Minimally invasive vs open nephrectomy in the modern era: does approach matter?

Purpose

To evaluate if the widespread adoption of a minimally invasive approach to radical nephrectomy has affected short- and long-term patient outcomes in the modern era.

Methods

A retrospective cohort study of patients who underwent radical nephrectomy from 2001 to 2012 was conducted using the US National Cancer Institute Surveillance Epidemiology and End Results (SEER) Program and Medicare insurance program database. Patients who underwent open surgery were compared to those who underwent minimally invasive surgery using propensity score matching.

Results

10,739 (85.9%) underwent open surgery and 1776 (14.1%) underwent minimally invasive surgery. Minimally invasive surgery increased from 18.4% from 2001–2004 to 43.5% from 2009 to 2012. After median follow-up of 57.1 months, minimally invasive radical nephrectomy conferred long-term oncologic efficacy in terms of overall (HR 0.84; 95% CI 0.75–0.95) survival and cancer-specific (HR 0.68; 95% CI 0.54–0.86) survival compared to open radical nephrectomy. Minimally invasive surgery was associated with lower risk of inpatient death [risk ratio (RR) 0.45 with 95% CI: (0.20–0.99), p = 0.04], deep vein thrombosis [RR: 0.35 (0.18–0.69), p = 0.002], respiratory complications [RR: 0.73 (0.60–0.89), p = 0.001], infectious complications [RR: 0.35 (0.14–0.90), p = 0.02], acute kidney injury [RR: 0.66 (0.52–0.84), p < 0.001], sepsis [RR: 0.55 (0.31–0.98), p = 0.04], prolonged length of stay (18.6 vs 30.0%, p < 0.001), and ICU admission (19.7 vs 26.3%, p < 0.001). Costs were similar between the two approaches (30-day costs $15,882 vs $15,564; p = 0.70).

Conclusion

After widespread adoption of minimally invasive approaches to radical nephrectomy across the United States, oncologic standards remain preserved with improved perioperative outcomes at no additional cost burden.

     

Readmission After Abdominal Surgery for Crohn’s Disease: Identification of High-Risk Patients

Background

Although many predictive factors for postoperative morbidity are known, few data are available about readmission after abdominal surgery for Crohn’s disease (CD). The objective of this study is to identify predictive factors and high-risk patients for readmission after abdominal CD surgery.

Methods

All patients who underwent abdominal surgery for CD in one tertiary referral center between January 2004 and December 2016 were included. Patients who required readmission and those without were compared. Perineal procedures, elective readmissions, and abdominal procedures for non-Crohn’s indications were not included.

Results

Nine hundred eight abdominal procedures were performed in 712 patients. Readmission rates were 8, 8.5, 8.6, 8.8, and 8.9% at 30, 60, and 90 days and 12 and 60 months, respectively. The main reasons were wound infection (14%), deep abscess (13%), small-bowel obstruction (13%), and dehydration (11%). Eight (11%) patients required percutaneous drainage and 19 (27%) underwent an unplanned surgery. After multivariate analysis, three independent predictive factors for readmission were identified: older age (OR 1.02, 95%CI 1.005–1.04; p?<?0.006), a history of previous proctectomy (OR 3, 95%CI 1.2–9, p?<?0.02), and higher blood loss volume during surgery (OR 1.0001, 95%CI 1–1.002, p?<?0.05).

Conclusion

Readmission occurred in 8–9% of abdominal procedures for CD within 1–3 months after surgery and it required unplanned reoperation in a quarter of them. Identification of high-risk groups and knowledge of the more common postoperative complications requiring readmission help in increasing postoperative vigilance to select patients who may benefit from early interventions.

     

Radiologically Determined Sarcopenia Predicts Morbidity and Mortality Following Abdominal Surgery: A Systematic Review and Meta-Analysis

Background

Individualised risk prediction is crucial if targeted pre-operative risk reduction strategies are to be deployed effectively. Radiologically determined sarcopenia has been shown to predict outcomes across a range of intra-abdominal pathologies. Access to pre-operative cross-sectional imaging has resulted in a number of studies investigating the predictive value of radiologically assessed sarcopenia over recent years. This systematic review and meta-analysis aimed to determine whether radiologically determined sarcopenia predicts post-operative morbidity and mortality following abdominal surgery.

Method

CENTRAL, EMBASE and MEDLINE databases were searched using terms to capture the concept of radiologically assessed sarcopenia used to predict post-operative complications in abdominal surgery. Outcomes included 30 day post-operative morbidity and mortality, 1-, 3- and 5-year overall and disease-free survival and length of stay. Data were extracted and meta-analysed using either random or fixed effects model (Revman ^® 5.3).

Results

A total of 24 studies involving 5267 patients were included in the review. The presence of sarcopenia was associated with a significant increase in major post-operative complications (RR 1.61 95% CI 1.24–4.15 p = <0.00001) and 30-day mortality (RR 2.06 95% CI 1.02–4.17 p = 0.04). In addition, sarcopenia predicted 1-, 3- and 5-year survival (RR 1.61 95% CI 1.36–1.91 p = <0.0001, RR 1.45 95% CI 1.33–1.58 p = <0.0001, RR 1.25 95% CI 1.11–1.42 p = 0.0003, respectively) and 1- and 3-year disease-free survival (RR 1.30 95% CI 1.12–1.52 p = 0.0008).

Conclusion

Peri-operative cross-sectional imaging may be utilised in order to predict those at risk of complications following abdominal surgery. These findings should be interpreted in the context of retrospectively collected data and no universal sarcopenic threshold. Targeted prehabilitation strategies aiming to reverse sarcopenia may benefit patients undergoing abdominal surgery.

     

Risk Prediction Model for Severe Postoperative Complication in Bariatric Surgery

Background

Factors associated with risk for adverse outcome are important considerations in the preoperative assessment of patients for bariatric surgery. As yet, prediction models based on preoperative risk factors have not been able to predict adverse outcome sufficiently.

Objective

This study aimed to identify preoperative risk factors and to construct a risk prediction model based on these.

Methods

Patients who underwent a bariatric surgical procedure in Sweden between 2010 and 2014 were identified from the Scandinavian Obesity Surgery Registry (SOReg). Associations between preoperative potential risk factors and severe postoperative complications were analysed using a logistic regression model. A multivariate model for risk prediction was created and validated in the SOReg for patients who underwent bariatric surgery in Sweden, 2015.

Results

Revision surgery (standardized OR 1.19, 95% confidence interval (CI) 1.14–0.24, p <?0.001), age (standardized OR 1.10, 95%CI 1.03–1.17, p =?0.007), low body mass index (standardized OR 0.89, 95%CI 0.82–0.98, p =?0.012), operation year (standardized OR 0.91, 95%CI 0.85–0.97, p =?0.003), waist circumference (standardized OR 1.09, 95%CI 1.00–1.19, p =?0.059), and dyspepsia/GERD (standardized OR 1.08, 95%CI 1.02–1.15, p?=?0.007) were all associated with risk for severe postoperative complication and were included in the risk prediction model. Despite high specificity, the sensitivity of the model was low.

Conclusion

Revision surgery, high age, low BMI, large waist circumference, and dyspepsia/GERD were associated with an increased risk for severe postoperative complication. The prediction model based on these factors, however, had a sensitivity that was too low to predict risk in the individual patient case.

     

Readmission Following Gastric Cancer Resection: Risk Factors and Survival

Background

This study utilized a multi-institutional database to evaluate risk factors for readmission in patients undergoing curative gastrectomy for gastric adenocarcinoma with the intent of describing both perioperative risk factors and the relationship of readmission to survival.

Methods

Patients who underwent curative resection of gastric adenocarcinoma from 2000 to 2012 from seven academic institutions of the US Gastric Cancer Collaborative were analyzed. In-hospital deaths and palliative surgeries were excluded, and readmission was defined as within 30 days of discharge. Univariate and multivariable logistic regression analyses were employed and survival analysis conducted.

Results

Of the 855 patients, 121 patients (14.2 %) were readmitted. Univariate analysis identified advanced age (p?<?0.0128), American Society of Anesthesiology status ≥3 (p?=?0.0045), preexisting cardiac disease (p?<?0.0001), hypertension (p?=?0.0142), history of smoking (p?=?0.0254), increased preoperative blood urea nitrogen (BUN; p?=?0.0426), concomitant pancreatectomy (p?=?0.0056), increased operation time (p?=?0.0384), estimated blood loss (p?=?0.0196), 25th percentile length of stay (<7 days, p?=?0.0166), 75th percentile length of stay (>12 days, p?=?0.0256), postoperative complication (p?<?0.0001), and total gastrectomy (p?=?0.0167) as risk factors for readmission. Multivariable analysis identified cardiac disease (odds ratio (OR) 2.4, 95 % confidence interval (CI) 1.6–3.3, p?<?0.0001), postoperative complication (OR 2.3, 95 % CI 1.6–5.4, p?<?0.0001), and pancreatectomy (OR 2.2, 95 % CI 1.1–4.1, p?=?0.0202) as independent risk factors for readmission. There was an association of decreased overall median survival in readmitted patients (39 months for readmitted vs. 103 months for non-readmitted). This was due to decreased survival in readmitted stage 1 (p?=?0.0039), while there was no difference in survival for other stages. Stage I readmitted patients had a higher incidence of cardiac disease than stage I non-readmitted patients (58 vs. 24 %, respectively, p?=?0.0002).

Conclusions

Within this multi-institutional study investigating readmission in patients undergoing curative resection for gastric cancer, cardiac disease, postoperative complication, and concomitant pancreatectomy were identified as significant risk factors for readmission. Readmission was associated with decreased overall median survival, but on further analysis, this was driven by differences in survival for stage I disease only.

     

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N?=?2,799, 76.1 %) and had resection for malignancy (N?=?2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR?=?1.01, 95 % CI?=?1.01–1.02, p?=?0.001), preoperative malnutrition (OR?=?1.65, 95 % CI?=?1.35–2.02, p?<?0.001), total gastrectomy (OR?=?1.63, 95 % CI?=?1.31–2.03, p?<?0.001), benign indication for resection (OR?=?1.60, 95 % CI?=?1.29–1.97, p?<?0.001), blood transfusion (OR?=?2.57, 95 % CI?=?2.10–3.13, p?<?0.001), and intraoperative placement of a feeding tubes (OR?=?1.28, 95 % CI?=?1.00–1.62, p?=?0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR?=?1.23, 95 % CI?=?0.99–1.53, p?=?0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p?<?0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

     

C-Reactive Protein on Postoperative Day 1 Is a Reliable Predictor of Pancreas-Specific Complications After Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications.

Methods

Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis.

Results

Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n?=?58 (53%); pancreatic fistula: n?=?48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter <?3 mm and serum C-reactive protein ≥?100 mg/L on postoperative day 1 were independent predictors of pancreas-specific complications (p?<?0.01) and pancreatic fistula (p?<?0.01). ROC analysis showed that serum C-reactive protein ≥?100 mg/L on postoperative day 1 was a significant predictor of pancreatic fistula (AUC: 0.70; 95%CI: 0.60–0.79, p?<?0.01) and pancreas-specific complications (AUC: 0.72; 95%CI: 0.62–0.82, p?<?0.01). ROC analysis showed that serum C-reactive protein ≥?50 mg/L at discharge was a significant predictor of 90-day hospital readmission (AUC: 0.70; 95%CI: 0.60–0.79, p?<?0.01).

Conclusions

C-reactive protein levels reliably predict risks of pancreatic fistula, pancreas-specific complications, and hospital readmission, and should be inserted in risk-stratified management algorithms after pancreaticoduodenectomy.

     

Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality,Readmission, and Cost of Care

Objective(s)

Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs.

Methods

From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable.

Results

The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortality rate was 2.3 % and the 30-day readmission rate was 13.4 %. Hospitals performing >30 hepatic lobectomies per year had significantly lower mortality and readmission rates than those hospitals performing ≤15 lobectomies annually (both p?<?0.05). On multivariate analysis, higher severity of illness (odd ratio (OR) 2.13, 95 % confidence interval (CI) [1.48–3.07], p?<?0.001), discharge to rehab (OR 1.84, [1.28–2.64], p?<?0.001), home with home health care (OR 1.38, [1.08–1.76], p?=?0.01), and surgery at a low-volume hospital (OR 1.49, [1.18–1.88], p?<?0.001) were significant predictors of readmission. Conversely, surgical intervention at high-volume centers was associated with decreased risk of readmission (OR 0.67, [0.53–0.85], p?<?0.001). When both index and readmission costs were considered, per-patient cost at low-volume centers was 21.9 % higher than at high-volume centers ($19,669 vs. $16,137). Sensitivity analyses adjusting for perioperative mortality and readmission at all centers did not significantly change the analysis.

Conclusions

These data, for the first time, demonstrate that hospital volume in hepatic lobectomy is an important, modifiable risk factor for readmission and cost. To optimize resource utilization, patients undergoing complex hepatic surgery should be directed to higher-volume surgical institutions.

     

The Impact of Discharge Timing on Readmission Following Hepatopancreatobiliary Surgery: a Nationwide Readmission Database Analysis

Objective

Decreasing hospital length-of-stay (LOS) may be an effective strategy to reduce costs while also improving outcomes through earlier discharge to the non-hospital setting. The objective of the current study was to define the impact of discharge timing on readmission, mortality, and charges following hepatopancreatobiliary (HPB) surgery.

Methods

The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HPB procedures between 2010 and 2014. Length of stay (LOS) was categorized as early discharge (4–5 days), routine discharge (6–9 days), and late discharge (10–14 days). Univariable and multivariable analyses were utilized to identify factors associated with 90-day readmission.

Results

A total of 28,114 patients underwent HPB procedures. Overall median LOS was 7 days (IQR 5–11); 10,438 (37.1%) patients had an early discharge, while 13,665 (48.6%) and 4011 (14.3%) patients had a routine or late discharge. The probability of early discharge increased over time (referent 2010: 2011–4% (OR 1.04, 95% CI 0.96–1.15) vs. 2012–10% (OR 1.10, 95% CI 1.01–1.20) vs. 2013–21% (OR 1.21, 95% CI 1.11–1.32) vs. 2014–32% (OR 1.32, 95% CI 1.21–1.44)) (p?<?0.001). Early discharge was associated with insurance status, diagnosis (benign vs. malignant disease), general health, and overall hospital volume (all p?<?0.05). Among patients who had an early discharge, 30- and 90-day readmission was 11.5 and 17.4%, respectively. In contrast, 30- and 90-day readmission was 16.9 and 24.7%, respectively, among patients who had a routine discharge group (p?<?0.001). Among patients readmitted within 90 days, in-hospital mortality was similar among patients who had early (n?=?43, 2.4%) versus routine discharge (n?=?65, 1.9%). Median charges were lower among patients who had an early versus routine versus late discharge ($54,476 [IQR 40,053–79,100] vs. $75,192 [IQR 53,296–113,123] vs. $115,061 [IQR 79,162–171,077], respectively) (p?<?0.001).

Conclusions

Early discharge after HPB surgery was not associated with increased 30- or 90-day readmission. Overall 90-day in-hospital mortality following a readmission was comparable among patients with an early, routine, and late discharge, while median charges were lower in the early discharge group.

     

Patient Preparation for Transitions of Surgical Care: Is Failing to Prepare Surgical Patients Preparing Them to Fail?

Background

Transitions of care before and after surgery are critical for patient preparation. We sought to determine whether the degree of exposure to health information resources before and after surgery increases preparedness and decreases hospital readmission.

Methods

A national Web-based, cross-sectional survey was conducted of 1917 patients and caregivers who had a recent surgical encounter. Health information resources used before and after surgery were correlated with patient level of preparedness. We also evaluated the association between preparedness and hospital readmission.

Results

Compared to unprepared patients, those who felt prepared were most likely to be given multiple health information resources before surgery (92 vs. 77%, p < 0.001) and before leaving the hospital (91 vs. 69%, p = 0.02). Feeling prepared was positively correlated with the number of resources provided to patients by their surgical team and used before surgery and before leaving the hospital (p < 0.05, both). 30-day readmission was significantly lower among patients who felt prepared either before (7% prepared vs. 22% not prepared, p = <0.001) or after surgery (9% prepared vs. 23% not prepared, p < 0.001).

Conclusions

Patients with access to more health information resources during transitions before and after surgery feel better prepared and have lower rates of 30-day readmission.

     

Early hospital readmission after bariatric surgery

Background

With the rise in bariatric procedures being performed nationwide and the growing focus on quality and outcome measures, reducing early hospital readmission (EHR) rates has garnered great clinical interest. The aim of this study was to identify the incidence, reasons, and risk factors for EHR after bariatric surgery.

Methods

Using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset (2012–2013), patients with a diagnosis of obesity and body mass index ≥35 who underwent bariatric surgery were identified. EHR was defined as at least one hospitalization within 30 days of bariatric procedure. The association between readmission and patient factors was assessed using multivariable logistic regression analysis. In addition, reasons for readmission were sought.

Results

A total of 36,042 patients were identified. The overall EHR rate was 4.70 % [laparoscopic (lap) adjustable band 1.87 %, lap gastric bypass (GBP) 5.94 %, open GBP 7.86 %, and sleeve gastrectomy 3.73 %], and it occurred at the median of 11 days postoperatively. The rate of EHR significantly decreased from 2012 to 2013 (5.15 vs. 4.32 %, p < 0.001). The median age and BMI were 44 years and 44.7 kg/m², respectively, 78.99 % were female, and 70.78 % were white. The most common reason for readmission was nausea/vomiting (12.95 %), followed by abdominal pain (11.75 %) and dehydration (10.54 %). On multivariable analysis, factors most strongly associated with readmission were procedure type (lap band: reference; open GBP: OR 3.78, 95 % CI 2.47–5.80; lap GBP 3.18, 2.39–4.22; sleeve gastrectomy: 2.03, 1.52–2.71; all p < 0.001), steroid use (1.82, 1.33–2.48, p < 0.001), pre-discharge complication (1.64, 1.20–2.24, p < 0.001), and black population (1.51, 1.34–1.71, p < 0.001).

Conclusions

Bariatric centers should consider implementing standardized protocols for outpatient monitoring of patients identified to be at high risk of experiencing early readmission, which in turn would decrease overall costs and improve quality of care.

     

Impact of Mucinous Histology on the Prognosis of Stage I–III Adenocarcinomas of the Appendix: a Population-Based,Propensity Score-Matched Analysis

Background

Whereas the poor prognosis of signet ring cell adenocarcinomas of the appendix is well known, the significance of mucinous histology remains unclear. The aim of this population-based study was to evaluate if mucinous histology is an independent prognostic factor in appendiceal adenocarcinomas.

Methods

Patients with stage I–III adenocarcinoma of the appendix who underwent surgery between 2004 and 2012 were identified in the Surveillance, Epidemiology, and End Results database. Overall survival (OS) and cancer-specific survival (CSS) were assessed using risk-adjusted Cox proportional hazards regression models and propensity score methods.

Results

Overall, 980 patients with appendix cancer were included, of which 449 (45.8 %) had a mucinous histology. In an unadjusted analysis, the 5-year OS and CSS in patients with a mucinous adenocarcinoma (MC) was 76.8 % (95 % confidence interval (95 %CI): 72.1–81.7 %) and 81.0 % (95 %CI: 76.6–85.6 %), respectively, compared with 70.0 % (95 %CI: 65.1–75.3 %) and 76.2 % (95 %CI: 71.5–81.2 %) in patients with non-mucinous adenocarcinoma (NMC) (P?=?0.082 and P?=?0.368). In multivariable analysis, no impact on survival was observed for OS (HR?=?1.22, 95 %CI: 0.89–1.68, P?=?0.208) and CSS (HR?=?1.21, 95 %CI: 0.84–1.74, P?=?0.296). After propensity score matching, nearly identical survival rates were observed (OS: HR?=?1.03, 95 %CI: 0.71–1.49, P?=?0.881 and CSS: HR?=?1.05, 95 %CI: 0.70–1.59, P?=?0.803).

Conclusions

The present population-based, propensity score matched analysis shows that mucinous histology does not affect survival in stage I–III appendiceal adenocarcinoma patients. Therefore, the same treatment strategies can be applied for patients with NMC and MC of the appendix.

     

Impact of Sarcopenia on Unplanned Readmission and Survival After Esophagectomy in Patients with Esophageal Cancer

Background

Although sarcopenia increases postoperative complications following esophagectomy, its effects on prognosis remain unclear. This study was performed to identify the effect of sarcopenia on 90-day unplanned readmission and overall survival (OS) after esophagectomy.

Methods

Ninety-eight patients with esophageal cancer who underwent esophagectomy were enrolled in this study. Unplanned readmission was defined as any emergent hospitalization within 90 days after discharge. Sarcopenia, defined as low muscle mass plus low muscle strength and/or low physical performance according to the Asian consensus definition, was assessed prior to esophagectomy. Multivariate logistic regression analysis was performed to identify factors that contributed to 90-day unplanned readmission. OS was estimated using the Kaplan–Meier method, and a Cox proportional hazards model was used to assess the relationship between sarcopenia and OS.

Results

Thirty-one patients (31.6%) were diagnosed with sarcopenia. The 90-day unplanned readmission rate was significantly higher in patients with sarcopenia than those without (42.9% vs. 16.4%, respectively; p = 0.01). Multivariable logistic regression analysis showed that sarcopenia was an independent predictor of 90-day unplanned readmission [odds ratio 3.71, 95% confidence interval (CI) 1.29–11.05; p = 0.02], and the log-rank test showed that sarcopenia was associated with OS (p = 0.01). Moreover, sarcopenia was a significant predictor of OS after adjustment for age, sex, and pathological stage (hazard ratio 2.35, 95% CI 1.21–4.54; p = 0.01).

Conclusions

Sarcopenia is a risk factor for 90-day unplanned readmission and OS following esophagectomy. Assessment of sarcopenia could help to identify patients at higher risk of a poor prognosis after esophagectomy.

     

Complications and cancer rates in spine fusion with recombinant human bone morphogenetic protein-2 (rhBMP-2)

Purpose

To quantitatively synthesize the available best evidence for general complications, heterotopic ossification (HO), retrograde ejaculation, cervical swelling, and cancer rates with the use of rhBMP-2 in lumbar and cervical spine fusion.

Methods

We conducted an online search for relevant controlled trials and extracted data on the abovementioned endpoints. Studies were eligible for inclusion if they reported on spinal fusion with rhBMP-2 in humans. Publication bias and heterogeneity were assessed mathematically. These data were synthesized in a meta-analysis using DerSimonian–Laird random effects modeling to calculate pooled odds ratios.

Results

We identified 26 studies reporting on a total of 184,324 patients (28,815 experimental, 155,509 controls) with a mean age of 51.1 ± 1.8 years. There was a significantly higher risk of general complications with rhBMP-2 compared to iliac crest bone graft (ICBG) with an odds ratio (OR) of 1.78 (95 %CI 1.20–2.63), (p = 0.004). The odds ratio for HO was 5.57 (95 %CI 1.90–16.36), (p = 0.002), for retrograde ejaculation 3.31 (95 %CI 1.20–9.09), (p = 0.020), and for cervical swelling 4.72 (95 %CI 1.42–15.67), (p = 0.011), all significantly higher in the rhBMP-2 group. The pooled odds ratio for new onset of tumor was 1.35 (95 %CI 0.93–1.96), which represents no statistically significant difference between the groups (p = 0.111).

Conclusion

rhBMP-2 is associated with a higher rate of general complications as well as retrograde ejaculation, HO, and cervical tissue swelling in spine fusion. There is a slightly increased risk of new onset of tumors, however, without statistical significance.

     

Propensity Score Analysis of an Enhanced Recovery Programme in Upper Gastrointestinal Cancer Surgery

Introduction

The aim of this study was to examine the influence of an enhanced recovery programme (ERP) on outcomes of upper gastrointestinal (UGI) cancer surgery by means of propensity score-matched analysis.

Methods

Three hundred consecutive patients diagnosed with UGI cancer were studied prospectively before and after the introduction of an ERP. Multiple regression models, including propensity scores, were developed to assess confounding variables associated with undergoing surgery, and the risk adjusted association between treatment and length of hospital stay (LOHS).

Results

After regression for confounding factors, a cohort of 252 patients was available of whom 160 received ERP [median age 66 years (IQR 58–73), 119 male, 81 oesophageal, 79 gastric cancer] and 92 control [66 years (IQR 58–74), 74 male, 58 oesophageal, 34 gastric cancer]. ERP operative morbidity (Clavien–Dindo ≥3) and mortality were 13.8 and 3.1 % compared with 17.4 (p = 0.449) and 2.2 % (p = 0.658) in controls. Median ERP critical care and total LOS were 1 (IQR 0–1) and 13 (IQR 10–17) days, compared with 1 (IQR 1–2, p = 0.009) and 16 (IQR 13–26, p < 0.001) days. Multivariable analysis revealed ERP (HR 1.477, 95 % CI 1.084–2.013, p = 0.013), tumour location (HR 2.420, 95 % CI 1.624–3.606, p < 0.001), operative procedure (HR 1.143, 95 % CI 1.032–1.265, p = 0.010), and operative morbidity (HR 0.277, 95 % CI 0.179–0.429, p < 0.001) to be associated with LOHS.

Conclusion

An ERP in UGI cancer surgery was feasible, safe, and effective.

     

Incidence and risk factors for proximal junctional kyphosis: a meta-analysis

Purpose

To analyse the incidence and risk factors associated with proximal junctional kyphosis (PJK) following spinal fusion, we collect relative statistics from the articles on PJK and perform a meta-analysis.

Methods

An extensive search of literature was performed in PubMed, Embase, and The Cochrane Library (up to April 2015). The following risk factors were extracted: age at surgery, gender, combined anterior-posterior surgery, use of pedicle screw at top of construct, hybrid instrumentation, thoracoplasty, fusion to sacrum (S1), preoperative thoracic kyphosis angle (T5–T12) >40°, bone mineral density (BMD) and preoperative to postoperative sagittal vertical axis (SVA difference) >5 cm. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

A total of 14 unique studies including 2215 patients were included in the final analyses. The pooled analysis showed that there were significant difference in age at surgery >55 years old (OR 2.19, 95 % CI 1.36–3.53, p = 0.001), fusion to S1 (OR 2.12, 95 % CI 1.57–2.87, p < 0.001), T5–T12 >40° (OR 2.68, 95 % CI 1.73–4.13, p < 0.001), low BMD (OR 2.37, 95 % CI 1.45–3.87, p < 0.001) and SVA difference >5 cm (OR 2.53, 95 % CI 1.24–5.18, p = 0.01). However, there was no significant difference in gender (OR 0.98, 95 % CI 0.74–1.30, p = 0.87), combined anterior-posterior surgery (OR 1.55, 95 % CI 0.98–2.46, p = 0.06), use of pedicle screw at top of construct (OR 1.55, 95 % CI 0.67–3.59, p = 0.30), hybrid instrumentation (OR 1.31, 95 % CI 0.92–1.87, p = 0.13) and thoracoplasty (OR 1.55, 95 % CI 0.89–2.72, p = 0.13). The incidence of PJK following spinal fusion was 30 % (ranged from 17 to 62 %) based on the 14 studies.

Conclusions

The results of our meta-analysis suggest that age at surgery >55 years, fusion to S1, T5–T12 >40°, low BMD and SVA difference >5 cm are risk factors for PJK. However, gender, combined anterior–posterior surgery, use of pedicle screw at top of construct, hybrid instrumentation and thoracoplasty are not associated with PJK.

     

Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis

Background

The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP).

Methods

We systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom).

Results

This meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR]?=?1.24; 95% confidence interval [CI], 0.78–1.97; p =?0.36), rate of postoperative complications (RR?=?1.06; 95% CI, 0.67–1.69; p =?0.80), rate of biliary-related complications (RR?=?1.28; 95% CI, 0.42–3.86; p =?0.66), or OT (RR?=?1.57; 95% CI, ??1.58–4.72; p =?0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR?=???2.08; 95% CI, ??3.17 to ??0.99; p =?0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR?=???0.40; 95% CI, ??0.80–0.01; p =?0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%).

Conclusion

This study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.

     

The survival outcome and prognostic factors for distal cholangiocarcinoma following surgical resection: a meta-analysis for the 5-year survival

Purpose

To assess the available evidence on the prognostic factors for the 5-year survival for patients with distal cholangiocarcinoma (DCC) following surgical resection.

Methods

We performed a comprehensive search of abstracts included in databases where relevant studies were published between January 2000 and August 2015. Risk ratios (RRs), 95 % confidence intervals (95 % CIs), and random-effects model were calculated using RevMan 5.3 software.

Results

A total of 23 observational studies involving 2063 patients with DCC were analyzed. The meta-analysis showed that postoperative adjuvant chemotherapy was not confirmed as a prognostic factor, with similar 5-year survival rates between those receiving and not receiving chemotherapy (RR 0.71; 95 % CI 0.21–2.36; P = 0.57). Perineural invasion (RR 0.51; 95 % CI 0.40–0.64; P < 0.00001), lymph node metastasis (RR 0.51; 95 % CI 0.38–0.70; P < 0.0001), positive resection margin status (RR 2.11; 95 % CI 1.36–3.30; P = 0.001), and not-well-differentiated adenocarcinoma (RR 1.77; 95 % CI 1.39–2.25; P < 0.00001) were associated with shorter survival.

Conclusions

Perineural invasion, lymph node metastasis, resection margin status, and tumor differentiation were the significant prognostic factors for the 5-year survival.

     

Impact of Neoadjuvant Chemotherapy on Nodal Disease and Nodal Surgery by Tumor Subtype

Background

Neoadjuvant chemotherapy (NAC) is known to downstage disease in the breast and increase breast conservation. It can also decrease nodal disease extent. We evaluated the impact of NAC on nodal positivity, nodal burden, and nodal surgery by tumor subtype.

Methods

All cT1–4c breast cancers from 2010 to 2014 in the National Cancer Database were evaluated, comparing patients receiving NAC with those undergoing primary surgery (PS). Rates of pathologic node-negative status (pN0) and sentinel lymph node (SLN) surgery (1–5 nodes) were compared using chi-square tests, and adjusted odds ratios (OR) were estimated.

Results

Of 461,549 patients, 36,715 (8.0%) received NAC and 424,834 (92.0%) had PS. In cN0 patients, pN0 rates were higher in NAC compared with PS patients in ER?/HER2+ [93.2 vs. 79.0%, odds ratio (OR) 3.64, p < 0.001], ER?/HER2? (89.9 vs. 85.2%, OR 1.55, p < 0.001), and ER+/HER2+ (84.7 vs. 78.3%, OR 1.54, p < 0.001). Patients with cT2–3, N0 tumors had significantly higher rate of SLN surgery for NAC versus PS for each biologic subtype except for ER+/HER2? tumors, amongst which this was true only for T3 tumors. In cN1–3 patients, pN0 rates after NAC were 61.3% in ER?/HER2+, 47.7% in ER+/HER2+, 47.3% in ER?/HER2?, and 20.2% in ER+/HER2? and SLN surgery was highest in ER?/HER2+ (28.9%, p < 0.05 versus other subtypes).

Conclusion

NAC increases rates of pN0 among cN0 patients compared with PS. Among cN+ patients, 20–61% undergoing NAC convert to pN0 depending on tumor type, with lowest nodal response in ER+/HER2? disease. Use of NAC results in less extensive axillary surgery than in patients treated with PS in both cN0 and cN+ disease.

     

Hysteropreservation versus hysterectomy in the surgical treatment of uterine prolapse: systematic review and meta-analysis

Introduction and hypothesis

The efficacy and safety of removing or preserving the uterus during reconstructive pelvic surgery is a matter of debate.

Methods

We performed a systematic review and meta-analysis of studies that compared hysteropreservation and hysterectomy in the management of uterine prolapse. PubMed, Medline, SciELO and LILACS databases were searched from inception until January 2017. We selected only randomized controlled trials and observational cohort prospective comparative studies. Primary outcomes were recurrence and reoperation rates. Secondary outcomes were: operative time, blood loss, visceral injury, voiding dysfunction, duration of catheterization, length of hospital stay, mesh exposure, dyspareunia, malignant neoplasia and quality of life.

Results

Eleven studies (six randomized and five non-randomized) were included involving 910 patients (462 in the hysteropreservation group and 448 in the hysterectomy group). Pooled data including all surgical techniques showed no difference between the groups regarding recurrence of uterine prolapse (RR 1.65, 95% CI 0.88–3.10; p = 0.12), but the risk of recurrence following hysterectomy was lower when the vaginal route was used with native tissue repair (RR 10.61; 95% CI 1.26–88.94; p = 0.03). Hysterectomy was associated with a lower reoperation rate for any prolapse compartment than hysteropreservation (RR 2.05; 95% CI 1.13–3.74; p = 0.02). Hysteropreservation was associated with a shorter operative time (mean difference ?12.43 min; 95% CI ?14.11 to ?10.74 ; p < 0.00001) and less blood loss (mean difference ?60.42 ml; 95% CI ?71.31 to ?49.53 ml; p < 0.00001). Other variables were similar between the groups.

Conclusions

Overall, the rate of recurrence of uterine prolapse was not lower but the rate of reoperation for prolapse was lower following hysterectomy, while operative time was shorter and blood loss was less with hysteropreservation. The limitations of this analysis were the inclusion of nonrandomized studies and the variety of surgical techniques. The results should be interpreted with caution due to potential biases.