated private hospitals. Overall, there were 101 male and 20 female patients, with a median age at surgery of 63 years (range 36-80). Survival data were available for all patients. The present study analysed factors affecting survival in these patients. RESULTS: Tumours were located entirely within the oesophagus in 83 patients, and involved the gastro-oesophageal junction in 38. Eighty-nine underwent an Ivor Lewis oesophagectomy; 20, a cervico-thoraco-abdominal oesophagectomy; nine, a cervico-abdominal oesophagectomy (with either transhiatal or blunt oesophageal dissection); and four procedures were abandoned. Sixty-four per cent of patients had evidence of Barrett's oesophagus in the resection specimen. The overall resection rate was 97%. Significant postoperative morbidity occurred in 36%, and the in-hospital mortality rate was 5% (30-day mortality 3%). The overall 1-year survival rate was 80%, and the 5-year survival rate (including surgical deaths) was 20%. Poorer survival was associated with advanced T stage, and lymph node metastasis. The outcome following resection of tumours confined to the oesophagus was similar to that for tumours involving the gastro-oesophageal junction. Since 2000, the number of oesophagectomies performed in men for adenocarcinoma has doubled, whereas the number performed in women and for squamous cell carcinoma has remained constant. CONCLUSIONS: Oesophagectomy can be performed for patients with adenocarcinoma with an acceptable perioperative mortality rate. However, the longer term outlook following oesophagectomy for most patients with adenocarcinoma remains poor. Nevertheless, early stage tumours are associated with much better survival. For this reason, efforts to diagnose this disease at an early stage are likely to offer the best chance for improving outcomes.     

Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery

Oesophageal Doppler monitoring allows non-invasive estimation of stroke volume and cardiac output. We studied the impact of Doppler guided fluid optimisation on haemodynamic parameters, peri-operative morbidity and hospital stay in patients undergoing major bowel surgery. Fifty-seven patients were randomly assigned to Doppler (D) or control (C) groups. All patients received intra-operative fluid therapy at the discretion of the non-investigating anaesthetist. In addition, Group D were given fluid challenges (3 ml x kg(-1)) guided by oesophageal Doppler. Group D received significantly more intra-operative colloid than Group C (mean 28 (SD 16) vs. 19.4 (SD 14.7) ml x kg(-1), p = 0.02). Cardiac output increased significantly for Group D whilst that of controls remained unchanged. The mean difference between the groups in final cardiac output was 0.87 l x min(-1) (95% confidence interval 0.31-1.43 l x min(-1), p = 0.003). Five control patients required postoperative critical care admission. Fluid titration using oesophageal Doppler during bowel surgery can improve haemodynamic parameters and may reduce critical care admissions postoperatively.     

Esophagectomy for carcinoma: impact of age on clinical results and survival

Advances in perioperative management have allowed more and more elderly patients to undergo major surgery with postoperative morbidity and mortality rates similar to those of younger individuals. The aim of this study was to evaluate the impact of age on the clinical outcome and long-term survival of patients with oesophageal cancer undergoing oesophagectomy. Eight hundred and seventy-five patients with oesophageal carcinoma were divided into two groups: A (n = 393) aged > or = 65 years, and B (n = 482) aged < 65 years. One hundred and forty-nine (38%) patients in group A underwent surgery compared to 263 (55%) in group B (P < 0.01). Postoperative mortality and the prevalence of anastomotic leak and respiratory complications were similar in both groups. There was, however, a higher prevalence of cardiovascular complications in group A (13% versus 3%, P < 0.01). Five-year survival was about 35% in both groups. In conclusion, advanced age should not be considered a contra-indication to oesophagectomy for carcinoma, since the long-term survival of elderly patients undergoing resection is similar to that of younger ones.     

Oncological Outcomes of Hepatic Resection vs Transplantation for Localized Hepatocellular Carcinoma

BackgroundScarce data are available comparing outcomes of hepatic resection vs orthotopic liver transplantation (OLT) for localized hepatocellular carcinoma (HCC) patients both meeting and exceeding the Milan criteria. This study compared the clinical and oncological outcomes of patients undergoing hepatic resection vs transplantation localized HCC.MethodBetween January 2005 and February 2017, clinical and oncological outcomes of patients who underwent liver resection (n = 38) vs OLT (n = 28) for localized HCC were compared using a prospectively maintained database.ResultsA total of 66 patients (with a median age of 62) who met the study criteria were analyzed. Comparable postoperative complications (13.2% vs 28.6%, P = .45) and perioperative mortality rates (7.9% vs 10.7%, P = .2) were noted for the resection vs OLT groups. While Child-Pugh Class A patients were more prevalent in the resection group (78.9% vs 7.1%, P = .0001), the rate of patients who met the Milan criteria was higher in the OLT group (89.3% vs 34.25, P = .0001). Recurrence rates were 36.8% in the resection group and 3.6% in the OLT group at the end of the median follow-up period (32 vs 39 months, respectively). The HCC-related mortality rate was significantly higher in the resection group (39.5% vs 10.7%, P = .034).However, a subgroup analysis of patients who met the Milan criteria revealed similar rates of recurrence and HCC-related mortality (15.4% vs 8%, P = .63). Based on logistic regression analysis, number of tumors (P = .034, odds ratio: 2.1) and “resection”-type surgery (P = .008, odds ratio: 20.2) were independently associated with recurrence.ConclusionCompared to liver transplantation, hepatic resection for localized hepatocellular carcinoma is associated with a higher rate of recurrence and disease-related mortality.     

Perioperative risk analysis for acute respiratory distress syndrome after elective oesophagectomy

Background: Acute respiratory distress syndrome (ARDS) is a major contributor to respiratory morbidity and mortality after oesophagectomy. Several pre‐, intra‐ and post‐operative factors are thought to predispose to its development in the post‐oesophagectomy period. The aim of this study was to determine factors predisposing to ARDS in the post‐oesophagectomy period. Methods: A total of 112 patients who underwent elective oesophagectomy for oesophageal cancer (gastro‐oesophageal adenocarcinoma and high‐grade dysplasia, 93; oesophageal squamous cell carcinoma, 16; oesophageal oat cell tumour, 1; oesophageal anaplastic carcinoma, 1; oesophageal colloid carcinoma, 1) between 1 January 2003 and 31 December 2006 formed the study group in this retrospective study. The pre‐, intra and post‐operative data for these patients (male : female = 89:23, mean age 60.8 years) were collected from an oesophagectomy database and hospital medical records. Results: The incidence of ARDS was 13%. The in‐hospital mortality among ARDS cases was 20% and 1‐year mortality was 40%. Various factors such as preoperative chronic respiratory disease (P‐value = 0.000, odds ratio = 17.76), smoking pack‐years (P‐value = 0.045, odds ratio = 1.02), abnormal preoperative forced expiratory volume in 1 s (P‐value = 0.009, odds ratio = 7.97), high percentage of oxygen in inspired air (P‐value = 0.041, odds ratio = 1.24) and use of perioperative inotropes (P‐value = 0.021, odds ratio = 4.26) were associated with ARDS. Conclusions: Preoperative physiological status as indicated by a preoperative history of chronic respiratory disease and preoperative pulmonary function influenced the post‐operative outcome in our patients. The use of perioperative inotropes suggests perioperative cardiorespiratory instability, and could also predispose to the development of ARDS in the post‐operative period.     

Association of operative approach with outcomes in neonates with esophageal atresia and tracheoesophageal fistula

Purpose: We sought to evaluate the impact of thoracoscopic repair on perioperative outcomes in infants with esophageal atresia and tracheoesophageal fistula (EA/TEF).Methods: The American College of Surgeons National Surgical Quality Improvement Program pediatric database from 2014 to 2018 was queried for all neonates who underwent operative repair of EA/TEF. Operative approach based on intention to treat was correlated with perioperative outcomes, including 30-day postoperative adverse events, in logistic regression models.Results: Among 855 neonates, initial thoracoscopic repair was performed in 133 (15.6%) cases. Seventy (53%) of these cases were converted to open. Those who underwent thoracoscopic repair were more likely to be full-term (p = 0.03) when compared to those in the open repair group. There were no significant differences in perioperative outcome measures based on surgical approach except for operative time (thoracoscopic: 217 min vs. open: 180 min, p<0.001). A major cardiac comorbidity (OR 1.6, 95% CI 1.2–2.1; p = 0.003) and preoperative ventilator requirement (OR 1.4, 95% CI 1.0–1.9; p = 0.034) were the only risk factors associated with adverse events.Conclusions: Thoracoscopic neonatal repair of EA/TEF continues to be used sparingly, is associated with high conversion rates, and has similar perioperative outcomes when compared to open repair.Level of evidence: III     

Long-gap oesophageal atresia: comparison of delayed primary anastomosis and oesophageal replacement with gastric tube

BackgroundLong-gap oesophageal atresia (LGOA) causes significant early and long-term morbidity. We conducted a retrospective 25-year review comparing outcomes of delayed primary anastomosis versus oesophageal replacement with greater curvature gastric tube.MethodsRecords of 44 consecutive patients undergoing LGOA repair (1986–2010) were obtained from OA database with ethics approval and were analysed for complication and long-term outcomes. Analysis was conducted using Student's t-test for quantitative and Fisher exact test for qualitative data.ResultsThirty (68%) patients underwent delayed primary anastomosis and 14 (32%) had oesophageal replacement. Oesophageal replacement patients had longer gaps (mean 5.5 vertebrae, range 4–9) compared to delayed primary anastomosis (mean 3.9, range 2–6) (p = 0.004), but no difference in perioperative complications (p = 0.2) (Table 1). Oesophageal replacement had more long-term complications (86%) compared to delayed primary anastomosis (30%) (p = 0.005). Almost all patients (> 90%) experienced gastro-oesophageal reflux and 21 delayed primary anastomosis patients (70%) underwent fundoplication. 60% of delayed primary anastomosis and 64.3% of oesophageal replacement patients had continued gastrointestinal symptoms years after repair.ConclusionsOur experience indicates that LGOA can be repaired safely using both methods, with no deaths and similar perioperative risk, but high long-term morbidity mandates long-term follow-up of these patients. Delayed primary anastomosis has a better long-term outcome compared to oesophageal replacement with gastric tube.     

Oesophageal cancer in patients with head and neck cancers: therapeutic implications

AIM OF THE STUDY: To determine therapeutic and prognostic implications of an associated head and neck primary cancer in patients undergoing oesophagectomy for squamous cell carcinoma of the oesophagus. PATIENTS AND METHODS: Between 1982 and 2000, 868 patients with oesophageal cancer were operated in our institution, including 78 (9%) who underwent oesophagectomy for associated oesophageal and head and neck cancers; the latter was synchronous (n = 52) or anterior metachronous (n = 26). Influence of head and neck cancer on the treatment of oesophageal carcinoma was analysed retrospectively in terms of surgical therapeutic strategy and survival. RESULTS: Oesophageal resection consisted of oeso-pharyngolaryngectomy (n = 14, 17.9%), subtotal oesophagectomy (n = 62, 79.5%) and cervical oesophagectomy (n = 2, 2.6%). Radical resection (R0) was obtained in 85% of cases. Postoperative mortality rate was 5 % (4/78). Main complications were pulmonary (18% = 14/78) and anastomotic leaks (14% = 11/78), all of them cervical. Follow-up (mean = 25 +/- 27 months) was complete for all 78 patients. Five-year survival after R0 resection was 25%. Survival pronostic factors were denutrition, complete resection, and pT status of oesophageal tumor. CONCLUSION: In patients with associated carcinomas of oesophagus and head and neck, agressive treatment -including an oesophagectomy- allowed a 5-year survival rate more than 25% without increased mortality or morbidity rates, compared with patients operated on for isolated oesophageal carcinoma.     

Survival after oesophagectomy for cancer of the oesophagus

Background Formerly an inevitably fatal disease, oesophageal cancer today has predictable chances for cure.Methods The recent literature and authors own experiences in the surgical management of oesophageal cancer was reviewed to identify factors associated with improved survival after oesophagectomy.Results Currently reported overall 5-year-survival rates are reaching 40% and more in patients who have had an oesophagectomy performed with curative intention. The reasons for improved survival after surgical resection are multifactorial in nature: decreased postoperative mortality and morbidity (due to improved patient selection, surgical technique and perioperative management), the use of tailored surgical strategies (adopted to the histological tumour type, tumour location, stage of disease and the individual patients risk profile), and multimodality treatment in patients with locally advanced disease.Conclusion The prognosis of patients who have had oesophagectomy for oesophageal cancer has markedly improved during the past decades. With improved long-term survival after oesophagectomy, postoperative quality of life gains importance as an additional parameter of outcome after oesophageal cancer surgery.     

A decade of experience with transthoracic and transhiatal esophagectomy

BACKGROUND: Morbidity and mortality remain significant for transthoracic (TT) and transhiatal (TH) esophagectomy. We report a case-specific approach employing either resection to minimize perioperative morbidity and mortality. METHODS: All primary esophageal resections performed for benign and malignant esophageal disease were reviewed over a 10-year period. The operative approach was tailored to the location and extent of disease and the physiologic reserve of the patient. RESULTS: In all, 115 patients underwent esophagectomy for benign (25) and malignant (90) disease. Fifty-six TT and 59 TH resections were performed. Four emergent TT cases did not have reconstruction. There was 1 hospital mortality. Perioperative transfusion was avoided in 65 patients. Respiratory complications occurred in 15. Three patients had a cervical anastomotic leak requiring open wound drainage. No association between resection type and complication was evident. CONCLUSIONS: The judicious use of both TT and TH esophagectomy resulted in an operative mortality of less than 1%, reduced operative blood loss, and a relatively low rate of perioperative complications.     

Poor glycemic control is a strong predictor of postoperative morbidity and mortality in patients undergoing vascular surgery

ObjectiveHyperglycemia is a common occurrence in patients undergoing cardiovascular surgery. It has been identified in several surgical cohorts that improved perioperative glycemic control reduced postoperative morbidity and mortality. A significant portion of the population with peripheral arterial disease suffers from the sequelae of diabetes or metabolic syndrome. A paucity of data exists regarding the relationship between perioperative glycemic control and postoperative outcomes in vascular surgery patients. The objective of this study was to better understand this relationship and to determine which negative perioperative outcomes could be abated with improved glycemic control.MethodsThis is a retrospective review of a vascular patient database at a large academic center from 2009 to 2013. Eligible procedures included carotid endarterectomy and stenting, endovascular and open aortic aneurysm repair, and all open bypass revascularization procedures. Data collected included standard demographics, outcome parameters, and glucose levels in the perioperative period. Perioperative hyperglycemia was defined as at least one glucose value >180 mg/dL within 72 hours of surgery. The primary outcome was 30-day mortality, with secondary outcomes of complications, need to return to the operating room, and readmission.ResultsOf the total 1051 patients reviewed, 366 (34.8%) were found to have perioperative hyperglycemia. Hyperglycemic patients had a higher 30-day mortality (5.7% vs 0.7%; P < .01) and increased rates of acute renal failure (4.9% vs 0.9%; P < .01), postoperative stroke (3.0% vs 0.7%; P < .01), and surgical site infections (5.7% vs 2.6%; P = .01). In addition, these patients were also more likely to undergo readmission (12.3% vs 7.9%; P = .02) and reoperation (6.3% vs 1.8%; P < .01). Furthermore, multivariable logistic regression demonstrated that perioperative hyperglycemia had a strong association with increased 30-day mortality and multiple negative postoperative outcomes, including myocardial infarction, stroke, renal failure, and wound complications.ConclusionsThis study demonstrates a strong association between perioperative glucose control and 30-day mortality in addition to multiple other postoperative outcomes after vascular surgery.     

Comparison between robotic-assisted and laparoscopic left hemi-hepatectomy

ObjectiveTo compare the safety and short-term outcomes between robotic-assisted and laparoscopic left hemi-hepatectomies in a single academic medical center.MethodsA cohort of 52 patients, who underwent robotic-assisted or laparoscopic left hemi-hepatectomies between April 2015 and January 2020 in Department of Pancreatobiliary Surgery, the First Affiliated Hospital of Sun Yat-Sen University was recruited into the study. Their clinicopathological features and short-term outcomes were analyzed retrospectively.ResultsThere were 25 robotic-assisted and 27 laparoscopic cases, with a median age of 55 years (34–77 years). There was one conversion to open in laparoscopic group. There were no significant differences in clinicopathological features between two groups, except robotic group had higher body mass index (23.9 vs. 22.0 kg/m², p = 0.047). Robotic-assisted and laparoscopic groups had similar operative time (300 vs. 310 min, p = 0.515), length of hospital stay (8 vs. 8 days, p = 0.981) and complication rates (4.0% vs. 14.8%, p = 0.395), but the former had less blood loss (100 vs. 200 ml, p < 0.001) and lower incidence of blood transfusion (0% vs. 22.2%, p = 0.023) in comparison with laparoscopic group. R0 resection was achieved for all patients with malignancies. There was no perioperative mortality in both groups. The cost of robotic group was higher than laparoscopic group (105,870 vs. 64,191 RMB yuan, p = 0.02).ConclusionThe robotic-assisted and laparoscopic approaches had similar safety and short-term outcomes in left hemi-hepatectomy, and the former can reduce operative blood loss and blood transfusion. However, the costs were higher in robotic group.     

Impact of conversion on the long-term outcome in laparoscopic resection of colorectal cancer

Background  Long-term outcome of patients with conversion following laparoscopic resection of colorectal cancer has seldom been reported. This study aimed to evaluate the impact of conversion on the operative outcome and survival of patients who underwent laparoscopic resection for colorectal malignancy. Methods  An analysis of a prospectively collected database of 470 patients who underwent laparoscopic colectomy between May 2000 and December 2006 was performed. The operative results and long-term outcomes of patients with conversion were compared with those with successful laparoscopic operations. Results  The overall conversion rate to open surgery was 8.7% (41 patients). There was no difference in age, comorbid illness, location of tumor, and stage of disease between the laparoscopic and conversion groups. The most common reasons for conversion include adhesions (34.1%), tumor invasion into adjacent structures (17.1%), bulky tumor (9.8%), and uncontrolled hemorrhage (9.8%). A male preponderance was observed in the conversion group. Tumor size was significantly larger in the conversion group compared with the laparoscopic group (5 versus 4 cm, P = 0.002). Although there was no difference in the operative time between the two groups, increased perioperative blood loss (461.9 vs. 191.2 ml, P < 0.001), increased postoperative complication rate (56.1% versus 16.7%, P = 0.001) and prolonged median hospital stay (10 versus 6 days, P < 0.001) were associated with the conversion group. Consequently, patients in the conversion group were more likely to develop local recurrence (9.8% versus 2.8%, P < 0.001) with a significantly reduced cumulative cancer-free survival. Conclusion  The disease-free survival and the local recurrence were significantly worse by the presence of conversion in laparoscopic resection for colorectal malignancy. Adoption of a standardized operative strategy may improve the perioperative outcome after conversion.     

Urgent versus elective laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for high-risk grade II acute cholecystitis

BackgroundThe aim of this study was to evaluate the safety of urgent laparoscopic cholecystectomy (Lap-C) for grade II acute cholecystitis (AC) in high-risk patients who were defined by Tokyo Guideline 18 as having age-adjusted Charlson comorbidity index ≥6 or American Society of Anesthesiologists physical status classification (ASA-PS) ≥ 3, compared with elective Lap-C following percutaneous transhepatic gallbladder drainage (PTGBD).MethodsIn 73 grade II AC patients who underwent Lap-C from January 2012 to March 2021, 35 were identified as high-risk; 22 underwent urgent Lap-C (urgent group) and 13 PTGBD followed by elective Lap-C (elective group). Surgical and perioperative outcomes were analyzed.ResultsThere was no significant difference in operation time (median: 101 min vs 125 min; P = 0.371), blood loss (25 ml vs 7 ml; P = 0.853), morbidity rate (31.8% vs 38.5%; P = 0.726), or the incidence of total perioperative major complications (13.6% vs 15.4%; P = 1.000) between the two groups. The total duration of treatment was significantly shorter in the urgent group than the elective group (11 days vs 71 days; P < 0.001). Multivariate analysis revealed that blood loss ≥45 ml [odds ratio (OS): 12.14, 95% confidence interval (CI): 2.03–72.42, P = 0.006], and age ≥75 years with ASA-PS ≥ 3 (OS: 9.85, 95%CI: 1.26–77.26, P = 0.03) were the independent risk factors for total perioperative major complications.ConclusionIn well-selected high-risk patients with grade II AC, urgent Lap-C can be performed with comparable safety to elective Lap-C following PTGBD.     

Use of Gliadel (BCNU) Wafer in the Surgical Treatment of Malignant Glioma: A 10-Year Institutional Experience

Background  Gliadel (polifeprosan 20 with carmustine [BCNU] implant) is commonly used for local delivery of BCNU to high-grade gliomas after resection and is associated with increased survival. Various complications of Gliadel wafers have been reported but not consistently reproduced. We set out to characterize Gliadel-associated morbidity in our 10-year experience with Gliadel wafers for treatment of malignant glioma. Methods  We retrospectively reviewed records of 1013 patients undergoing craniotomy for resection of malignant brain astrocytoma (World Health Organization grade III/IV disease). Perioperative morbidity occurring within 3 months of surgery was assessed for patients and compared between patients receiving versus not receiving Gliadel wafer. Overall survival was assessed for all patients. Results  A total of 1013 craniotomies were performed for malignant brain astrocytoma. A total of 288 (28%) received Gliadel wafer (250 glioblastoma multiforme (GBM), 38 anaplastic astrocytoma/anaplastic oligodendroglioma (AA/AO), 166 primary resection, 122 revision resection). Compared with the non-Gliadel cohort, patients receiving Gliadel were older (55 ± 14 vs. 50 ± 17, P = .001) and more frequently underwent gross total resection (75% vs 36%, P < .01) but otherwise similar. Patients in Gliadel versus non-Gliadel cohorts had similar incidences of perioperative surgical site infection (2.8% vs. 1.8%, P = .33), cerebrospinal fluid leak (2.8% vs. 1.8%, P = .33), meninigitis (.3% vs. .3%, P = 1.00), incisional wound healing difficulty (.7% vs. .4%, P = .63), symptomatic malignant edema (2.1% vs. 2.3%, P = 1.00), 3-month seizure incidence (14.6% vs. 15.7%, P = .65), deep-vein thrombosis (6.3% vs. 5.2%, P = .53), and pulmonary embolism (PE) (4.9% vs. 3.7%, P = .41). For patients receiving Gliadel for GBM, median survival was 13.5 months after primary resection (20% alive at 2 years) and 11.3 months after revision resection (13% alive at 2 years). For patients receiving Gliadel for AA/AO, median survival was 57 months after primary resection (66% alive at 2 years) and 23.6 months after revision resection (47% alive at 2 years). Conclusion  In our experience, use of Gliadel wafer was not associated with an increase in perioperative morbidity after surgical treatment of malignant astrocytoma.     

Surgical multimodality treatment for baseline resectable stage IIIA-N2 non-small cell lung cancer. Degree of mediastinal lymph node involvement and impact on survival

Objective: Analysis of single centre results and identification of prognostic factors of surgical combined modality treatment in pathological proven stage IIIA-N2 non-small cell lung cancer (NSCLC). Methods: Out of a total of 996 resections for NSCLC between 2000 and 2006, 92 patients with radiological response or stable disease after induction chemotherapy for pathologically proven ipsilateral positive lymph nodes (N2-disease) underwent surgical exploration with the aim of complete resection. Adenocarcinoma and squamous cell carcinomas were equally present (48% vs 43%). Median follow-up of surviving patients (n = 36) was 51 (10–94) months. Results: Complete resection (i.e., tumour with free margins and negative highest mediastinal lymph nodes, R0) was achieved in 68% (n = 63), resection was uncertain or incomplete in 24% (n = 22), while surgery was explorative in 8% (n = 7). Pneumonectomy was performed in 24%, (bi)lobectomy in 62%, and sleeve lobectomy in 13% of patients. In-hospital mortality was 2.3%. Overall need for ICU stay was 18% (30% after pneumonectomy). Median hospital stay was 10 days (6–157). Downstaging of mediastinal lymph nodes (ypN0-1) was found in 43% (n = 40). Overall survival at 5 years (5YS) was 33% (n = 92), and after complete resection 43% (n = 63). Detection of multilevel compared to single level positive nodes at initial mediastinoscopy was related to lower 5YS (17% vs 39%; p < 0.005), and this was identified as an independent prognostic factor in a multivariate analysis of the examined presurgical variables. We found a trend for a better 5YS in patients with mediastinal nodal downstaging compared to patients with persistent N2 disease (49% vs 27%; p = 0.095). In the subgroup with persistent N2 disease, single level disease has a significantly better survival (37% vs 7% 5YS, p < 0.005). Multivariate survival analysis of the examined surgical variables identified completeness of resection and classification of ypN category (ypN0-1 and ypN2-single level vs multilevel-ypN2 and ypN3) as independent prognostic factors. Conclusions: Surgery after induction chemotherapy for stage IIIA-N2 NSCLC can be performed with an acceptable mortality and morbidity. Baseline single level N2 disease is an independent prognostic factor for long-term survival. Patients with mediastinal downstaging, but also a subgroup of patients with single level persistent N2 disease, after induction therapy have a rewarding survival.