“En bloc” resection of sacral chordomas by combined anterior and posterior surgical approach: a monocentric retrospective review about 29 cases

Purpose

“En bloc” resection of sacral chordomas (SC) with wide margins is statistically linked with a decrease of local recurrence (LR). Nevertheless, surgery potentially leads to complications and neurological deficits. The effectiveness of radiotherapy (RT) and chemotherapy (CT) remains controversial. The aim of the study was to evaluate the margins of tumor resection, the morbidity of “En bloc” resection of SC by combined anterior and posterior surgical approach and to look for predictive factors on survival and LR.

Methods

We performed sacrococcygectomy by surgical combined approach in 29 SC between 1985 and 2012. We analyzed overall survival and survival to LR with survival analysis using Kaplan–Meier method. Complications and morbidity were reported.

Results

The mean follow-up was of 77.9 months (0–241 months). We found 18 (62.1 %) postoperative infections and 7 (24.1 %) wound dehiscences. Eighteen patients had tumor wide margins (62.1 %), 6 marginal (20.7 %) and 4 intralesional (13.8 %). Seven patients had a LR (24.1 %). OS rate was 84.4 % at 5 and 10 years, survival rate with LR was 64 and 56 %, respectively, after 5 and 10 years. Quality of margins (p = 0.106), tumor volume (p = 0.103), postoperative RT (p = 0.245) and postoperative local infection (p = 0.754) did not have effect on LR.

Conclusion

“En bloc” resection by combined surgical approach seems to be a relevant alternative especially for SC invading the high sacrum above S3. Nevertheless, it yet remains the problem of postoperative infection. Systematic Adjuvant RT might allow better control on LR in association with surgery.     

Meta-Analysis of Efficacy and Safety of Fast-Track Surgery in Gastrectomy for Gastric Cancer

Background

Fast-track surgery (FTS) is a promising program for surgical patients and has been applied to several surgical diseases. FTS is much superior to conventional perioperative care. Our aim was to evaluate and compare the safety and efficacy of FTS and conventional perioperative care for patients undergoing gastrectomy using a systematic review.

Methods

We searched the literature in PubMed, SCOPUS, and EMBASE up to November 2013. No language restriction was applied. Weighted mean differences (WMDs) and odds ratios (ORs) with their 95 % confidence intervals (CIs) were used for analysis by a fixed or a random effects model according to the heterogeneity assumption.

Results

In the present meta-analysis, we included five randomized controlled trials and one controlled clinical trial from five studies. Compared with conventional care, FTS shortened the duration of flatus (WMD ?21.08; 95 % CI ?27.46 to ?14.71, z = 6.48, p < 0.00001 in the open surgery group; WMD ?8.20; 95 % CI ?12.87 to ?3.53, z = 3.44, p = 0.0006 in the laparoscopic surgery group), accelerated the decrease in C-reactive protein (WMD ?15.56; 95 % CI 21.28 to 9.83, z = 5.33, p < 0.00001), shortened the postoperative stay (WMD ?2.00; 95 % CI ?2.69 to ?1.30, z = 5.64, p < 0.00001), and reduced hospitalization costs (WMD ?447.72; 95 % CI ?615.92 to ?279.51, z = 5.22, p < 0.00001). FTS made no significant difference in operation times (p = 0.93), intraoperative blood loss (p = 0.79), or postoperative complications (p = 0.07).

Conclusions

Based on current evidence, the FTS protocol was feasible for gastric cancer patients who underwent gastrectomy (distal subtotal gastrectomy, proximal subtotal gastrectomy, or radical total gastrectomy) via open or laparoscopic surgery. Larger studies are needed to validate our findings.     

Prospective Assessment of Trocar-Specific Morbidity in Laparoscopy

Background

The purpose of the present study was to challenge the hypothetical advantage of single port laparoscopy (SPL) over conventional laparoscopy by measuring prospectively the morbidity specifically related to conventional trocar sites (TS).

Methods

From November 2010 to December 2011, 300 patients undergoing various laparoscopic procedures were enrolled. Patient, surgery, and trocar characteristics were recorded. We evaluated at three time points (in-hospital and at 1 and 6 months postoperatively) specifically for each TS, pain (Visual Analog Scale), morbidity (infection, hematoma, hernia), and cosmesis (Patient Scar Assessment Score; PSAS). Patients designated their “worst TS,” and a composite endpoint “bad TS” was defined to include any adverse outcome at a TS.

Results

We analyzed 1,074 TS. Follow-up was >90 %. Pain scores of >3/10 at 1 and 6 months postoperatively, were reported by 3 and 1 % of patients at the 5 mm TS and by 9 and 1 % at the larger TS, respectively (5 mm TS vs larger TS; p = 0.001). Pain was significantly lower for TS located in the lower abdomen than for the upper abdomen or the umbilicus (p = 0.001). The overall complication rate was <1 % and significantly lower for the 5 mm TS (hematoma p = 0.046; infection p = 0.0001). No hernia was found. The overall PSAS score was low and significantly lower for the 5 mm TS (p = 0.0001). Significant predictors of “bad TS” were larger TS (p = 0.001), umbilical position (p = 0.0001), emergency surgery (p = 0.0001), accidental trocar exit (p = 0.022), fascia closure (p = 0.006), and specimen extraction site (p = 0.0001).

Conclusions

Specific trocar morbidity is low and almost negligible for 5 mm trocars. The umbilicus appears to be an unfavorable TS.     

Advanced Age Remains an Achilles Heel for Liver Resections

Background

As the general population is aging, surgery in elderly patients has become a major public health issue. This basic question is especially true for liver resection (LR). The aim of this study was to evaluate the operative risks of LR in the elderly.

Methods

Retrospective analysis of a large recent and monocentric database of LR was performed between January 1, 2005 and May 31, 2011. Patients were categorized into three groups (<60, 60–74, and ≥75 years old) to analyze postoperative outcomes and 1-year mortality. Clinicopathologic factors likely to influence outcomes were assessed by univariate and multivariate analysis.

Results

Altogether, 1,001 consecutive LRs were performed in 912 patients (mean age 62 ± 13 years). The distribution of the LR by age was 372 (37.2 %), 477 (47.6 %), and 152 (15.2 %) in patients <60, 60–74, and ≥75 years, respectively. The overall morbidity and mortality rates were 33.3 and 2.5 %, respectively. Age ≥75 years was independently associated with postoperative mortality [odds ratio (OR) 4.75, 95 % confidence interval (CI) 1.5–15.1; p = 0.008] and 1-year mortality (OR 2.8, 95 % CI 1.2–6.6; p = 0.015). The postoperative complication rate (p = 0.216) was not increased, even for major complications (p = 0.09). The other independent risk factors for mortality were a cirrhotic liver (p = 0.017), preoperative arterial chemoembolization (p = 0.001), caval vein clamping (p = 0.001), and intraoperative blood transfusion (p = 0.044).

Conclusions

Age beyond 75 years represent a risk factor of death after LR and should be avoided after chemoembolization or in cirrhotic patients. A specific assessment using geriatric indexes might be the key to success in this population.     

One-port video-assisted thoracic surgery versus three-port video-assisted thoracic surgery for primary spontaneous pneumothorax: a meta-analysis

Objective

To further understand the effects of video-assisted thoracic surgery (VATS) with one-port versus three-port VATS for primary spontaneous pneumothorax (PSP).

Methods

In this study, we searched information from the PubMed, Cochrane Library, Embase, ScienceDirect, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Data databases from inception to September 2015 to collect data of randomized controlled trials (RCTs) and cohort studies about one-port VATS versus three-port VATS for PSP. Two independent authors were committed to screen literature, extract data, and assess the risk of bias of related studies. Then, we used the RevMan 5.20 software for a meta-analysis of one-port VATS versus three-port VATS for PSP.

Results

Six cohort studies involving 310 patients were finally selected in this meta-analysis. The results of our study indicate that one-port VATS had a shorter hospital stay (SMD = ?0.39, 95 % CI ?0.69 to 0.09, P = 0.01), lower VAS score of 24-h post-operative pain (SMD = ?0.78, 95 % CI ?1.40 to ?0.52, P < 0.00001), shorter chest drainage time (SMD = ?0.68, 95 % CI ?1.15 to ?0.22, P = 0.004), and lower incidence of post-operative paraesthesia (OR = 0.13, 95 % CI 0.06 to 0.29, P < 0.00001) compared with three-port VATS. However, one-port VATS had a lower patient satisfaction score at 24 h (SMD = ?0.65, 95 % CI ?0.95 to ?0.35, P < 0.0001) and 48 h (SMD = ?0.46, 95 % CI ?0.71 to ?0.21, P = 0.0002). No differences in the recurrence of pneumothorax (OR = 0.58, 95 % CI 0.20 to 1.67, P = 0.32), the operation time (SMD = 1.01, 95 % CI ?4.63 to 2.60, P = 0.58), and the satisfaction score at 72 h (SMD = ?0.11, 95 % CI ?0.44 to 0.22, P < 0.00001) were noted between the groups.

Conclusion

Current evidence suggests that one-port VATS may have certain advantages over three-port VATS for PSP. More large-scale and high-quality studies are needed for authentication.

     

Intramucosal carcinoma of the rectum can be safely treated with transanal endoscopic microsurgery; clinical support of the revised Vienna classification

Aim

The revised Vienna criteria were proposed for classifying rectal neoplasia and subsequent treatment strategies. Restaging intramucosal carcinoma to a non-invasive subgroup seems logical, but clinical support is lacking. In this study, we investigated whether distinction between intramucosal carcinomas (IMC) and rectal adenoma (RA) is of clinical relevance and whether these neoplasms can all be similarly and safely treated by transanal endoscopic microsurgery (TEM).

Methods

All consecutive patients with IMC and RA, treated with TEM between 1996 and 2010 in tertiary referral centre for TEM were included. Long-term outcome of 88 IMC was compared to 356 pure rectal adenomas (RA). Local recurrence (LR) rate was the primary endpoint. Risk factors for LR were analysed.

Results

LR was diagnosed in 7/88 patients (8.0 %) with IMC and in 33/356 patients with primary RA (9.3 %; p = 0.700) and LR-free survival did not differ (p = 0.438). Median time to recurrence was 10 months (IQR IMC 5–30; RA 6–16). Overall recurrence occurred mainly in the first 3 years (38/40; 95 %). None of the LR revealed malignancy on pathological evaluation. No differences could be found in complication rates (IMC 9 %; RA 13 %; p = 0.34). Metastases did not occur in either group. Independent risk factors for LR were irradical margins at final histopathology (HR 2.32; 95 % CI 1.17–4.59; p = 0.016) and more proximal tumours (HR 0.84; 95 % CI 0.77–0.92; P = <0.001).

Conclusion

In this study, IMC of the rectum and RA have similar recurrence rates. This supports the revised Vienna classification. Both entities can be safely treated with TEM.     

The effect of social support and coping style on depression in patients with continuous ambulatory peritoneal dialysis in southern China

Purpose

To explore the effect of social support and coping style on depression in patients on CAPD in Southern China.

Methods

The patients undergoing CAPD therapy for more than 3 months were recruited from Jan 1 to May 31, 2009. The Beck Depression Inventory–II (BDI-II), Social Support Rating Scale, Medical Coping Modes Questionnaire, and Medical Outcomes Study Short Form (SF-36) were used to evaluate depression, social support, coping style, and quality of life (QoL), respectively.

Results

Of the 191 recruited patients, 65 patients (34.0 %) suffered from depression, with a BDI-II score of 23.8 ± 8.4. The average score of QoL (44.9 ± 13.9 vs. 64.7 ± 14.2, p < 0.001), social support (37.9 ± 7.2 vs. 42.1 ± 7.3, p < 0.001), and “confrontation” coping style (17.2 ± 3.9 vs. 18.8 ± 3.8, p = 0.006) in depressed patients was significantly lower than those in non-depressed patients, respectively. While the depressed patients had significantly higher score of “acceptance–resignation” coping style (12.9 ± 2.5 vs. 10.4 ± 3.5, p < 0.001) compared with those of non-depressed patients. Univariate analysis showed that the BDI-II score was negatively associated with social support (r = ?0.284, p < 0.001) and “confrontation” (r = ?0.180, p = 0.013), but positively associated with “acceptance–resignation” (r = 0.482, p < 0.001). Logistic regression analysis revealed that age (OR = 0.971, p = 0.038), female sex (OR = 2.211, p = 0.039), diabetes mellitus (OR = 3.046, p = 0.015), long PD duration (OR = 1.021, p = 0.020), fatigue (OR = 2.500, p = 0.032), high Pittsburgh Sleep Quality Index (PSQI) score (OR = 1.143, p = 0.001), low social support (OR = 0.945, p = 0.046), and high “acceptance–resignation” (OR = 1.096, p = 0.020) were independently associated with depression.

Conclusion

There was a high prevalence of depression in CAPD patients. Age, female sex, diabetes mellitus, long PD duration, fatigue, sleep disturbance, low social support, and high “acceptance–resignation” coping style were independently associated with depression.     

What is the Effect of Laparoscopic Colectomy on Pattern of Colon Cancer Recurrence? A Propensity Score and Competing Risk Analysis Compared with Open Colectomy

Background

Variability in colon cancer recurrence after laparoscopic colectomy (LAC) remains poorly understood. The aim of our study was to quantify the influence of LAC on colon cancer recurrence patterns.

Methods

We included 986 patients undergoing curative colectomy at our institution between 1992 and 2008. Kaplan–Meier, multivariable Cox regression, propensity score adjustment, and competing risks modeling were used to evaluate the influence of laparoscopic surgery on the site of colon cancer recurrence, including the following: liver metastasis, lung metastasis, local recurrence, peritoneal dissemination, other, and multiple sites. We estimated the risk factors for each recurrence site.

Results

Laparoscopic surgery was used in 419 (42.5 %) of 986 patients, with an overall median follow-up time of 5.0 years (interquartile range 3.5). The overall 5-year disease-free survival rate was 86.1 % (open surgery 81.8 % vs. laparoscopic surgery 92.0 %; p < 0.001). However, after covariates and propensity score adjustment, laparoscopic surgery was not a significant risk factor for each type of recurrence: liver hazard ratio (HR) 0.93 (95 % CI 0.45–1.89), p = 0.84; lung HR 0.67 (95 % CI 0.26–1.70), p = 0.39; local HR 0.56 (95 % CI 0.12–2.63), p = 0.46; peritoneal HR 2.49 (95 % CI 0.75–8.27), p = 0.14; others HR 0.47 (95 % CI 0.04–5.13), p = 0.53; multiple HR 0.88 (95 % CI 0.25–3.14), p = 0.84. The risk factors for each type of recurrence were variable and characterized by specific clinicopathological features.

Conclusion

Our study reveals that LAC and open colectomy demonstrate comparable overall colon cancer recurrence rates and recurrence sites. Specific clinicopathological characteristics may have a stronger influence on colon cancer recurrence site compared with the surgical technique.     

A Systematic Review and Meta-Analysis Comparing Laparoscopic Versus Open Gastric Resections for Gastrointestinal Stromal Tumors of the Stomach

Background

This study is a systematic review and meta-analysis that compares the short- and long-term outcomes of laparoscopic gastric resection (LR) versus open gastric resection (OR) for gastric gastrointestinal stromal tumors (GISTs).

Methods

Comparative studies reporting the outcomes of LR and OR for GIST were reviewed.

Results

A total of 11 nonrandomized studies reviewed 765 patients: 381 LR and 384 OR. A higher proportion of high-risk tumors and gastrectomies were in the OR compared with LR (odds ratio, 3.348; 95 % CI, 1.248–8.983; p = .016) and (odds ratio, .169; 95 % CI, .090–.315; p < .001), respectively. Intraoperative blood loss was significantly lower in the LR group [weighted mean difference (WMD), ?86.508 ml; 95 % CI, ?141.184 to ?31.831 ml; p < .002]. The LR group was associated with a significantly lower risk of minor complications (odds ratio, .517; 95 % CI, .277–.965; p = .038), a decreased postoperative hospital stay (WMD, ?3.421 days; 95 % CI, ?4.737 to ?2.104 days; p < .001), a shorter time to first flatus (WMD, ?1.395 days; 95 % CI, ?1.655 to ?1.135 days; p < .001), and shorter time for resumption of oral intake (WMD, ?1.887 days; 95 % CI, ?2.785 to ?.989 days; p < .001). There was no statistically significant difference between the two groups with regard to operation time (WMD, 5.731 min; 95 % CI, ?15.354–26.815 min; p = .594), rate of major complications (odds ratio, .631; 95 % CI, .202–1.969; p = .428), margin positivity (odds ratio, .501; 95 % CI, .157–1.603; p = .244), local recurrence rate (odds ratio, .629; 95 % CI, .208–1.903; p = .412), recurrence-free survival (RFS) (odds ratio, 1.28; 95 % CI, .705–2.325; p = .417), and overall survival (OS) (odds ratio, 1.879; 95 % CI, .591–5.979; p = .285).

Conclusions

LR results in superior short-term postoperative outcomes without compromising oncological safety and long-term oncological outcomes compared with OR.     

Is Vocal Cord Asymmetry Seen on Transcutaneous Laryngeal Ultrasonography a Significant Predictor of Voice Quality Changes After Thyroidectomy?

Background

Vocal cord asymmetry (VCA) on laryngoscopic examination (LE) may suggest voice impairment after thyroidectomy, but LE may cause patient discomfort. We aimed to correlate the presence of postoperative VCA assessed by noninvasive transcutaneous laryngeal ultrasonography (TLUSG) with voice quality changes after thyroidectomy.

Methods

A total of 169 patients scheduled for thyroidectomy completed two validated voice symptoms questionnaires—the GRBAS (grade, roughness, breathiness, asthenia, strain) scale and the voice impairment score (VIS)—and underwent TLUSG and LE at 1 day before and 7–10 days after thyroidectomy. Postoperative VCA was apparent in 51 patients on TLUSG (group I), whereas there was no VCA in the other 118 patients (group II, controls). The GRBAS scale and VIS results were compared between the groups.

Results

Before operation, the two groups had comparable preoperative GRBAS and VIS status. After operation, the “grade” and “roughness” components on the GRBAS scale were significantly worse in group I than in group II: 0.24 versus 0.07 (p = 0.016) and 0.33 versus 0.14 (p = 0.022), respectively. “Grade” and “roughness” in the GRBAS scale significantly worsened after the operation in group I: from 0.04 to 0.24 (p = 0.008) and from 0.02 to 0.33 (p = 0.001), respectively. They did not change in group II. Also, the overall VIS was significantly worse after thyroidectomy in group I: 4.97 versus 12.97 (p < 0.001).

Conclusions

VCA seen on TLUSG significantly correlated with “grade” and “roughness” components on the GRBAS scale and the overall VIS. Thus, VCA might be used as a surrogate of postoperative voice changes.     

Early Outcomes for Rectal Cancer Surgery in the Republic of Ireland Following a National Centralization Program

Background

Following a national audit of rectal cancer management in 2007, a national centralization program in the Republic of Ireland was initiated. In 2010, a prospective evaluation of rectal cancer treatment and early outcomes was conducted.

Methods

A total of 29 colorectal surgeons in 14 centers prospectively collated data on all patients with rectal cancer who underwent curative surgery in 2010.

Results

Data were available on 447 patients who underwent proctectomy with curative intent for rectal cancer in 2010; 23.7 % of patients underwent abdominoperineal excision. The median number of lymph nodes identified was 12. The 30-day mortality rate was 1.1 %. Compared with 2007, there was a reduction in positive circumferential margin rate (15.8 vs 4.5 %, P < 0.001), clinical anastomotic leak rate (10.8 vs 4.3 %, P = 0.002), and postoperative radiotherapy use (17.8 vs 4.0 %, P < 0.001). Also, 53.9 % received preoperative radiotherapy in 2010. Four centers gave statistically more patients (high-administration), and four centers gave fewer patients (low-administration) preoperative radiotherapy for T2/T3 tumors (P < 0.05). On multivariate analysis, being treated in a “high-administration center” increased the likelihood (likelihood ratio [LR], 2.9; 95 % CI 1.7–4.8; P < 0.001) while attending a “low-administration center” (LR, 0.3; 95 % CI 0.2–0.5; P < 0.001) reduced the likelihood of receiving preoperative radiotherapy for a T2/T3 rectal cancer.

Conclusions

Patients undergoing rectal cancer surgery in hospitals following a national centralization initiative received high-quality surgery. Significant heterogeneity exists in radiotherapy administration, and evidence-based guidelines should be developed and implemented.     

Therapeutic strategy for treating aortoesophageal fistulas

Purpose

The development fistulas between the thoracic aorta and the esophagus are highly fatal conditions. We aimed to identify a therapeutic strategy for treating aortoesophageal fistula (AEF) in this study, by investigating all AEF cases presented in this special symposium at the 65th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery.

Methods

Forty-seven AEF patients were included in this study. The survivors and nonsurvivors at six and 18 months after diagnosis of AEF were classified into “Group A6”, “Group D6”, “Group A18”, and “Group D18”, respectively. Comparisons between Group A6 and Group D6 and between Group A18 and Group D18 were made with regard to therapeutic strategy.

Results

Twenty-two (46.8 %) and 33 (70.3 %) of the 47 patients died within 6 and 18 months, respectively. The patients treated with omentum wrapping (p = 0.0052), esophagectomy (p = 0.0269) and a graft replacement strategy for the aorta (p = 0.002) were more frequently included in Group A6. The patients with the omentum wrapping (p = 0.0174) and esophagectomy (p = 0.0203) and graft replacement were more significantly included in Group A18. The results of the multivariate analysis indicated that the mortality rate at 6 and 18 months after diagnosis was significantly correlated with graft replacement (p = 0.0188) and esophagectomy (p = 0.0257), respectively. There were significant differences in the actuarial survival curves in patients who had omentum wrapping, graft replacement, and esophagectomy compared to patients who did not have these 3 therapeutic procedures.

Conclusion

The use of thoracic endovascular aortic repair alone for AEF should not be considered a definitive surgery. In contrast, esophagectomy, open surgery with aortic replacement using prostheses and homografts and greater omentum wrapping significantly improve the mid-term survival of AEF.     

The effect of 5α-reductase inhibitors on prostate growth in men receiving testosterone replacement therapy: a systematic review and meta-analysis

Purpose

Androgen replacement therapy is a widely accepted form of treatment worldwide for aging men with late-onset hypogonadism (LOH) syndrome. Urologists have been concerned with the use of androgen supplements due to the possibility of enhancing prostate growth. We performed a systematic review and meta-analysis to assess the effect of 5α-reductase inhibitors on prostate growth in men receiving testosterone replacement therapy.

Methods

A literature review was performed to identify all published randomized placebo-controlled trials (RCT) that used exogenous testosterone combined with 5α-reductase inhibitor therapy for the treatment of hypogonadism. The search included the following databases: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The reference lists of the retrieved studies were also investigated, and a systematic review and meta-analysis were conducted.

Results

Five publications involving a total of 250 patients were used in the analysis, including 4 RCTs that were short-term (≤6 mo) comparisons of testosterone plus a 5α-reductase inhibitor with testosterone plus placebo and 3 RCTs that were long-term (18–36 mo) comparisons of testosterone plus a 5α-reductase inhibitor with testosterone plus placebo. In our meta-analysis, we found that testosterone plus a 5α-reductase inhibitor may slow the progression of prostate growth. For the comparison of short-term testosterone plus 5α-reductase inhibitor treatment with testosterone plus placebo therapy, the prostate-specific antigen (PSA) level (the standardized mean difference (SMD) = ?0.24, 95 % confidence interval (CI) = ?0.45 to 0.04, p = 0.02)) and the prostate volume (SMD = ?1.66, 95 % CI = ?4.54 to 1.22, p = 0.26) indicated that, compared with testosterone plus placebo therapy, the testosterone plus 5α-reductase inhibitor may decrease the PSA level. For the comparison of long-term testosterone plus 5α-reductase inhibitor with testosterone plus placebo, the PSA level (SMD = ?0.53, 95 % CI = ?0.84 to 0.21, p = 0.001) and the prostate volume (SMD = ?8.53, 95 % CI = ?15.51 to 1.54, p = 0.02) showed that, compared with testosterone plus placebo therapy, the testosterone plus 5α-reductase inhibitor treatment may slow the progression of prostate growth.

Conclusions

Our meta-analysis indicates that the treatment of LOH patients with short-term testosterone plus 5α-reductase inhibitor therapy does not lead to prostate growth; however, this treatment could effectively decrease the PSA level. Additionally, long-term testosterone plus 5α-reductase inhibitor therapy could slow the progression of prostate growth.     

Short-Term Outcomes after Combined Colon and Liver Resection for Synchronous Colon Cancer Liver Metastases: A Population Study

Introduction

The timing of surgical resection for stage IV colon cancer with liver metastasis and the safety of simultaneous colon and liver resection remains controversial. The purpose of our study was to evaluate short-term outcomes after combined colon and liver resection (CCLR) versus colon resection (CR) or liver resection alone (LR) using a population database.

Methods

The National Inpatient Sample was used to select patients who had surgery for colon cancer from 2002 to 2006. We evaluated for in-hospital morbidity, mortality, and prolonged length of stay (PLOS). Our analysis was done using design-weighted unadjusted analysis and logistic regression.

Results

We identified 361,096 patients during our study period (CCLR 3,625; CR 322,286; LR 35,185). CCLR was not associated with an increased risk of complications (odds ratio (OR) 1.12; 95 % confidence interval (CI) 0.94–1.33; P = 0.21) or PLOS (OR 1.19; 95 % CI 0.99–1.4; P = 0.06) compared with CR. In-hospital mortality occurred in 3.5 % of patients who underwent CCLR and was not significantly associated with mortality compared with CR alone (OR 1.17; 95 % CI 0.79–1.74; P = 0.43). Liver lobectomy with CR was associated with a PLOS and a trend toward increased morbidity and mortality. Significant predictors of complications, mortality, and PLOS included: age >70 years, male gender, nonprivate health insurance, and Elixhauser score >1.

Conclusions

CCLR with limited liver resection can be performed with similar morbidity and mortality to colectomy alone. For patients who require hepatic lobectomy, however, strong consideration should be given to a staged approach.     

A cost comparison of laparoscopic and open colon surgery in a publicly funded academic institution

Background

The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution.

Methods

Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann–Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost.

Results

There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost.

Conclusions

Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.     

Adjuvant Chemotherapy for Stage II Right-Sided and Left-Sided Colon Cancer: Analysis of SEER-Medicare Data

Background

Survival benefit from adjuvant chemotherapy is established for stage III colon cancer; however, uncertainty exists for stage II patients. Tumor heterogeneity, specifically microsatellite instability (MSI), which is more common in right-sided cancers, may be the reason for this observation. We examined the relationship between adjuvant chemotherapy and overall 5-year mortality for stage II colon cancer by location (right- vs left-side) as a surrogate for MSI.

Methods

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified Medicare beneficiaries from 1992 to 2005 with AJCC stage II (n = 23,578) and III (n = 17,148) primary adenocarcinoma of the colon who underwent surgery for curative intent. Overall 5-year mortality was examined with Kaplan–Meier survival analysis and Cox proportional hazards regression with propensity score weighting.

Results

It was found that 18 % of stage II patients (n = 2941) with right-sided cancer and 22 % (n = 1693) with left-sided cancer received adjuvant chemotherapy. After adjustment, overall 5-year survival benefit from chemotherapy was observed only for stage III patients (right-sided: hazard ratio [HR], 0.64; 95 % CI, 0.59–0.68; p < .001 and left-sided: HR, 0.61; 95 % CI, 0.56–0.68; p < .001). No survival benefit was observed for stage II patients with either right-sided (HR, 0.97; 95 % CI, 0.87–1.09; p = .64) or left-sided cancer (HR, 0.97; 95 % CI, 0.84–1.12; p = .68).

Conclusions

Among Medicare patients with stage II colon cancer, a substantial number receive adjuvant chemotherapy. Adjuvant chemotherapy did not improve overall 5-year survival for either right- or left-sided colon cancers. Our results reinforce existing guidelines and should be considered in treatment algorithms for older adults with stage II colon cancer.     

A meta-analysis comparing tacker mesh fixation with suture mesh fixation in laparoscopic incisional and ventral hernia repair

Objective

To systematically compare the tacker mesh fixation (TMF) with the suture mesh fixation (SMF) in laparoscopic incisional and ventral hernia (LIVH) repair.

Methods

Trials evaluating the TMF with the SMF in LIVH repair were analysed using the statistical tool RevMan^®. Combined dichotomous and continuous data were expressed as odds ratio (OR) and mean difference (MD), respectively.

Results

Four trials (2 randomised and 2 non-randomised) encompassing 207 patients undergoing LIVH repair with TMF versus SMF were retrieved from the standard electronic databases and analysed systematically. Ninety-nine patients underwent TMF and 108 patients underwent SMF in LIVH repair. There was no statistically significant heterogeneity (p = 0.27)] among trials. In the fixed-effects model, LIVH repair with TMF was associated with shorter operation time (MD, ?23.65; 95 % CI, ?31.06, ?16.25; z = 6.26; p < 0.00001). Four- to six-week postoperative pain score was significantly lower (MD, ?0.69; 95 % CI, ?1.16, ?0.23; z = 2.92; p < 0.004) following TMF. Peri-operative complications (p = 0.65), length of hospital stay (p = 1) and risk of hernia recurrence (OR, 1.54; 95 % CI, 0.38, 6.27; z = 0.61; p = 0.54) following TMF and SMF were statistically not different.

Conclusion

TMF in LIVH repair is associated with shorter operative time and lesser postoperative pain. TMF is comparable with SMF in terms of peri-operative complications, length of hospital stay and hernia recurrence. Therefore, TMF may be used in LIVH repair. However, further randomised trials recruiting higher number of patients are required to validate these findings.     

Do we really need tranexamic acid in total hip arthroplasty? A meta-analysis of nineteen randomized controlled trials

Background

Studies have shown that tranexamic acid reduces blood loss and transfusion need in patients undergoing total hip arthroplasty. However, no to date, no study has been large enough to determine definitively whether the drug is safe and effective. We examined whether intravenous tranexamic acid, when compared with placebo, was safe and effective in total hip arthroplasty.

Methods

The literature search was conducted using the PubMed, Cochrane Library, MEDLINE, EMBASE, and China National Knowledge Infrastructure (CNKI) databases. Data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. Ultimately, 19 randomized controlled trials involving 1,030 patients were included.

Results

The use of tranexamic acid significantly reduced total blood loss by a mean of 305.27 mL [95 % confidence interval (CI) ?397.66 to ?212.89, p < 0.001], intraoperative blood loss by a mean of 86.33 mL(95 % CI ?152.29 to ?20.37, p = 0.01), postoperative blood loss by a mean of 176.79 mL (95 % CI ?236.78 to ?116.39, p < 0.001), and “hidden” blood loss by a mean of 152.70 mL (95 % CI ?187.98 to ?117.42, p < 0.001), resulting in a meaningful reduction in the proportion of patients requiring blood transfusion (odds ratio 0.28, 95 % CI 0.19 to 0.42, p < 0.001). There was no significant difference in occurrence of deep vein thrombosis, pulmonary embolism, or other complications among the study groups, or cost or hospitalization duration.

Conclusions

The data from this meta-analysis indicate that intravenous tranexamic acid may reduce blood loss and transfusion need in patients undergoing total hip arthroplasty without increasing the risk of complications. However, high-quality randomized controlled trials are required to validate the results.