Femoral vein thrombosis after right-sided electrophysiological procedures

Purpose

Electrophysiological studies and radiofrequency catheter ablations require single or multiple sheath placements through femoral vein cannulation. The objective of this study was to determine the incidence, predictors, and outcomes of deep vein thrombosis (DVT) following such procedures.

Methods and results

We prospectively enrolled 220 consecutive patients with a median age of 70 [60–79]?years. The median duration of the procedures from insertion to removal of sheaths was 45 [30–75]?min. At least two sheaths were inserted in 158 (72 %) of the cases. Duplex ultrasonography evaluation of the lower leg veins was performed 6 h after the procedure and revealed common femoral vein thrombosis in 11 (5 %) patients. All thrombi were partial and none was complete. Thrombi were mobile in four patients and extended to the external iliac vein in three patients. None of the patients presented with clinical signs of DVT or pulmonary embolism. Anticoagulation was prescribed for 2–4 weeks and a follow-up duplex ultrasonography obtained in the first seven patients revealed complete resolution of thrombi in all cases. On multivariate analysis, two predictors of thrombosis occurrence were identified: a greater sum of sheath diameters (odds ratio, 1.41 [95 % confidence interval, 1.25–1.60] per 1-French increase; p?<?0.001) and a longer procedural duration (odds ratio, 1.02 [95 % confidence interval, 1.00–1.04] per 1-min increase; p?=?0.04).

Conclusions

Asymptomatic femoral DVT occur in 5 % of electrophysiological studies and right-heart radiofrequency catheter ablations, particularly when large sheaths are inserted for a longer period. The role of anticoagulation in this clinical setting warrants further evaluation.     

Living donor intestinal transplant using a standardized technique: first report from India

Aim

We describe the first living donor intestinal transplant (LDIT) in India and discuss the indications and problems of this complex procedure.

Methods

A 43-year-old male patient required massive bowel resection for gangrene due to thrombosis of the superior mesenteric artery. He was maintained on parenteral nutrition but developed cholestasis and well as repeated catheter related infections with progressive loss of venous access due to thrombosis of central veins. A LDIT was performed using 200?cm of small intestine from the patient's son. The graft was based on the continuation of the superior mesenteric vessels beyond the ileocolic branch. The artery was anastomosed directly to the aorta and the vein to the venacava.

Results

The graft functioned well and he was weaned off parenteral nutrition. However, he later developed complications (wound dehiscence and enterocutaneous fistula) and developed sepsis. He succumbed to sepsis with a functioning graft 6?weeks after the transplant. The donor recovered uneventfully and was discharged on the 4th postoperative day.

Conclusions

LDIT can be life saving in patients with intestinal failure and failure of parenteral nutrition. There is a need to introduce this modality in India. In a setting of scarcity of deceased donor organs the living donor option has advantages.     

Salvage lymphadenectomy without esophagectomy is an option for recurrent or residual lymph nodes after definitive chemoradiotherapy for esophageal cancer

Purposes

The aim of this study was to determine the prognostic factors in salvage surgery following definitive chemoradiotherapy (dCRT) for esophageal cancer.

Methods

We retrospectively reviewed twenty-five patients who underwent salvage surgery from 1986 to 2011 at Kurume University Hospital.

Results

Esophagectomy was adopted for 20 patients, while lymphadenectomy alone without esophagectomy was adopted for the other 5 patients. Univariate analysis found that age, response to initial treatment, presence of residual tumor, pT after salvage surgery, and severe complications were each significantly correlated with overall survival after salvage surgery. The type of surgery (esophagectomy vs lymphadenectomy) and presence of residual tumor (R) were each determined to be an independent prognostic factor by the multivariate analysis. Namely, the prognosis after R0 resection was better than that after R1/2 resection (HR 18.050, p < 0.0001), and the prognosis after salvage lymphadenectomy was better than that after salvage esophagectomy (HR 5.091, p = 0.0086).

Conclusions

Salvage lymphadenectomy without esophagectomy is suggested to be an option for patients having recurrent or residual lymph nodes without any other recurrence or residual tumor after dCRT for esophageal cancer.     

Erythropoiesis-stimulating agents are not associated with increased risk of thrombosis in patients with myelodysplastic syndromes

Background

There are limited reports of thrombosis among myelodysplastic syndrome patients exposed to erythropoiesis stimulating agents. It is not clear whether erythropoiesis stimulating agents are associated with an increased risk of thrombosis in myelodysplastic syndromes, as they are among patients with solid tumors.

Design and Methods

The association between use of erythropoiesis stimulating agent and transient thrombosis risk in patients with myelodysplastic syndromes was assessed in a case-crossover study nested within a cohort of incident myelodysplastic syndrome patients. Using the US Surveillance, Epidemiology, and End Results Medicare-linked database, cases with an incident diagnosis of deep vein thrombosis were identified. Using conditional logistical regression, the odds of exposure to erythropoiesis stimulating agents in the 12 weeks prior to the incident deep vein thrombosis (hazard period) was compared to the exposure odds in a prior 12-week comparison period.

Results

Within the cohort of eligibles with myelodysplastic syndromes (n=5,673) there were 212 incident cases of deep vein thrombosis events. Mean age was 76.2 (standard deviation=±8.6) years. Use of erythropoiesis stimulating agents was not associated with deep vein thrombosis in the crude nor the adjusted models (OR=1.21, 95% CI: 0.60, 2.43). Central venous catheter placement (OR=6.47, 95% CI: 2.37, 17.62) and red blood cell transfusion (OR=4.60, 95% CI: 2.29, 9.23) were associated with deep vein thrombosis.

Conclusions

Despite the link between use of erythropoiesis stimulating agents and thrombosis among patients with solid tumors, this study provides evidence that their safety profile may be different among patients with myelodysplastic syndromes.     

Cerebral air embolism as a complication of peptic ulcer in the gastric tube: case report

Background

The reported incidence of ulcer formation in the gastric tube in esophageal replacement is rare.

Case Presentation

This is the first report of a case of cerebral air embolism as a result of spontaneous perforation of an ulcer in the constructed gastric tube into the pulmonary vein during post-operative follow-up in a patient with esophageal cancer.

Conclusions

Cerebral air embolism is a rare complication of penetrating gastric ulcer, but should be considered in patients with a history of esophagectomy with gastric conduit that present with acute neurologic findings.     

Multi-institution retrospective study of the onset frequency of postoperative pneumonia in thoracic esophageal cancer patients

Background

Esophagectomy for thoracic esophageal cancer is a highly invasive procedure. Most studies analyzing the risk factors for pulmonary morbidity were conducted in the early 1990s. However, previous studies did not use fixed diagnostic criteria for postoperative pneumonia and reported widely varying onset frequencies.

Purpose

To define postoperative pneumonia diagnostic criteria, clarify the onset frequency of postoperative pneumonia after esophagectomy in accordance with these criteria, and investigate the risk factors of postoperative pneumonia.

Methods

Risk factors for postoperative pneumonia were analyzed in 615 patients who underwent esophagectomy between January 2006 and December 2007 at 7 Japanese institutions using logistic regression models. The necessary criterion for a pneumonia diagnosis was an infiltrative shadow on a chest radiograph. Furthermore, a pneumonia diagnosis was based on the presence of at least 2 of the following 3 criteria: white blood count abnormalities, body temperature of 38 °C or higher, and purulent sputum.

Results

Overall, 615 patients were statistically analyzed. Pneumonia onset occurred in 66 cases (10.7 %). The risk of postoperative pneumonia was associated with a preoperative body weight loss of 5 % or more and late tracheal tube extubation.

Conclusions

This study revealed that preoperative body weight loss increased the risk of postoperative pneumonia after esophagectomy for esophageal cancer, while early-stage tracheal tube extubation reduced the risk.     

Risk of Venous Thromboembolism Following Peripherally Inserted Central Catheter Exchange: An Analysis of 23,000 Hospitalized Patients

Background

Catheter exchange over a guidewire is frequently performed for malfunctioning peripherally inserted central catheters (PICCs). Whether such exchanges are associated with venous thromboembolism is not known.

Long-term low-molecular-weight heparin and the post-thrombotic syndrome: a systematic review

Objective

Post-thrombotic syndrome causes considerable morbidity. The Home-LITE study showed a lower incidence of post-thrombotic syndrome and venous ulcers after 3 months of treating deep vein thrombosis with the low-molecular-weight heparin tinzaparin versus oral anticoagulation. This systematic review examined whether long-term treatment of deep vein thrombosis using low-molecular-weight heparin, rather than oral anticoagulation, reduces development of post-thrombotic syndrome.

Methods

We identified 9 articles comparing treatment of deep vein thrombosis using long-term low-molecular-weight heparin with any comparator, which reported outcomes relevant to the post-thrombotic syndrome assessed ≥ 3 months post-deep vein thrombosis.

Results

Pooled analysis of 2 studies yielded an 87% risk reduction with low-molecular-weight heparin in the incidence of venous ulcers at ≥ 3 months (P = .019). One study showed an overall odds ratio of 0.77 (P = .001) favoring low-molecular-weight heparin for the presence of 8 patient-reported post-thrombotic syndrome signs and symptoms. Pooled analysis of 5 studies showed a risk ratio for low-molecular-weight heparin versus oral anticoagulation of 0.66 (P < .0001) for complete recanalization of thrombosed veins.

Conclusion

These results support the lower incidence of post-thrombotic syndrome and venous ulcers observed in Home-LITE. Long-term treatment with low-molecular-weight heparin rather than oral anticoagulation after a deep vein thrombosis may reduce or prevent development of signs and symptoms associated with post-thrombotic syndrome. Post-thrombotic syndrome and associated acute ulcers may develop more rapidly after deep vein thrombosis than previously recognized.     

Clinical implications of quantitative pathological and immunohistochemical markers for lymph node metastasis in esophageal cancer patients based on preoperative treatment status

Background

Whether the prognostic abilities of markers of lymphatic spread are affected by preoperative chemotherapy or chemoradiotherapy for esophageal cancer has not been clarified. The purpose of this study was to determine significant prognostic predictors related to lymphatic spread in potentially curable esophageal cancer according to preoperative treatment status.

Methods

The prognostic significance of quantitative pathological and immunohistochemical markers of lymphatic spread was determined in 80 esophageal cancer patients undergoing R0 resection with or without preoperative treatment.

Results

Univariate analysis revealed that the presence or absence of immunohistochemical nodal micrometastasis (iNM), number of pathological nodal metastases (pNM) and iNM, and the ratios of pNM and iNM to removed nodes were significant prognostic predictors in patients undergoing esophagectomy without preoperative treatment. In contrast, only the presence or absence of pNM, number of pNM, and pNM ratio were significant prognostic indicators in patients undergoing esophagectomy after preoperative treatment. Multivariate analysis revealed that the number of iNM, a novel prognostic indicator found in the present study, was the only independent prognostic predictor in the former patients, whereas the number of pNM was the only independent prognostic predictor in the latter patients.

Conclusions

In esophageal cancer, the prognostic values of factors related to lymphatic spread depend on the patient’s preoperative treatment status. Two or more pNM indicated poor prognosis after esophagectomy in patients undergoing preoperative treatment for advanced disease. However, 2 or more iNM indicated poor prognosis after esophagectomy in patients undergoing upfront esophagectomy for less advanced disease.     

Mode of anesthesia,mortality and outcome in geriatric patients

Background

In older non-cardiac surgery patients, the influence of the mode of anesthesia on late-term outcome (rehabilitation, mobility, independence) is a controversial issue in the medical literature. In light of an aging society, this review assessed the association between regional (RA), local (LA) and general anesthesia (GA) and mortality and morbidity.

Methods

A literature search within the PubMed and Cochrane databases yielded 47 clinical trials and 35 reviews/meta-analyses published between 1965 and 2013. Potential outcome-influencing factors such as mortality, risk factors, early complications (e.g. postoperative confusion, aspiration, vomiting), adverse events (e.g. deep vein thrombosis, pulmonary embolism), discharge, rehabilitation and mobilization were evaluated in relation to the mode of anesthesia (RA, LA or GA).

Results

The current literature contains 82 references covering 74,476 non-cardiac surgery patients. Analysis shows that the particular mode of anesthesia influences mortality and morbidity. RA is associated with reduced early mortality and morbidity, e.g. fewer incidents of deep vein thrombosis and less acute postoperative confusion, as well as a tendency toward fewer myocardial infarctions and fatal pulmonary embolisms. GA has the advantages of a lower incidence of hypotension and reduced surgery time.

Conclusion

Strictly speaking, true anesthesia-related complications appear to be rare and many adverse outcomes may be multifactorial. Postoperative complications are largely related to the perioperative procedure and not to the anesthesia itself. GA and RA are both useful for older non-cardiac patients, but for some procedures, e.g. hip fracture surgery, RA seems to be the technique of choice. The mode of anesthesia may only play a secondary role in mobility, rehabilitation and discharge destination. In general, due to the many different possible outcomes—which are often very difficult or impossible to compare—no other specific recommendations can be made with regard to the type of anesthesia to be preferred for older non-cardiac patients.     

Predictive factors for postoperative tachyarrhythmia after thoracoscopic esophagectomy and the usefulness of landiolol hydrochloride for its treatment

Background

Tachyarrhythmia after esophagectomy is a severe complication that should not be underestimated because of its negative impact. The aims of this study were to clarify the cause and impact of postoperative tachyarrhythmia after thoracoscopic esophagectomy. Additionally, we analyzed the usefulness of landiolol administration for postoperative tachyarrhythmia.

Methods

We evaluated the predictive factors for tachyarrhythmia onset after surgery and its clinical impact in 127 patients who underwent thoracoscopic esophagectomy with extended lymphadenectomy. Moreover, we analyzed the efficacy of landiolol for postoperative tachyarrhythmia.

Results

Tachyarrhythmia developed in 38 of the 127 patients. Multivariate analysis showed that advanced age, heart disease, and hyperlipidemia were associated with postoperative tachyarrhythmia. Hyponatremia, hypoalbuminemia, and leukocytosis on postoperative day 3 were significantly associated with tachyarrhythmia onset. The incidence of all complications and respiratory complications, including pneumonia, was significantly higher in patients with than in those without tachyarrhythmia. The mortality rate in the tachyarrhythmia group tended to be higher than that in the nontachyarrhythmia group. Landiolol as a treatment for tachyarrhythmia immediately decreased heart rate and safely reduced subsequent respiratory complications.

Conclusion

In elderly patients with cardiac disease or hyperlipidemia, surgeons should be alert for the occurrence of tachyarrhythmia after esophagectomy. Postoperative tachyarrhythmia is a marker of morbidities with particular emphasis on respiratory complications. However, it can be adequately managed by landiolol, resulting in fewer respiratory complications. Landiolol might be a safe and convenient agent for managing postoperative tachyarrhythmia after thoracoscopic esophagectomy, resulting in lower mortality and morbidity rates.     

Using an age-dependent D-dimer cut-off value increases the number of older patients in whom deep vein thrombosis can be safely excluded

Background

D-dimer testing to rule out deep vein thrombosis is less useful in older patients because of a lower specificity. An age-adjusted D-dimer cut-off value increased the proportion of older patients (>50 years) in whom pulmonary embolism could be excluded. We retrospectively validated the efficacy of this cut-off combined with clinical probability for the exclusion of deep vein thrombosis.

Design and Methods

Five management study cohorts of 2818 consecutive outpatients with suspected deep vein thrombosis were used. Patients with non-high or unlikely probability of deep vein thrombosis were included in the analysis; four different D-dimer tests were used. The proportion of patients with a normal D-dimer test and the failure rates were calculated using the conventional (500 μg/L) and the age-adjusted D-dimer cut-off (patient''s age x 10 μg/L in patients >50 years).

Results

In 1672 patients with non-high probability, deep vein thrombosis could be excluded in 850 (51%) patients with the age-adjusted cut-off value versus 707 (42%) patients with the conventional cut-off value. The failure rates were 7 (0.8; 95% confidence interval 0.3-1.7%) for the age-adjusted cut-off value and 5 (0.7%, 0.2-1.6%) for the conventional cut-off value. The absolute increase in patients in whom deep vein thrombosis could be ruled out using the age-adjusted cut-off value was largest in patients >70 years: 19% among patients with non-high probability.

Conclusions

The age-adjusted cut-off of the D-dimer combined with clinical probability greatly increases the proportion of older patients in whom deep vein thrombosis can be safely excluded.Key words: deep vein thrombosis, D-dimer, diagnosis, hemostasis, pulmonary embolism, venous thromboembolism     

Risk factors contributing to hepatic artery thrombosis following living-donor liver transplantation

Background/Purpose

This study was carried out to investigate the risk factors contributing to hepatic artery thrombosis in living-donor liver transplantation.

Methods

Two hundred and twenty-two recipients (113 adults and 109 children) of living-donor liver transplantation were the subjects of this study. The diagnosis of hepatic artery thrombosis was made by color-Doppler ultrasonography and/or hepatic angiography. Parameters for this study were: (1) donor sex, age, and body weight; (2) recipient sex, age, body weight, liver disease, preoperative prothrombin time, and type of arterial reconstruction; and (3) previous liver transplantation.

Results

Hepatic artery thrombosis occurred in 12 patients (5.4%) at 3 to 15 days posttransplant. Recipient female sex and metabolic disorder as the original disease were found to be significantly associated with hepatic artery thrombosis. The 5-year patient survival rate in recipients with hepatic artery thrombosis (58.3%) was significantly lower than that in recipients without this complication (84.4%).

Conclusions

Female sex and metabolic disease may be factors contributing to hepatic artery thrombosis after living-donor liver transplantation. More intensive anticoagulation therapy for this patient population might decrease the incidence of hepatic artery thrombosis and, thus, posttransplant recipient mortality.     

Upper extremity deep vein thrombosis: a community-based perspective

Purpose

The purpose of this study was to examine the magnitude, risk factors, management strategies, and outcomes in a population-based investigation of patients with upper, as compared with lower, extremity deep vein thrombosis diagnosed in 1999.

Methods

The medical records of all residents from Worcester, Massachusetts (2000 census = 478,000) diagnosed with ICD-9 codes consistent with possible deep vein thrombosis at all Worcester hospitals during 1999 were reviewed and validated.

Results

The age-adjusted attack rate (per 100,000 population) of upper extremity deep vein thrombosis was 16 (95% confidence interval [CI], 13-20) compared with 91 (95% CI, 83-100) for lower extremity deep vein thrombosis. Patients with upper extremity deep vein thrombosis were significantly more likely to have undergone recent central line placement, a cardiac procedure, or an intensive care unit admission than patients with lower extremity deep vein thrombosis. Although short-term and 1-year recurrence rates of venous thromboembolism and all-cause mortality were not significantly different between patients with upper, versus lower, extremity deep vein thrombosis, patients with upper extremity deep vein thrombosis were less likely to have pulmonary embolism at presentation or in follow-up.

Conclusions

Patients with upper extremity deep vein thrombosis represent a clinically important patient population in the community setting. Risk factors, occurrence of pulmonary embolism, and timing and location of venous thromboembolism recurrence differ between patients with upper as compared with lower extremity deep vein thrombosis. These data suggest that strategies for prophylaxis and treatment of upper extremity deep vein thrombosis need further study and refinement.     

La thrombose veineuse portale de l’adulte: à propos de 28 cas

Aim

To study clinical, epidemiological character, aetiology and treatment of portal thrombosis in Morocco.

Material and method

A retrospective study of 28 cases of portal thrombosis at Gastroenterology Department of University Hospital Mohamed-VI Marrakech for a period of four years between January 2004 and December 2008.

Results

Twenty women and eight men of the average age of 40 were studied. The clinical symptoms included acute abdominal pain in 11 cases, a mesenteric infarct in one case, an assessment of portal hypertension in 14 patients and ascitis in two cases. The abdominal ultrasound combined with Doppler in patients showed portal thrombosis in 15 cases and portal cavernoma in 13 cases. Local cause was found in 21 patients. The assessment to find a prothrombotic disorder was required in 15 patients, but it was carried out in only five patients due to lack of means. The assessment results were deficiency in C and S proteins in three cases, a protein S deficiency in one case and an AC antiphospholipide syndrome in one case. Twelve patients in whom thrombosis was considered as acute according to clinical and radiological evidences were given anticoagulant treatment for six months, while eight patients received anticoagulant treatment for life. The prognosis was good for all medicated patients except one patient who died due to a mesenteric infarct.

Discussion

Portal thrombosis is the main cause of portal vein occlusion outside malignancy obstructive tumor. It’s a rare pathology with prevalence between 0.05 and 0.5% according to series; in our study, it represents 1% of hospitalised patients. Because of the low specificity of clinical presentation dominated by abdominal pain, it is usually discovered in late stage after the occurrence of portal cavernome. Abdominal ultrasounds accompanied by Doppler is an effective exam, which confirms the diagnosis in 85% of patients. Angiotomography gives more precisions. Many factors are often responsive of portal thrombosis. Etiological investigation is required to make treatment.

Conclusion

Portal thrombosis is a frequent pathology in our context. Its therapeutic care is difficult because of the high cost of its etiological analysis and its occurrence in particular patients.     

Thrombophilia differences in splanchnic vein thrombosis and lower extremity deep venous thrombosis in North America

Background

The utility of thrombophilia testing in patients with splanchnic vein thrombosis (SpVT) has not previously been rigorously evaluated. The purpose of this study was to characterize differences in the prevalence of thrombophilia in patients with SpVT involving portal (PVT), mesenteric (MVT), splenic (SVT), or hepatic (HVT) veins in isolation or with multisegmental (M-SpVT) involvement compared to patients with lower extremity deep vein thrombosis (DVT).

Methods

An inception cohort of patients with incident SpVT was identified for whom comprehensive thrombophilia testing was performed between 1995 and 2005 and compared to DVT controls.

Results

341 patients with SpVT (mean age 50 ± 16 years, 53 % women) including isolated PVT (n = 112), MVT (n = 67), HVT (n = 22), SVT (n = 11), and M-SpVT (n = 129) involvement and 3621 DVT controls (mean age 55 ± 16 years, 56 % women) had comprehensive thrombophilia testing. The prevalence of abnormal results was similar for SpVT (24.6 %) and DVT (25.9 %) patients. “Strong” thrombophilias were more prevalent among SpVT patients (12.3 vs. 8.5 %, p = 0.0168). Patients with splenic (45.5 %) and mesenteric (41.8 %) thrombosis had the highest thrombophilia prevalence. Protein S deficiency was more common in SpVT patients (3.5 vs. 0.9 %, p < 0.001). In contrast, FV Leiden was more prevalent among DVT patients (15.8 vs. 10.9 %, p = 0.0497).

Conclusion

The prevalence of selected thrombophilia factors differ comparing SpVT and DVT patients. The prevalence is particularly high for patients with splenic and mesenteric vein thrombosis. Whereby the finding of strong thrombophilia impacts duration of anticoagulant therapy, such testing is warranted in the evaluation of patients with unprovoked SpVT.     

Snare coupling of the pre-pectoral pacing lead delivery catheter to the femoral transseptal apparatus for endocardial cardiac resynchronization therapy

Aims

Limitations imposed by the coronary sinus venous anatomy triggered the transseptal approach for endocardial LV lead placement. The alignment of the interatrial septum (IAS) and its neighborhood anatomy does not favor transseptal puncture from the pre-pectoral area. Locating and advancing a pre-pectoral LV lead delivery catheter (PDC) through an opening created in the IAS via femoral transseptal puncture (FTP) is time consuming and technically difficult. We describe a method where the PDC is snare coupled to the femoral transseptal apparatus (FTA). When the FTA is advanced into the left atrium (LA) the coupled PDC follows.

Methods

The catheter of a 25-mm loop snare kit is replaced with the PDC (SelectSite®). The snare loop is positioned in the right common iliac vein from the pre-pectoral access. The PDC is coupled to the FTA by advancing the transseptal apparatus through the open snare loop. After conventional FTP, the FTA is withdrawn back into the right atrium (RA) over an extra support wire positioned in the LA. The PDC with open snare loop is pulled over the FTA up to the RA. The PDC is advanced to close the snare loop on the extra support wire immediately distal to the tip of the dilator close to the puncture site. The PDC is deflected to align with the FTA. The snare coupled catheters are gently advanced across the IAS into the LA. The PDC is released from the FTA by advancing the snare and opening the loop; the snare is then removed from the PDC. The PDC is deflected and advanced into the left ventricle (LV). After positioning the 4.1 Fr lumen less LV lead, the PDC is sliced and removed.

Results

The PDC snare coupled to the FTA was advanced into the LA in all five patients, however, access was lost during catheter manipulation in the one right-sided case. Endocardial LV lead was successfully positioned in all five patients.

Conclusion

Snare coupling the pre-pectoral SelectSite® catheter to the FTA is technically simple, reliable and a safe method for transseptal endocardial LV lead placement for left pre-pectoral implantation.     

National and Regional Trends in Deep Vein Thrombosis Hospitalization Rates,Discharge Disposition,and Outcomes for Medicare Beneficiaries

Introduction

Older adults are at increased risk of developing deep vein thrombosis. Little is known about national trends of deep vein thrombosis hospitalizations in the context of primary and secondary prevention efforts.

Short-term postoperative superiority and 5-year follow-up outcomes of video-assisted thoracoscopic esophagectomy for treatment of esophageal carcinoma: a historical comparison with conventional open esophagectomy under a single experienced surgeon

Background

Few reports have provided a direct comparison of thoracoscopic and open esophagectomy for treatment of esophageal carcinoma in a sufficiently large number of patients with an adequate follow-up period.

Methods

We compared the short- and long-term (up to 5 years after surgery) outcomes of 121 patients who had undergone video-assisted thoracoscopic esophagectomy with 3-field lymphadenectomy (the VATE group) and 74 patients who had undergone conventional open esophagectomy with 3-field lymphadenectomy (the OE group) for treatment of esophageal squamous cell carcinoma.

Results

Total and intrathoracic operation times were longer and total and intrathoracic blood losses were lower in the VATE group than in the OE group. The number of dissected lymph nodes around the left recurrent laryngeal nerve was significantly higher, while both the intensive care unit stay and postoperative hospital stay were significantly shorter in the VATE group. Moreover, the frequency of postoperative analgesia use was lower in the VATE group. Overall morbidity and mortality rates were similar, and the incidences of overall, surgical-site, and thoracic wound infections were significantly lower in the VATE group. Additionally, the incidence of postoperative pneumonia was also lower in the VATE group, although the difference was not statistically significant. No differences were observed in recurrence or survival rates.

Conclusion

Video-assisted thoracoscopic esophagectomy with 3-field lymphadenectomy is a safe and effective surgical method that can be used as an alternative to conventional open esophagectomy in patients with curable esophageal carcinoma.     

Estimation of physiologic ability and surgical stress (E-PASS) can assess short-term outcome after esophagectomy for esophageal cancer

Background

Postoperative morbidity after esophagectomy for esophageal cancer is still frequent. Tools for prediction of postoperative complications have been sought, with the estimation of physiologic ability and surgical stress (E-PASS) scoring system being one of the candidates. The aim of this study was to determine the usefulness of the E-PASS system for risk assessment of esophagectomy.

Methods

The clinical courses of 308 patients who underwent elective subtotal esophagectomy with lymph node dissection for esophageal cancer were analyzed. The incidence and severity of complication and influence of preoperative therapy were investigated using the E-PASS system.

Results

The incidence of any complication was as high as 42.2 %. The frequency of severe and critical complications was 13.0 and 6.8 %, respectively. The E-PASS system could estimate the incidence and severity of complications. Patients with a comprehensive risk score (CRS) >0.9 had a significantly higher probability of incidence of severe or critical complications. The incidence of complication and the CRS increased linearly according to preoperative treatment in the following order: no preoperative treatment < neoadjuvant chemotherapy < neoadjuvant chemoradiotherapy < definitive chemoradiotherapy. These were significantly higher after salvage esophagectomy.

Conclusion

The E-PASS scoring system was useful for risk assessment after esophagectomy. Patients with a CRS >0.9 and patients undergoing salvage esophagectomy should be treated carefully after surgery. Among two scoring systems of which the CRS consisted, the surgical stress score strongly correlated with postoperative complications after esophagectomy, but the preoperative risk score did not.